Spring 2014 (Volume 24, Number 1)

The Six Million Dollar Rheumatologist

By Philip A. Baer, MDCM, FRCPC, FACR

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“For five seasons between 1974 and 1978, actor Lee Majors played Col. Steve Austin, on the mega-popular television show The Six Million Dollar Man. Barely surviving a near fatal crash, Austin was equipped with a bionic arm, two bionic legs and a bionic eye, making him ‘better, stronger, faster,’ and all for the price of...”, well, you can guess.

“I've had recent knee surgery. Both knees are kind of down to the bone and [I have] a little bit of back problems. It's from almost 48 years of stunt work. I did 90% of all my stuff.”

- “Lee Majors dishes on Six Million Dollar Man role”, CBC Interview, 2011.

Eventually everybody will be a potential rheumatology patient, even the fabled Six Million Dollar Man, now 74 years old. My long-distance diagnosis is spinal and peripheral osteoarthritis (OA). A wide variety of therapies are available, usually administered in multimodal fashion, from the generic acetaminophen to the more expensive viscosupplements, and the ultimate undertaking, joint replacement surgery. Moving from the individual patient to a national perspective, the cost of total hip and knee replacements increased in Canada by $100 million over the 2010-2012 timeframe, according to Canadian Institute for Health Information (CIHI) data.

In September 2013, the Society of Actuaries and the Canadian Institute of Actuaries (CIA) released a report entitled Sustainability of the Canadian Health Care System; “the findings indicate that, without significant government intervention, the Canadian health care system in its current form is not sustainable.”

That started me thinking about my own economic role as a typical rheumatology clinician. Am I a six million dollar rheumatologist? After 27 years in practice, I have certainly had six million dollars in gross revenue pass through my hands. Regrettably, the stickiness of that bundle of dollars has been rather low when judged by my latest bank account statement. I do have the satisfaction of contributing to Canada’s economy over the last quarter century, including funding my share of Senate spending, perpetually dry-docked submarines, and failed Ontario initiatives in e-Health, green energy, and power plant construction, among others. On the other hand, I feel happy about the money I have generated for employee salaries, local business service providers, and worthwhile infrastructure and social services funded by my tax dollars.

Could I be a six million dollar rheumatologist in another context? Well, CIHI and the CIA indicate that Canadian spending on drugs accounts for 16% of health expenditures, versus only 14% for physician services. We all know that biologic therapies are a driver of drug costs in rheumatology. At $20,000 per patient per year for biologic therapy, if I have 100 patients on biologics, I am generating two million dollars a year in direct costs. I could be a six million dollar rheumatologist every three years! With rheumatologists in my local area retiring, and preferentially transferring patients who are on biologics to me for ongoing care, biologic spending dispensed under my signature can only increase. No doubt some of our colleagues with bigger practices could be six million dollar a year rheumatologists already.

Of course, I am also ignoring the offsetting financial benefits of treatments which reach the target of remission or low disease activity, facilitated in many patients by biologic therapies: maintenance of work productivity, and reduction in other direct and indirect costs (short- and long-term disability, joint replacement surgery, etc.). Perhaps I should get a credit of a million dollars a year against my practice’s drug costs to be fair. Lee Majors was married for nine years to Farrah Fawcett. After they split, Fawcett said, "If he's the six million dollar man, I'm the ten billion dollar woman." Will there be a ten billion dollar rheumatologist? I hope not.

Philip A. Baer, MDCM, FRCPC, FACR
Editor-in-chief, CRAJ
Scarborough, Ontario