11. Unveiling the Truth: Financial Incentives in Healthcare

One of the questions I am asked most often by patients is this:

“Don’t doctors get paid to prescribe medications?”

It is a fair question. And if you have ever left a medical visit feeling rushed, unheard, or confused about why a prescription was offered when you wanted to talk about lifestyle change, you are not alone.

The short answer, from my experience, is no. Doctors are not paid directly for writing prescriptions. I have never seen that arrangement in my own career. But the longer and more important answer is where things get complicated, and where a lot of patient frustration actually starts to make sense.

In this episode, I share how modern healthcare really works behind the scenes, specifically the metric driven systems that shape many outpatient medical visits, often without patients ever being told those systems exist.

Insurance contracts commonly withhold a portion of physician reimbursement. That money can only be earned back if certain population level targets are met. These targets include cancer screening rates, blood pressure control, diabetes markers, depression screenings, and age based testing requirements.

These systems were created with good public health intentions. On a population level, they aim to reduce disease, improve outcomes, and lower long term healthcare costs. But in real life, they can unintentionally distort the patient experience.

When metrics drive behavior, office visits can become crowded with checklists, screenings, and documentation that have little to do with the reason you came in that day, whether that is back pain, fatigue, brain fog, or something else entirely.

This helps explain why you may feel frustrated when:

• You are asked the same questions at every visit
• Screenings feel unrelated to your concern
• Lifestyle conversations feel rushed or absent
• Medications are offered before behavior change has time to work

This episode is not about blaming doctors. I speak honestly about the difficult position many clinicians are placed in. They are often caught between wanting to support their patients and being financially penalized if metrics are not met by the end of the calendar year.

I also explain why lifestyle change, while essential, often does not move the numbers fast enough for these systems. That reality can quietly influence medical decisions, especially late in the year, even when a patient is motivated and ready to make change.

This conversation is about clarity, not conspiracy. It is about helping you understand why healthcare can feel transactional, why visits sometimes miss the mark, and how understanding the system can help you advocate for yourself more effectively.

My goal is not to create fear or distrust. It is to offer context, compassion, and empowerment.

If you have ever wondered why your healthcare experience feels the way it does, this episode is for you.

Let’s get real and get results.

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Disclaimer: This podcast is for educational purposes only.  Information discussed is not intended for diagnosis, curing, or prevention of any disease and is not intended to replace advice given by a licensed healthcare practitioner. This podcast and its guests may have direct or indirect financial interests associated with products mentioned.

Transcript

Welcome And Podcast Mission;

Dr. Mark Su 0:09

I'm Dr. Mark Su and welcome to the Functional Medicine Reality Podcast. Join me and our community weekly as we bring you unfiltered health from inflammation to longevity. Real stories, real people, real solutions. Experience real life health changes from both patients and practitioners, and learn how to turn cutting-edge information into real results in your own life so you can feel better, live longer, live healthier, and be confident and clear in your healthcare choices. Let's get real and get results.

Do Doctors Get Paid To Prescribe;

Dr. Mark Su 0:41

The one thing I've been asked many times by patients is the following. I've had a couple of patients who have worked in leadership or administration on some level, maybe coincidentally, in the mental health field. And I'm talking in this case, inpatient mental health, all right, psychiatric facilities, inpatient care, where they were of the understanding or outright awareness, reportedly, that there was something of that sort happening many years ago. All right. But I've never seen that myself in any subspecialty. And I'm not aware of how that would be an arrangement, whether it be between pharmaceutical companies or healthcare facilities, whether it's a hospital or other kind of care facility and a prescribing practitioner. However, I am aware of metrics, all right, measurements that doctors and hospitals for that matter, beyond that, I don't know. Physical therapists, rehab facility, short and long-term facilities, rehab facilities, absolutely. Okay. But physical therapists, x-ray centers, imaging centers, and stuff like that, I don't know. But there are metrics that I will just speak for the outpatient doctors. There are metrics that are asked to be met. So here's what that looks like and why that matters to you as a patient. All right. So there is there it is illegal to have unions in America for doctors. All right. When I say doctors here, I'm going to include other prescribing practitioners. I don't care if it's an MD or a DO or a nurse practitioner or a physician assistant, but I'm not including naturopaths. I can't speak for naturopaths who are prescribers in many states. And I'm not excluding here chiropractors and other healthcare practitioners who are not able to prescribe medication. Okay. In America, it is illegal to have unions. However, there are these entities that I like to call pseudo-unions. And I'm not being facetious. It's just, see, the insurance companies don't want to have to set

How Pseudo Unions And Contracts Work;

Dr. Mark Su 2:43

up contracts with thousands, hundreds and thousands, or who knows, whatever the numbers are, millions of prescribers. Okay. They don't want to have to create a negotiating contract. They don't want to have to negotiate a contract with every single office in America. If I in our brick and mortar office, we're an independent office, and whichever insurance company doesn't want to have to negotiate with us just for the five of us in our office. If we were part of Mass General Brigham or Kaiser Permanente or whatever, pick your uh large healthcare group, then it's easier for any given insurance company to just come to us as a large group and say, hey, can we let's negotiate a contract with your 150 different outpatient office practicing doctors, right? Or to go to a huge hospital system that employs hundreds of internists, hospitalists, specialists, et cetera, ER doctors, et cetera, and just negotiate contracts with all of the lot all at one time. There are these pseudo-unions that where these doctors group together and they're represented by a given legal entity that then coordinates these contracts with the insurance companies. And so everyone basically gets the same contracting and the insurance, it's just a lot easier for the insurance companies, and it's a heck of a lot easier for the doctors too. The doctors don't want to have to deal with all this stuff. But here's what happens.

The Withhold And Metrics Model;

Dr. Mark Su 4:02

Over the years, let's say if the insurance company used to pay myself, let's say, I'm gonna make up a number, right? For this kind of office visit for a given patient, you're we are reimbursing you $200. All right. But over the years, the contracting, the agreement became we're gonna hold back 30% of your pay. Again, I'm making up the numbers. Could be 20%. I don't know. 15%, who knows? We're gonna hold for easy numbers, for easy numbers, we're gonna hold back 25% of your pay. All right, of that $200 for all your visits across the board, not just for those visits, all visits. All right. A quarter of the reimbursement that we know from our data from the previous X number of years, we're likely to have to pay you out X amount of money over the next coming fiscal year because we can see all our members who are under your care, and we have the data, and we're gonna hold back 25%, but you can earn it back. All right. How do you earn it back? You gotta meet some standards, you gotta meet some metrics. All right. So what are we talking about? This is where doctors, I'm gonna speak for outpatient only, prescribing practitioners, and I'm gonna speak specifically to primary care doctors, okay? Because that's where we live in our brick and mortar office. And so I can't speak for specialists by first hand knowledge, but for you as a primary care practitioner, primary care doctor, you have to meet certain metrics, and

What Counts As Quality Metrics;

Dr. Mark Su 5:18

then you can have your money back that we've withheld you. Not extra, not bonus, just the money that you used to get, but we're holding back now. What are those metrics like? Do all the 50 plus year old women who are under your care in our membership in our system, as members of our insurance plan in your practice, among all the 50 plus year old women, do you have at least, again, I'm making up the number, 65, 68% of your women who are who are uh candidates for a mammogram, have they had mammogram screening in the last year? And for those who don't need it every year, you have to document and prove who those people are so that they don't get counted against you. All right. For all individuals 50 years and older, now 45 years and older, men or women, are they up to date with colon cancer screening? Are they are there 70%, 72% of all individuals over that age have they had appropriate colon cancer screening based on their profile? Okay. All 17 to 23 year old women, how what percent have you had met a metric of 53%, 58%, whatever, who have had screening for gonorrhea and chlamydia by urine testing? All right. All your pediatric individuals under the age of 18, under certain age bracket categories, what percentage have you met in all of them having had an annual well visit? Furthermore, diabetics, how many of your diabetic patients have met a criteria of their A1C, their three-month blood sugar, being under a certain percent, as a marker, a biomarker number in that year? Your hypertensives do 74% more or over or under 74% of your hypertensive patients meet the criteria of whatever blood pressure number is the criteria. Let's call it 140 over 90. All right. Okay, and the list goes on and on. Now, what's the big deal? Here's a couple things.

Why Visits Feel Off Track;

Dr. Mark Su 7:08

One is you it is important for you to realize that practitioners have this financial incentive that they're trying to meet. No one's keeping track of all the numbers. No one's able to do that. That's what those third-party entities are for, these pseudo-unions. They're helping all these doctors and practices keep track of those that data. It's data mining in the end, okay? And they'll and it's look, it's I do believe it's with good intention, all right? These are the a lot of these are, I'll say most, if not all of these, are based on public health level, scale, population health level, good intentions for better health for our communities, our country, all right? Cancer screening, blood pressure management, diabetes management, et cetera. But the downside is it is important to know that there is financial incentive to meet these metrics. And that, and secondly, that is why some patients get so frustrated and don't understand why I walk in there to talk about my back pain, but they gotta measure me every single freaking time. And they make me check, take this depression questionnaire every single freaking time. Like, why do I got to do that every time? It's so annoying. It takes time. It's another piece of paperwork, another form to fill out. And then why are they I'm 17 years old old with back pain. Why do they gotta make me check this urine testing? What does that to do with back pain? Are they checking me for drugs? No. Are they checking me for a urine infection? Maybe, maybe not. But the reason is they're checking you for gonering chlamydia. And if you ask that and found that out, and you're thinking, like, do they think my back pains from gonering chlamydia? No, absolutely not. It has nothing to do with your back pain. But the reason they're doing that is for totally separate reasons. And when you have these multiple components vying for the attention of what's in the not necessarily just even the practitioner, the doctor, nurse practitioner, whoever, but the office as a whole, okay, there's systems all in place to capture all these people, right? When they're in the office to do X, Y, and Z, depression questionnaire screening, gonerry chlamydia testing. They want to take advantage of those moments to try to meet these metrics. And so it dilutes the experience of why you're there for, let's say, your back pain or your arm, your shoulder pain. And it makes it easy for a patient to feel like, do am I just a number? They're not paying attention to why I'm here. They're like, they have alternative or ulterior interests, which is true to some degree. Okay. So it it leaves us as patients and consumers of the system to feel more like a number. And truth be told, when we're talking about population health, we are a number. All right. That just sucks, but it's not necessarily bad, in my opinion, in value, but it's the way we feel, and that just kind of sucks. All right. Now, so going back to the very original uh question, right?

Lifestyle Change Versus Fast Metrics;

Dr. Mark Su 9:44

Don't doctors get paid for writing prescriptions? Not that I'm aware of, but they are financially incentivized and they're thinking about their financial issues from this other way. Okay. And so then, furthermore, if you are someone who has high blood pressure, if you're someone who does have diabetes and it feels like doctors are trying to push prescriptions, all right? Whatever happened, hey Mark, like whatever happened to lifestyle change, how come I'm never, no one's ever talking to me about trying to improve my eating and exercise habits? Why is that not happening? Because that isn't gonna move the numbers, all right? To get your A1C down, to get your blood pressure numbers down, it doesn't, who knows how long that's gonna take for your eating and exercise habits to get started and to sustain, all right? And therefore for the doctor's office to be able to see the results and be able to document that before the end of the calendar year. All right. God help you, if you're in October and you're you have high blood pressure and you're on medication already, let's say, or let's say you're not on any medication, your blood pressure's been high for three years, they see your blood pressure is still high, and then you've never really taken full action to change your eating and exercise habits, but you're more motivated than ever right now, all right, for whatever reason. And you're saying, like, I know this and that, but I have a plan. Here it is, I'm laying out for you strategically. This is what I'm gonna do, and I'm revved up. I'm let's go. And they're saying, no, here's a medication. And you're like, what happened? Like, how come you're not on my team? How come you're not supporting me? It's October, dude. They got to meet metrics by the end of the calendar year. Even if you execute those plans now, the chance of your blood pressure changing in the next two months, three months is pretty low. All right. It's really statistically speaking, it's pretty low. And then they've got to be sure you come back before the end of the calendar year. Even if you make an appointment, the likelihood of you canceling that appointment or rescheduling it, something came up, you were sick, your family member's sick, you don't make the appointment, and then they can't document it. And then the last blood pressure they have on record is the high one, they're penalized. So they're doing everything they can with within their power. That's the thing, within their control to try to get your blood pressure down because they're trying to meet metrics. All right. Now, if you've got a doctor who isn't so minded about that stuff, right? They're like more of an idealist and a purist, and they're like, Yeah, man, I'm on the side of my patient. All right. And they don't feel and they're not thinking about those voices and pressures in the middle of their visits. Awesome for you. All right. Now, whether you actually take those steps and execute those steps

October Pressure And Medication Push;

Dr. Mark Su 12:09

and lower your blood pressure or your A1C as a diabetic or whatever, over the coming six months, year, two years, or whatever, that's between you and your practitioner. And a lot of us, those things don't happen or they don't sustain. And then we don't actually ever, or we very much in a delayed fashion, if ever, do what we voice that we're going to do. But that's another story. All right. Your practitioners, your practitioner, our practitioners, they know that they can only control things to a certain degree, and they're financially penalized for not getting results. The insurance plans want to see change in their members so that there is on a population level less disease, less cost to them. Cancer screening, let's reduce cancer so that we're not having to pay for all that chemotherapy and radiation therapy and surgeries and blah, blah, blah, which is big time, big bucks, right? But we can only make that happen by cancer screening, let's say, okay? Let's reduce the risk of heart disease with all the costs of caths and stents and bypasses and blah, blah, blah. But we got to start with getting people's blood pressure down, their weight down. The insurance plans are not coming after their the actual users and patients and saying, you've got to stop smoking, you've got to stop, blah, blah, blah. If you keep smoking, you're going to pay more for your plan. We've heard that in the news for years. Should people who partake in less healthy habits or meet metrics like have a high BMI or whatever, should they have to pay more for the insurance plans? I don't know where that's going, but insurance plans have never taken that step to say, yeah, we're going to execute some level of that. No, instead, they're penalizing and they're making the doctors be responsible for executing that behavior change, which is the holy grail of medicine, the holy grail of healthcare is behavior change, in my opinion. All right. No, that's for another time. They're making the doctors responsible for that. And then they're penalizing them if it doesn't happen. All right. They're believing, this is my interpretation,

Population Health Costs And Tradeoffs;

Dr. Mark Su 14:03

they're believing, likely, arguably so, that a doctor is going to be able to affect behavioral change more than they are, at least, to a patient. But the doctors are getting are screwed and they're in this kind of in-between, they're put in a really hard position in the corner of the room. All right. So there you have it. There are financial incentives, but as far as I'm aware, they're not in the form of prescription writing. It might feel like they're just looking to write prescriptions, but it's not because they're paid prescription. They're paid per for writing prescriptions. There are financial incentives for meeting metrics. And that, my friends, is one of the biggest reasons a lot of patients feel like they're a number and their visits are not prioritized to what their wants and needs are for that given visit, but towards other undefined and uncommunicated, poor non communicated activities that occur in any given office visit. So there you have it. That's the world as I see it.