Anyone here against expanding GME?

[username456789]

I'm always impressed with how hard people in medicineare willing to work/whine to ensure decreased job security and decreased salaries for themselves.

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[VA Hopeful Dr]

I'm always impressed with how hard people in medicineare willing to work/whine to ensure decreased job security and decreased salaries for themselves.

Meh, students have always been idealistic and naive.

 

[username456789]

And the lower wages will be because of increased competition. I get it we all got to eat, but it's pretty hard to make claims about other people's "selflessness" as you call it when you want to keep your salary up not by being better than the competition but rather by preventing the competition.

Forcing more bodies through medical school doesn't somehow ensure a better product via competition. You should not even be viewing this as "physician vs physician". We are not the ones who set the prices of our services. It's not a matter of "uh oh, Dr. Smith moved into town and he's offering 50% off colonoscopies."

The economic principles you learned freshman year of college do not apply in the same manner with healthcare.

 

[username456789]

Meh, students have always been idealistic and naive.

Indeed, but when those naive kids become physicians and take positions with the AMA, it is more than a little bit dangerous.

 

[Dredge]

Forcing more bodies through medical school doesn't somehow ensure a better product via competition. You should not even be viewing this as "physician vs physician". We are not the ones who set the prices of our services. It's not a matter of "uh oh, Dr. Smith moved into town and he's offering 50% off colonoscopies."

The economic principles you learned freshman year of college do not apply in the same manner with healthcare.

I never advocated for more medical school graduates. My argument was entirely limited to the idea of increasing residency spots with a preference towards the fields that are most undersupplied with trained physicians. Those being primary care and general surgery as suggested by the two bills supported by the AAMC.
Moreover, I completely agree with you that more doctors will result in lower salaries. Whether the patient's decide what the price is by going to the cheapest doctor (which is not a possibility, I agree), or insurance companies/gov't will reimburse less per procedure/hour worked; the result is the same. The pie will be split into smaller and smaller pieces. But I suggest you look to Europe and see what happens when countries flood the market with doctors.No one in an attending position is struggling to eat and 15k residency spots over 5 years is not going result in a communist utopia.
But I get it, my youthful naiveté just doesn't appreciate how scary the cold war was. Maybe another Ensure would help?

 

[VA Hopeful Dr]

I never advocated for more medical school graduates. My argument was entirely limited to the idea of increasing residency spots with a preference towards the fields that are most undersupplied with trained physicians. Those being primary care and general surgery as suggested by the two bills supported by the AAMC.
Moreover, I completely agree with you that more doctors will result in lower salaries. Whether the patient's decide what the price is by going to the cheapest doctor (which is not a possibility, I agree), or insurance companies/gov't will reimburse less per procedure/hour worked; the result is the same. The pie will be split into smaller and smaller pieces. But I suggest you look to Europe and see what happens when countries flood the market with doctors.No one in an attending position is struggling to eat and 15k residency spots over 5 years is not going result in a communist utopia.
But I get it, my youthful naiveté just doesn't appreciate how scary the cold war was. Maybe another Ensure would help?

Have you not been following the news? The NHS is getting into scandal after scandal, just like the VA here. Its not only about physician compensation, although if you cut salaries enough you will lose the best and brightest. There are very few people who would endure, say, general surgery training to come out making $150k.

 

[jl lin]

Forcing more bodies through medical school doesn't somehow ensure a better product via competition. You should not even be viewing this as "physician vs physician". We are not the ones who set the prices of our services. It's not a matter of "uh oh, Dr. Smith moved into town and he's offering 50% off colonoscopies."

The economic principles you learned freshman year of college do not apply in the same manner with healthcare.

LOL, I wasn't ready to read the 50% off colonoscopies. I aspirated on my coffee.

 

[jl lin]

1. Nurse anesthetists have been around for over 100 years and were practicing autonomously before doctors even had anesthesiology residencies. The development of CRNAs was not because there was a shortage of anesthesiologists, but because nurses had been doing it so long and were losing their own autonomy in the field. The only reason CRNAs can practice autonomously is because the education required to get that license is far more in depth than any other licensure a nurse would get. Even with that, the vast majority of CRNAs still work under an anesthesiologist and several states don't legally allow them to practice without physician supervision.

2. It doesn't matter how entrepreneurial they are if the system doesn't allow for independent businesses. If they want to do FM or psych they could probably stay independent. If they want to do IM or anything having to do with a hospital though (which in my experiences most FMGs do because of how complex it is to navigate our healthcare system), they won't be able to do that. Besides, why would any of us want the U.S. to start hiring more FMGs in place of people trained here unless they were that much better (which some are).

3. Are you really going to argue that generating more revenue for a hospital isn't going to increase the hospital's demand for that type of physician?

1. Is quite true.

Another point: I am shocked people don't see the coming fall-off (bursting bubble) of medical school applicants due to the rate of upping costs of attendance at many schools along with a very troubling economy. In due time, there indeed may be diminishing amounts of residents, and when that happens, FMGs will look appealing again.

 

[Dredge]

Have you not been following the news? The NHS is getting into scandal after scandal, just like the VA here. Its not only about physician compensation, although if you cut salaries enough you will lose the best and brightest. There are very few people who would endure, say, general surgery training to come out making $150k.

You're mixing a lot of issues when you say "NHS Scandals" the NHS has a lot of problems to be sure. However, the discussion is about the ramifications of increasing GME spots and in particular, the bills currently in the house and the senate in Washington. Alder Hey, Bristol Heart, and the Stafford hospital are complete messes but to say that these are closely linked with GME is a little bit of a stretch. Sure, the number of doctors matters but these are problems of a misallocation and misuse of countless different resources. Same thing with the VA. I'm pretty sure the fact that the programs HHS and VA use to follow patients can't communicate with each other isn't because there are "too many IMGs" working at Walter Reed.
About the General surgery thing, personally, I'd kill to be in that situation, but ok, let's say lower salaries results in a brain drain and only the dregs of the medical trainees in the system want to become surgeons (which I completely don't accept btw). Then what? Medicine isn't practiced uniformly throughout a state, let alone a country, let alone the world but it is still a relatively tightly regulated field with numerous standards of minimum quality. The implication that people will be getting substandard care is tough to accept with lawyers around every corner ready to crush one wrong move you make and that you still need to pass a multitude of examinations to assess an applicant's competence. But hey, I'm an IMG don't get me started on fair assessments of competence...
Also, sorry about the Ensure thing, that was rude. It's exams, I'm a little touchy.

 

[IlDestriero]

Most anesthesiologists would be opposed to significant expansion. There seems to be adequate supply with existing training.
There's actually a group looking into whether we should decrease the number of Pediatric Anesthesia fellowship positions nationwide.

 

[Dr. Death]

LOL, I wasn't ready to read the 50% off colonoscopies. I aspirated on my coffee.

This would make an excellent Christmas present to tell the older males in your life that you care.

 

[VA Hopeful Dr]

You're mixing a lot of issues when you say "NHS Scandals" the NHS has a lot of problems to be sure. However, the discussion is about the ramifications of increasing GME spots and in particular, the bills currently in the house and the senate in Washington. Alder Hey, Bristol Heart, and the Stafford hospital are complete messes but to say that these are closely linked with GME is a little bit of a stretch. Sure, the number of doctors matters but these are problems of a misallocation and misuse of countless different resources. Same thing with the VA. I'm pretty sure the fact that the programs HHS and VA use to follow patients can't communicate with each other isn't because there are "too many IMGs" working at Walter Reed.
About the General surgery thing, personally, I'd kill to be in that situation, but ok, let's say lower salaries results in a brain drain and only the dregs of the medical trainees in the system want to become surgeons (which I completely don't accept btw). Then what? Medicine isn't practiced uniformly throughout a state, let alone a country, let alone the world but it is still a relatively tightly regulated field with numerous standards of minimum quality. The implication that people will be getting substandard care is tough to accept with lawyers around every corner ready to crush one wrong move you make and that you still need to pass a multitude of examinations to assess an applicant's competence. But hey, I'm an IMG don't get me started on fair assessments of competence...
Also, sorry about the Ensure thing, that was rude. It's exams, I'm a little touchy.

You brought up Europe first, I was showing why its unwise to blanket-statement about how good things are there.

Minimum competency is easy, that should absolutely not be the goal. Also, the vast majority of screw ups don't involve lawyers, so that won't work as well as you think.

 

[W19]

A couple of thousand additional primary care spots (FM/peds/psych) might be needed IMO.

 

[username456789]

As many have pointed out, increasing the number of spots doesn't somehow magically make middle-of-nowhere more desirable. The only way to accomplish the goal of "significantly more doctors going to underserved areas" via the "more spots for primary care" route is to create such an absurd glut of physicians that it is completely unsustainable to work as a physician in anything but an underserved area. And I am going to give people on here the benefit of the doubt and assume that no one is stupid enough to advocate for that.

We need to work more on incentives to draw people to these areas. Unfortunately, this isn't easy, as the current incentives out there do not seem to be achieving that goal. I don't have all the answers, but I think most of us can identify which potential answers are obviously wrong.

 

[Dredge]

You brought up Europe first, I was showing why its unwise to blanket-statement about how good things are there.

Minimum competency is easy, that should absolutely not be the goal. Also, the vast majority of screw ups don't involve lawyers, so that won't work as well as you think.

I did bring up Europe first, but, I did not make a blanket statement about it. I specifically mentioned physician compensation in relation to the high numbers of doctors they have there, which is a function of the higher number of GME they fund. Their system has its own problems but compensation is not a big one. Also I'd like to repeat, those other issues with the NHS are at best peripherally associated with the GME system in Europe.
Regarding competency, you're right, it very well might be a breeze to achieve. However, minimum competency and standards of care are one of the only objective ways we have at measuring performance. So will the pool of talent get depleted? Maybe (doubt it though). How much worse? Who knows..Assuming the system will be worse off is a stretch without any hard proof in your favour.

 

[Stagg737]

As many have pointed out, increasing the number of spots doesn't somehow magically make middle-of-nowhere more desirable. The only way to accomplish the goal of "significantly more doctors going to underserved areas" via the "more spots for primary care" route is to create such an absurd glut of physicians that it is completely unsustainable to work as a physician in anything but an underserved area. And I am going to give people on here the benefit of the doubt and assume that no one is stupid enough to advocate for that.

We need to work more on incentives to draw people to these areas. Unfortunately, this isn't easy, as the current incentives out there do not seem to be achieving that goal. I don't have all the answers, but I think most of us can identify which potential answers are obviously wrong.

Agree, aside from offering to pay off student debt or give higher pay, idk what else smaller/poorer communities could reasonably offer. Ideally, paying off 100% of student debt would be great, although that might not encourage people to stay there long-term. I also think making research materials and resources available through working in a low-access area would help many as well, though I'm not sure how that would work logistically. Especially if people can do that research at other places already.

 

[Postictal Raiden]

A couple of thousand additional primary care spots (FM/peds/psych) might be needed IMO.

Perhaps instead of expanding residency spots, simply cut spots from specialties where there's a surplus of specialists (i.e. radiology, pathology, etc..) and give those to primary care. Wouldn't that be better? Hitting two birds (shortage of PCPs and saturated market of pathologists) with one stone.

 

[W19]

Perhaps instead of expanding residency spots, simply cut spots from specialties where there's a surplus of specialists (i.e. radiology, pathology, etc..) and give those to primary care. Wouldn't that be better? Hitting two birds (shortage of PCPs and saturated market of pathologists) with one stone.

That is probably a better idea...

 

[VA Hopeful Dr]

That is probably a better idea...

Maybe, but I'm not sure those 2 specialties have enough spots to make a difference.

 

[Postictal Raiden]

Maybe, but I'm not sure those 2 specialties have enough spots to make a difference.

I realize that, but we also need to account for the expansion of midlevel practitioners. Can't remember the numbers but NP schools pump an upward of 15K individuals per year. PA schools graduate also a high number of practitioners every year.

 

[W19]

Maybe, but I'm not sure those 2 specialties have enough spots to make a difference.

A combination of incentive and that might be a good start...

 

[VA Hopeful Dr]

I realize that, but we also need to account for the expansion of midlevel practitioners. Can't remember the numbers but NP schools pump an upward of 15K individuals per year. PA schools graduate also a high number of practitioners every year.

I'm not too concerned about that

 

[W19]

I'm not too concerned about that

The ASA was not too concerned about CRNA and look at what is happening...

 

[VA Hopeful Dr]

The ASA was not too concerned about CRNA and look at what is happening...

Find me one anesthesiologist who has actually lost their job, then we'll talk.

 

[W19]

The conditions are not the same like they were 10 years ago.

 

[neusu]

I'm still filtering through replies, so perhaps my take has already been stated.

Rather than expand the pool of physicians, e.g. have more residency positions and more medical students graduating, we need to revise the incentives to pursue training and positions in environments with need. This includes primary care and practice in a rural or inner city urban environments. There are a plethora of midlevel provider programs opening, and it is evident there, much like on the physician side, the graduates pursue positions in lifestyle fields in preference to the positions in at need environments. Fundamentally, having an underpaid, understaffed, overworked opportunity vs the polar opposite a newly graduated job applicant would be foolish, or without self interest/preservation, to pursue the former.

Issues at play here are multiple.
1) Changing the incentives (e.g. increasing/guaranteeing pay, loan forgiveness, capping hours/patients of pcps, etc) would make it a more desirable job. By increasing the attractiveness of these positions, less people would put it off the table because of financial, location, or lifestyle constraints.
2) Creating an increase supply of physicians will only create more competition for the more desirable positions. Likewise, expansion of these positions without an actual need would create a glut of trained physicians and decrease both salaries and lifestyle associated with these positions.

While both models would potentially have the same ends, the time-frame for the change is upfront for my suggestion, and delayed for the proposed expansion of AAMC/ACGME. That is to say, if we switch trainees to primary care now they'll be practicing there in 3 years. If we add positions across the board, it'll take a minimum of 7 years to get more primary care physicians. More likely though, we'd go through a phase adjustment and need a glut of physicians in currently desirable fields to offset the attractiveness, thereby making the primary care more attractive.

 

[IlDestriero]

Find me one anesthesiologist who has actually lost their job, then we'll talk.

There are MANY anesthesiologists that lost their MD only jobs to be replaced by management companies with 3-4:1 coverage of CRNAs. Some willingly (sold out) and some unwillingly (lost contract).
Are they unemployed? No, not likely. There is work, but they would have to join the AMCs for less $$ or pack up their lives and move.
So you'd be wrong to think that CRNAs aren't taking MD jobs. They're just not doing it the way you think.
In my practice we have CRNAs and we're hiring more. 20 years ago there were none. The adult hospital next door had limited CRNA coverage but is expanding their CRNA coverage right now. One 5️ hospital system and 5️ training program is actively looking at dumping their MD only model and hiring CRNAs. I suspect they will be there in 2 years in a limited trial basis and expand quickly over the next 4-5. Those are all jobs that used to be and still could be physician jobs, but are going to CRNAs. And it's mostly driven by cost containment. We are expensive, they're not.

 

[PL198]

Well the "average" law school class is actually nowhere near that big -- actually only a couple law schools are that size. But the real difference is the length of the pipeline. Law school is only 3 years and there's no residency, so you end up with 2-4 classes of new lawyers in the time it takes to school and train one new class of doctors.

how would you know



sarcasm

 

[FlowRate]

Completely against it. Aren't there something like 30,000 residency spots vs 20,000 graduating US medical students? Even with currently planned school expansion, those numbers will never cross. Please do not believe AAMC propaganda that US med students are "threatened" by a stagnant number of residencies. The only people threatened are AAMC bureaucrats who wish to keep on a course of heedless school expansion to increase the size of their fiefdom, regardless of what it means for the careers of their graduates. Them, and of course the third world doctors who selfessly want to leave their physician saturated nations in Africa and South Asia to help us deal with our doctor shortage. Because that's the only thing increasing GME would do at this point: increase the number of FMGs.

Keep this in mind: the government and insurance/hospitals are hell bent on making the independent practice of medicine an impossibility. Employee model is the future, and there is nothing you can do about it. It's been decided in high places. In an employee model, your wage is determined completely by supply and demand. Why are EM doctors currently getting $300/hr despite being a fungible commodity? Because of supply vs demand. So just realize that by expanding GME and thus allowing in thousands of additional FMGs every year you're shifting the balance of power against your future self and in favor of your hospital CEO when it comes time to determine your compensation and autonomy.

I feel like freakonomics or someone similar did an article similar to your point, but about the alleged "science and technology shortage." It turns out that more scientists and engineers means it's easier for large corporations to pick, choose, and replace those scientists and engineers (and cheaply, to boot!). Yet the scientific and industrial wheel keeps turning, despite the shortage, and without dramatically growing salaries for those professions (which you would expect, were there an actual shortage.) My undergrad major was ChemE and at the time it was already expected that many engineers would have to switch jobs after 2-4 years when the design project was completed, because you don't need a huge team of design engineers to run the plant.

Any self-interested profession understands the need for scarcity. This is why urology is winning. They haven't expanded spots in ages.

The PPACA was the nail in the coffin of independent practice for most physicians, thanks to the ACO incentive to regionally monopolize. The really weird thing is the tension between state-level political forces and that monopolistic drive. See: Partners/BWH and not being allowed to purchase South Shore.

Well the "average" law school class is actually nowhere near that big -- actually only a couple law schools are that size. But the real difference is the length of the pipeline. Law school is only 3 years and there's no residency, so you end up with 2-4 classes of new lawyers in the time it takes to school and train one new class of doctors.

Internal transit time doesn't matter, all that matters is the flow rate. If you train 20,000 doctors a year, it doesn't matter whether the training time is 2 years or 20 years, you still end up with 20,000 new doctors every year. The only exception to that rule is when the market shrinks, because obviously in the ad extremum case where new docs are very young, it's easier for the current group to stay in their jobs, whereas if people graduate right before they die, new jobs will open up.

 

[Lord Humongus]

Your entitlement is showing..

Hahaha, my entitlement is showing, eh comrade? WTF does that even mean? I guess I could take a look at The Little Red Book and try to decipher it, but unfortunately the last time I saw my copy it was in a garbage bin outside of General Tso's Chinese Carryout. Right next to The Audacity of Hope.

 

[VA Hopeful Dr]

There are MANY anesthesiologists that lost their MD only jobs to be replaced by management companies with 3-4:1 coverage of CRNAs. Some willingly (sold out) and some unwillingly (lost contract).
Are they unemployed? No, not likely. There is work, but they would have to join the AMCs for less $$ or pack up their lives and move.
So you'd be wrong to think that CRNAs aren't taking MD jobs. They're just not doing it the way you think.
In my practice we have CRNAs and we're hiring more. 20 years ago there were none. The adult hospital next door had limited CRNA coverage but is expanding their CRNA coverage right now. One 5️ hospital system and 5️ training program is actively looking at dumping their MD only model and hiring CRNAs. I suspect they will be there in 2 years in a limited trial basis and expand quickly over the next 4-5. Those are all jobs that used to be and still could be physician jobs, but are going to CRNAs. And it's mostly driven by cost containment. We are expensive, they're not.

So the jobs are there, they just aren't as good as they used to be. Got it. I can think of very very few fields where this isn't the case, both within medicine and without.

I think part of this is due to the huge cost difference between you and CRNAs. From my understanding, CRNAs are usually somewhere in the 100s, rarely less than 6 figures but not often over 200k. I have seen many an anesthesiologist on this board alone bragging about 400k+ incomes. That is a huge cost disparity, and y'all are not generally all that much more efficient than they are. By that I mean its not like an MD-only room can do 4 total knees in 6 hours while a CRNA-room takes 10 hours to do those same 4 total knees.

Contrast this to us PCPs. We average around 200k, our midlevels are usually just shy of 100k - so half the cost difference. I have never seen a midlevel in primary care seeing more than 2-3 patients per hour. Most MDs I know are seeing more like 4-6 so we're bringing in 2X the volume just at the start. Plus, right or wrong, patients want to see a doctor when there is a problem. For us, its easy to make that happen. When y'all have a problem, the patient is unconscious so they aren't aware that you saved the CRNA's ass.

And here's the thing: hospitals are actively bringing in more and more CRNAs, including independent when its allowed, while trying to up y'all's supervision ration. Outpatient clinics are getting more midlevels, but I've yet to see a place where they are even on a 1-1 ratio with the docs.

 

[IlDestriero]

When you used to make over 500 working less and taking more vacation, 400 isn't so great.

 

[VA Hopeful Dr]

When you used to make over 500 working less and taking more vacation, 400 isn't so great.

Hence why cost containment is impacting y'all more than the res of us...

 

[jw3600]

When you used to make over 500 working less and taking more vacation, 400 isn't so great.

Heavy lies the crown. Being at the top made you a target.

 

[Psai]

So the jobs are there, they just aren't as good as they used to be. Got it. I can think of very very few fields where this isn't the case, both within medicine and without.

I think part of this is due to the huge cost difference between you and CRNAs. From my understanding, CRNAs are usually somewhere in the 100s, rarely less than 6 figures but not often over 200k. I have seen many an anesthesiologist on this board alone bragging about 400k+ incomes. That is a huge cost disparity, and y'all are not generally all that much more efficient than they are. By that I mean its not like an MD-only room can do 4 total knees in 6 hours while a CRNA-room takes 10 hours to do those same 4 total knees.

Contrast this to us PCPs. We average around 200k, our midlevels are usually just shy of 100k - so half the cost difference. I have never seen a midlevel in primary care seeing more than 2-3 patients per hour. Most MDs I know are seeing more like 4-6 so we're bringing in 2X the volume just at the start. Plus, right or wrong, patients want to see a doctor when there is a problem. For us, its easy to make that happen. When y'all have a problem, the patient is unconscious so they aren't aware that you saved the CRNA's ass.

And here's the thing: hospitals are actively bringing in more and more CRNAs, including independent when its allowed, while trying to up y'all's supervision ration. Outpatient clinics are getting more midlevels, but I've yet to see a place where they are even on a 1-1 ratio with the docs.

You're assuming that the hours worked are the same. Crnas are just shy of 200 working 40 hours a week and no call. If you do it hourly and calculate with overtime, it's basically the same and less than half the cost difference overall while getting higher quality. You get what you pay for. Don't be surprised if your knockoff from china isn't as reliable.

 

[VA Hopeful Dr]

You're assuming that the hours worked are the same. Crnas are just shy of 200 working 40 hours a week and no call. If you do it hourly and calculate with overtime, it's basically the same and less than half the cost difference overall while getting higher quality. You get what you pay for. Don't be surprised if your knockoff from china isn't as reliable.

See, that's not entirely true. Every hospital I've worked at, including med school and residency, the CRNAs took call the same as the physicians with reasonably similar hours.

Also, no where did I say I liked this trend. I don't really trust CRNAs, but patients really don't get a say in it if we like our surgeon and go where he/she operates.

 

[IlDestriero]

Heavy lies the crown. Being at the top made you a target.

If you think 500s are the top, your misinformed.

 

[jw3600]

If you think 500s are the top, your misinformed.

500k with 8 weeks vacation working sub 60 hour weeks might not be tops for physicians, but it's probably 95th percentile for ideal package. Regardless, it being "the top" does not matter, it was high enough to earn the crosshairs.

 

[Psai]

500k with 8 weeks vacation working sub 60 hour weeks might not be tops for physicians, but it's probably 95th percentile for ideal package. Regardless, it being "the top" does not matter, it was high enough to earn the crosshairs.

So this crab mentality is helping who exactly? Physician management company ceos?

 

[jw3600]

So this crab mentality is helping who exactly? Physician management company ceos?

Hmm. Typo or is crab mentality something I do not know about? I'm not sure what your question is. All I'm saying is I think a reason gas got hit hard by midlevels was because of their good days in the 2000s.

 

[IlDestriero]

Your ignorance is showing.
Anesthesiologists used mid levels to make the big money. You can't make 90th percentile income sitting solo. Now the management companies are cutting us out of the deal and employing us as well. They see us, for now, as a resource that can be exploited. And they're doing a good job of it. As I noted in another post, they're a real cancer as they, by their large size and market penetration, command better reimbursements and end up costing the system more, while funneling profits out of the community to hedge funds and stock holders elsewhere.

 

[jw3600]

Your ignorance is showing.
Anesthesiologists used mid levels to make the big money. You can't make 90th percentile income sitting solo. Now the management companies are cutting us out of the deal and employing us as well. They see us, for now, as a resource that can be exploited. And they're doing a good job of it. As I noted in another post, they're a real cancer as they, by their large size and market penetration, command better reimbursements and end up costing the system more, while funneling profits out of the community to hedge funds and stock holders elsewhere.

I don't know why you think I'm ignorant to the issue. This whole back and forth started because I said anesthesiologists making good money made them a target. And it seems we both agree that management companies using midlevels to outbid private partner groups was the main strategy used. Are you ever not condescending?

 

[Psai]

I don't know why you think I'm ignorant to the issue. This whole back and forth started because I said anesthesiologists making good money made them a target. And it seems we both agree that management companies using midlevels to outbid private partner groups was the main strategy used. Are you ever not condescending?

They are using sheer size and market share to outbid the competition. They can afford to be cheaper by paying their employees less so if a group is receiving a large subsidy, then that group is easily targeted. Or they offer golden handshakes to the aging partners who sell their independence for a large payout. These partners work as employees for a few years and then retire while their associates become employees without any benefit. It's not really about midlevels at all.

 

[Lord Humongus]

They are using sheer size and market share to outbid the competition. They can afford to be cheaper by paying their employees less so if a group is receiving a large subsidy, then that group is easily targeted. Or they offer golden handshakes to the aging partners who sell their independence for a large payout. These partners work as employees for a few years and then retire while their associates become employees without any benefit. It's not really about midlevels at all.

Midlevels actually do pay a part in this analysis. I may be sounding like a broken record but it all comes down to supply and demand. The midlevels provide a boost to the total anesthesia "supply" and in so doing make anesthesiologists more easily replaceable. The contract management groups would have much less leverage to treat their anesthesiologist employees like garbage in a world where CRNAs did not exist and each anesthesia "provider" was much more scarce and thus much less easily replaced.

When you have 10 people applying for 1 position, you can dictate your own terms and skim 20-30% off the top of whatever revenue the physician generates. When you have 10 positions and 8 candidates, you will have to give your "employees" much better terms.

 

[deleted564680]

Heavy lies the crown. Being at the top made you a target.

On a related note - Radiologist compensation decreased for the same reason. Medicare actually cited in one of its reimbursement updates that a reason they were lowering payments was due to data and forum talk of how much money radiologists were making....

 

[jw3600]

They are using sheer size and market share to outbid the competition. They can afford to be cheaper by paying their employees less so if a group is receiving a large subsidy, then that group is easily targeted. Or they offer golden handshakes to the aging partners who sell their independence for a large payout. These partners work as employees for a few years and then retire while their associates become employees without any benefit. It's not really about midlevels at all.

You don't agree that part of the reason they could afford to be cheaper was the utilization of midlevels?

 

[Stagg737]

Midlevels actually do pay a part in this analysis. I may be sounding like a broken record but it all comes down to supply and demand. The midlevels provide a boost to the total anesthesia "supply" and in so doing make anesthesiologists more easily replaceable. The contract management groups would have much less leverage to treat their anesthesiologist employees like garbage in a world where CRNAs did not exist and each anesthesia "provider" was much more scarce and thus much less easily replaced.

To a certain extent, yes. However there's a reason that pretty much every hospital still employs at least some anesthesiologists while some don't employ CRNAs. The boost in 'supply' only goes so far when the skills of one individual (CRNA) are significantly lower than the other (anesthesiologists).

 

[Psai]

Many private groups employ crnas. It's not like management companies came up with the idea.

 

[FlowRate]

I think Psai is speaking to a larger trend in certain subspecialties. Emergency medicine, where it's a little harder to replace the MD with a midlevel, also has large groups taking over a portion of the market. It's the corporatization of healthcare.

 

[Shark7500]

I say we prohibit DOs/FMGs from pursuing anything outside of primary care and prohibit anyone other than AMG MDs from pursuing fellowships or non-primary care specialties. Oh, and stop making new MD schools. The problem will sort itself out. People who can't get into MD programs will feed into DO schools or the Caribbean knowing exactly what lies ahead for them. Also, the future careers/salaries of AMG MD graduates will be safe from encroachment.

I understand it may be hard to pass something that will keep DOs out of fellowships initially from a legal standpoint, but if we bring back things like MCAT and undergrad GPA into consideration for the fellowship match, DOs will be effectively screened out due to their inferior stats.