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why is FM so hard but pay so little?
little pay in FM
- Thread starter ActionFigure
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Family physicians are in such high demand, they are always on top of the most requested physician types( along with general internal medicine). Whoop de Do!
Unfortunately, we work in a highly regulated system. As such, the most in demand doctors are paid dirt cheap. To truly understand why is to understand the intricate politically buffed profit maximizing system we have in place.
In short, procedures make money. Family doctors don't do a ton of them. Family doctors don't make a ton of money
The way health care is funded in the US is a top down approach. Hospitals are funded at a much higher rate for the same care because they can charge facility fees. They make the most profit by getting the most patients through as quickly as possible while doing as little as possible for them, but charging the most to do it.
Example: UofM advertises their GERD center (you might need an endoscopy!); Beaumont advertises their heart center (heart caths!!), and my local hospital has become a regional colonoscopy hub. These hospitals have come to see PCPs are the "referral people". To maximize profit they want to ensure you get less and less so they can get more and more. They lobby gov'ts, they buy out practices to reduce competition, they buy up PCPs so they can streamline their ACO's to get more patients through the system, get them a highly reimbursed, low overhead procedure that takes 20 minutes, and out the door with "your results will be available in a few weeks"
The standard 99213 gets paid $74.44 by medicare, colonoscopy gets much much more. They take the same time.
That is only the beginning of why FP's get paid dirt.
Unfortunately, we work in a highly regulated system. As such, the most in demand doctors are paid dirt cheap. To truly understand why is to understand the intricate politically buffed profit maximizing system we have in place.
In short, procedures make money. Family doctors don't do a ton of them. Family doctors don't make a ton of money
The way health care is funded in the US is a top down approach. Hospitals are funded at a much higher rate for the same care because they can charge facility fees. They make the most profit by getting the most patients through as quickly as possible while doing as little as possible for them, but charging the most to do it.
Example: UofM advertises their GERD center (you might need an endoscopy!); Beaumont advertises their heart center (heart caths!!), and my local hospital has become a regional colonoscopy hub. These hospitals have come to see PCPs are the "referral people". To maximize profit they want to ensure you get less and less so they can get more and more. They lobby gov'ts, they buy out practices to reduce competition, they buy up PCPs so they can streamline their ACO's to get more patients through the system, get them a highly reimbursed, low overhead procedure that takes 20 minutes, and out the door with "your results will be available in a few weeks"
The standard 99213 gets paid $74.44 by medicare, colonoscopy gets much much more. They take the same time.
That is only the beginning of why FP's get paid dirt.
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If you only work 40 hours a week, seeing 20 people a day and turfing out anything difficult or with risk then of course your pay will be low. If you work hard like the specialist then your pay will be comparable to many IM subspecialties 200-300k range. My current job prospects are set to about 220-250k working 50ish hours a week with 4 weeks of vacation a year, first year out of residency
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Managing a patient's ten problems is much less cost efficient than turfing nine of them to others in a pure FFS model. I sincerely try to take care of nearly all of the patient's problems myself and assure you that it is dramatically less efficient.
I think PCP pay is actually pretty reasonable when compared to international PCP incomes. The issue at question is the broken RVU system, which pays way too much for come codes. If the RVU system was equalized, Medicare part A was tightened more, and drugs were brown bagged, incomes from different specialties would nearly normalize.
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I don't think making over $200K/yr is "little". Not getting your point.
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boom!
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220-250k in FM?
Where does it come from? Sheer volume, upper-class population, complicated care, procedures?
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220-250k in FM?
Where does it come from? Sheer volume, upper-class population, complicated care, procedures?
Very easy to do working locums or rural medicine. Working hourly in urgent care with bonuses for procedures. It's all about the contract you negotiate.
I'm with ya on that statement. The more you can do/will do, the more you stand to make.
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Um... seriously? Occasionally a very easy colonoscopy could take the same time as the average 99213 office visit. But most of the time... no.
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This sounds pretty good:
http://www.physicianrecruiting.com/curare/jobs/detail.aspx?ID=106202&v=10&r=1&noreg=true
http://www.physicianrecruiting.com/curare/jobs/detail.aspx?ID=106202&v=10&r=1&noreg=true
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Let me translate that add for you:
"The physicians in the group average about 25 patients a day" You will see at least 25 patients a day.
"Compensation in year two will fall in the $210,000-$280,000 range." Your compensation in year 2 will be 210k.
"There is also the possibility ownership in building/property" Your actual compensation will be reduced because some of it will go towards buying ownership in a run-down, rapidly depreciating building.
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still 210k for 25 patients isn't bad. how long does it take you to up the bp med, add another 5 units of lantus and to follow up in 3 months for a repeat A1c? 6-7 hours at most.
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MichaelRack,
Thank you for your input. What about other benefits of this job--I mean....having retirement, malpractice, disability, paid time off, sick time off....qualifies for a lot......right? So how bad is this job? It sounds like if I am willing to work 50+ hours per week I will be able to live a pretty good life.
So what's the problem?
thanx (Devil's Advocate of course)
D
deleted480308
Minus the buyin, i love what michealrack described....
But he did make a good point about life, you almost always make lowest of the range and highest of tge range of work....in any job
But he did make a good point about life, you almost always make lowest of the range and highest of tge range of work....in any job
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6-7 hours for 25 patients isn't bad? I know I'm just a med student but...Christ talk about being a line worker.
D
deleted87716
Nah. 25 patients in 7 hours works out to somewhere between 3-4 patients/hour, which is pretty typical.
Most specialists see way more than that when they're in the office. Of course, they're usually only dealing with one issue.
The typical urgent care sees 40-50 in an 8-hr. day
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I've read your posts cb and you're an exception because you work where no one else works. I'm talking about in slightly more populated areas like where i'm from. FMs will make average 160...yet they still have to know how to treat everything that comes through their door. and as an FM that can be anything...it's actually really hard to be a good FM physician and takes a lot of practice than some other more well paid specialties
D
deleted87716
The essence of your question seems to imply that you believe that doctors should be compensated based on "degree of difficulty." In theory, we are (that's why we have higher-level E&M codes - e.g, 99214 and 99215 for established outpatient visits). However, the entire reimbursement deck is stacked against us by the RUC, which is dominated by procedure-based specialties. Read more about that, and you'll find the answer to your question.
What Every Physician Should Know About the RUC
http://www.aafp.org/fpm/2008/0200/p36.html
Also, don't say "FMs." We're Family Physicians (FPs). Family Medicine (FM) is the specialty.
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guys anyone can comment on the average urgent care salary in NYC and nationwide average?
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Well, of course if you plan to work in a saturated market, then the pay scale is going to be lower. True, I do work in shortage areas, it's a lot of fun, and there is always an end date to a locums assignment.
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Everyone in my graduating class in residency (except me since I'm doing a fellowship ) is making at least $200k if not more, and mind you I just graduated this past June.
My PD always said to us, "if you're not making money in FM, then you're doing it wrong".
In my city I know the local outpatient private practice docs make $250-400k, even doing strict outpatient.
The rural private guys I know, and also the people who graduated from my residency above me are making $280-$300k at a minimum.
It's definitely possible to make a lot of money doing FM, but then again it all goes back to what you're doing in your practice. Procedures? Inpatient? OB? Surgical OB?
) is making at least $200k if not more, and mind you I just graduated this past June.My PD always said to us, "if you're not making money in FM, then you're doing it wrong".
In my city I know the local outpatient private practice docs make $250-400k, even doing strict outpatient.
The rural private guys I know, and also the people who graduated from my residency above me are making $280-$300k at a minimum.
It's definitely possible to make a lot of money doing FM, but then again it all goes back to what you're doing in your practice. Procedures? Inpatient? OB? Surgical OB?
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I would agree with CB. Getting 200k$ in rural settings is no problem, even easier to do in suburbs.
If your a resident you may have skewed view of clinic. If you have a typical family medicine practice not every patient you have is going to be a train wreck. When I worked in a clinic I was shocked at how healthy people were in general compared to my residency clinic. Most of my visits consisted of well child checks/physicals, blood pressure or DM2 checks, and URIs.
I will say your 160K number isn't totally off the mark for starting Family Physicians in my area. From my experience though that is usually the garunteed salary a practice or company will give a physician while they build their practice. Once your go to production or get a production bonus that number becomes higher. 200K is not out of the question. I have actually heard of specialty groups paying their new partners similar pay for the first year as they build their practice or counting the extra money they generated as the buy in.
If you want to start pushing the 300K mark you have to be willing to do a little more work. For instance if you do locums at a small hospital one weekend a month you can bring in an additional 6K a month or 72K a year. Yeah it falls outside of your typical typical 8 to 5 job but specialists don't generate their salaries solely by keeping standard office hours either.
I do agree that the RVU system is currently broken. I work as a hospitalist now and a cardiologist friend makes as many RVUs doing 1 heart cath as I do rounding on 14 patients. Maybe a few less depending on how many are ICU patients.
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I am about to graduate and have signed a 4 year contract - essentially my first year salary is guaranteed at around $180K -- but then the recruiting hospital is paying for my office set up, 1st year office expenses, 1st year malpractice, 1st year CME to the tune of $1500, advertising plus helped me get the rural student loan payoff to the tune of $160K over 4 years.....I have to have my office open 48 weeks out of the year for 40 hours a week over the next 4 years as my part of the contract.
Now - the area is heavily medicare/medicaid and salary predictions from other physicians in the area are around $120+....that's for 5 days a week and sick call only on Saturday morning with no hospital work.....we haven't even started talking an OMM cash only clinic or urgent care supplementation....
I think the OP's question is a common one -- I've heard it from med students who went high school - college - +/- retail/research/scribe job while trying to get into med school - med school - residency.... in other words, no basis in reality of what it takes to pay for a household/family and what the value of money is --- they hear the specialties/subspecialties bragging about the money which is really just another way to validate their choices of specialty.....
Do what you love and you won't work a day in your life.....
Now - the area is heavily medicare/medicaid and salary predictions from other physicians in the area are around $120+....that's for 5 days a week and sick call only on Saturday morning with no hospital work.....we haven't even started talking an OMM cash only clinic or urgent care supplementation....
I think the OP's question is a common one -- I've heard it from med students who went high school - college - +/- retail/research/scribe job while trying to get into med school - med school - residency.... in other words, no basis in reality of what it takes to pay for a household/family and what the value of money is --- they hear the specialties/subspecialties bragging about the money which is really just another way to validate their choices of specialty.....
Do what you love and you won't work a day in your life.....
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Well I have worked before med school as an engineer and with the sacrifices/skill involved with becoming a physician ~120 for 5d + sat morning is insulting and unacceptable. Where I came from people with a bachelors and 5 yrs experience were making that.
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Dang, I couldn't pay my bills with that. That's a PA salary. No way.
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I thought this was normal? My girlfriend did NHSC and is now in her second year of being an attending FP in a practice in an underserved community. While she is scheduled for 28 patients a day (runs in the low 20s with no-shows), a large percentage of them are trainwrecks, and even new patients are only slotted for 15 minutes. She has very limited support staff, and almost everyone has poor insurance so she's constantly fighting for referrals/authorizations. So even though she is scheduled for something like 40 hours a week of clinic, she has no time to do anything but see patients, and so the paperwork backs up so badly that she is up late almost every night and typically works a full weekend day just to catch up on paperwork. She gets a whole 2 weeks a year of vacation. She makes about $120k/year.
There are two NHSC qualified health centers in the area, and we've heard that the other one pays even less. Both practices are revolving doors, i.e. when the NHSC gets paid back, the doctors immediately quit. My girlfriend seems to think this is just the way it is for FPs. I think it's crazy when she talks about signing back up with them when her NHSC contract runs out. But supposedly the other jobs in the area are the same way. There are better jobs out there?
She would be silly to sign back on. She is in an indentured servitude situation. Do your time and get out and make real money. You can make 200+K/yr in FP easy working 45 hr/week. ON the plus side for her, she doesn't have a student loan payment of 1500/mo coming out of that 120K which makes a difference in monthly bills. She needs to do some research and work where she is compensated fairly and add 100,000 to her salary.
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I thought this was normal? My girlfriend did NHSC and is now in her second year of being an attending FP in a practice in an underserved community. While she is scheduled for 28 patients a day (runs in the low 20s with no-shows), a large percentage of them are trainwrecks, and even new patients are only slotted for 15 minutes. She has very limited support staff, and almost everyone has poor insurance so she's constantly fighting for referrals/authorizations. So even though she is scheduled for something like 40 hours a week of clinic, she has no time to do anything but see patients, and so the paperwork backs up so badly that she is up late almost every night and typically works a full weekend day just to catch up on paperwork. She gets a whole 2 weeks a year of vacation. She makes about $120k/year.
There are two NHSC qualified health centers in the area, and we've heard that the other one pays even less. Both practices are revolving doors, i.e. when the NHSC gets paid back, the doctors immediately quit. My girlfriend seems to think this is just the way it is for FPs. I think it's crazy when she talks about signing back up with them when her NHSC contract runs out. But supposedly the other jobs in the area are the same way. There are better jobs out there?
I have mentors (that I trust) who tell me they are seeing starting jobs for finishing residents around 185k. This is for community FP with no OB in the Midwest. Obviously there are many other factors but at least this gives a ball park number.
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Most of my residency class was somewhere in that neighborhood.
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Yes, my first job out of residency ws 180K.
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CB,
Don't you cover all of your own benefits, retirement, and malpractice as a locums?
Don't you cover all of your own benefits, retirement, and malpractice as a locums?
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What are you getting at?
Just health insurance and retirement, not malpractice.
My first job out of residency was a "real" job where I was employed.
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Agreed. I did make that as a PA! (Working more than full-time....)
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I can confirm that this is pretty much the norm...and that's in the city. Rural can go higher
D
deleted87716
We all cover our own benefits, retirement, and malpractice. Even if you work for "the man," you're still paying for it. Trust me.
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My point is that 200K+ isn't really 200K+ if you have to pay for malpractice, benefits, and retirement. In fact, it's basically similar to 120K+ with malpractice, benefits, and retirement. That's what I am getting at. And now with the new tax structure (ie, single person 200K+) that fact becomes even more relevant.
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From my experience, that is ballpark for new grad salaries outside the big cities (Chicago / Chicago Suburbs were significantly less). If you are busy and efficient, it should be higher once you are off guarantee.
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Word. There are no free rides -- someone is covering for it... and if it's not you personally, don't expect to be loved or subsidized forever.
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I make +200$k and don't pay for malpractice (and I do OB), I also don't pay for benefits. Everyone has to pay for retirement unless you are government/military - full employer payed pensions are a thing of the past my friend. So no, making 200, is not like making 120.
Some Urgent Care jobs pay per RVU (which is often much higher than RVU in Primary Care ) so you can increase your income quite much.
Some Urgent Care jobs pay hourly rate and you may earn less per hour than at the office job.
As usual, it depends on the contract.
D
deleted87716
RVUs are for suckers. Show me the money.
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In my current job, my partner and I are actively rebelling against going to RVUs when our salary runs out after year 2 (with a 50% medicaid rate, the no shows alone would cost us a fortune). The hospital has no idea how to pay us if not based on production. Do you mind if I ask how you guys do it so I have an alternative to offer?
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There are four basic models of payment to physicians: salary, wRVUs, percent of collections, and time based. Many contracts are a hybrid of more than one model with a few minor variables added such as meeting PG targets or internal quotas. If you are going to an wRVU model, the insurance is factored out because your income is based upon production, not percent of collections. If you were going on a percent of collections, as Medicaid is 100% of Medicare currently until 2015, your income would still be fine until Medicaid rates change back to the state levels.
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Medicaid is not 100% of Medicare in my state. RVUs are fine except for the insanely high no-show rate of medicaid patients. Currently if I have a fairly full day, my no-show rate is between 30-50%. Getting paid with RVUs given that is not so good.
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"The average rate of no-shows nationally in 2000 was 5.5 percent, according to the Medical Group Management Association."
--Fam Pract Manag. 2005 Feb;12(2):65-66.
As a result, a no-show rate of 30-50% is significantly off the norm. This is a very serious problem IMHO and needs to be dissected down to understand how to improve the numbers. As a practice becomes more established, the no-show rates drop. Consider decreasing the number of new Medicaid patients or even stop taking new Medicaid patients.
--------------------------------------
It is my understanding that currently all states have Medicaid rates up to the level of Medicare rates set for each regional fee schedule.
"To prepare the primary care workforce for the influx of new Medicaid-eligible patients established through the
Patient Protection and Affordable Care Act (ACA), this provision increases payment rates for certain primary
care services to at least the level of Medicare in 2013 and 2014."
--http://www.acponline.org/advocacy/where_we_stand/assets/v1-enhanced-medicaid-reimbursement-rates.pdf
--Fam Pract Manag. 2005 Feb;12(2):65-66.
As a result, a no-show rate of 30-50% is significantly off the norm. This is a very serious problem IMHO and needs to be dissected down to understand how to improve the numbers. As a practice becomes more established, the no-show rates drop. Consider decreasing the number of new Medicaid patients or even stop taking new Medicaid patients.
--------------------------------------
It is my understanding that currently all states have Medicaid rates up to the level of Medicare rates set for each regional fee schedule.
"To prepare the primary care workforce for the influx of new Medicaid-eligible patients established through the
Patient Protection and Affordable Care Act (ACA), this provision increases payment rates for certain primary
care services to at least the level of Medicare in 2013 and 2014."
--http://www.acponline.org/advocacy/where_we_stand/assets/v1-enhanced-medicaid-reimbursement-rates.pdf
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To your first point, my practice was started by the local Catholic hospital specifically to address the problem of loads of Medicaid patients who can't find doctors. I can't stop taking them.
To the second, this only applies if your state takes the Medicaid expansion which mine does not.
