Medicare Plans to Cut Specialists' Payments

[asmallchild]

What a joke. Medicine in the US is competitive how? If it was truly competitive, then whoever wanted to could practice medicine and charge whatever rates he/she wanted that patients were willing to pay. Medicine is a highly regulated profession and has nothing to with the free market. You need to complete medical school, then you need to complete a residency program, and the slots are determined in a noncompetitive manner. We need a lot more dermatologists for all the demand. We squeeze the spots so the number of dermatologists stays low, and so that dermatologists never run out of patients and so they can demand high rates. Compensation is largely determined by the state via Medicare (noncompetitive), and then the insurance companies follow suit (therefore, also noncompetitive since all can fall back to the lowest common denominator set by the state). There's nothing free market about this at all.

You contradicted yourself in 2 consecutive sentences.

You say dermatologists control their own rates. And then you turn around and say compensation is determined by the state. Which is it?

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[MOHS_01]

What a joke. Medicine in the US is competitive how? If it was truly competitive, then whoever wanted to could practice medicine and charge whatever rates he/she wanted that patients were willing to pay. Medicine is a highly regulated profession and has nothing to with the free market. You need to complete medical school, then you need to complete a residency program, and the slots are determined in a noncompetitive manner. We need a lot more dermatologists for all the demand. We squeeze the spots so the number of dermatologists stays low, and so that dermatologists never run out of patients and so they can demand high rates. Compensation is largely determined by the state via Medicare (noncompetitive), and then the insurance companies follow suit (therefore, also noncompetitive since all can fall back to the lowest common denominator set by the state). There's nothing free market about this at all.

mercapto,

Most of the time you have decent, informed, well thought out posts.... not in this thread. You argue "there are no free markets, highly regulated..." then state that "derms keep their numbers low so that they can maintain demand and keep prices high"... then go on to acknowledge that Medicare sets the fee schedule. Inconsistent throughout. It is true that medicine is highly regulated and there exists little free market forces, but specialty selection remains somewhat based in free market principles. The "desirable" specialties (be it financial potential or lifestyle) are in higher demand from prospective applicants... and the "better" medical school products tend to gravitate toward those specialties. Further, have a little insight and acknowledge the fact that students want more derm (or plastics or any number of specialty) spots -- not because there exists a shortage beyond any other specialty -- but because more students want to have a chance to get in. Look at the studies that have been performed on national wait times and you will see that derm is mid pack and generally universally below OB in wait times....

 

[size_tens]

I'm not sure how all these policy changes will impact physician salaries if implemented but I agree with the general idea. Healthcare costs in this country are out of control and the nation as a whole can't afford to be paying out such an increasingly large chunk of gdp for healthcare. In case you folks hadn't noticed our national unemployment rate is approaching 10% and tax revenues are falling quickly. Therefore the total cost of healthcare must come down. That being said it makes sense to lower reimbursement for the procedures and fields that currently have the greatest profit margins. Why should a cardiologist get paid $1000 to read an echo in 10 min when a PCP might get paid $50 to spend the same amount of time to see a patient in clinic? If radiologists start making ONLY $300k a year instead of $500k I think they'll still be able to feed their families just fine and I have no problem what that sort of decrease.

 

[Hernandez]

Why should a cardiologist get paid $1000 to read an echo in 10 min when a PCP might get paid $50 to spend the same amount of time to see a patient in clinic?

They get paid $49.77 to read TTEs.

I love the misperceptions that everyone has about the other specialties. Everyone is the one who's under appreciated, under paid, over worked, and actually does ohh soo much for the other specialties.

Physician reimbursement is not the root of the issue. only 4% of the total health care expenditures is related to physician pay.

 

[MOHS_01]

I'm not sure how all these policy changes will impact physician salaries if implemented but I agree with the general idea. Healthcare costs in this country are out of control and the nation as a whole can't afford to be paying out such an increasingly large chunk of gdp for healthcare. In case you folks hadn't noticed our national unemployment rate is approaching 10% and tax revenues are falling quickly. Therefore the total cost of healthcare must come down. That being said it makes sense to lower reimbursement for the procedures and fields that currently have the greatest profit margins. Why should a cardiologist get paid $1000 to read an echo in 10 min when a PCP might get paid $50 to spend the same amount of time to see a patient in clinic? If radiologists start making ONLY $300k a year instead of $500k I think they'll still be able to feed their families just fine and I have no problem what that sort of decrease.

Nice social justice BS response there, bubba....

It is for ignorance like this that I am given great pause for the future of our profession. I'm so taken aback that I know not where to begin.

First off, I do wish that people would gain some sense of self awareness for their own knowledge base deficiencies... and refrain from commenting on matters on which they haven no understanding.

Next, let us examine the premise that "it makes sense to lower reimbursement for fields that have the greatest profit margins". How are these "profits" realized? In order to answer that question, one must understand how the "business" of healthcare works -- which I would lay good money is lost on many who have never operated a practice. One must understand the basic cost and revenue structure. One must understand payor mix implications. One must understand how these fee schedules are arrived at. The simple fact of the matter is that it is not a simple matter at all.

Finally, let us examine the premise that slashing physician reimbursement will achieve significant savings to the overall healthcare cost structure. IT WILL NOT. Physician spending accounts for less than one third of all healthcare dollars (varies according to payor). Cutting it fully in half (taking physician income essentially to zero) would not result in fiscal solvency for current federal programs.

Read, learn, digest, then comment...

 

[radslooking]

I second the notion that physician salaries are certainly not going to make a huge dent in our healthcare disaster. Our major problem is we order too many expensive and/or unneeded tests. And that's for lots of reasons. Partially because of litigation fears, others do it for curiosity, others because its remunerative, and still others because we have a cultural tendency towards using the newest, coolest gadgets. (I forgot one....also an inability to give up at the end of life) Either way, unnecessary garbage is our major problem.

The specialist/PCP pay issue has more to do with attracting quality PCP's than it does to reducing healthcare deficit. American doctors could and should be paid well. I'm sure other countries will dispute this (UK, Canada) etc., but it is generally accepted American doctors are the best trained and undergo the most rigorous process to become physicians.

 

[gluon999]

I'm not sure how all these policy changes will impact physician salaries if implemented but I agree with the general idea. Healthcare costs in this country are out of control and the nation as a whole can't afford to be paying out such an increasingly large chunk of gdp for healthcare. In case you folks hadn't noticed our national unemployment rate is approaching 10% and tax revenues are falling quickly. Therefore the total cost of healthcare must come down. That being said it makes sense to lower reimbursement for the procedures and fields that currently have the greatest profit margins. Why should a cardiologist get paid $1000 to read an echo in 10 min when a PCP might get paid $50 to spend the same amount of time to see a patient in clinic? If radiologists start making ONLY $300k a year instead of $500k I think they'll still be able to feed their families just fine and I have no problem what that sort of decrease.

$1000 for reading an echo? Muahahaha!! Where did you pull that number out of?

As far as healthcare costs are concerned, tort reform is one avenue where I'd like to see some change. I was really disappointed in Obama when he blatantly mentioned he is against it. Not that I should have been surprised as the biggest winners are the lawyers. Not just the trial lawyers, but also the defense lawyers too.

 

[radslooking]

$1000 for reading an echo? Muahahaha!! Where did you pull that number out of?

As far as healthcare costs are concerned, tort reform is one avenue where I'd like to see some change. I was really disappointed in Obama when he blatantly mentioned he is against it. Not that I should have been surprised as the biggest winners are the lawyers. Not just the trial lawyers, but also the defense lawyers too.

I have to say this was pretty disappointing from Obama. He's a smart guy and he knows better. He knows you have to decrease the litiginous culture in order to reduce testing. I usually don't mind his policies too badly--in that at least he has a decent reason. This one, I'm at a total loss. Its a lose-lose situation for everyone. Except lawyers.

 

[size_tens]

Wow I wish I had your incredible mental capacity to understand that providers bill for their services and that profits = revenue - expenses. That concept is so lost on me that I know not where to begin. You don't need to insult my intelligence simply because you're in obvious disagreement with me.

Physicians work hard to complete training and establish themselves in their respective fields. Everyone wants to be reimbursed fairly for their services. That's fine. However when costs need to be cut the money needs to come from somewhere. Obviously healthcare spending is quite diverse and there are many avenues to consider. However since you don't think it's ok to reimburse 15% less for an MRI what would you suggest instead? I love social pundits that are so quick to criticize everyone else and so slow to come up with any substantive solutions of their own.

Nice social justice BS response there, bubba....

It is for ignorance like this that I am given great pause for the future of our profession. I'm so taken aback that I know not where to begin.

First off, I do wish that people would gain some sense of self awareness for their own knowledge base deficiencies... and refrain from commenting on matters on which they haven no understanding.

Next, let us examine the premise that "it makes sense to lower reimbursement for fields that have the greatest profit margins". How are these "profits" realized? In order to answer that question, one must understand how the "business" of healthcare works -- which I would lay good money is lost on many who have never operated a practice. One must understand the basic cost and revenue structure. One must understand payor mix implications. One must understand how these fee schedules are arrived at. The simple fact of the matter is that it is not a simple matter at all.

Finally, let us examine the premise that slashing physician reimbursement will achieve significant savings to the overall healthcare cost structure. IT WILL NOT. Physician spending accounts for less than one third of all healthcare dollars (varies according to payor). Cutting it fully in half (taking physician income essentially to zero) would not result in fiscal solvency for current federal programs.

Read, learn, digest, then comment...

 

[Good Solutions]

The government, like every citizen spends more than it should. It is as symbolic as the obesity epidemic.

The government will squeeze savings from easy targets, and we are the easy targets. Until we opt out, we bare the mark of a lemming. We sign the contract and by default that means we accept it as fair.

Squabbling and bickering about what should be and how things ought to be reimbursed is a lost cause. No one cares.

You must make the changes in your practice that you want to see. We are still professionals who have the ability to set our own fees. So do so.

CMS is bankrupt. Start planning to make the transition now. We are on the verge of entering a cash only climate. Primary care and general surgery will be king and once again reclaim their roots from the specialists.

We bemoan the fact of rampant entitlement within our patients. Look in the mirror. We too are suckling off the entitlement sow that permits the policy of 'moving meat.' Polish up your bedside manner, communication skills, and expertise for the patient-physician relationship is going to be reborn in the ashes of government care. Just being a licensed physician won't cut it anymore and then you will see just how much our specialties are really worth...


Oh, and primary care has less years of training because medical school is geared to make you a generalist first, i.e. PCP or IM. Of course radiology or other surgical specialities are longer. It is as though you are starting fresh to learn an entire new knowledge base, rather than expanding what you already know. Comparing years of training is silly.

 

[radslooking]

The government, like every citizen spends more than it should. It is as symbolic as the obesity epidemic.

The government will squeeze savings from easy targets, and we are the easy targets. Until we opt out, we bare the mark of a lemming. We sign the contract and by default that means we accept it as fair.

Squabbling and bickering about what should be and how things ought to be reimbursed is a lost cause. No one cares.

You must make the changes in your practice that you want to see. We are still professionals who have the ability to set our own fees. So do so.

CMS is bankrupt. Start planning to make the transition now. We are on the verge of entering a cash only climate. Primary care and general surgery will be king and once again reclaim their roots from the specialists.

We bemoan the fact of rampant entitlement within our patients. Look in the mirror. We too are suckling off the entitlement sow that permits the policy of 'moving meat.' Polish up your bedside manner, communication skills, and expertise for the patient-physician relationship is going to be reborn in the ashes of government care. Just being a licensed physician won't cut it anymore and then you will see just how much our specialties are really worth...


Oh, and primary care has less years of training because medical school is geared to make you a generalist first, i.e. PCP or IM. Of course radiology or other surgical specialities are longer. It is as though you are starting fresh to learn an entire new knowledge base, rather than expanding what you already know. Comparing years of training is silly.

interesting points. I can't say we'll see that big of a regression to primary care and general surgery. People love technology, and generally, so does the U.S. govt. I think we'd rather let a few ten thousand people get really subpar care than give up our Cyberknife. But your point is well taken.

And if we all go to an all-cash practice, I dont' think very many people will do very well. You would see far less utilization of services than you do now. I mean, would you really pay 400 dollars a year for your cholesterol med? It doesn't make you feel any better. How about 20,000 for a knee? Not unless you have quite a bit of money.
The only way it could be a boon to business is if all rules were relaxed and you didn't have to worry about documenting, being sued, etc. Then you could whip through lots of patients, even if it was less remunerative.

I dunno, I'd have to think about this more.

 

[size_tens]

They get paid $49.77 to read TTEs.

I love the misperceptions that everyone has about the other specialties. Everyone is the one who's under appreciated, under paid, over worked, and actually does ohh soo much for the other specialties.

Physician reimbursement is not the root of the issue. only 4% of the total health care expenditures is related to physician pay.

According to sources I've been able to find private reimbursement for an echo ranges from about $350-700 and medicare pays a little less than $300 on average. Of course that's total reimbursement for the procedure and doesn't take into account the cost of the echo tech, equipments, facilities, etc. I personally know a cardiologist who routinely billed about $1000 per echo a few years ago. I don't know how much of that he actually collected but my numbers have some real-world basis.

 

[Hernandez]

According to sources I've been able to find private reimbursement for an echo ranges from about $350-700 and medicare pays a little less than $300 on average. Of course that's total reimbursement for the procedure and doesn't take into account the cost of the echo tech, equipments, facilities, etc. I personally know a cardiologist who routinely billed about $1000 per echo a few years ago. I don't know how much of that he actually collected but my numbers have some real-world basis.

The total bill for an Echo is about $800 at my hospital. But you're optimistic if you think that full amount goes to the cardiologist. The CPT code for TTE w/o doppler is 93307.

Medicaid lists reimbursement as $167 but someone correct me if I'm wrong, but the physician component (page 721) is only $49.77

 

[MOHS_01]

Wow I wish I had your incredible mental capacity to understand that providers bill for their services and that profits = revenue - expenses. That concept is so lost on me that I know not where to begin. You don't need to insult my intelligence simply because you're in obvious disagreement with me.

When taking a very macro view, this is true... here is the point that you may have missed: it is not a linear relationship. In any private practice, the vast majority of your costs are fixed in nature. Rent, payroll, malpractice, business insurance, etc. Baseline supplies, phone, housekeeping... the list goes on and on. Profit is a product of services provided over and above this threshold. Physician income is ultimately a mix of productivity, management of costs, payor mix, and disease mix. The RVU values assigned to any given CPT code is based upon the costs incurred on average as determined by specialty surveys and a factor for physician time -- which implies a set "value" figure assigned to physician time. For many, if not most specialties, the "overhead" averages around 50%. The mathematical relationship between fee schedule cuts and their impact upon physician income has a multiplier effect based upon the underlying cost structure for the practice.

Physicians work hard to complete training and establish themselves in their respective fields. Everyone wants to be reimbursed fairly for their services. That's fine. However when costs need to be cut the money needs to come from somewhere. Obviously healthcare spending is quite diverse and there are many avenues to consider. However since you don't think it's ok to reimburse 15% less for an MRI what would you suggest instead? I love social pundits that are so quick to criticize everyone else and so slow to come up with any substantive solutions of their own.

Well, since you asked...

Here's the problem with the proposed "reform": it does nothing to address the fundamental problems with our current system. Cutting reimbursement does nothing to curb utilization frequencies; in fact, it perversely increases the incentive to provide more and higher intensity services. Speaking specifically to the MRI/PET "advanced" imaging issue: a cut in the technical component is possibly appropriate as the values were derived in a day where utilization frequencies were much lower. Economies do come with volume; however, the problem comes in when dealing with low volume rural hospitals and providers who do not enjoy the benefit of having a population density adequate to drive volume. Perversely, these providers already face diminished reimbursements due to payor mix and the "geographic price index adjustment". Any cut in reimbursement rates for one of the few profit centers for community hospitals would prove counter evolutionary for rural healthcare provision.

More broadly speaking -- we, in conjunction with the payors, should determine what procedures/medications/interventions/etc work (and are cost effective) for what conditions. They should then stratify these procedures based upon efficacy and relative costs much in the same way medications are tiered, and they should then pay appropriately for said services based upon the costs of their provision. Neither national GDP nor "budget neutrality" adjustments should enter into the equation. If costs continue to escalate, they can either raise premiums or start denying more services. What we cannot do, however, is expect to pay for everything for all... and lay claim to the intellectual property and labors of the healthcare provision workforce. This is not the USSR (at least not yet).

 

[Good Solutions]

interesting points. I can't say we'll see that big of a regression to primary care and general surgery. People love technology, and generally, so does the U.S. govt. I think we'd rather let a few ten thousand people get really subpar care than give up our Cyberknife. But your point is well taken.

And if we all go to an all-cash practice, I dont' think very many people will do very well. You would see far less utilization of services than you do now. I mean, would you really pay 400 dollars a year for your cholesterol med? It doesn't make you feel any better. How about 20,000 for a knee? Not unless you have quite a bit of money.
The only way it could be a boon to business is if all rules were relaxed and you didn't have to worry about documenting, being sued, etc. Then you could whip through lots of patients, even if it was less remunerative.

I dunno, I'd have to think about this more.

Lovastatin and pravastatin are $4 generics. Yes, you are hitting the nail on the head. Efficiency and cost reduction. OB/GYNs in florida no longer carry liability insurance and yet they still practice. Why? They communicate this up front with their patients. The same can work for most every other specialty. Don't see any patient who is not keenly aware of this. If you have unassigned call obligations with the hospital, work it into the deal that the hospital will cover your insurance or you won't practice there. Put the oness on the hospitals to lobby for decreased liability premiums. If you no longer submit claims to insurance companies (decreased overhead, less staff, less paperwork), and have shunned the burden of lawyers (knowing one suit could take you out of practice) then there is no need to document the garbage done for CYA or billing purposes. However, the point of this is not to whip through patients but the exact opposite.

Whipping through patients leads to poor communication which begets lawsuits. The main reason for suits is the USS Poor Outcomes plowing full speed into the north atlantic iceberg of unmet expectations. If we had done our jobs in the first place and communicated these side effects/complications earnestly with people this would not happen nearly as often as it does. Another main reason for suits is not reporting labs to patients (i.e. lost, less staff means less hands to lose them in). This can be rectified with systems improvement.

Yes, utilization of services would decrease. But this isn't neccesarily a bad thing.

 

[MOHS_01]

The government, like every citizen spends more than it should. It is as symbolic as the obesity epidemic.

The government will squeeze savings from easy targets, and we are the easy targets. Until we opt out, we bare the mark of a lemming. We sign the contract and by default that means we accept it as fair.

Squabbling and bickering about what should be and how things ought to be reimbursed is a lost cause. No one cares.

QFT

You must make the changes in your practice that you want to see. We are still professionals who have the ability to set our own fees. So do so.

Not very pragmatic... for low cost transactions, very true. For surgeries, not so much. Simply not realistic given the disposable income of the populace and the cost structure of medical practice.

CMS is bankrupt.

Also QFT.

Start planning to make the transition now. We are on the verge of entering a cash only climate.

No, we are on the verge of entering into either a completely government dominated industry or a two tier system. If it is the former, we're all f'ed... if it's the latter, many will be f'ed because they have the personality of a wet rag.

Primary care and general surgery will be king and once again reclaim their roots from the specialists.

Primary care will be well positioned in a cash model... but not as well positioned as other specialties... GS? Really? Please do explain that one...

We bemoan the fact of rampant entitlement within our patients. Look in the mirror. We too are suckling off the entitlement sow that permits the policy of 'moving meat.' Polish up your bedside manner, communication skills, and expertise for the patient-physician relationship is going to be reborn in the ashes of government care. Just being a licensed physician won't cut it anymore and then you will see just how much our specialties are really worth...


Oh, and primary care has less years of training because medical school is geared to make you a generalist first, i.e. PCP or IM. Of course radiology or other surgical specialities are longer. It is as though you are starting fresh to learn an entire new knowledge base, rather than expanding what you already know. Comparing years of training is silly.

Primary care is an interesting construct, really. In practice (for many) it is often like never leaving residency -- you always have someone waiting in the wing to bounce things off of or to send to. With all due respect -- if you truly believe that all specialties are created equal I have a bridge to sell you.

 

[Good Solutions]

No, we are on the verge of entering into either a completely government dominated industry or a two tier system. If it is the former, we're all f'ed... if it's the latter, many will be f'ed because they have the personality of a wet rag.

Here is an excellent link that helps paint the picture of how and why there will be no universal system in our country. We are broke. We can't keep leveraging our nation for the sake of entitlements, we can try, don't get me wrong, but it will not last. No matter what a two tier system is coming regardless, to some degree it is already here. http://www.dallasfed.org/news/speeches/fisher/2008/fs080528.cfm

Primary care will be well positioned in a cash model... but not as well positioned as other specialties... GS? Really? Please do explain that one...

Immediately until things settle down there will be ways to ease the transition. One idea I have read that was posited is to utilize indian reservations as sanctuaries in the bureaucracy storm. As things start to contract and the new medical economy emerges GS will start to market themselves as what they once were GS. They will be able to undercut specialists in price. Do you wan to go to the ENT for your thyroidectomy $$$ or do you wan to be seen by the GS for $$? With the contraction in utilization of services, there will be less demand for specialists and many will retreat to academic centers or major metropolisis where they belong. This utilization contraction will only leave enough demand for the versatility that is a GS. Patients will likely be given a supply list by their doctors to go to medical supply stores to buy the drapes, suctions etc. placing the power of consumers in the purchase of medical supplies. There will be less selections in sutures. Less selection in mesh. There will be less auxillary staff. Less scrub nurses, less patient transport personel. Surgeons will probably employ their own nurses rather than use the hospitals.

Primary care is an interesting construct, really. In practice (for many) it is often like never leaving residency -- you always have someone waiting in the wing to bounce things off of or to send to. With all due respect -- if you truly believe that all specialties are created equal I have a bridge to sell you.

I do not believe that all specialities are created equal. Far from it. I do believe that the impending free market will eliminate the 'should' in the equation of pay, which is often held as the metric of specialty worth. Primary care now is the product of insurance and government meddling. GPs back in the day had no difficulty performing tonsilectomies, c-sections, appies, and a whole skew of other things. There is no reason to expect that PCPs will stay in their cage once the shackles of the government and insurance are gone. Most referals are for bread and butter things that the PCP already knows. They are simply shifting the liability either intentionally or by default since it is the new 'standard of care'. Othertimes it is because the insurance will not reimburse because the are a PCP.

 

[radslooking]

Lovastatin and pravastatin are $4 generics. Yes, you are hitting the nail on the head. Efficiency and cost reduction. OB/GYNs in florida no longer carry liability insurance and yet they still practice. Why? They communicate this up front with their patients. The same can work for most every other specialty. Don't see any patient who is not keenly aware of this. If you have unassigned call obligations with the hospital, work it into the deal that the hospital will cover your insurance or you won't practice there. Put the oness on the hospitals to lobby for decreased liability premiums. If you no longer submit claims to insurance companies (decreased overhead, less staff, less paperwork), and have shunned the burden of lawyers (knowing one suit could take you out of practice) then there is no need to document the garbage done for CYA or billing purposes. However, the point of this is not to whip through patients but the exact opposite.

Whipping through patients leads to poor communication which begets lawsuits. The main reason for suits is the USS Poor Outcomes plowing full speed into the north atlantic iceberg of unmet expectations. If we had done our jobs in the first place and communicated these side effects/complications earnestly with people this would not happen nearly as often as it does. Another main reason for suits is not reporting labs to patients (i.e. lost, less staff means less hands to lose them in). This can be rectified with systems improvement.

Yes, utilization of services would decrease. But this isn't neccesarily a bad thing.

No, decreased utilization is not bad, I am fully in support of it in a lot of ways. And yes, it would encourage buying cheaper generics, etc. But I fail to see how seeing less patients and (i would assume) getting paid less because patients would be paying out of pocket would be very good for physician pay. Not that that's the end all be all, but as MOHS said, people don't plan for medical emergencies, or medical nonemergencies for that matter. Its not like they are setting aside a lot of money for what medicine actually costs.

And about the OB-Gyn's....are you saying the patients can't sue these providers, regardless of what they sign? Is that truly legally binding where they can't sue? Seems odd to me.

I'm all for communication. But you would need to see some pretty awesome and sophisticated and/or well run systems that would improve that, and I haven't seen them yet.

As for malpractice...I would favor spreading out the risk some so that the entire hospital would be named in suits, not necessarily individual providers. As it is now you are left hanging in the wind and they can go directly after you as a provider. I am no expert in the arena, but I wonder if there is a way to spread the risk (ala VA systems) where providers don't feel so inclined to CYA because of the individual risk to your career.

 

[size_tens]

When taking a very macro view, this is true... here is the point that you may have missed: it is not a linear relationship. In any private practice, the vast majority of your costs are fixed in nature. Rent, payroll, malpractice, business insurance, etc. Baseline supplies, phone, housekeeping... the list goes on and on. Profit is a product of services provided over and above this threshold. Physician income is ultimately a mix of productivity, management of costs, payor mix, and disease mix. The RVU values assigned to any given CPT code is based upon the costs incurred on average as determined by specialty surveys and a factor for physician time -- which implies a set "value" figure assigned to physician time. For many, if not most specialties, the "overhead" averages around 50%. The mathematical relationship between fee schedule cuts and their impact upon physician income has a multiplier effect based upon the underlying cost structure for the practice.



Well, since you asked...

Here's the problem with the proposed "reform": it does nothing to address the fundamental problems with our current system. Cutting reimbursement does nothing to curb utilization frequencies; in fact, it perversely increases the incentive to provide more and higher intensity services. Speaking specifically to the MRI/PET "advanced" imaging issue: a cut in the technical component is possibly appropriate as the values were derived in a day where utilization frequencies were much lower. Economies do come with volume; however, the problem comes in when dealing with low volume rural hospitals and providers who do not enjoy the benefit of having a population density adequate to drive volume. Perversely, these providers already face diminished reimbursements due to payor mix and the "geographic price index adjustment". Any cut in reimbursement rates for one of the few profit centers for community hospitals would prove counter evolutionary for rural healthcare provision.

More broadly speaking -- we, in conjunction with the payors, should determine what procedures/medications/interventions/etc work (and are cost effective) for what conditions. They should then stratify these procedures based upon efficacy and relative costs much in the same way medications are tiered, and they should then pay appropriately for said services based upon the costs of their provision. Neither national GDP nor "budget neutrality" adjustments should enter into the equation. If costs continue to escalate, they can either raise premiums or start denying more services. What we cannot do, however, is expect to pay for everything for all... and lay claim to the intellectual property and labors of the healthcare provision workforce. This is not the USSR (at least not yet).

That was quite a complex way of saying that if you decrease revenue while maintaining the same expenses your profits will decrease proportionally more than the decrease in revenue. But yes very true. As far as your proposed plan it sounds like you would like to ration out the most cost-effective care possible to those who can afford it. Fair enough. Simply raising premiums to pay for increasingly expensive care is what we've been doing for decades and our nation's capacity to do so has just about run dry. Paying for health care isn't as complicated as people make it out to be: the only two ways to lower cost are to lower the quantity of healthcare consumption or decrease payment for said consumption (or both). If we could somehow lower the cost of health care delivery in proportion to proposed decreases in payments as to maintain adequate profit levels that would be ideal. I hope somebody in Washington figures out a way to get this done.

 

[radslooking]

and I agree with MOHS that we are likely evolving (or devolving, based on your point of view) of either a totally gov't run system, or a two tier system (more likely, given our country's history) where you would get basic services provided, and if you want special treatment, you can get private insurance or some other insurance for extra money.

I don't see cash only as being a great option. Our people simply don't save enough, nor do they make good enough decisions to support that.

 

[MOHS_01]

.....

You sound like the Alex Jones of medicine. PCP's and GS's simply do not have the skill set required to perform many of the services you desire. They are not trained in it, and we have a much higher bar today than the pre-1920 medical structure you envision.

Gov't is broke -- private insurers are not facing the same shortfalls. Eventually premiums, co-pays, and payor driven rationing would find their balance. This cannot happen, however, with the highly regulated gov't driven cluster**** that we have today.

 

[tiredmd]

Interesting thread. Don't know if this applies to the US healthcare situation but I think it will in the more distant future (I'm a pessimist...)

Just got back from Africa in a moderately stable, moderately wealthy country. Everything was strictly fee for service. No money, no service. The mission hospital would treat people if they promised to pay, but the government hospital wouldn't. Even emergencies. No money, at least a sizeable downpayment, no service.

I was only there for a month, but it was interesting. You have to explain to the patient exactly what everything is for to convince them to get the medication/test/etc. If you order an xray, or a lab, or a medication, or even dressing changes, they (or family member) take(s) the Rx to radiology/the lab/the pharmacy/medical supply and brings it back to the hospital. Very interesting having to make decisions about what is REALLY needed. Do you choose the abx or the DVT proph? Do they really need a CXR every day? And on and on.

Operating was very interesting. Obviously keeping costs low was a priority. No scrub tech. You pick the instruments you need off a sterile field and put them on the Mayo stand. The pt gets charged for all the instruments you use, so you minimize what you pick. Every surgery gets 2 lap pads unless you absolutely have to have more. No bovie unless you have to have it. (Amazing what holding pressure and stick ties can do).

Anyway, it probably isn't in the near future for the US, but when the Chinese decide our country is so broke they don't want to loan us any more money to keep throwing away on nonsustainable geriatric projects, cash-only practices will somehow lead to a drastic decrease in the price of basic healthcare, including surgery. Comments?

 

[MOHS_01]

That was quite a complex way of saying that if you decrease revenue while maintaining the same expenses your profits will decrease proportionally more than the decrease in revenue. But yes very true. As far as your proposed plan it sounds like you would like to ration out the most cost-effective care possible to those who can afford it. Fair enough. Simply raising premiums to pay for increasingly expensive care is what we've been doing for decades and our nation's capacity to do so has just about run dry. Paying for health care isn't as complicated as people make it out to be: the only two ways to lower cost are to lower the quantity of healthcare consumption or decrease payment for said consumption (or both). If we could somehow lower the cost of health care delivery in proportion to proposed decreases in payments as to maintain adequate profit levels that would be ideal. I hope somebody in Washington figures out a way to get this done.

Bolded portion -- not 100% true. This same complaint has been used for most of the 20th century. Let us lay the blame where it belongs -- at the feet of those who created Medicare and the wage controls of the 1930's. This removed any semblance of market forces from a huge swath of healthcare.

There are two sustainable and effective ways to control healthcare costs: ration services or have a healthier populace. Since the populace is unwilling to do the latter, someone will have to do the former. There simply is not enough savings in reimbursement cramdown to make it an effective cost control mechanism.

 

[Good Solutions]

I don't see cash only as being a great option. Our people simply don't save enough, nor do they make good enough decisions to support that.

Nor does our government as I pointed out earlier. No one in our country does. But change is coming. It isn't going to be easy, but the end result will be following the rule no one gets away with. You can't spend money you don't have. People will save once they realize darwinian principles are reemerging. If people can muster up the change to support a pack a day habit while on government support, they'll find a way.

Anyway, it probably isn't in the near future for the US, but when the Chinese decide our country is so broke they don't want to loan us any more money to keep throwing away on nonsustainable geriatric projects, cash-only practices will somehow lead to a drastic decrease in the price of basic healthcare, including surgery. Comments?

You just explained what I attempted to in a much shorter eloquent fashion. And yes, let's not forget the chinese. Their history and culture shows, they will come for their money. We will pay them back one way or another and healthcare will be considered what it always has been - a luxory and not a right.

There are two sustainable and effective ways to control healthcare costs: ration services or have a healthier populace. Since the populace is unwilling to do the latter, someone will have to do the former. There simply is not enough savings in reimbursement cramdown to make it an effective cost control mechanism.

Our country will only be able to carry on with the illusion for a short time that they can afford universal care. Afterwards, rationing will no longer be in the hands of the government, because they simply won't be paying for anything anymore. Cost control will be at the level of the consumer.

Sociologically, these doom gloom predictions will ultimately be good for the country as it will place an emphasis on family and the support that can be garnered from the original family unit (the WHOLE family).

 

[Taurus]

Instead of debating PC vs specialty medicine, one area we should focus on is the non-physician groups. Why are CRNA's, who spend an extra whopping 2 years after college and averaging more than $140k each, getting a 2% bump? We should be decreasing their payments to more accurately reflect their training level.

 

[radslooking]

Bolded portion -- not 100% true. This same complaint has been used for most of the 20th century. Let us lay the blame where it belongs -- at the feet of those who created Medicare and the wage controls of the 1930's. This removed any semblance of market forces from a huge swath of healthcare.

There are two sustainable and effective ways to control healthcare costs: ration services or have a healthier populace. Since the populace is unwilling to do the latter, someone will have to do the former. There simply is not enough savings in reimbursement cramdown to make it an effective cost control mechanism.

by wage controls do you mean unions and the union contracts/entitlements that come with it?

i.e. the forces that are choking major institutions today (GM, etc?)

 

[radslooking]

Instead of debating PC vs specialty medicine, one area we should focus on is the non-physician groups. Why are CRNA's, who spend an extra whopping 2 years after college and averaging more than $140k each, getting a 2% bump? We should be decreasing their payments to more accurately reflect their training level.

not that i disagree, but you are going to have to somehow justify paying them less for procedures that are usually reimbursed at a higher fee for other providers. i.e. same work, less pay

 

[radslooking]

On a side note, I'm not sure that universal healthcare will cost as much as people think it will. We are already subsidizing uninsureds/poorly insured through ER visits, etc. And many uninsureds are younger, "relatively" (i use that probably too loosely) healthy people. Older folks automatically get Medicare.

The unreimbursed costs of caring for them are eaten by the hospitals, which pass along the costs to mostly private insurance, which increases premiums. My point is I don't think providing coverage to uninsured people will dramatically raise costs as much as people think it will.

Correct me if I'm wrong.

One more thing. Do they count people on Medicaid as "insured"?

On another side note....keeping people healthy is only one part of the equation. You have to decide what to do at the end of life too, everyone has to die, and we can make it expensive, drawn out, and painful, or we can be a bit more holistic about it. Also, smokers actually cost less than the avg person b/c they die sooner, don't incur huge costs, and don't collect SS. Healthier people live longer, will acquire chronic conditions, nursing home placement, and will collect social security. I know that sounds harsh, but true.

Obesity is a killer because they need knees, hips, and very expensive diabetic care for sometimes decades.

 

[MOHS_01]

by wage controls do you mean unions and the union contracts/entitlements that come with it?

i.e. the forces that are choking major institutions today (GM, etc?)

Well, that is a problem too, but FDR enacted wage controls that stimulated the advent of health insurance as a way to compete for labor -- effectively disconnecting the consumer from the cost.

 

[travelbug73]

I don't understand why everybody is bashing the current govt. The proposed cuts by CMS have been predicted since 2004 (Republican everything) and yes cardiology and radiology were discussed even then. Please take a look at this:

http://www.neurosurgeon.org/advocacy/wc/archives/medicare/IssueOverview-FutureofMDreimbursement.pdf

In 2006 too it was predicted that medicare reimbursements to physicians will be slashed by nearly 40% over the next 8 years.

Why hasn't the physician community been proactive? Why is it that we are crying after the milk has spilled and acting like all of this came from the left field?

Just curious!

 

[Winged Scapula]

I don't understand why everybody is bashing the current govt. The proposed cuts by CMS have been predicted since 2004 (Republican everything) and yes cardiology and radiology were discussed even then. Please take a look at this:

http://www.neurosurgeon.org/advocacy/wc/archives/medicare/IssueOverview-FutureofMDreimbursement.pdf

In 2006 too it was predicted that medicare reimbursements to physicians will be slashed by nearly 40% over the next 8 years.

Why hasn't the physician community been proactive? Why is it that we are crying after the milk has spilled and acting like all of this came from the left field?

Just curious!

I for one have been proactive, calling and writing my legislators for years about the proposed cuts. I'm sure other attendings here have as well.

As for the students and residents replying in this thread, 2004 and 2006 were a long time ago in terms of presenting information they were concerned about *at the time*. You can't really blame people who were med students and pre-meds 5 years ago for not understanding the implications.

But its also true that many physicians are not proactive, prefer to leave the work to others, thinking things will get "taken care of". That's the reason general surgery reimbursements are so low and that we got rooked into the 90 day global period BS.

 

[radslooking]

Well, that is a problem too, but FDR enacted wage controls that stimulated the advent of health insurance as a way to compete for labor -- effectively disconnecting the consumer from the cost.

ah yes, a good point. I knew this was true but its good to hear it again. I never did understand why jobs and healthcare were linked, it never made sense to me. This detail makes it all makes sense. Its a weird twist of history that unfortunately has persisted to the current day. Employers have no business administering healthcare. Obama knows the country isn't ready for that much change though.

 

[DHT]

Im not sure why no one has brought this up yet:
I for one am thrilled that someone is finally doing something about those money grubbing social worker salaries. They have been dragging the system down for way too long!

It is nice to see CRNAs finally get some love, I was starting to get worried that they wouldn't be able to feed their families anymore!

Our healthcare is in good hands!

 

[radslooking]

Im not sure why no one has brought this up yet:
I for one am thrilled that someone is finally doing something about those money grubbing social worker salaries. They have been dragging the system down for way too long!

It is nice to see CRNAs finally get some love, I was starting to get worried that they wouldn't be able to feed their families anymore!

Our healthcare is in good hands!

can't argue with either. good lord, decreasing a SW salary who's already underpaid.

 

[radslooking]

wagy, if you're still around....nytimes put radonc's salaries at about 500K average last year.
And if you think you are worth 3-4x what a PCP gets, I think you are either extremely egotistical, or just misinformed.

 

[surag]

reducing the pay disparity is going to happen one way or another. if you have another way of solving the problem let us know.

there's no objective reason why a specialist should get paid 3x-5x what a PCP is. There just isn't.

I know that I'm not a medical student...or even a physician. But don't you think that the number of years spent more time than a family care physician in residency as well as the long hours justifies as an objective reason for higher pay? How about the increased stressful life of a neurosurgeon/ortho/plastics/gen surgeon?

In terms of only income:
4+extra years for residency=that many years less of income as practicing physician
extra residency also means no extra pay during that time. so assuming that a family physician makes 100k+after 2,3 years, and a neurosurg resident makes on avg 50K throughout all 7 years, he's minus 700k easily during that time.

How about the stress? do family physicians face the same emotional stress as a neurosurgeon for potentially being responsible for death, injury, etc. on a higher level and more consistent basis?

How about the number of hours worked? how many hours do family physicians work? I'm not sure of the hours but isn't it around 40-60 hours? Whereas a neurosurgeon/ortho works 50-80? maybe more? I dont know exact numbers.

To me, in my opinion, with what limited knowledge I have, there seems to be a very strong objective reason for higher pay.

how about just looking it in terms of merit. Don't neurosurgeons/plastics work harder in medical school to acheive a higher step score, work harder to do research etc. shouldn't pay be merit based in this sense?

I completely agree that family physicians, too, is incredibly hard. Getting into medical school itself is difficult. But shouldnt the fact that it requires more effort to get into say neurosurg than family practice thus be more rewarding? This is a very dicey subject and I could very well be wrong, but I'm just throwing out my observations, and to a certain extent, these could very well be observations by the layman with limited understanding of the medical world...

Finally,
Would neurosurgeons be willing to do the current job with a 150000 pay?

 

[surag]

Here is something else we should all consider when it comes to reimbursment rates, income, and general physician well being.

I think there are several issues that handicapp physicians in terms of being able to make a good living. I am going to try and elaborate and point these facts out. I am not a physician, but I have spent a consierable amount of my life studying business, success in business, finance etc. and I wish to share my two cents.

Because of my limited knowledge of medicine I wont discuss reimbursement rates, the amount a physician deserves etc. I just dont have the information, and more importantly the intuitive sense for what is deserved and what isnt. However, here goes my thinking:


1. Physicians have a weak business sense.
I don't mean that doctors are mathematicall/financially stupid. I mean that they dont have the time nor do they spend much effort into determining the best way to make this field succeed economically. Many can argue that indeed physicians understand how reimbursment works, what they should be receiving etc.

I am not reflecting on this. I am comparing the physicians(plural) ability as an entire group to generate enough pressure and influence to ensure that the standard of living is proportionate to their work. If you look at the business industry it is regulated to a certain extent. Not nearly anywhere even as close as medicine but nevertheless with this regulation people in business are capable of making millions under the watchful eyes of the SEC/etc.

why can't physicians do the same? Why can't the ensure that their income is protected? I think it is because physicians do not go into this with the same interest as a business person. Many if not all go into medicine for a variety of reasons, prestige, power, good income etc. Never do physicians(nor should they) go into medicine with the SOLE intent of becoming millionaires or extermely wealthy. In addition, the environment is not designed nor receptive to make money.

Furthermore, many procedures, tests, etc. don't even have an established impact qualifier, nor an effective basis for why the tests/procedures are done, could cheaper ones be done etc. This information is not established, allowing politicians to attack physicians because of the outdated public view that physicians are too wealthy and dont deserve as much. In otherwords, physicians don't have the ammunition to protect themselves. I think a great fear is that indeed if the government were to set up such programs to investigate treatment effectivness income may go down rapidly and affect the pay of physicians. While this may indeed be a real problem, how about proactive physician involvement to prevent such populist idealism affecting treatment quality? Biases from the government, especially liberal government would inherently creep into their reports/investigation to gain support from their citizens.

2. Why should physicians pay for malpractice?

In fact, when most doctors are indeed doing such a good service, taking a risk, etc. why should doctors be held financially responsible for their actions? When a physician makes an honest mistake(which is what happens in most cases) and is taken to court and loses money, he has now lost, not only income(or an increased malpractice premium) he has lost pay for time lost from work, increased stress-potential loss in quality of work, etc.

Why not have the government payout qualified and quantified reimbursement rates to families who have lost loved ones/ are injured etc. when it has been shown that the physician has not done it through gross malignancy? Not only would physicians not pay malpractice premiums they would be protected in general. The government can also set a standard payout for malpractice to help families. Families who have suffered should not be given the opportunity to become rich off a death. Proper compensation should be the only option(and yes in the vast majority it most likely is but in the few cases it isn't it can be troublesome and scary)

Indeed, in the UK the court system is designed so that only knowledgeable indivduals can decide the cases in medical malpractice. I'm not sure how the insurance/etc. works but we could potentially adopt something of this sort.

3. Its the economy STUPID.

Many of us are incredibly upset over the decreasing physician income overtime and how it will continue. And rightly so. But perhaps we should look at another factor involved. The cost of living has been rising considerably in the past 20 years mimicking the increasing difficulty for patients to pay for medicine/care as well as the lower wealth of physicians. The increase in credit debt, easy credit, etc. has allowed people to buy things they can't afford. Thus, a family making 60k a year can potentially live the life of a family making 150k a year making everything from cars, to houses(especially homes) and items normally expensive more accesible to everyone. This does two things over time, 1. it dilutes the physicians expectaiton of wealth(we expect more compared to our neighbors living beyond their means) and 2. it makes the standard of living for physicians harder.

I think while decreasing physician income has been a real big issue and plays a MAJOR major factor, I also think that physicians are overlooking the fact that everyone seems to have their fingers in the moneypot when they really shouldnt have such an opportunity. This sort of capitalism has not only been destructive to those who have had foreclosures but to upper class physicians who have to now pay more for less. Indeed, this is one of the reasons why income has not increased nationally in the past 10-20 years substantially but the cost of living has.

When my parents began the search for a house 20 years ago the average home price was 100k...now its over 200k. in 20 years the COST OF A HOME HAS RISEN 100%.

 

[surag]

Ok, so now onto physician salary reimbursements...

to all those who think that we as doctors should be happy with what we make and shouldnt be complaining. I want to make some comments on that.

All of you have gone to undergraduate school and then medical school. Undergrad costs upwards of 50k now. in ten twenty years when your children go to school it could easly cost 70k. now assume you have two or 3 children. thats nearly 300k per child for 4 years. making it almost a million dollars for college education.

A physician working 60-80 hours a week deserves more than 150k. In fact, a physician easily deserves 200k+ based on several factors such as stress/work/education/etc.

Now imagine paying for a house under current economic situation. Suppose the cost of a home only goes down so much and in 10 years to buy a house it costs 240k. Thats the average person's home.

Now suppose you want to live a better lifestyle because you deserve it. You're home costs upwards of 500k. You now have a mortgage that is more than a 1000/mnth payment making 12k. after paying taxes someone over 250k tax bracket has to pay 35% taxes. so your 300k salary is now about 200k salary.

Now take away the mortage payment, interests, car payments, college savings for 3 kids, and your income is now less than 100k. You can spend some of that for vacations and whatever you want but now you have to save your money for retirement.

Oh yea, I didn't even take into consideration malpractice premiums...thank you, please come again.

So please tell me, how exactly is it that a doctor who works twice as hard as a engineer, has more college education, more loans, higher cost of living, higher chance of being sued deserves 300k salary compared to the guy making 120-150k?

Furthermore, capitalism is PRECISELY about paying higher incomes to those in the stratosphere. Claiming that because we have limited seats is what makes physicans in the US wealthy is meaningless.

Also claiming that physicians in other countries are doing just fine with lower incomes is meaningless. In those countries were doctors are living comfortably with lower pay you are forgetting to account for the fact that the effects are present to EVERYONE. So if you're comfortable with doctors being paid less, then every single person in this country should be comfortable with being PAID less. In fact, thats exactly why the US has the most expensive property on average compared to other countries. And small states like luxemburg and Switzerland dont count. neither do japan and UK when they're tiny miserable islands.

Please feel free to rebut what I have to say...I will come back and argue my points more clearly. But this is just to get people thinking.

 

[radslooking]

I know that I'm not a medical student...or even a physician. But don't you think that the number of years spent more time than a family care physician in residency as well as the long hours justifies as an objective reason for higher pay? How about the increased stressful life of a neurosurgeon/ortho/plastics/gen surgeon?

In terms of only income:
4+extra years for residency=that many years less of income as practicing physician
extra residency also means no extra pay during that time. so assuming that a family physician makes 100k+after 2,3 years, and a neurosurg resident makes on avg 50K throughout all 7 years, he's minus 700k easily during that time.

How about the stress? do family physicians face the same emotional stress as a neurosurgeon for potentially being responsible for death, injury, etc. on a higher level and more consistent basis?

How about the number of hours worked? how many hours do family physicians work? I'm not sure of the hours but isn't it around 40-60 hours? Whereas a neurosurgeon/ortho works 50-80? maybe more? I dont know exact numbers.

To me, in my opinion, with what limited knowledge I have, there seems to be a very strong objective reason for higher pay.

how about just looking it in terms of merit. Don't neurosurgeons/plastics work harder in medical school to acheive a higher step score, work harder to do research etc. shouldn't pay be merit based in this sense?

I completely agree that family physicians, too, is incredibly hard. Getting into medical school itself is difficult. But shouldnt the fact that it requires more effort to get into say neurosurg than family practice thus be more rewarding? This is a very dicey subject and I could very well be wrong, but I'm just throwing out my observations, and to a certain extent, these could very well be observations by the layman with limited understanding of the medical world...

Finally,
Would neurosurgeons be willing to do the current job with a 150000 pay?

I'm not saying payment should be the same. It doesnt make sense why a GI doc should be 400+, and cards 400-800+, and a PCP 150. that's silly.
go ahead and pay people more. Put it should be at least somewhat commensurate with hours/stress/length of training etc. These numbers are way off.

 

[radslooking]

extra residency also means no extra pay during that time. so assuming that a family physician makes 100k+after 2,3 years, and a neurosurg resident makes on avg 50K throughout all 7 years, he's minus 700k easily during that time.
Finally,
Would neurosurgeons be willing to do the current job with a 150000 pay?

in regards to this point, it would make more sense to pay people better in residencies/fellowships, even if it means slightly less later on. it sucks being into your mid 30's and barely earning a salary. Especially with residencies/fellowships/research years going farther and farther out, it seems this model is horribly outdated.

 

[surag]

I'm not saying payment should be the same. It doesnt make sense why a GI doc should be 400+, and cards 400-800+, and a PCP 150. that's silly.
go ahead and pay people more. Put it should be at least somewhat commensurate with hours/stress/length of training etc. These numbers are way off.

just read my last post! I say the same thing and come to a different conclusion. Does a FP get sued as often as a gen surg or interventional card? Does he have the same stress levels as someone operating?

How about meritocracy? Shouldn't someone who has the best grades/research/ who is going into the most difficult specialties to match be paid more? That is the pure essence of our country and capitalism. And if you're going to argue that medicine in the USA isn't capitalist i've already mentioned y i think it is above.

what do you think is fair? There are far more family practitioners than any specialists. DO you think its fair that all of the FPs get paid as much?

How many hours do FPs work on average? How many hours does a neurosurgeon work? Nsurgeons are one of the lowest hourly paid physicians.

it makes perfect sense. Perhaps certain fields shouldnt be paid as much, i cant say for sure, but generalizing about all of the specialties isn't fair nor subjective.

also that range you just listed 400-800 is unfair. that range could reflect someone working for 30+ years. there are family practitioners who do quite well after running their own businesses 20-30 years later. But I'm not entirely sure about it.

 

[radslooking]

just read my last post! I say the same thing and come to a different conclusion. Does a FP get sued as often as a gen surg or interventional card? Does he have the same stress levels as someone operating?

How about meritocracy? Shouldn't someone who has the best grades/research/ who is going into the most difficult specialties to match be paid more? That is the pure essence of our country and capitalism. And if you're going to argue that medicine in the USA isn't capitalist i've already mentioned y i think it is above.

what do you think is fair? There are far more family practitioners than any specialists. DO you think its fair that all of the FPs get paid as much?

How many hours do FPs work on average? How many hours does a neurosurgeon work? Nsurgeons are one of the lowest hourly paid physicians.

it makes perfect sense. Perhaps certain fields shouldnt be paid as much, i cant say for sure, but generalizing about all of the specialties isn't fair nor subjective.

also that range you just listed 400-800 is unfair. that range could reflect someone working for 30+ years. there are family practitioners who do quite well after running their own businesses 20-30 years later. But I'm not entirely sure about it.

No, the range I gave is not unfair. I know people immediately leaving cardiology fellowships (granted, an extra 4-5 years, getting 600-800$ offers) That's income they will be making for 30 years, at 4x what another person (who finished medical school and a residency) makes. These perverse incentives only destroy primary care, drive specialty care, which is expensive and doesn't have nearly as good outcomes for its cost. Its a huge negative.

And don't bring up neurosurgery. Those guys are nuts, you can pay them anything you want and I won't care. 7+ years of getting up at 5am and poking at goo for 11 hours straight with no margin of error. Go ahead and pay them.

I think you underestimate the hassle of being a primary care. They work long hours, deal with endless BS. There is stress to operating, but ask how many surgeons want to deal with annoying patients and their pain meds, etc. Answer, not many. Surgeons have slightly more hours, but its not that huge of a difference, generally. RadOncs,Derms,Rads, and most medical specialties have less hours, generally, except for cards and gi possibly.

 

[gluon999]

Cards work very hard for what they make, especially the interventional guys. Gen cards get half has much what an interventional/EP can make. In any case, they go thru 6-8 years of training after med school (hell Interventional trains as much as neurosurg, and EP trains even more than them) and work pretty damn hard at it, even during residency to land a cards spot (as only the elite medicine residents can get in).

Nonetheless, no doubt that primary care docs should make more, for they deal with way too much BS and I do feel bad for them when they don't get compensated for the mountain of paperwork they fill out/phone calls they answer/emails that they have to respond from their pts, etc.

 

[surag]

I entirely agree. In fact, for me personally, the reason why I would never go into family practice isn't even the pay. 150k isn't bad income especially after 2 year residency. Granted making 200k would be nice and is actually about what a physician in UK makes.

For me, its all the endless BS paperwork and getting shafted by the insurance companies. At least the surgeons are fighting for higher dollars...primary care physicians are trying to get money for their work and aren't really being paid appropriately. They're not rewarded for spending time with patients and to me thats the biggest reason I would go into family care...

 

[surag]

As a matter of fact, cutting down on specialty care income wont exactly help physicians. Those people are paid for operations and reducing reimbursments wont really help the health care situation. The percentage of health care cost reflected by physician income(and thereby reimbursements) is incredibly small compared to the overall cost. Bringing that down will only lead to crappy job satisfaction(even lower than where it is now) and not do anything to help the overall healthcare system other than to satisfy the ignorant jerk who thinks doctors make too much...its just a lot easier to blame a person or people than a flatering system that may require years to fix.

has anyone noted how the expected decrease in reimbursements is for areas that are the most hotly debated? Such as scans and so forth. All it takes is the media to discuss how neurosurgical procedures are unnecessary and their reimbursements will go down.

 

[mercaptovizadeh]

surag:

You are confounding the entire discussion by presenting the dichotomy of family medicine vs. neurosurgery. There's a lot in between. Do you actually realize that getting an internal medicine residency at JHU or MGH or a pediatrics residency at CHOP or Boston Children's takes just as much work as these rads/rad onc/ophtho/anesthesia/EM/derm/ortho bound people? Or maybe even MORE than the average "lifestyle" residency? We are not talking about neurosurgery here. I don't think ANYONE begrudges their salary - they cut into people's heads, their training is the most rigorous and lengthy out there, and their personal sacrifices and responsibilities are immense.

And you make a big assumption that people who go into primary care do so because their scores and grades are poor. Plenty of people go into primary care residencies with superb board scores and grades. Yes, there are people in primary care and general surgery who couldn't get the lifestyle or surgical subspecialty residency, but to suggest that these core fields of medicine are just a dumping ground for inferior med students is ridiculous.

In the MD/PhD graduating class in my medschool this year, the only two people who got AOA (of the MD/PhDs) went on to IM and psychiatry residencies - not dermatology, rad onc, radiology, etc.

And again, general surgeons are making almost half of what orthopedic surgeons are making. Is this fair? Don't they do residencies of equal length, with gen surg requiring a broader knowledge base, generally more critically ill patients, more call, a more grueling lifestyle after residency (less elective work), etc?

Have you read what Winged Scapula (a general surgeon) said? She gets paid less than the anesthesiologist for a mastectomy. She gets paid more for an US-guided biopsy than for the mastectomy. Something is wrong here!

All we want is some fairness. It is emphatically not fair that a rad onc (5 year residency) is making 400-500k whereas a peds heme/onc (6 years residency + fellowship) is making around 200k. Who deals with the complications of the child's cancer? Who has the crazy call hours? Who's breaking the news to the parents that the child has cancer?

But according to you and wagy, apparently, rad oncs deserve 2-3x pay because of their "vastly greater knowledge base," their "physics," and the fact that on average they had higher board scores in medical school.

 

[radslooking]

As a matter of fact, cutting down on specialty care income wont exactly help physicians. Those people are paid for operations and reducing reimbursments wont really help the health care situation. The percentage of health care cost reflected by physician income(and thereby reimbursements) is incredibly small compared to the overall cost. Bringing that down will only lead to crappy job satisfaction(even lower than where it is now) and not do anything to help the overall healthcare system other than to satisfy the ignorant jerk who thinks doctors make too much...its just a lot easier to blame a person or people than a flatering system that may require years to fix.

has anyone noted how the expected decrease in reimbursements is for areas that are the most hotly debated? Such as scans and so forth. All it takes is the media to discuss how neurosurgical procedures are unnecessary and their reimbursements will go down.

no, by specifically bringing down salaries won't help much. And I think anybody who says doctors should be paid less are missing the mark as to where the real problem lies. In our country, the sacrifice to be a doctor greater than anywhere in the world. Nobody goes into debt like we do. Nobody incurs the same number of hours/year in training. Nobody has higher scores. And nobody gets paid jack for tons of years of training. (except poor countries)

Changing the culture of overtesting would do far more in containing costs. We need to find what works best and is cost-effective. And a lot of times, what works best is pretty "low-tech".

 

[surag]

Actually Mercapto, I must disagree and agree with you at the same time.

I used neurosurgery as a general example but meant to reflect on the majority of specialties, ortho, plastics, etc.

The initial posts decried that all other surgical specialties got too much money whereas fampractice didn't...neurosurgery perhaps as such is a poor example. But that doesn't mean that what I'm saying is wrong.

Discalimer: The following commentary will come across as inflammatory if taken in such a manner. I don't mean that at all and I apologize beforehand. I am merely stating facts. If the moderators feel that what I am writing is trolling please let me know and I will stop...I dont think it is and I am trying to present what can only be considered as my opinion:

Your argument about Boston and JHU is not fair. Those students go into it not only for IM residency but also research. Look at a lot of the MD/PhDs or even MDs who end up at JHU for residency in IM who graduated AOA and they're doing great research. In effect, they're making a sacrifice to really follow a passion. Some wont' even perform actual medicine. In any case, you're reflecting on the top of your class going into any field htey want to.

But the reality is that the vast majority of students who perform poorly do end up in the dumping grounds of medicine and that happens to be family practice and psychiatry. If you don't believe me then look up the match statistics. In dermatology AOA is around 30 or 40% and the avg. step is 240. It is significantly lower for IM/pediatrics in both categories.

You used two individuals as anecdotal evidence, I am using averages. Let me give an example...two individuals graduate from Harvard Law School(Business school can be used interchangeably). Both graduate top of their class. One goes to work corporate the other goes to work nonprofit/public/etc. Just because the nonprofit guy is from harvard and top of his class doesnt mean he will make as much as the corporate guy. He may be more coveted but he's definately not getting paid as much. In fact, the vast majority of Law students who don't end up at top Law schools/do as well as they want to dont work at corporate law firms or high paying jobs...they end up in the dumping grounds of their respective careers. The fact is these 'dumping grounds' are almost always fields that are probably more important for society and do more for more people..i.e. public defender, legal council for the poor etc. Occasionally the top students do work here because of their high ethics/moral values. But salaries are still low.

The same applies to medicine.

End disclaimer.

General surgeons don't always do residencies of same length unless they specialize/fellowship. And besides, many choose general surgery knowing what they're getting into. I have friends who want to go into gen surg...and I have friends who went into gen surg because they didnt do as well to apply for ortho etc.

Also, that spine orthopeadic surgeon spent an extra year doing spine fellowship. His residency is now 7 years, same as most neurosurgeons. So why not pay him just as much? What does elective surgery have to do with grueling lifestyle? I dont know how thats related. If it is then you have a point.

I have to agree with Winged Scapula and you about the reimbursements, and not being a doctor I really have no right to have an opinion on what she says. That being said, this is an issue that shouldn't turn into which doctors should be paid less and who should be paid more across the board.

This is an issue of reimbursements and as such, these payment methodologies need to be revised as I'm sure many have stated before. What you say about this is entirely fair. I have never been a big fan of rads..and to this day I'm not sure how and why reimbursements are so high for rads.

as a side note, do you guys know where the whole payment for procedures came from? I read atul gawandes book and he describes how in the 80s and 90s studies were done to determine which procedures should be paid how much and why...revisions should be done i think.

What is not fair(and where I disagree again) is that you think a particular specialty deserves less than they make in order to compensate for another residency(peds heme). In this case, I think that people should go in knowing that they are doing what they are doing out of choice...they know what they're getting into.

Also, using dermatology, ortho(elective surgery), plastics as examples of excessive payments is also unfair. Many of those procedures are, as you've stated, elective. These are from patients who have the money to pay for them and are not necessarily covered by their health care plan.

Back pain surgery is not always covered, and many succesful orthopaedic surgeons dont even accept plans because the insurance companies try and deny insurance for as many patients as they can(stating that its not necessary etc.)...if you're going to pay outside of your plan then medicare has no control over what you earn, its nearly marketplace based and chances are even if you're being paid by medicare rates youre getting it out of pocket and making money since they can't be denied.

Cosemetics is the same idea.

Indeed, plastic surgeons who don't do as much cosmetic surgery make about 200-300 in salary. The same goes for academic dermatologists. The dermatologist PI next door to my lab makes about 180 a year. And this at a very top notch medical school/hospital.

What I think needs to be done is a revision for payments for those people who do not necessarily do as many procedures or have jobs that offer procedures such as neurologists, oncologists, etc.

What I think is unfair is to reduce the income of others with the hopes that somehow this will pay for family practice, IM etc.

This is a lot like the frogs that keep trying to prevent the other frogs from jumping out of the pail....trying to bring down other incomes wont help the situation...it only exacerbates it. Giving the public and in general the government the power to bring down salaries will embolden them to in general pinch the doctors.

what needs to be done is a general acceptance and consensus to revise the payment plans of today. Certain revisions such as paying more for other than procedures need to be put in place to take into account the work done by oncologists etc. Also, what needs to be done is a reassessment of malpractice insurance and so forth. While malpractice lawsuits may not be common and the payouts not as terrible, the mere fact that these loom over give physicians an excuse to order more tests. and when physicians arent ordering more tests to make a buck they are ordering to cover their behind. All these add up SIGNIFICANTLy to affect salary rates.

Also, paying residents more money will not help anyone. There are a lot of residents and currently all residents get almost same pay depending on year. Increasing pay merely takes away more money from attendings and physicians and will decrease overall reimbursements. I think residents get paid enough as it is. getting paid between 40 and 60 a year is certainly enough to sustain one's life. And as a resident I doubt one has the time to splurge on extravagant vacations or homes. Indeed..even if you make more money what exactly are you going to spend it on? Sure medical school loans are nice to pay off but I guarantee that a substantial increase in residency pay for the 17k students who go into residency everyyear will not only put a pinch on medicare reimbursements but will trickle down eventually in the form of higher medical tuition, less pay for physicians, and even lower job satisfaction! In effect, whatever gains are to come from higher residency pay will disappear.

 

[surag]

I also want to make a very important comment on stratifying pay based on grades etc.

Medical profession is all about weeding out applicants. There's a reason why we take organic chemistry and biology and chemistry and physics and why GPA is so important. If you think that grades in medical school dont matter then do you think grades in undergrad dont as well? At my school of the entering class 700 said initially they were interested in pre medicine and signed up for a pre med advisor. At graduation only 80 applied. 70 got accepted. Thats how it is and has been.

If you feel that somehow payment shouldnt reflect this, then you're basically saying that success in medical school shouldnt carry weight (money is the currency of importance, and while a passion for academics is there...the vast majority of us dont go into it for that nor are we capable/interested in Nobel prize work).

For example, lets say you're right in that we shouldn't reward medical school success...then should we really reward undergraduate success? Is there any correlation in UG and orthopedic success(i doubt it)? If we dont reward UG success then perhaps we should let anyone and everyone become a physician. In fact, we may even need to do away with the MCAT because it really isnt a reflection of surgical aptitude at all. Perhaps we shouldn't bother with students studying physics and mathematics nor should we carry weight with undergraduate coursework.

Indeed, perhaps we shouldnt even hold weight with the SAT as its only a precursor for college and not medical school.

And that my friend is PRECISELY what ALL OTHER COUNTRIES DO. For those claiming how we get paid more here than other countries also recognize that very very very few countries require an undergraduate degree...All most all students go to medical school IMMEDIATELY from High school. There is no SAT, no MCAT no undergraduate studies. Most are surgeons in the late 20s and finish residency before reaching 30.

So if you think that paying and rewarding medical competitiveness in the US is wrong then you are implicitly accepting that the entire system is flawed...

The question is, are you willing to accept a deluge of medical students if we were to revise the entire medical system? Are you willing to actually get much much lower pay because o the many physicians? If not, then why should the 'non'-rewarding of physicians for hard work in medical school be limited to that only? Why not to the entire system? Why not do away with it all and revert to what the rest of the world does?

If you really do have a problem with our system, then note this...2/3 of Nobel prizes in medicine have been awarded to people in the US. of that, 60% have a medical degree. go figure.

 

[E Dubble]

Actually Mercapto, I must disagree and agree with you at the same time.

I used neurosurgery as a general example but meant to reflect on the majority of specialties, ortho, plastics, etc.

The initial posts decried that all other surgical specialties got too much money whereas fampractice didn't...neurosurgery perhaps as such is a poor example. But that doesn't mean that what I'm saying is wrong.

Discalimer: The following commentary will come across as inflammatory if taken in such a manner. I don't mean that at all and I apologize beforehand. I am merely stating facts. If the moderators feel that what I am writing is trolling please let me know and I will stop...I dont think it is and I am trying to present what can only be considered as my opinion:

Your argument about Boston and JHU is not fair. Those students go into it not only for IM residency but also research. Look at a lot of the MD/PhDs or even MDs who end up at JHU for residency in IM who graduated AOA and they're doing great research. In effect, they're making a sacrifice to really follow a passion. Some wont' even perform actual medicine. In any case, you're reflecting on the top of your class going into any field htey want to.

But the reality is that the vast majority of students who perform poorly do end up in the dumping grounds of medicine and that happens to be family practice and psychiatry. If you don't believe me then look up the match statistics. In dermatology AOA is around 30 or 40% and the avg. step is 240. It is significantly lower for IM/pediatrics in both categories.

You used two individuals as anecdotal evidence, I am using averages. Let me give an example...two individuals graduate from Harvard Law School(Business school can be used interchangeably). Both graduate top of their class. One goes to work corporate the other goes to work nonprofit/public/etc. Just because the nonprofit guy is from harvard and top of his class doesnt mean he will make as much as the corporate guy. He may be more coveted but he's definately not getting paid as much. In fact, the vast majority of Law students who don't end up at top Law schools/do as well as they want to dont work at corporate law firms or high paying jobs...they end up in the dumping grounds of their respective careers. The fact is these 'dumping grounds' are almost always fields that are probably more important for society and do more for more people..i.e. public defender, legal council for the poor etc. Occasionally the top students do work here because of their high ethics/moral values. But salaries are still low.

The same applies to medicine.

End disclaimer.

General surgeons don't always do residencies of same length unless they specialize/fellowship. And besides, many choose general surgery knowing what they're getting into. I have friends who want to go into gen surg...and I have friends who went into gen surg because they didnt do as well to apply for ortho etc.

Also, that spine orthopeadic surgeon spent an extra year doing spine fellowship. His residency is now 7 years, same as most neurosurgeons. So why not pay him just as much? What does elective surgery have to do with grueling lifestyle? I dont know how thats related. If it is then you have a point.

I have to agree with Winged Scapula and you about the reimbursements, and not being a doctor I really have no right to have an opinion on what she says. That being said, this is an issue that shouldn't turn into which doctors should be paid less and who should be paid more across the board.

This is an issue of reimbursements and as such, these payment methodologies need to be revised as I'm sure many have stated before. What you say about this is entirely fair. I have never been a big fan of rads..and to this day I'm not sure how and why reimbursements are so high for rads.

as a side note, do you guys know where the whole payment for procedures came from? I read atul gawandes book and he describes how in the 80s and 90s studies were done to determine which procedures should be paid how much and why...revisions should be done i think.

What is not fair(and where I disagree again) is that you think a particular specialty deserves less than they make in order to compensate for another residency(peds heme). In this case, I think that people should go in knowing that they are doing what they are doing out of choice...they know what they're getting into.

Also, using dermatology, ortho(elective surgery), plastics as examples of excessive payments is also unfair. Many of those procedures are, as you've stated, elective. These are from patients who have the money to pay for them and are not necessarily covered by their health care plan.

Back pain surgery is not always covered, and many succesful orthopaedic surgeons dont even accept plans because the insurance companies try and deny insurance for as many patients as they can(stating that its not necessary etc.)...if you're going to pay outside of your plan then medicare has no control over what you earn, its nearly marketplace based and chances are even if you're being paid by medicare rates youre getting it out of pocket and making money since they can't be denied.

Cosemetics is the same idea.

Indeed, plastic surgeons who don't do as much cosmetic surgery make about 200-300 in salary. The same goes for academic dermatologists. The dermatologist PI next door to my lab makes about 180 a year. And this at a very top notch medical school/hospital.

What I think needs to be done is a revision for payments for those people who do not necessarily do as many procedures or have jobs that offer procedures such as neurologists, oncologists, etc.

What I think is unfair is to reduce the income of others with the hopes that somehow this will pay for family practice, IM etc.

This is a lot like the frogs that keep trying to prevent the other frogs from jumping out of the pail....trying to bring down other incomes wont help the situation...it only exacerbates it. Giving the public and in general the government the power to bring down salaries will embolden them to in general pinch the doctors.

what needs to be done is a general acceptance and consensus to revise the payment plans of today. Certain revisions such as paying more for other than procedures need to be put in place to take into account the work done by oncologists etc. Also, what needs to be done is a reassessment of malpractice insurance and so forth. While malpractice lawsuits may not be common and the payouts not as terrible, the mere fact that these loom over give physicians an excuse to order more tests. and when physicians arent ordering more tests to make a buck they are ordering to cover their behind. All these add up SIGNIFICANTLy to affect salary rates.

Also, paying residents more money will not help anyone. There are a lot of residents and currently all residents get almost same pay depending on year. Increasing pay merely takes away more money from attendings and physicians and will decrease overall reimbursements. I think residents get paid enough as it is. getting paid between 40 and 60 a year is certainly enough to sustain one's life. And as a resident I doubt one has the time to splurge on extravagant vacations or homes. Indeed..even if you make more money what exactly are you going to spend it on? Sure medical school loans are nice to pay off but I guarantee that a substantial increase in residency pay for the 17k students who go into residency everyyear will not only put a pinch on medicare reimbursements but will trickle down eventually in the form of higher medical tuition, less pay for physicians, and even lower job satisfaction! In effect, whatever gains are to come from higher residency pay will disappear.

Competitiveness among specialties is cyclical and is based on several factors such as reimbursement, prestige, lifestyle etc. All of these factors can and will change with time. Radiology was not always competitive, nor was derm, rad-onc, anesthesia. At one time psych was a competitive and prestigious specialty so I hear. What happens if the coin flips and the "lowly" fields you mentioned become more attractive and hence become competitive. Should we then increase reimbursement in said specialty since more AOA students are gunning for them?