Primary Care doctors struggling to survive

This is sad. 9000/month for office rent sounds pretty excessive, though. It sounds like she is too nice (i.e. giving patientd $3 for lunch when she can't pay for her lease and still has 80,000 in medical school loans). I think it's sad that the 1 or 2 doc primary care office is going the way of the dinosaur, though, particularly in certain states like California. I do think that these 1 and 2 doc practices take a lot of pride in their patient care and feel an "ownership" over their patients that may not be quite the same when one becomes an employed physician and/or joins one of those giant megapractices.

I agree that the rent was excessive, the Oriental carpets and modern art were perhaps a bit OTT, etc, but still that does NOTHING to mitigate how sad this is. Especially the "happy ending," her stable job in a mega-practice with a salary of $115K. She's 40 and still has debt (loans + credit card) equal to her annual pre-tax salary. And she seems extremely dedicated to the philosophy and practice of primary care, too.

Not collecting co-pays was a major mistake

wow, 115K at new job, that's pretty low!!

Some people don't have any business sense.

Aesculapius said:

Some people don't have any business sense.

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too right. ...and they all work for CMS...one way or another.

mig26x said:

wow, 115K at new job, that's pretty low!!

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I make more than that right now as a pharmacist. Significantly more. For less work. (also less satisfying, but Sallie Mae doesn't care whether you like your job.)

If i were in that dr shoes I would have become an hospitalist for 2-3 years earnining 150-175,000 per year and pay my loans etc and then go back to primary care medicine, she still has 80,000 dollars to pay off her loan!!!

wow.
Incredible

Samoa said:

I make more than that right now as a pharmacist. Significantly more. For less work. (also less satisfying, but Sallie Mae doesn't care whether you like your job.)

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Pharmacist make that much?? I didnt know.

115k plus benefits is probably about right/good ballpark range for an employed primary care doc, particularly in a sought-after area like the DC suburbs. If she wanted to live in the middle of Iowa or Montana she could likely do a bit better.

I could be mistaken, but I believe quite a few pharmacists make in the range of what a lot of primary care doctors make, and very likely are working less hours. That says nothing about job satisfaction and other things, but that's definitely true. I'm not sure why people have a hard time believing that.

As far as some docs not having business sense, that is correct, but do you think this guy who has been in business 28 years suddently developed a lack of business sense? No. The main issue is that CMS (entity that determined Medicare payments) has been holding physician reimbursements steady (and threatening to cut them yearly) for several years now. Assuming this doc's fixed costs (office rent or mortgage, cost of his office staff, cost for buying flu shots, other office equipment) slowly go up, the his income will go down...and down...and down.

As far as a hospitalist making 170k, most don't. Some do, but it would depend on location/area of the country and the hours worked. If you want to work like a resident you probably can make that.

dragonfly99 said:

115k plus benefits is probably about right/good ballpark range for an employed primary care doc, particularly in a sought-after area like the DC suburbs. If she wanted to live in the middle of Iowa or Montana she could likely do a bit better.

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Ouch.

mig26x said:

Pharmacist make that much?? I didnt know.

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There's a shortage of pharmacists, and in the outpatient setting, no one else is legally authorized to dispense (and charge for) more than one dose of medication at a time. In hospitals, the pharmacy, lab, ER and OR are the major profit centers. Nursing is an overhead expense. I'm really surprised the nurses aren't trying to grab a piece of the dispensing pie as well.

Samoa said:

There's a shortage of pharmacists, and in the outpatient setting, no one else is legally authorized to dispense (and charge for) more than one dose of medication at a time. In hospitals, the pharmacy, lab, ER and OR are the major profit centers. Nursing is an overhead expense. I'm really surprised the nurses aren't trying to grab a piece of the dispensing pie as well.

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Bite your tongue!

Aesculapius said:

Some people don't have any business sense.

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This quote probably covers most of your classmates/coworkers though. Having come from a field where I represented quite a few folks who made business missteps, including physicians, I would suggest that this article describes the norm, rather than the exception, these days. It's not like someone who majors in biochem in college, then goes to med school, and then dives into residency, knows the first thing about running a business. The smart folks realize they know nothing, and surround themselves with the appropriate ancillary professionals -- accountants, lawyers, financial advisors, book-keepers. Most of the others play it safe and join existing practices, so they don't have to be at the front line of business decisions (which they would likely flub). The remainder end up like the folks in this article. Running a successful business is not easy, but can be done if you do your homework. Surprisingly, folks who spent their life studying medicine rarely are astute enough to even pick up a book or two on how to run a business, before they take the plunge and make decisions which make it impossible to generate a living wage.

howelljolly said:

Bite your tongue!

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I'm not all that worried about it, even if they tried. Those nursing pharmacology classes are a joke, and even nurses at the top of their educational and practice pyramid can't BS their way through a discussion of drug therapy options. Which is one major difference between them and physicians. I'm just surprised they haven't tried, since that particular kind of issue doesn't seem to be much of an impediment for them.

I agree... my mom is a clinical pharmacist, absolutely adores her job, and is very well-compensated. They usually earn upwards of $80/hr. She works a lot (last week over 80 hours, poor mom!), have a niche which absolutely no one can touch due to the knowledge base, go on rounds, consult on patients, etc. Most pharmacists I've met are extremely happy with their jobs.

And medical school pharm is quite frankly peanuts compared to what they know. You know Tarascon's and the Sanford guide? My mother could probably quote every single word. And their theoretical knowledge goes much deeper too.

I've come to think that a lot about being happy in your professional life is having a niche that no one else can touch and on which everyone defers to you.

<I've come to think that a lot about being happy in your professional life is having a niche that no one else can touch and on which everyone defers to you. >

Excellent observation.

BlondeDocteur said:

I've come to think that a lot about being happy in your professional life is having a niche that no one else can touch and on which everyone defers to you.

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It's important, but not absolutely necessary, and speaking as someone who held such a job before med school, certainly not sufficient. What's truly necessary (and can be sufficient in many circumstances) is to enjoy the substance of your work.

When I first left that job, I wondered all through med school--with the exception of the rotations in my specialty--if I'd really be any happier on this side of the fence. Once intern year rolled around, and particularly on those same rotations, I never questioned it again.

Maybe there is no primary care shortage in Beverly Hills?

dragonfly99 said:

115k plus benefits is probably about right/good ballpark range for an employed primary care doc, particularly in a sought-after area like the DC suburbs. If she wanted to live in the middle of Iowa or Montana she could likely do a bit better.

I could be mistaken, but I believe quite a few pharmacists make in the range of what a lot of primary care doctors make, and very likely are working less hours. That says nothing about job satisfaction and other things, but that's definitely true. I'm not sure why people have a hard time believing that.

As far as some docs not having business sense, that is correct, but do you think this guy who has been in business 28 years suddently developed a lack of business sense? No. The main issue is that CMS (entity that determined Medicare payments) has been holding physician reimbursements steady (and threatening to cut them yearly) for several years now. Assuming this doc's fixed costs (office rent or mortgage, cost of his office staff, cost for buying flu shots, other office equipment) slowly go up, the his income will go down...and down...and down.

As far as a hospitalist making 170k, most don't. Some do, but it would depend on location/area of the country and the hours worked. If you want to work like a resident you probably can make that.

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I'd say most hospitalists make 170k now. Some quite a bit more. Primary care outpatient varies. The pay can be quite low, no doubt. Rare to see someone clearing 200k by much.

the AVERAGE salary of hospitalists is 170,000-175,000.

Guys,
I have been a practicing internist in the past.
I'm sure it depends on where you live, but the average salary for a starting hospitalist is not 170k where I live. 120-150k would be more like it.

Also, this lady was not working as a hospitalist (unless I read this wrong) she took a job that looks like traditional primary care (i.e. a lot of clinic). That pays less. Yes, the employed salary is lowish, but like I said that's because she's taken a job in an area that probably isn't desperate at all for physicians (thus the lower salary).

this hasnt changed in 20+ years Ive been watching it. Primary care SUCKS. It always has. It will only get worse.

Every primary care doc should strike IMO. Hell, every doctor should strike. I need like 2 weeks off in Europe and a reason to go there!

Organize people!!

Whats this I hear about a 21% reimbursement cut scheduled for 2010?

dragonfly99 said:

Guys,
I have been a practicing internist in the past.
I'm sure it depends on where you live, but the average salary for a starting hospitalist is not 170k where I live. 120-150k would be more like it.

Also, this lady was not working as a hospitalist (unless I read this wrong) she took a job that looks like traditional primary care (i.e. a lot of clinic). That pays less. Yes, the employed salary is lowish, but like I said that's because she's taken a job in an area that probably isn't desperate at all for physicians (thus the lower salary).

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interesting information. I have received 5-10 job offers for hospitalist and the lowest salary offered was 150K with the highest offer been 190K plus bonuses can go up to 225K, but this is for southeast (specifically FL). What area are you from?

I was once an fp with a solo practice. I found myself fighting an uphill battle.
In medical school you are not told how things really work. The sad truth is that pcps work harder than everyone else and are compensated the least. I felt bitter and angry. The specialists to whom I referred my patients were not necessarily any smarter than me , they simply picked the ,"right" specialty.

I got rid of my office and retrained in another specialty.

I do not know what the answers to the problems seen in primary care are.

I do not think that universal healthcare is the answer. I have said this before.
We must address the waste that takes place in the delivery of healthcare in the US.

Cambie

This was an interesting article, thanks for posting it. I wish it told us what happened to Dr. Walford's patient load, how it went from 30 per day a couple of years ago to 12-15 now. Could she have joined an HMO and have had patients assigned to her panel (before she laid off the other office staff and started to dissolve her practice)? Or is the market in the Los Angeles area that saturated they don't need that many physicians in primary care? Whatever the reason, it's still very sad that people have to close down the practices they built because it becomes too expensive for them to run.

I wish it told us what happened to Dr. Walford's patient load, how it went from 30 per day a couple of years ago to 12-15 now. Could she have joined an HMO and have had patients assigned to her panel (before she laid off the other office staff and started to dissolve her practice)?

It sounds like there are plenty of potential patients in LA but many of them lack the ability to pay.

Many communities are in dire need of PCPs but these communities cannot support a practice.

Cambie

Let's forget business training because a lot of successful business men/women are not formally trained in business, but one thing they don't do is continuously practice something that obviously does not work. They make adjustments to improve. Primary care has the highest pt volume, and in business world that translates to highest dollar potential. If accepting insurance is costing you money, then don't accept insurance. Sounds funky, but if you realize that the average pt pays 50 - 70 dollars out of pocket even with insurance per clinic visit, then you can see how a doctor who is already pushing 30 pts a day while spending half the day filling out insurance paperwork could increase his/her pt load to 50-60 if they charged the same 50-70 dollars in cash and simply cut out insurance totally. The math favors this model.

The three top areas in medicine that can run a pure cash business and maintain a decent pt volume are derm, Plastics, and primary care (yes I said it). PCPs can convert their high pt volume into cash if they simply brake out of what they think is the norm and start trying brave new ways of doing business.

BTW, if the AMA cannot protect PCPs then this might be a good time for PCPs to break away and form a new organization with a sole purpose of canvassing for universal healthcare, and start educating the pts and the public on why this is the best way to go. PCPs have nothing to loose that they haven't already lost.

mig26x said:

interesting information. I have received 5-10 job offers for hospitalist and the lowest salary offered was 150K with the highest offer been 190K plus bonuses can go up to 225K, but this is for southeast (specifically FL). What area are you from?

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i agree with this.

sirus_virus said:

Let's forget business training because a lot of successful business men/women are not formally trained in business, but one thing they don't do is continuously practice something that obviously does not work. They make adjustments to improve. Primary care has the highest pt volume, and in business world that translates to highest dollar potential. If accepting insurance is costing you money, then don't accept insurance. Sounds funky, but if you realize that the average pt pays 50 - 70 dollars out of pocket even with insurance per clinic visit, then you can see how a doctor who is already pushing 30 pts a day while spending half the day filling out insurance paperwork could increase his/her pt load to 50-60 if they charged the same 50-70 dollars in cash and simply cut out insurance totally. The math favors this model.

The three top areas in medicine that can run a pure cash business and maintain a decent pt volume are derm, Plastics, and primary care (yes I said it). PCPs can convert their high pt volume into cash if they simply brake out of what they think is the norm and start trying brave new ways of doing business.

BTW, if the AMA cannot protect PCPs then this might be a good time for PCPs to break away and form a new organization with a sole purpose of canvassing for universal healthcare, and start educating the pts and the public on why this is the best way to go. PCPs have nothing to loose that they haven't already lost.

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Here is a no nonsense post for you.

Go out there and do just what you said above. Tell us how it goes.

If you do it and it works you will be our hero. You can charge money to teach it to everyone.

But don't preach something you have never done. Talk is cheap.

sirus_virus said:

The three top areas in medicine that can run a pure cash business and maintain a decent pt volume are derm, Plastics, and primary care (yes I said it). PCPs can convert their high pt volume into cash if they simply brake out of what they think is the norm and start trying brave new ways of doing business.

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that's the thing that bothers me the most.

Most people aren't sick enough to need to buy the lowest-deductible ripoff insurance plan.

why don't they just get catastrophic insurance, and then pay everything else out of pocket?
that's what I do. I pay the lowest premiums, and then pay cash on the RARE occasion that I do see a dr.

my catastrophic insurance also pays for part of my prescriptions.

in the end, it's the cheapest way to go. I pay $40-60 cash, and it saves the doctor from paperwork torture.



Another thing that's really fcked up about this article- patients who don't pay. How does that work?
The insurance company is the middleman who cuts the doctor's bill by 30-70%, and then pays part of it. The remainder is billed to the patient, who can't pay for it.

There should be a way to push the responsibility onto the credit card companies. i.e pt must have valid credit card or bank account linked to the insurance plan, and is automatically billed.
If the pt can't pay, too bad so sad. let the credit card company handle it and get the collection agency and tank your credit rating.
After all, that's what the 3% processing fees goes toward right?

There's gotta be a way to **** over the non-payer and teach him a lesson.
Anyone who visits a doctor should have at least $100 lying around. It's not that they can't pay..... these bastards just choose not to pay to steal.

Joe Richards said:

Here is a no nonsense post for you.

Go out there and do just what you said above. Tell us how it goes.

If you do it and it works you will be our hero. You can charge money to teach it to everyone.

But don't preach something you have never done. Talk is cheap.

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Sorry if I offended you, but I am not clueless on this issue either. I have done enough graduate and personal research on healthcare business. Contrary to popular belief, the healthcare market is not tilted against PCPs, insurance reimbursements and healthcare employers are. For too long doctors have enjoyed the advantage of running their businesses however they wanted to, mainly because the money came regardless. Now physicians like other businessmen/women have to be creative to make money. No one has an incentive to teach physicians how to make money, not the HMOs, insurance companies, and definitely not fellow physicians who happen to have found a working formula. IMO, the solution to the issues PCPs are facing will have to come from PCPs and no one else.

BTW, there is a group of PCPs running cash heavy practices out in Nevada with huge success. They are now infiltrating California with a lot of dermatology incorporated into their business. For obvious reasons, you can imagine they will not be holding seminars to teach other physicians how to do this either.

PCPs have to band together in partnerships like Partners Healthcare in Boston control overhead and buy equipment to bring testing in house. Then they will be able to negotiate as heavyweights with the insurance companies.

Seriously, they are:

http://www.jdunderground.com/thread.php?threadId=28117

StreamTeam said:

Seriously, they are:

http://www.jdunderground.com/thread.php?threadId=28117

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I just read the thread. Reminds me of a lawyer party I went to. That's how they talk with one another too (both on & off the cocaine & lexapro). What a bunch of d-bags.

Not every MD needs a lawyer. But every lawyer, & their families, need(s) an MD... particularly a primary care one.

Besides, everyone knows the legal system, especially the public defense system, is in shambles. I know many lawyers who don't practice law anymore (or ever for that matter), either because they can't find a job, they don't enjoy it, or can't make enough money.

Insurance industry's starting to invade law as well with their law HMO's (Prepaid Legal)

Who cares if the lawyers are laughing. We've been laughing at them for centuries.

StreamTeam said:

Seriously, they are:

http://www.jdunderground.com/thread.php?threadId=28117

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Do you wonder why they have to dig for threads like this to make themselves feel better? Most people having a good time in their professions do not get into the whole comparison game, unless they infact feel inferior or unsatisfied on some level. I dont know much about being a lawyer, and I dont give a rats ***** either.

My brother's an attorney. At one point he was considering law vs medicine, and chose law because of the shorter training for potentially similar income. But he didn't realize that the vast majority of lawyers aren't making medicine-level incomes (even the level of that family practice doc). I think if he had it to do over again, he'd choose medicine.

sirus_virus said:

Sorry if I offended you, but I am not clueless on this issue either. I have done enough graduate and personal research on healthcare business. Contrary to popular belief, the healthcare market is not tilted against PCPs, insurance reimbursements and healthcare employers are. For too long doctors have enjoyed the advantage of running their businesses however they wanted to, mainly because the money came regardless. Now physicians like other businessmen/women have to be creative to make money. No one has an incentive to teach physicians how to make money, not the HMOs, insurance companies, and definitely not fellow physicians who happen to have found a working formula. IMO, the solution to the issues PCPs are facing will have to come from PCPs and no one else.

BTW, there is a group of PCPs running cash heavy practices out in Nevada with huge success. They are now infiltrating California with a lot of dermatology incorporated into their business. For obvious reasons, you can imagine they will not be holding seminars to teach other physicians how to do this either.

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You didn't offend me. But you are not talking from experience. You are talking from research. In the real world research has to PROVE itself.
You can do all the work you want in a computer but until there is a working model it means nothing.

Doctors do need to learn how to run their practice like a business but my point was that you have no real world experience.

Joe Richards said:

You didn't offend me. But you are not talking from experience. You are talking from research. In the real world research has to PROVE itself.
You can do all the work you want in a computer but until there is a working model it means nothing.

Doctors do need to learn how to run their practice like a business but my point was that you have no real world experience.

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thats what they call 'translational research.... thats my useless dos pesos.

Joe Richards said:

You didn't offend me. But you are not talking from experience. You are talking from research. In the real world research has to PROVE itself.
You can do all the work you want in a computer but until there is a working model it means nothing.

Doctors do need to learn how to run their practice like a business but my point was that you have no real world experience.

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Why not? Once again, I don't have any incentive to convince you or anyone that this works.

http://www.hippocratespublishing.com/medicalpracticewhitepaper.php

"Summary
The cash only medical practice is a niche medical practice that will continue to grow in popularity among both physicians and patients in the United States. Cash only medical practices represent a special area of demand for a service that is less common, but growing rapidly.

With over 45 million Americans without health insurance, and millions more who are underinsured, cash only medical practices provide patients with affordable, accessible medical care performed by qualified physicians. These patients are the perfect match for physicians who are frustrated with managed-care contracts, endless paperwork, and low reimbursement rates.

Today, there is an increasing amount of support and marketing tools for physicians aspiring to start their own cash only medical practices. As physicians take the time to explore the niche medical practice field, it is important to recognize that such a transition will require research, patience, and versatility."

sirius and dr richards,
There are examples of primary care docs who have gone cash only and have done all right, and also examples of primary care docs who have gone cash only and have gone broke. It seems to work best in areas that have not as many docs (i.e. rural area of a southern state) and there have to be people who are willing to pay cash (i.e. have a job and have money, but may not have insurance or the insurance already has a high copay). In areas with high HMO penetration and/or where most patients are covered by an insurance plan where they pay only $10-30/visit, what is the patient's motivation to pay a primary care doc $50-100 for a doctor visit? Not much unless perhaps they already know and trust the doc...but usually the dollar is king. "Boutique" practices where the doc charges a fee per month or year in addition to doctor visits are a niche market and really only for areas with a lot of rich and/or upper middle class patients who are willing to pay the retainer.

I think in many areas "cash only" for primary care would be a highly risky proposition right now. Most patients don't value primary care services so highly that they'd choose to pay someone $90 when a doc down the street will see them for their $15 copay. You can't totally blame the patients when they are already paying several hundred dollars/month for their insurance policy...why should they pay 2x unless you are a real hotshot?

dermatology is somewhat of a different situation because folks who pay for that generally are not indigent.

I am afraid cambie is right...there are many folks in need of primary care but many of those cannot afford to pay much for it, and/or are unwilling to. Preventive and primary care doesn't seem important to people until they become ill...

Aesculapius said:

Some people don't have any business sense.

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thats an ignorant statement.


In any business, you figure out what your costs are and you charge accordingly based on what that figure is. MEdicine is a business where you have "fixed costs" and the people you bill either dont pay you. dont pay you promptly so you have a cash flow problem, or pay you what they feel you are worth or based on what they pay other docs in other states. How can one think you can run a business like this? Its no wonder why physician owned businesses are going under left and right. In my opinion, the beauty and appeal of medicine was the fact that you could "put out your shingle" and practice the way you see fit. IF the norm was finishing residency and working at a mega group with 200 other docs as your partners there is no way i would be interested in something like that. I could get a business degree and go to work everyday for abc company like that. its a real shame

Half of family doctors would quit if they could: http://www.ajc.com/services/content..._primary_care.html?cxtype=rss&cxsvc=7&cxcat=9

Aesculapius said:

Some people don't have any business sense.

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While I don't think this explains ALL of the problems effecting primary care, I recently met a general internist who lives on the upper east side in New York. Has 3 clinics, works 4 days a week spends his weekends in the Hamptons. He said he worked his arse off out of residency to bulid his patient load but says he is currently doing very well. Obviously this guy who runs exclusively ambulatory clinics is doing something that works.

My point being that all primary care residencies should have a business foundations course.

UT_mikie said:

While I don't think this explains ALL of the problems effecting primary care, I recently met a general internist who lives on the upper east side in New York. Has 3 clinics, works 4 days a week spends his weekends in the Hamptons. He said he worked his arse off out of residency to bulid his patient load but says he is currently doing very well. Obviously this guy who runs exclusively ambulatory clinics is doing something that works.

My point being that all primary care residencies should have a business foundations course.

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i dont believe this. Whats his name? if it were easy everyone would be doign it.. insurance companyes pay you 20 dollars per patient. You cant make it with that amount. I dont care how smart or how hard you work.

This is why so many primary care providers are switching to cash-only practices.

mdjkim said:

This is why so many primary care providers are switching to cash-only practices.

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indeed, the patient can pay cash and if they have insurance they can fight for the reimbursment. The fact is though...you need to be willing to say no to patients. Sorethroat? No cash? the ER is that way, I'll be golfing.