How Can We Encourage Medical Students To Choose Primary Care?

[deleted87716]

A radical suggestion: pay specialists less.

http://drpullen.com/how-can-we-encourage-medical-students-to-choose-primary-care

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Members don't see this ad.

 

[MOHS_01]

You disappoint me, friend.

 

[Lesassier]

While efforts to improve primary care may result in decreased reimbursements elsewhere, I certainly don't think the motivation should primarily present itself as a counter-campaign to specialist lobbies. Certainly wouldn't be in the spirit of collaborative, multi-disciplinary medicine.

My personal belief is that there is soo much money being wasted on things that have no valuable return to the medical care of patients, that we should focus on reclaiming money from those areas to promote primary care, rather than chop down specialists. Additionally, there does seem to be certain types of procedural specialists that are in shortage as well, so really, we don't want to be trading one problem for another.

What I find most disturbing is in the formula for calculation for RVUs. We can argue about the inequities and unfairness of money driven lobbies to make these formulas.... But again, a personal feeling I have is that RVUs should primarily focus on the NEEDS of the community in the region being served. However, this isn't even a minor consideration in the formula. Without that being fixed, there will always be over-utilization of certain resources and our system will continue to be quite inefficient.

The medical economics need to factor in the fact that we are first here to serve the sick... and not the other way around. Only after that should consideration be given to compensation for what we do or remuneration for what we have gone through in terms of training.

Im sure I will be accused of being an idealist for this...

 

[deleted87716]

You disappoint me, friend.

I didn't write the article.

 

[bronx43]

A radical suggestion: pay specialists less.

http://drpullen.com/2010/06/14/how-can-we-encourage-medical-students-to-choose-primary-care/

I wouldn't really call this idea radical, as I'm sure this approach is already on the radar of many politicians.
The chance of primary care reimbursement rates going up enough to attract medical students away from specializing is slim to none. If promoting primary care is really a goal of the government, then reducing specialist pay seems to be the only way. Whether or not this is philosophically ideal is a different argument.

 

[MOHS_01]

I didn't write the article.

Don't be coy -- it's not becoming. Merely posting this is, without any form of dissenting commentary, is a de facto admission of like thought.

 

[MJB]

This is the realistic, but crappy, solution. Thank the politicians.

And, the folks that are in charge of assigning RVU's.

Just gonna guess there aren't many PCP's on that committee.

 

[deleted87716]

Don't be coy -- it's not becoming. Merely posting this is, without any form of dissenting commentary, is a de facto admission of like thought.

Not really. I posted it to stimulate discussion.

You'll note that I didn't post it in the derm forum.

 

[MOHS_01]

Not really. I posted it to stimulate discussion.

You'll note that I didn't post it in the derm forum.

Noted. We both know that there will be several on here who will buy into this line of thinking, swallowing the hook in the process. Even if you remove me from the clinical practice of providing procedural services (something that I am seriously contemplating transitioning away from for many reasons), I would disagree that a redistribution just for redistribution's sake is a great course to pursue. Granted, I do not like any top-down centrally dictated mechanism of reimbursement; by its very nature it is susceptible to and invites in politics and corruption. The system that we have now, however, is at least based in principle on quantifiable objective inputs; the problem is that, like many things todays, it employs false assumptions with an effort to generalize the aggregate data and subsequently apply it to individual situations.

Most economic systems do not function by zero-sum rules; Medicare, unfortunately, does assume some level of zero-sum restrictions.... which leads to a system promoting political gamesmanship (rent seeking behaviors). I feel that the entire system is corrupt, and this is a good case in point....

 

[Lesassier]

I really reject the idea that reducing specialist pay, even if acknowledged as a bad approach, is the only way to encourage students to select primary care. This kind of gives me the feel that the main reason a student would choose their specialty is financially motivated, which certainly is not universally true of students. Furthermore, increasing re-imbursement for primary care is not inseparably linked to reducing specialist pay.

Perhaps we should have more discussion of what students might find scary or disappointing about primary care fields first if we really want to identify how to motivate them pursue it. While I think a lot of this has to do with decreased faculty advisement for students at a lot of schools, there are definitely misperceptions about the field that don't even encourage students to investigate its possibilities. I can guarantee you that most of my class really doesn't have an idea of what the full-scope of family medicine practice could entail (Northeast).

We already know some of the things that scare students even if their response is not proportional to the actual threat:
1. Loan repayment from escalating student debt levels
2. Malpractice insurance

Perhaps offering national coverage for medmal insurance for primary care might be appealing... (?wishful thinking?)

 

[Lesassier]

Apart from the financial I might also submit that prestige, desire to be an "expert" in something, inability to command respect from specialist peers, prideful personality quirks preventing one from admitting they need help (and might have to refer to a more knowledgeable/skilled specialist), are all things that might play into someone not wanting to generalize.

Then again I've also met a few who seemed to understand a bit more about general practice and said things like, "I didn't think I could get a handle on everything I would have to understand and know". The breadth of knowledge required can be pretty scary and some might feel more comfortable shying away to focus on a smaller area of practice.

For those with the latter feelings--- then perhaps changing the self-esteem destroying style of teaching that is medical school might help develop their confidence that they could be a good generalist...

 

[bronx43]

Noted. We both know that there will be several on here who will buy into this line of thinking, swallowing the hook in the process. Even if you remove me from the clinical practice of providing procedural services (something that I am seriously contemplating transitioning away from for many reasons), I would disagree that a redistribution just for redistribution's sake is a great course to pursue. Granted, I do not like any top-down centrally dictated mechanism of reimbursement; by its very nature it is susceptible to and invites in politics and corruption. The system that we have now, however, is at least based in principle on quantifiable objective inputs; the problem is that, like many things todays, it employs false assumptions with an effort to generalize the aggregate data and subsequently apply it to individual situations.

Most economic systems do not function by zero-sum rules; Medicare, unfortunately, does assume some level of zero-sum restrictions.... which leads to a system promoting political gamesmanship (rent seeking behaviors). I feel that the entire system is corrupt, and this is a good case in point....

What do you suggest? Stopping fee for service? The problem with not having a top-down centrally dictated pricing mechanism is that free market principles simply can't be administered, given the fact that the supply is artificial limited.

 

[MJB]

Many, if not most, of my classmates (including myself) were convinced that FM in particular is nothing but managing non-compliant DM and HTN patients over and over and over.

That hasn't been my experience, thankfully. In fact, while you DO have to manage those diseases quite a bit, it's usually in patients that actually give a damn about themselves (particularly in the clinic), and I can get behind that.


It's the inpatient side of things that I found VERY discouraging (Internal Medicine). I don't know exactly what it is about inpatient medicine, but I know it's not something I would enjoy doing for extended periods of time (like a 3 year IM residency)


Showing students that FP can have a great lifestyle, see a variety of patients and problems, and consists of performing procedures, all while making in the neighborhood of 200k...would help immensely. From what I've gathered..none of that is unrealistic.

 

[medmom]

As a medical student currently debating FM vs OB/GYN I hate to admit it but student loans are a HUGE factor in my choice of specialty. Yes, I know that in FM I will make more than enough to cover the cost and live a nice lifestyle. I also have 3 kids and a husband to support. So, when looking at income potential I feel like my student loan burden goes right along with it. Do I really want to still be paying on my student loans when I am 60? That is a hefty monthly payment. Will I be able to save for retirement? I will also admit that I have no true concept of 150K vs 250K, etc. in the real world. I grew up with lower middle class parents. Therefore, my decision to specialize or not, as far as finances are concerned, is being made purely by hypothetical number put on paper.
Now student loan repayment/forgiveness, if I knew that I would qualify for some of these programs without having to raise my kids on the Alaskan tundra, the decision might be easier. However, again, that is a hypothetical scenario. I think what would be an ideal situation would be some sort of loan forgiveness program that you can sign up for upon graduating medical school. There is a big gap in these programs. They are offered when you begin med school and aren't sure that you want to commit to primary care and then again after you have graduated residency and gotten your first job. Why not catch them in between?

 

[JackADeli]

Many, if not most, of my classmates (including myself) were convinced that FM in particular is nothing but managing non-compliant DM and HTN patients over and over and over...

Showing students that FP can have a great lifestyle, see a variety of patients and problems, and consists of performing procedures, all while making in the neighborhood of 200k...would help immensely. From what I've gathered..none of that is unrealistic.

I think we had almost this entire line of conversation in the past few months on this forum...

My comment then was that a good deal does have to do with very poor marketing. Can any particular specialty find/declare reasons why their pay check at the end of the month should be more? Yes.

But, I have spoken with medical students. Some often lack a real understanding of the specialties and what is involved in the specialties. I know plenty of medical students that know nothing about FM other then the highly publicized claims of underpayment and "discrepancies" in compensation. I know plenty of students that know of the surgical specialties and what their income is without much appreciation of the workload involved in obtaining said income. I am certain I can find any number of surgeons that would love their current incomes ~$250-350K/yr with the M-F, ~9-5/6, limited call, and quality of lifestyle practice of many FM physicians. I do not know any PCPs that will accept the 60-80hr/wk, Q3 call lifestyles of surgeons in exchange for their income.... correction, I do know a few that put in extra moonlighting hours and do make upwards of $300k/yr.

My point now as it was previously.... We need to fully educate the students not just about the specialty but what is the "compensation PACKAGE" of the career. They need to know what the actual clinical practice involves. They need to know what the actual training involves. They need to know what the dollars are. Continued emphasis on comparing check stubs without context will only serve to hurt efforts to recruit for ALL specialties. It is NOT easy money in any specialty. It is sad to see the drop out of a surgical resident because life style and work hours and see them exceedingly happy in PC medicine. It suggests poor personal awareness and a lack of mentoring.

Let's have some truth in advertising. So, "Johnny", yes you will probably earn ~180-250k/yr in FM. You will likely have very limited call, most weekends and hollidays off, etc.... Now, you can work in GSurgery. It will take atleast another 2 yrs of residency. Your residency training may be more intense. You will probably earn $220-350k/yr. Your malpractice may be greater, your hours will be longer, you will probably have Q3 call, you will work many weekends and hollidays. So to your previous statement:

...Showing students that FP can have a great lifestyle, see a variety of patients and problems, and consists of performing procedures, all while making in the neighborhood of 200k...would help immensely...

I agree. But, this honest disclosure may not be so helpful in the political agenda towards obtaining at larger portion of the pie at the current work levels.

 

[Chris Knight]

4th year applying to FM this fall. The way I see it there are 2 main issues:

1. Money- Debt vs Earning Potential. Very real issue, too real for some. I myself am coming from a private school, joint MD/MPH, and looking at a touch over 400k. How I'm going to deal with that weighs heavily upon my mind. I'm genuinely interested in working with both inner city underserved as well as rural populations, be it through NHSC or USPHS or on my own. These loan repayment programs don't put much of a dent in my debt.

2. Quality of Education/Prestige- The biggest issue for me. Family Medicine satisfies my interests better than any other specialty, but it often scares me whether I can find the training I need. This is a particular issue as I want to stay on the east coast, and it seems there is a greater prevalence of quality programs over yonder.

Seriously, FM is perceived as the bottom of the barrel by many. I've gone through medical school at the top of my class, and now that I've recently decided to go for FM its quite commonplace for me to endure the looks of disappointment/confusion of classmates and mentors when I inform them of my decision. I can't entirely blame them. I've come across some amazing doctors in FM, the best around, but I've also come across many that are a disgrace. As I'm currently on a sub internship, I've been working closely with a large number of FM interns, residents and attendings. Lets just say that in many cases I'm very glad I am there, for the patients sake. I pray I don't end up in a program that turns out such physicians, but its hard to tell that from the outside. Interview season is going to be stressful. I'm ranting a little I know, and I apologize. But there is a point. Increase the caliber of the docs, but how to do that with out enticing them with more money?

 

[themorphinerule]

We pharmacists are more than happy to take FM As it stands though, we can only aspire to be physician extenders-- which is no problem, our education promotes multi-disciplinary efforts for patient care, and despite all the pathophysiology and pharmacotherapeutics, we only get a crash course in physical assessment, and thus, diagnostics, we do not.

But I'm very happy and excited at the thought of what the future might hold... A PharmD in every clinic helping to ensure optimum medication therapy, 1 patient at a time.

I'm bored.. anyone want to chat? lol

 

[sylvanthus]

"We pharmacists are more than happy to take FM As it stands though, we can only aspire to be physician extenders-- which is no problem, our education promotes multi-disciplinary efforts for patient care, and despite all the pathophysiology and pharmacotherapeutics, we only get a crash course in physical assessment, and thus, diagnostics, we do not.

But I'm very happy and excited at the thought of what the future might hold... A PharmD in every clinic helping to ensure optimum medication therapy, 1 patient at a time.

I'm bored.. anyone want to chat? lol "

Whether this post was genuine or sarcasm, this brings up a point noone has mentioned. Everyone and their mom thinks they can do what a family medicine specialist does. NPs, PAs, hell pharmacists to an extent. So, why as a medical student would we put in far more time and money to do essentially the same job? I would like to see someone address this.

 

[lowbudget]

I know plenty of students that know of the surgical specialties and what their income is without much appreciation of the workload involved in obtaining said income. I am certain I can find any number of surgeons that would love their current incomes ~$250-350K/yr with the M-F, ~9-5/6, limited call, and quality of lifestyle practice of many FM physicians. I do not know any PCPs that will accept the 60-80hr/wk, Q3 call lifestyles of surgeons in exchange for their income.... correction, I do know a few that put in extra moonlighting hours and do make upwards of $300k/yr.

My point now as it was previously.... We need to fully educate the students not just about the specialty but what is the "compensation PACKAGE" of the career. They need to know what the actual clinical practice involves. They need to know what the actual training involves. They need to know what the dollars are. Continued emphasis on comparing check stubs without context will only serve to hurt efforts to recruit for ALL specialties. It is NOT easy money in any specialty. It is sad to see the drop out of a surgical resident because life style and work hours and see them exceedingly happy in PC medicine.

Let's have some truth in advertising. So, "Johnny", yes you will probably earn ~180-250k/yr in FM. You will likely have very limited call, most weekends and hollidays off, etc....

If I follow this logic, maybe if I train as hard and as long, work as many hours, and take on as much liability... as a CRNA does... maybe, one day I'll get paid as much as a CRNA.

Really? Come on, JAD. I see where you're coming from in principle... but deep down, there's gotta be a part of you that knows the system's rigged. Or at least run by the Mob.

Isn't there a part of you that think it's messed up that ENT, Ophtho, Plastics, Uro, & some elective-cases only Ortho get paid better than you only because you're a general surgeon?

 

[JackADeli]

If I follow this logic, maybe if I train as hard and as long, work as many hours, and take on as much liability...

...I see where you're coming from in principle... but deep down, there's gotta be a part of you that knows the system's rigged...

Isn't there a part of you that think it's messed up that ...get paid better than you only because you're a general surgeon?

I am in no way saying the system is correct or that it comes particularly close to free market function. Does it cause a twinge in my gut to hear the hospital makes upwards of 5-10million on the work I perform and I don't even come close to 500k? Sure.

My point now as before, is that the "class warfare-esque" argument that ignores all factors but the pay stub does not:

1. inform med-students well
or
2. enable physicians to work well together/multidiscipline/mutual respect/etc...

I appreciate that the "dramatic" difference in pay stubs [out of context] makes for good talking points when fighting for a "fair" increase piece of the pie. Again, I think med-students need to understand the realities of what their lifestyle will be relative to the income. They need to have a realistic perspective on what income will enable them to pay off student loans. They need to be realistic about how much debt they will accumulate outside of student loans.

I have seen too many surgery residents drop and go FM because the lifestyle was not conducive to their goals. Then get into FM, graduate, and continue to pay low on their student loans while buying decent home, one fancy car, minivan, +/- bass boat or big vacations. Yet, I hear folks all the time talking about paying their student loan in 2-5yrs and how that is an ~absolute! Most do not. On the flip side, you have this "Mother Theresa" type stereotype being portrayed while simultaneously making all the arguments in this thread and others.....

During medical school, FM attendings seemed happy, comfortable, in no financial distress. They took vacations, time off, and had family and home. When asked, they ALL told me they were paying off student loans over >10yrs. "Why", I asked. Their answer was consistent. They had other priorities and interests not served by trying to tie up their capital for a rapid pay-off. Medical students and residents need to have better counseling on these financial matters that goes beyond alot of the political agenda.

Having said all that, I am one that honestly believe FM is a difficult field to practice in and should be full of the best, brightest, and academic excellence in order to do it well. Some programs strive for that but others seem to promote the residency comforts to recruit....

 

[deleted87716]

Whether this post was genuine or sarcasm, this brings up a point noone has mentioned. Everyone and their mom thinks they can do what a family medicine specialist does. NPs, PAs, hell pharmacists to an extent. So, why as a medical student would we put in far more time and money to do essentially the same job? I would like to see someone address this.

It's been mentioned here plenty of times.

The only people who think that primary care is easy are those who have never done it.

Like most things, it's really easy to do it badly. It's very challenging to do it well.

 

[MJB]

The biggest problem I have with the loans is that tuition has gone way up in recent years and gone are the days of low low interest.

 

[JackADeli]

...Like most things, it's really easy to do it badly. It's very challenging to do it well.

sad but so true.

 

[sylvanthus]

It's been mentioned here plenty of times.

The only people who think that primary care is easy are those who have never done it.

Like most things, it's really easy to do it badly. It's very challenging to do it well.

Heh forget it thats the kind of response I have come to expect when discussing the drawbacks of primary care.

 

[hrandani]

All of the medical students I know refuse to go into primary care because it has a reputation of being a black hole of paperwork and time-suck with very little medicine.

I don't know if that's actually true or not, but I don't see the perception changing anytime soon.

 

[JackADeli]

All of the medical students I know refuse to go into primary care because it has a reputation of being a black hole of paperwork and time-suck with very little medicine.

I don't know if that's actually true or not, but I don't see the perception changing anytime soon.

It's not the experience I had in medical school. It's not the experience I have with referring PCPs. I have always found many aspects of PC fascinating.

Unfortunately, I don't get that message when hearing popular press or PCPs lobbying for change. Rather, I hear two messages loudest:

1. PC is for the "American Ghandis".... I think I heard med students on TV speaking about PC and how proud they were and that money doesn't matter and "we aren't going into it for the money.... it's about caring for the needy". Then you have the post here or somewhere else about the non-traditional PCP that went to med school and moved his family into a ghetto after residency. Or, the story on the news the past few months about the PCP that is drowning in debt, not charging patients, can't afford home, kids school, etc....

2. ~PC is so underpaid and the student loans, etc... make it almost an impossible option.

I generally do not hear on the news how interesting or exciting PC is... rather just that it is more ~social service. All of which I find very sad. Again, I think a more balanced presentation of PC would go a long way to recruiting. It's a catch 22. More balanced representation may not help the political/lobbying goals. A large in flux of med-school grads would also hurt some efforts to obtain ~support to "enhance recruitment" and "prestige".

 

[deleted87716]

Heh forget it thats the kind of response I have come to expect when discussing the drawbacks of primary care.

I'd certainly hate for the facts to get in the way of your misinformation.

 

[deleted87716]

I generally do not hear on the news how interesting or exciting PC is...

That's because good news is boring. Bad news sells.

 

[digitlnoize]

Med student here. Here's my 2 cents:

FM Pros: good schedule/lifestyle, great pt contact (cradle to grave, etc), short residency, lots of flexibility in terms of practice styles and options, great variety of conditions and I even find the bread and butter ones interesting and important to treat, more outpt based (thus somewhat more control over your schedule/practice/staff/EMR/etc than in a hospital with CEOs etc...)

FM Cons: lower pay than other specialties (for now), less flexible than IM in some ways (you can escape IM into subspecialties or inpt if you change your mind), PC paperwork nightmares, less respect (not a huge concern for me)...

Just a few of my med student thoughts...

 

[JackADeli]

...FM Cons: lower pay than other specialties...

I appreciate your pro/con list. However, this piece, IMHO, is again posted out of context. Lower pay based on pay stub comparison? Or, are you making that statement with any consideration of all the other "pro" items you listed.... i.e. less yrs training, less hours, ?more free time = less hours for the pay on that check stub? It just seems so easy for folks to say, "less pay" without any relative considerations. are you making 180k+/yr with limited call, limited weekends, limited hollidays, Mon to Thur/Friday, 50-60hrs/wk? as compared to what? someone working 80hrs/wk, more call, more weekends, more holidays?

Can PC physicians be paid more? yeh, sure. But, you will need more then a pay check stub comparison to really decide what. I know some will try to site "societal contributions" and worth of labor.... but, again how much labor for how much pay needs to be considered before "low pay" or the favorite "discrepancy" is thrown around.

Otherwise, you are just throwing talking points that may have lobby benefits but also adversely impact recruitment.

 

[bronx43]

I appreciate your pro/con list. However, this piece, IMHO, is again posted out of context. Lower pay based on pay stub comparison? Or, are you making that statement with any consideration of all the other "pro" items you listed.... i.e. less yrs training, less hours, ?more free time = less hours for the pay on that check stub? It just seems so easy for folks to say, "less pay" without any relative considerations. are you making 180k+/yr with limited call, limited weekends, limited hollidays, Mon to Thur/Friday, 50-60hrs/wk? as compared to what? someone working 80hrs/wk, more call, more weekends, more holidays?

Can PC physicians be paid more? yeh, sure. But, you will need more then a pay check stub comparison to really decide what.

Less training, sure. But, even if a PCP works 80 hours a week, and on weekends/holidays, he wouldn't come close to making the same as one of the more lucrative fields. Some of that is/should be attributable to the amount of training, but the gap is still too big.
And don't get me wrong, I don't consider something like gen surg as one of those "lucrative" fields, because general surgeons deserve every penny they make, and then some.

 

[lowbudget]

Wow, JAD. There has to be a reason why you reiterate your position multiple times. But I love a good debate, so I'll bite.

To summarize-
We say: FM is underpaid
You say: No, PCPs are fairly paid because we work less hours, have less training, take less liability.
I say: The system is rigged even if you account for all that.
You say: Maybe, but bottom line, those factors matter.

You may be right. So let's figure it out together... (I'll explain later):

What would you say is general surgery's bread & butter CPT code? i.e. what procedure do you do that's distinctively Gen Surg that you bill that powers your practice?

That's Part A. Part B: Tell me how long does it take for you to do that procedure.

You go first.

 

[JackADeli]

Wow, JAD. There has to be a reason why you reiterate your position multiple times...

Because, some have a clear difficulty with reading comprehension...

I am in no way saying the system is correct or that it comes particularly close to free market function...

My point now as before, is that the "class warfare-esque" argument that ignores all factors but the pay stub does not...

...I am one that honestly believe FM is a difficult field to practice in and should be full of the best, brightest, and academic excellence in order to do it well...

...Can PC physicians be paid more? yeh, sure. But, you will need more then a pay check stub comparison to really decide what...

...To summarize-
We say: FM is underpaid
You say: No, PCPs are fairly paid because we work less hours, have less training, take less liability....

Absolutely false statement! I have in this thread and others stated I believe PC can and probably should be paid more. I appreciate the folks trying to twist and flame the issue and create a ~you against us discussion. However, I don't appreciate misrepresentation to further your debate. You want to discuss/debate something I have NOT said.... you should probably create a new SDN account name and then debate yourself.

Ultimately, you are free to debate these issues how see fit. I think a big part of the problem/fallacy is this need to use comparisons to FM & surgical subspecialties to determine your "worth" and or "prestige". I don't care what social "worth" or "prestige" Bill Gates, Steve Jobs, President, LASIK surgeon may enjoy. I don't sit back and argue I should get "x" dollars because the LASIK guy makes 1k/10minutes. In essence, this "paycheck stube" comparison approach puts FM/PC (and other specialties) ~subserviant to what they are being compared to... i.e. ~ I have less prestige then the LASIK surgeon or dermatologist...

The question/s is/are, what do you think you should be paid? How should it be calculated? To contiunually say, "I am underpaid because specialty "X" makes this much more then I...", IMHO is a problem. It hurts your argument, it creates a "classwarfare-esqu" scenario, it divides you from those that could be advocating along side of you.

As for CPT codes, it is not just a matter of how long the procedure is... I suspect you already know that!

 

[lowbudget]

Lot of noise.

CPT code, please. And, how long it takes you to perform that procedure. And we'll compare bread & butter vs. bread & butter.

 

[JackADeli]

Lot of noise.

CPT code, please. And, how long it takes you to perform that procedure. And we'll compare bread & butter vs. bread & butter.

The noise and mis-representation seems to be coming from you.

As to providing you a CPT code or ?fuel to your little arsen attempt, Nope. I am pretty sure you participated in the last thread that tried to compare CPT... out of context. As you know, the CPT reimbursement for an operative procedure includes pre-operative components, post-operative care and a GLOBAL PERIOD. It is far more then the 30 minutes to 5-6 operative hours any particular procedure takes to perform.

Again an attempt to debate the issue of compensation with pieces taken out of context and... probably not fair comparatives for EITHER party. Though, I am certain the tactic makes for good drama. Or in your words, "lot of noise".]

...To summarize-
You say: No, PCPs are fairly paid because we work less hours, have less training, take less liability....

Finally, I will again state, I have NOT said PC is undeserving of increased compensation. I am NOT making the statement/argument or position you claimed earlier in above quoted excerpt.

 

[neurologist]

It's very simple really. All medical work is "challenging" in intellectual terms, i.e., we all have to use our brains and think about what we do (albeit about different specific things depending on specialty). I will grant that some of us have more physically demanding jobs (I don't think I could stand up for 12 hours doing some crazy microneurosurgical procedure). And some of us, granted, spend more or less time than others in fellowship, residency, etc. Regardless, in the end, all of us, as physicians, use essentially the same basic tool: our intellect.

Thus, since we are really all using the same ultimate skill set, I would propose that we all be paid the same. NOT in the manner of everyone being paid the exact same salary, but rather an arrangement whereby everyone makes the same hourly rate. I'm arrogant enough to propose that an hour of my brainpower is worth the same as that of a cardiologist or a dermatologist or a pathologist or an ENT surgeon, or you name it.

That, to me, makes much more sense than trying to put different values on different services and procedures. It's pretty hard, in my mind, to decide that the professional fee for reading an MRI should be $X and for reading a sleep study should be $Y. They both require the MD to draw on their training and experience to think and interpret. How do you say that the radiologist's thinking is worth more or less than the neurologists? (No smart-ass comments from either specialty, please! ) But it's very easy to simply say "an hour of any physician's time is worth $X" and go from there depending on how much time he works.

That way, we all start off even. And if you're a lazy-ass neurologist who only wants to work 35 hours a week, fine. You'll make less than the ortho surgeon who spends 100 hours in the OR. But you bust your butt for 100 hours, you'll do better than the ortho surgeon who only works 80 hours. You'll also make more if you do more call, so you can trade off money for lifestyle if that's your preference.

That all seems very fair to me. Or am I missing something?

The only problem with this, of course, is setting the basic hourly rate. Maybe we should just base that off a typical FP doc with no hospital work and no call, and go from there.

Thoughts?

 

[JackADeli]

...I would propose that we all be paid the same....an arrangement whereby everyone makes the same hourly rate...

That all seems very fair to me. Or am I missing something?...

Thoughts?

I appreciate the attractiveness of simplicity. Some of the first and basic issues/questions that will arise are:

1. CPT codes and reimbursement actually take into some account that some funds are to cover malpractice and such for a certain service or procedure. An hourly rate will not take into account the differing levels of liability and risk from one service to the next.
2. Are you saying the patients will pay by the hour too? Again, dfferent services are paid in different ~periods. If you take out a gallbladder in say ?80minutes.... are you paid for the rounding time in the hospital and subsequent follow-up? Currently all of that is ~covered under the global period.
3. A by the hour scheme would actually reward innefficient providers and discourage the more efficient ones. A PC physician could see less patients and spend more time. A surgeon could take their time on the gallbladder. Instead of the glorified 30 minutes skin to skin it is more valuable to take 90 minutes.
4. Are you suggesting one hourly rate without accounting anything for additional training? years of experience? etc.... Most hourly rates type employments have raises and adjustments for years and experience even when in about the same position.

The simple extrapolation is not really that simple.

 

[MOHS_01]

Did anyone take economics? Does anyone know what goes into RVU valuations? I'm dying a slow and painful death reading some of these rationalizations.... don't take it personally, anyone. Jack, you are definitely on the right track my friend.

 

[JackADeli]

...Does anyone know what goes into RVU valuations? ...Jack, you are definitely on the right track my friend.

Yep, I went to the national conference/s. I attended the talks about the changes and the valuations, etc.... Thus, while not an expert, I do have an idea that the RVU calculations, etc... are a great deal more then just a one time reimbursement to the MD/DO. Again, not saying I like or agree with the values assigned to the different components within the RVUs. I am saying people need a far better understanding when trying to come up with their beliefs and ideas and/or simply comparing CPT codes or paycheck stubs.

http://www.acro.org/washington/RVU.pdf

 

[MOHS_01]

Yep, I went to the national conference/s. I attended the talks about the changes and the valuations, etc.... Thus, while not an expert, I do have an idea that the RVU calculations, etc... are a great deal more then just a one time reimbursement to the MD/DO. Again, not saying I like or agree with the values assigned to the different components within the RVUs. I am saying people need a far better understanding when trying to come up with their beliefs and ideas and/or simply comparing CPT codes or paycheck stubs.

http://www.acro.org/washington/RVU.pdf

Yes, most definitely.... agreed x 2... but realize that you are arguing with someone who has no interest in these pesky little trivial facts.

 

[neurologist]

I appreciate the attractiveness of simplicity. Some of the first and basic issues/questions that will arise are:

1. CPT codes and reimbursement actually take into some account that some funds are to cover malpractice and such for a certain service or procedure. An hourly rate will not take into account the differing levels of liability and risk from one service to the next.

Excellent points, thanks.

The way I see it, my proposal covers physician time, period. Much in the same way your mechanic, plumber, etc, charge you for "parts and labor," I am talking just about the labor. The other stuff (that artificial joint you put in, the gloves you wore, risk and malpractice differentials for different services, etc) would be the "parts" component. Not too dissimilar from how procedures are billed for both "technical" and "professional" components. But the "professional" part would be the same hourly rate regardless of the procedure, not varying from one procedure to another.

2. Are you saying the patients will pay by the hour too? Again, dfferent services are paid in different ~periods. If you take out a gallbladder in say ?80minutes.... are you paid for the rounding time in the hospital and subsequent follow-up? Currently all of that is ~covered under the global period.

Yes, patients would pay by the hour. If they want to sit there and tell me every ache and pain that they've had since 1952 regardless of it's relevance, they should pay for my time. If they can be in and out in 10 minutes for something simple and focused, that's fine too.

3. A by the hour scheme would actually reward innefficient providers and discourage the more efficient ones. A PC physician could see less patients and spend more time. A surgeon could take their time on the gallbladder. Instead of the glorified 30 minutes skin to skin it is more valuable to take 90 minutes.

On the surgical side, I think we all realize that there are increasing risks to keeping patients under anesthesia for longer periods of time. And honestly, I doubt any surgeon would want to spend any more time on one patient than necessary.

I grant that this might be a little more of a problem on the non-surgical side, but still, if the MD has a practice where patients need to be seen, he is going to be dis-incentivized from killing his whole day with 2 or 3 patients, because the ones who can't get in to see him leave the practice and eventually his practice dries up. Plus, since the patients are paying by the hour, they have an investment in getting the job done as quickly and efficiently as possible.

4. Are you suggesting one hourly rate without accounting anything for additional training? years of experience? etc.... Most hourly rates type employments have raises and adjustments for years and experience even when in about the same position.

I suppose there could be some gradation of salary based on training/experience. I realize that's complex and I haven't got a quick suggestion on how to do it yet. I think there may have to be some kind of "outcomes based" gradation rather than simple "years on the job" system.

 

[MOHS_01]

neurologist,

I understand what you are saying, really, I do. I can see this line of reasoning. Are you familiar with the varying theories of pricing? What you are describing is the "labor theory of value". I do not agree with the originators of this train of thought any more than I agree with the reasoning as applied here.

What we must consider here is that medicine, as it is traditionally practiced, is a service industry provided in a one-on-one fashion. It has quantifiable units of service, and while the CPT system makes an effort to standardize this, it fails in many respects. We all are aware that not every 99203 = ever other 99203... and the same can be said for the majority of procedural codes as well. The "product" being purchased are the ends -- the results -- not the means, which is what the CPT system attempts to codify. The "ends" are not a guaranteed, quantifiable, equitable, or even definable unit, however, which is why the "value based purchasing" mechanism has yet to catch on.

There are two issues being discussed here -- the pricing mechanism of individual services and net provider compensation. Some seemingly consider these two separately, something that I am not in favor of. Our services are, in reality, rendered on a per unit basis; it is only logical to pay for them as such and any attempt to alter the payment from this per unit basis has an inherently perverse incentive program.

So how should we price the individual services? Ideally it would ultimately be left the agreed upon price between the parties directly involved... but the transition to this mechanism on a widespread scale would be chaotic and we would have a ton of out-of-work and bankrupt providers in the process (there is NO way that the market would have arrived at price levels anywhere near our current price levels for procedures, imaging, facility fees, etc -- E&M is possibly even undervalued, actually).... so, at this point, we are left with a choice set of imperfect options. The option that factors in the cost of providing said service, including the risk, labor, and time involved would seem to me to be the most sound alternative. That is what the RBRVU system was designed to do; unfortunately it, like all things, falls prey to political forces....

As for how the provider should be compensated -- surely you would not argue against a system whereby he or she who works longer or more efficiently would be earn more? Surely you do not suggest either a straight salary or straight hourly wage rate....

 

[JackADeli]

...realize that you are arguing with someone who has no interest in these pesky little trivial facts.

Yep, I got that many threads ago. There is a obvious undercurrent and overt agenda.

If you want money, you need to be sure you appear to be the most unfortunate. I understand that effective marketing. The problem is that that effective marketing hurts and goes against the other supposed efforts, i.e. wanting to recruit the best and brightest into PC. Crying and using ~deceptive and tabloid-esque dramatic paycheck stub comparisons may gain you public sympathy and political endorsements.

However, such conduct alienates those that should be your peers and discourages otherwise ~above average intelligence individuals from joining your field. Why would they want to join a field that you hear so often how miserable it is. The contradictions in the arguments of being a victim, wanting to be Ghandi and wanting money of a ~surgeon, IMHO are what degrade the prestige and credibility.

Again, I think the system can use some change. I am not opposed to PC being better compensated. But, some acurate truth in advertising and less class-warfare would, IMHO go a long way..... When seeking political favor, I am reminded by that nagging voice in my head about "deal with the devil..."

 

[lowbudget]

I think you know the direction I'm going. Agree with JAD that time/effort/malpractice needs to be accounted for. And, agree with Moh that those factors are accounted for by the RVU's. Let's pretend for a second that the RVU system is perfect.

For me, my bread & butter "procedure" is the "office visit". A Level 4 visit (CPT 99214) which can take between 15-30 min. According to Trailblazer (http://www.trailblazerhealth.com/Tools/Fee%20Schedule/MedicareFeeSchedule.aspx), Medicare reimburses $94.30. On a good day, if I bang it out in 15 min, that's $377 per hr. If I get bogged down at 30 mins, that's $188 per hr.

For you, a lap chole (CPT 47564) pays $809. If it takes you 45 min with a 15 min post-op visit, that's $809 per hr. If it takes you 60 min with a 15 min post-op, that's $647 per hr.

But let's take into account malpractice, practice expenses, and "work". "Work" (as you can see from Moh's website above) already accounts for time. So, if we control for Geographic Practice Costs (set it =1), *and* if we hold malpractice, practice expense, and work constant, a lap chole yields $36 per RVU but a level 4 office visit yields $23.6 per RVU. We hold those factors constant by taking $Fee div RVU.

So, it doesn't matter how long I work, how many q3 calls, how many in house calls I take. If I consistently code 99214, I will never catch up to you if you code 47564 *in the same time period*; no matter how you look at it.

Thoughts?

 

[JackADeli]

...A Level 4 visit (CPT 99214) which can take between 15-30 min. ...if I bang it out in 15 min, that's $377 per hr. If I get bogged down at 30 mins, that's $188 per hr.

For you, a lap chole (CPT 47564) pays $809. If it takes you 45 min with a 15 min post-op visit, that's $809 per hr. If it takes you 60 min with a 15 min post-op, that's $647 per hr...

Thoughts?

Very few lap choles I performed involved just 85 minutes. Most involved a ~drawn out evaluation in the ED, then stuck in the ED/hospital waiting for OR time, post-op family conference, post-op patient check, post-op day 1 check and possible discharge, and as many post-op visits as the PATIENT wanted within the global period.... just to name a few. Your analogy/comparison suggests a lack of understanding in what another specialty is actually doing to earn their RVUs/cash. Which goes right back to my original point of out of context comparison of check stubs.

...The question/s is/are, what do you think you should be paid? How should it be calculated? To contiunually say, "I am underpaid because specialty "X" makes this much more then I...", IMHO is a problem. It hurts your argument, it creates a "classwarfare-esque" scenario, it divides you from those that could be advocating along side of you.

As for CPT codes, it is not just a matter of how long the procedure is... I suspect you already know that!

...Again, I think the system can use some change. I am not opposed to PC being better compensated. But, some acurate truth in advertising and less class-warfare would, IMHO go a long way..... When seeking political favor, I am reminded by that nagging voice in my head about "deal with the devil..."

Again, your simplification overlooks the additional time involved with other specialties services provided. I do not think trying to value your labors of a finite 15 minute visit in comparison to another specialties does either specialty justice. It is fairly apples and oranges. The discussion/debate is IMHO a distractor.

 

[Lesassier]

Not to distract from the sidebar in alternate payment strategies... but returning to the inverse of the original post... How bout paying specialists more as a way to increase primary care recruitment with the caveat that the more only comes with relocation to underserved areas.

I suspect that part of the lack of interest in primary care in highly desirable living areas has to do with specialist saturation. Primary care obviously is practiced differently and the spectrum of practice is greatly diminished when specialist counterparts can so easily assume that part of your practice. So not only are hospital privileges harder to come by, but it is more difficult to market your services when patients all expect to go to the 'best' and most experienced in a procedure.

I imagine the contracted spectrum of primary care in over-saturated specialist regions would not be as appealing to medical students. So lets ship some of the specialists out with a nice carrot.

 

[lowbudget]

Your analogy/comparison suggests a lack of understanding in what another specialty is actually doing to earn their RVUs/cash. Which goes right back to my original point of out of context comparison of check stubs.

Hmm... true. Sounds pretty crappy to be a general surgeon, no offense. Glad I'm a family doc.

 

[JackADeli]

...but it is more difficult to market your services when patients all expect to go to the 'best' and most experienced in a procedure.

...lets ship some of the specialists out with a nice carrot.

Interesting, but.... A specialist has a different and somewhat refined arsenal. Shipping them to where ever would likely equate a decreased volume of work. A home sales person makes money by selling homes, a home builder by building homes, a PC physician by providing PC medicine, surgeon/etc... by providing surgical care. A PC physician needs far smaller population to have a workable market then a surgeon/etc...

If one wants a practice based on large numbers of procedures, you really should consider a primarily procedural based residency. It is somewhat ludicrous to suggest the procedural specialist leave the larger market so the PC physician can have larger volume of procedural practice.

 

[JackADeli]

Very few lap choles I performed involved just 85 minutes. Most involved a ~drawn out evaluation in the ED, then stuck in the ED/hospital waiting for OR time, post-op family conference, post-op patient check, post-op day 1 check and possible discharge, and as many post-op visits as the PATIENT wanted within the global period.... just to name a few...

Hmm... true. Sounds pretty crappy to be a general surgeon, no offense. Glad I'm a family doc.

No offense taken. My point is that plenty of med-students, when faced with a little more reality, may find surgery to be in their opinions "crappy". They might also realize FM/PC is more to what they envision their practice goals.

 

[lowbudget]

Again, your simplification overlooks the additional time involved with other specialties services provided. I do not think trying to value your labors of a finite 15 minute visit in comparison to another specialties does either specialty justice. It is fairly apples and oranges. The discussion/debate is IMHO a distractor.

I don't think it's a distractor. Bottom line, people are economic actors. At the end of the day, any one who looks out for their own interests will maximize the ratio between their marginal revenue to marginal cost. I don't care how you calculate it. I don't care if the numbers don't perfectly fit in a "simplistic" economic model that explains human behavior or systemic inefficiencies that obstruct free markets in how services are delivered. You can choose to dismiss the model & that's ok. I think it's universally accepted that people want to maximize value.

Actually, when I just recalculated the numbers in another way (on a $ per RVU per hour), FM really beats out Gen Surgery. So, I actually don't feel too bad... but I do feel bad for Gen Surg because given all the work they put in. Maybe Gen Surg is underpaid. Maybe they should say something.