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[kumar28]

what does obama winning election mean for primary care..better reimbursements? less struggle with insurance companies??

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[deleted87716]

what does obama winning election mean for primary care..better reimbursements? less struggle with insurance companies??

Details (such as they are) here: http://www.barackobama.com/issues/healthcare/

He's not advocating a single-payer system, but he is advocating universal coverage.

The only thing he says specifically about reimbursement is to support pay-for-performance (or non-pay for non-performance, which is probably more like it). Since P4P has not yet been shown to improve quality, and has lots of potential unintended consequences, I'm not sure that's a good thing.

 

[Dr McSteamy]

obama won't do chit.

he's all talk. and no walk.

 

[lilnoelle]

I read through the AAFP's comparison of the two candidate's proposals for healthcare and they seem to favor O'Bama.

I would consider myself a conservative and am nervous about O'Bama's lack of a previous record (amongst other things) but I am curious as to which candidate will have a more positive effect on primary care physicians.

What do you guy's think?

 

[MOHS_01]

IF the AAFP is favoring Obama, they need to have their prescriptions changed. Regardless of what he does with healthcare the remainder of his policies will do more harm to you than the uninsured ever thought of doing.

As far as "what's best for primary care" -- everyone seems to be a little confused on the matter as far as who the actual beef is with. If you really want to effect change, the first order on the agenda would be to address the AMA, for they set the relative pricing; Medicare et al simply apply their respective conversion factors to the RVU.

Now I understand that PCP's will argue that the RUC is skewed toward proceduralist specialties, which is true -- so address the issue. Perhaps a good compromise would be to disband the RUC and set up something more in line with congress -- equal respective specialty representation on one side and a demographically driven representation on the other side -- or perhaps a blended mix of this and the current system where there are more seats or mathematically weighted votes based upon physician and specialty impact.

The very bottom line is that Obama's plan (as I understand it) -- mandatory health insurance coverage with the creation of a large, federally backed health insurance organization (read Fannie and Freddie, and we all should know how that has worked out), with governmental subsidies provided to anyone who falls below 400% of the federal poverty level, will create huge shifts in practice payer class, crippling the only crutch that is propping up the system currently.

Not that McCain has the best answer here, but his plan is more palatable (for me at least, and I would not be affected as much as many b/c I see a large percentage of Medicare already). Obama scares the hell out of me.

 

[chibihamsta]

Most industrialized countries have tax-funded national health insurance programs (Canada, Germany, UK, Japan), but we don't.

Health insurance (private or public) means access to care. The 40 million+ people in this country who don't have insurance are going to get access to care the only way they know how: through our ER's. What that means is higher medical costs, inefficient use of resources, more unnecessary consults in the ER, primary care provided by ER docs, and congested ERs and waiting rooms.

We need universal health insurance coverage so PCPs can manage chronic medical diseases before they get out of control and take care of small acute issues in the office.

How else can we even hope to improve health care in this country without universal coverage?

 

[MOHS_01]

Most industrialized countries have tax-funded national health insurance programs (Canada, Germany, UK, Japan), but we don't.

...and most industrialized countries do not face the same sort of domestic and foreign issues and obligations that we do. I would also like to point out that their relative taxation is comparable to ours, and in many cases less oppressive than ours (and they used Illinois, some states are even worse) -- and this is without the burden of providing a NHI. Their demographics are different, their lifestyles are different, their relative use of technology and innovation is different. A direct comparison cannot reliably made.


http://www.mercer.com/pressrelease/details.htm?idContent=1287670

Health insurance (private or public) means access to care.

False assumption # 1: insurance does not equal access. Ask any Medicaid patient (and more and more Medicare patients) how "easy" it is to secure care. "Good" insurance may mean easier access, but given the proliferation of high deductible plans "access" unfortunately does not equate to "availability" or "affordability".

The 40 million+ people in this country who don't have insurance are going to get access to care the only way they know how: through our ER's. What that means is higher medical costs, inefficient use of resources, more unnecessary consults in the ER, primary care provided by ER docs, and congested ERs and waiting rooms.

True, at least in part -- but you do realize that you are largely arguing accounting, correct? The true "costs" to the system associated with writing a Rx for otitis media should be very little to no higher in a urgent care clinic than a PCP office -- for MD time, resources expended, etc are similar in both situations. The bill will be much higher, however, due to the effects of cost shifting. The real "cost" of this situation, as you point out, is congested ER's. There are numerous ways to address this aside from NHI, however -- think Wal-Mart walk-in clinics, expansion of Health Dept offerings, etc. Further, we should discontinue the non-punishment of this bad behaviour -- without repercussions there is no incentive to act responsibly. Run to the ER b/c you were watching the soaps during the day and don't get your check next month sort of thing.....

We need universal health insurance coverage so PCPs can manage chronic medical diseases before they get out of control and take care of small acute issues in the office.

Again, if you don't encourage responsible activity, including wellness, there is little incentive for folks to go to their PCP in the first place.

How else can we even hope to improve health care in this country without universal coverage?

Well, there are a few ways.... we have a couple of options -- we can either wrestle some of the control away from private insurances, do away with the barriers to individual policy coverage, and make health insurance truly portable between jobs. Right now small companies cannot afford "good plans" and it becomes prohibitively expensive to try when just one employee gets sick. Our unemployment rate is 6% -- the uninsured number should not exceed this -- we should promote a business environment where every employer can afford to offer health insurance benefits; if employers choose not to offer benefits, perhaps the better employees can leave for another job -- eventually the employer would get the hint. I would not argue against some form of tax credit that would allow for people to purchase coverage in the event that their employer does not offer it -- in which cases the employer should be face some sort of tax (which really equates to a fine).

Beyone coverage, cost containment must be addressed -- something that the proposed NHI plans do not adequately address. We have to do a better job of determining what treatments and interventions work and are cost-effective and which ones are not. IT adoption will help with some of the inefficiency issues.

The single biggest problem that I see with Obama's plan is that the new insurance class developed is likely to swell well beyond anyone's expectations. This new risk pool will not only absorb a sizable amount of the currently uninsured, it will siphon off many of the currently privately insured (who will buy individual coverage when they can save their own money and utilize government subsidies? What company will continue to pay for private insurance once accounting informs them that they would be better off dropping their current insurance plan and paying the penalty tax?).

 

[lilnoelle]

What do you think of this type of concept?

http://www.medscape.com/viewarticle/580345?src=mpnews&spon=18&uac=42325EV

 

[MOHS_01]

I think that the concept is great. In some ways what you are essentially doing is making the PCP a babysitter / parent, carefully guiding and encouraging folks to do that which they should already do themselves. It would boost the pay for PCP's and get people who need specialists to them earlier (hopefully) when their problems are more easily managed. As with everything, the devil is in the details however; reimbursement would have to structured such that it does not devolve into capitation and there cannot be perverse incentives for restricting or rationing care....

 

[deleted87716]

I think that the concept is great. In some ways what you are essentially doing is making the PCP a babysitter / parent, carefully guiding and encouraging folks to do that which they should already do themselves. It would boost the pay for PCP's and get people who need specialists to them earlier (hopefully) when their problems are more easily managed.

The medical home concept has nothing to do with "babysitting" or referrals. Primary care is cheaper than specialist care, and in many cases, better.

Sure, it's what we're already doing now...we're just not being paid enough to do it.

 

[MOHS_01]

The medical home concept has nothing to do with "babysitting" or referrals. Primary care is cheaper than specialist care, and in many cases, better.

Sure, it's what we're already doing now...we're just not being paid enough to do it.

Now we don't often disagree, but....

Quote:

Many reports have shown that Americans pay more per capita for health care, and yet are more likely to die prematurely from preventable and treatable diseases than people in other developed countries.

The secret to reversing this, said Geisinger's Chief Technology and Innovation Officer Dr. Ronald Paulus, is paying primary care practices to look out for patients.

"It provides a centralized place for a consumer, patient, to receive their care," Paulus said in a telephone interview.

The primary care medical staff are available around the clock to refer patients to specialists, provide direct care, help with billing and other queries.

"They remain advocates for the patient and his or her family," Paulus said.

This approach contrasts to the decades-old concept of a "gatekeeper" who would approve all specialist care.

"Their financial incentive was not necessarily to provide the most care. They made the most money if they could get by with a lower amount of care," Paulus said.

The medical home concept instead pays a practice up front to take care of patients and gives them a large bonus if they meet targets, such as controlling blood sugar, cholesterol, preventing heart attacks and screening for cancer.

"They can't scrimp to get efficiency," Paulus said. "We paid in advance for the actual work but we earned the savings on the back side."

"The doctors made more money -- they were happy. The health plans saved money -- they were happy. Patients got more care -- they were happy. But someone has to provide the funding to kick-start the program."



Now the first two highlighted quotes is where the "babysitting" inference comes from, while the last last highlighted quote sure sounds a lot like capitation rehashed under a different name.

As far as the specialist vs PCP -- age old debate with no clear answers based in solid fact from what I can tell. I really don't care -- my job is relatively safe from my experience.

 

[deleted87716]

Now the first two highlighted quotes is where the "babysitting" inference comes from

I don't know how you got "babysitting" out of all that, unless you consider coordination of care and "controlling blood sugar, cholesterol, preventing heart attacks and screening for cancer" to be "babysitting."

my job is relatively safe from my experience.

Ditto.

 

[MOHS_01]

I don't know how you got "babysitting" out of all that, unless you consider coordination of care and "controlling blood sugar, cholesterol, preventing heart attacks and screening for cancer" to be "babysitting."

My thoughts after reading this article: this sounds curiously enough like tried and failed capitation (lipstick, pig, capitation) -- the transfer of risk associated with patient compliance and outcome from the insurer to the provider. When the provider assumes a role where their livelihood (read compensation) is directly tied to the actions of the patient, the provider becomes responsible for most aspects of their care, including coordination of care and compliance. Now PCP's do all of this already to a large extent -- which does sound a lot like parenting / babysitting to me, and I do not mean that as derogatory in any way -- medicine has traditionally always been like this, a paternalistic profession.

Ditto.

Good docs will always be in demand -- the real question that remains is will they be adequately and appropriately compensated (doubtful)... and if not, how many years before the quality of the physician pool reflects the downgrade in societal relative worth?

 

[deleted87716]

My thoughts after reading this article: this sounds curiously enough like tried and failed capitation

There are similarities, but it's not the same thing.

When the provider assumes a role where their livelihood (read compensation) is directly tied to the actions of the patient, the provider becomes responsible for most aspects of their care, including coordination of care and compliance.

We're already responsible for it. We're just not being paid to be responsible for it.

Poorly-implemented pay-for-performance or patient centered medical home initiatives can have unintended consequences (e.g., "cherry-picking," "chart buffing," etc.), and many of us (including myself) are skeptical that it'll ever be done right. Preliminary reports from government P4P (Pay-for-Performance) pilot sites aren't particularly encouraging as far as the effort-to-reward ratio and quality improvement outcomes.

It's worth noting that P4P and PCMH (Patient-Centered Medical Home) are not the same thing, but they're often talked about as if they were. You can have one without the other.

how many years before the quality of the physician pool reflects the downgrade in societal relative worth?

IMO, we're already seeing it.

 

[MOHS_01]

There are similarities, but it's not the same thing.

Please help me here (and absolutely no sarcasm intended) -- what is the difference? Is there some FFS component in addition to the "medical home" rate? And if so, does this essentially amount to a PCP subsidy program to compensate for perceived inadequacies that they lack the political power or will to change? Are there P4P incentives? I am sure that there are as many different setups as there are institutions rolling them out, but what do you see as the general trend? I am so far removed from this concept or way of thinking for that matter that I really don't have much of a frame of reference...

We're already responsible for it. We're just not being paid to be responsible for it.

True, from a personal and professional responsibility standpoint PCP's are the front line folks responsible for these tasks... but I maintain that it is fundamentally different when you become directly "on the line" or "at risk" for patient compliance (medical liability issues aside, which this does nothing that I can see to address). It is my belief that PCP's should be better compensated for this pain-in-the-a** aspect of clinical medicine; it is the manner that is suggested that leaves for want.

Poorly-implemented pay-for-performance or patient centered medical home initiatives can have unintended consequences (e.g., "cherry-picking," "chart buffing," etc.), and many of us (including myself) are skeptical that it'll ever be done right. Preliminary reports from government P4P (Pay-for-Performance) pilot sites aren't particularly encouraging as far as the effort-to-reward ratio and quality improvement outcomes.

You can say that again -- in this PCMH & P4P system non-compliant as well as the frankly ill will likely find themselves searching for docs, regardless of "coverage status" -- at least at the beginning. Once this problem is widespread enough (I give it one year), contracts from payors will likely change such that providers enrolled in their "incentive programs" will not be allowed to discriminate based upon patient compliance, etc... and you are also quite correct in stating that the P4P pilot sites results were pretty lame.

IMO, we're already seeing it.

Now I know that was not a dig aimed at anyone in particular....

... but I would have to agree based upon my experience with the residency program and medical students that I deal with now as faculty. Their intelligence levels seem fine (as demonstrated by their board scores, etc) -- but the work ethic is nothing short of shocking sometimes.... the mere thought that one can license and print money working 3-4 days per week, not seeing many patients per day, and doing a little Botox, fillers, and lasers on the side is prevalent... and nuts.

 

[deleted87716]

Is there some FFS component in addition to the "medical home" rate?

Yes. The typical proposals would pay primary care practices a management fee for care coordination in addition to fee-for-service.

does this essentially amount to a PCP subsidy program to compensate for perceived inadequacies that they lack the political power or will to change?

I wouldn't say that. It does get around the issue of crappy reimbursement for ambulatory care CPT codes, which I think still needs to be addressed.

Are there P4P incentives?

Usually. P4P is one way to gain some savings to help offset the additional monies being paid for management fees.

what do you see as the general trend?

Probably some mix of the two.

It is my belief that PCP's should be better compensated for this pain-in-the-a** aspect of clinical medicine; it is the manner that is suggested that leaves for want.

I agree.

I know that was not a dig aimed at anyone in particular....

Not at all. I was referring to some of our newest crop of family physicians, as evidenced by what's happened to the board pass rates for first-time test takers.

 

[iatrosB]

IMO, we're already seeing it.

For sure, I even see it in my colleagues.

On my recent inpatient peds sub-I, a FM intern was whinning the whole time about not wanting to work the long hours in the peds hospital and saying they would never need to know how to manage sick kids in the hospital anyway cause they're going to work 9-4, Monday through Thursday, outpatient only, and all "healthy" people. Lazy! Gives FM a bad name

 

[secretwave101]

We need universal health insurance coverage so PCPs can manage chronic medical diseases before they get out of control and take care of small acute issues in the office.

I can see how this is important to the system of U.S. medical care, but why exactly does the average primary care doc want it to happen? Everybody with no money going to ER's is terrible medical care, but I don't see why business-minded primary care docs would fret about that.

Thanks to the government's inefficient provision of medical care for all through ER's, primary care docs can turn down poor-paying patients (because they are covered, after all) and open their doors to well-insured patients who have a head on their shoulders, care about their own health and actually comply with agreed-upon treatment plans.

Seems like Obama's plan just forces private docs to be ER's. This doesn't seem like a fun idea, given how poorly the government pays for anything. Think, for example, how long everyone has agreed that teachers are paid waay to little for what they do. Perhaps this is because their entire profession is paid for by government. Why do that to medicine...especially when the government is NOT paying for doctor's education (as is the case in other countries with socialized medicine)?

Creating a system of "universal" medical coverage is unethical to doctors unless there first is a system of "universal" training for them. Otherwise, they'll be in debt into their 4th generation (not that passing on debt to future generations belabors the thinking of anyone in the current D.C. regime).

 

[deleted87716]

IF the AAFP is favoring Obama, they need to have their prescriptions changed. Regardless of what he does with healthcare the remainder of his policies will do more harm to you than the uninsured ever thought of doing.

Obama clearly states that he does not support caps on malpractice awards, despite the evidence that states with caps are doing much better than those without in terms of the cost of malpractice coverage and physician retention.

That's not good, IMO.

 

[Joe Richards]

Now we don't often disagree, but....

Quote:

The medical home concept instead pays a practice up front to take care of patients and gives them a large bonus if they meet targets, such as controlling blood sugar, cholesterol, preventing heart attacks and screening for cancer.

"They can't scrimp to get efficiency," Paulus said. "We paid in advance for the actual work but we earned the savings on the back side."

"The doctors made more money -- they were happy. The health plans saved money -- they were happy. Patients got more care -- they were happy. But someone has to provide the funding to kick-start the program."


I would like to make several point here.

1. There is truly no adequate and accurate method to MAKE SURE that individuals will stay at target blood sugar, or control their diet or anything else. We can TRY. But the patient is responsible for their own behavior.
So to base a doctors PAY on performance or for meeting guidelines is irresponsible and won't help the patient.

We can tell a patient his blood sugar is high, he is obese and can get cancer and he needs to stop smoking. He can look at us and say he will lose weight, stop smoking and get a colonoscopy right away. Next month he will say the same. Some take your advice and some won't.

2. Paying someone in Advance for something is just stupid. I would not pay my mechanic or contractor in advance. Why pay your doctor in advance?
Unless he is practicing retainer medicine and you get something for the retainer.

3. The concept of a medical home is a sound concept if we are trying to get the patient to get better overall care by providing care more efficiently. Like blue dog said, many times a patient can get better care in the primary care setting than the specialty setting.

However, if they were thinking about "babysitting" or paying in advance, then they are way off.

They need to pay more per visit. That means they need to place equal value or at least some form of proportional value to the Medical visit vs. the surgical or procedural visit.

 

[MOHS_01]

.... They need to pay more per visit. That means they need to place equal value or at least some form of proportional value to the Medical visit vs. the surgical or procedural visit.

Joe,

I'm not sure that I follow -- unless you are advocating that primary care E&M should have inflated fee schedules compared to specialist E&M... which, conceptually, would constitute a subsidy of sorts. One of the most popular misconceptions that I have to correct when dealing with both my primary care and surgical colleagues has to do with "what I get paid for a procedure vs. what they get paid for the very same procedure". There seems to be a quite common fallacy that, as a dermatologist, I somehow get paid better to do the same thing - which is completely, 100% false.

Regarding "procedural visits" -- these often have an E&M component as well as the procedure code. If there is not substantial E&M independent of the diagnosis being treated with the procedure, then the E&M for that service is often bundled (read not paid). Some minor procedures are probably a little overvalued; by that very same token some of our larger procedures are grossly devalued relative to time, cost, and risk committments.

 

[Joe Richards]

Joe,

I'm not sure that I follow -- unless you are advocating that primary care E&M should have inflated fee schedules compared to specialist E&M... which, conceptually, would constitute a subsidy of sorts. One of the most popular misconceptions that I have to correct when dealing with both my primary care and surgical colleagues has to do with "what I get paid for a procedure vs. what they get paid for the very same procedure". There seems to be a quite common fallacy that, as a dermatologist, I somehow get paid better to do the same thing - which is completely, 100% false.

Regarding "procedural visits" -- these often have an E&M component as well as the procedure code. If there is not substantial E&M independent of the diagnosis being treated with the procedure, then the E&M for that service is often bundled (read not paid). Some minor procedures are probably a little overvalued; by that very same token some of our larger procedures are grossly devalued relative to time, cost, and risk committments.

I understand that.
But, the average Derm makes 300 K / year. That is a fact. Actually many make more because of cosmetic procedures but we can't count that.

Every specialty makes significantly more than Primary care.

That is because they get paid much more for specific procedures done their specialty.

So, Primary care needs to get paid by either a different set of codes with different pricing or higher rates for the same codes.

WHY?

Because primary care is lowest paid of specialties. And this is so because we don't do nearly as many procedures and the system pays for most procedures much more than office visits.

That is the bottom line.

We can call I subsidy if you want. I don't think it is. I call it equal pay.

 

[MOHS_01]

I understand that.
But, the average Derm makes 300 K / year. That is a fact. Actually many make more because of cosmetic procedures but we can't count that.

Every specialty makes significantly more than Primary care.

That is because they get paid much more for specific procedures done their specialty.

So, Primary care needs to get paid by either a different set of codes with different pricing or higher rates for the same codes.

WHY?

Because primary care is lowest paid of specialties. And this is so because we don't do nearly as many procedures and the system pays for most procedures much more than office visits.

That is the bottom line.

We can call I subsidy if you want. I don't think it is. I call it equal pay.

Joe,

First let me say that this is not meant to be confrontational or dismissive in any way -- I am all for PCP's earning incomes greater than they currently do; it is the manner suggested on how this is to be accomplished that I take issue with.

I would like to stress to anyone interested that cosmetics are not the path to riches that many would have you believe. Expensive upfront capital requirements, low margins (in areas with any competition), demanding patients, etc -- are the reasons that most who enter the arena exit it within a year or two disappointed with the experience.

"Equal pay" without "equal work" is a socialistic concept that would ultimately be doomed for failure and has no place in our quasi-capitalistic society.

Before everyone jumps out of their skin, go back through my old posts -- you will find that I do not bash PCP's and am quite sympathetic to their plight. I am a staunch advocate, however, of appropriate pay for any and every service -- something that today's system is performing poorly at by my estimation.

To address the pay discrepancy (and I know before saying this that it will not be the most populist opinion that I have ever pronounced) -- to some extent it exists for good reason. In a fair and just system the financial rewards (since cash remuneration is the variable which "does not matter" but everyone measures and bitc**s about) would be somehow indexed according to the length and rigors of obtaining a spot and subsequent training (while this can be hard to measure, it needs to be taken into consideration --relative competitiveness, lifestyle sacrifices, and risks assumed should all be factored in).

From my vantage point PCP's are underpaid for all of the services that they provide due to the bundling that is inherent to the current E&M system. I have advocated for the creation of a series of codes that would be treated for billing purposes the same as minor procedures; one code would be for diabetic counseling, another for hypertension monitoring, one for coordination of care, etc. These would be add-on codes that are not subject to the multiple surgery reduction, and would go a long way in addressing the shortcomings of complex E&M payment.

Speaking specifically to the "equal pay" comment -- that exists within the current system. If I perform a level two new patient on a psoriasis, acne, eczema, lupus, etc, patient, I get paid the very same as a the internist, FP, or pediatrician who performs the same service. If I decide that a biopsy is warranted, I get paid the exact same as well. Disease mix, procedure mix, etc comes into play here -- but not as much as sheer volume does. I see, on average, 50-60+ patients per day on general derm days. (It is not easy, not fun, very tiring, and, frankly, I hate it -- but I really have little choice because of the sheer demand for dermatology services. Believe it or not, virtually everyone understands and is appreciative) The vast, vast majority are for acne, eczema, warts, or skin checks. It is the rare wart that I freeze, so for greater that 80% of my patients it is straight E&M.

Surely one cannot tell me that they did not know going in what their expected pay would be once they finished training -- if so, they were ill prepared and ill informed and justly reap what they sow. If financial remuneration is to be the #1 measure, one should have chosen rads, some ophtho subspecialty, rad onc, neurosurgery, plastics, interventional cardiology, dermpath, etc.

 

[deleted87716]

In a fair and just system the financial rewards (since cash remuneration is the variable which "does not matter" but everyone measures and bitc**s about) would be somehow indexed according to the length and rigors of obtaining a spot and subsequent training

Let's be honest. The only reason derm is so competitive is that it pays well and has a good lifestyle. There's nothing particularly "rigorous" (intellectually or physically) about the actual practice of dermatology relative to other medical specialties, including primary care.

If I perform a level two new patient on a psoriasis, acne, eczema, lupus, etc, patient, I get paid the very same as a the internist, FP, or pediatrician who performs the same service. If I decide that a biopsy is warranted, I get paid the exact same as well.

This is true only for Medicare. Nearly every commercial insurance plan reimburses specialists at a higher rate than primary care for the same CPT codes.

Surely one cannot tell me that they did not know going in what their expected pay would be once they finished training -- if so, they were ill prepared and ill informed and justly reap what they sow.

What are you suggesting, that we should all just quit whining and suck it up? Give me a break. The reimbursement discrepancies and inequalities in our current system are strangling primary care in this country. The fact that I knew what I was getting into doesn't change that.

 

[MOHS_01]

Let's be honest. The only reason derm is so competitive is that it pays well and has a good lifestyle. There's nothing particularly "rigorous" (intellectually or physically) about the actual practice of dermatology relative to other medical specialties, including primary care.



This is true only for Medicare. Nearly every commercial insurance plan reimburses specialists at a higher rate than primary care for the same CPT codes.



What are you suggesting, that we should all just quit whining and suck it up? Give me a break. The reimbursement discrepancies and inequalities in our current system are strangling primary care in this country. The fact that I knew what I was getting into doesn't change that.

OK -- I'll be honest.


Yes, the balance between lifestyle and income, along with the capacity to legitimately perform cosmetics, makes dermatology competitive. The income per unit work is not as great as everyone would like to believe, however. Look at MGMA median, Medical Economics annual survey, even the AMA's socioeconomic surveys -- you will find that the regular dermatologist sees a ton of patients for less pay than many specialties. Folks who either have a high elective component or strong procedural mix do better, and they skew the average. You are mistaken, however, regarding the relative difficulty of being a good dermatologist -- I know not one dermatologist who finds medical dermatology unchallenging -- not one -- and given the talent pool that comprises dermatology, that is a strong statement. Likewise, the surgery that I perform day in and day out requires a great deal of effort (and hopefully skill) to do well. I perfom a service that local plastic and head & neck surgeons either do not feel comfortable with or feel is beneath them. The reconstructive techniques and skills required are harder to master than many give credit. Having said all that, I am NOT attempting to belittle the very difficult job of a PCP. There are reasons behind the relative length of training, however. While some seem to be excessive (any OB subspecialty comes to mind), the ABMS decides the length of training based upon the recommendations of leaders in the house of medicine.

Things must be different where you practice compared to where I practice -- my IM and FP friends actually have higher E&M fee schedules than I was able to get (for the few commercial plans that direct contract). The two large MSC's, both of which have high PCP component, have higher E&M schedules (as a % of MC) than the derms get. We did not discuss the fee schedules for procedures as there is not a lot of overlap between what we do.

No, I never said "quit whining and suck it up" or anything of the sort as far as that goes -- but I still contend that every choice provides (and limits) opportunity... and the more informed one is the better gauge they can have of the relative value of said opportunity. For instance -- dermpath is a moneymaker right now. I knew that, I did not like it, I went another direction and gave up 40-50% in potential income. I do not begrudge their prosperity; I made a well informed choice and am happy with it (for the most part -- the kick in the teeth that I got this past January was not enjoyable, however).

Further, since we are being honest.... primary care is facing strong headwinds right now, and while most of the ire seems to be directed at relative reimbursement and perceived inequalities, I do not see those as the largest battle. I have sat on healthcare policy boards, policy watchdog panels, and committees to investigate the changing trends in medicine. The primary care model is changing due to forces beyond the physician population's control -- that is the largest threat to PCP's, and that is what goes largely unrecognized by PCP proponents today. These changes, from every shred of evidence and policy propositions that I have seen, are inevitable. The advent of the mid-level provider was the welcomed proverbial "flap of the butterfly's wing" that will ultimately irreparably damage the mom-and-pop primary care model. When we lost the oversight battle we lost the war. The popular opinion now is that they can do 80% of what a doc does at 80% of the cost; this is a problem.

 

[deleted87716]

The primary care model is changing due to forces beyond the physician population's control -- that is the largest threat to PCP's, and that is what goes largely unrecognized by PCP proponents today. These changes, from every shred of evidence and policy propositions that I have seen, are inevitable. The advent of the mid-level provider was the welcomed proverbial "flap of the butterfly's wing" that will ultimately irreparably damage the mom-and-pop primary care model. When we lost the oversight battle we lost the war. The popular opinion now is that they can do 80% of what a doc does at 80% of the cost; this is a problem.

It's not unrecognized. You are changing the subject, however.