CMS Proposes Primary Care Raises Funded With Specialist Cuts

[deleted87716]

That is easily changed. A midlevel makes 1/2 of what a PCP makes, and codes can be billed as such. Right there, you have saved millions. My husband's complaint, and those of many many people, are simple and don't need a doctor. Many midlevels practice like this, I think expanding midlevel scope in primary care makes sense.

The reason most midlevels make so much less than physicians is because they're employed by physicians who pay their salary. Typically, they see fewer patients compared to physicians in the same practice, and their patients are generally of lower acuity/complexity. That means their charges and collections are less. Typically, midlevels no not take call, and bear no personal risk in the financial viability of the practice other than their continued employment. Many of them work part-time. Most of them have no desire to practice independently.

So if we cannot afford to pay specialists so much, then how are we saving money by paying PCP such a high amount, and paying such a high amount to such a large # of providers?

No specific dollar figures have been suggested. Since there are many more specialists in the US than primary care physicians (70% vs. 30%), you could, in theory, give primary care physicians a substantial increase in pay while reducing the pay of specialists by a much smaller amount. Again, as other threads discuss (linked previously), paying more for primary care has the potential to result in big savings for the system as a whole.

BlueDog-do you feel 200k is inappropriate pay for a PCP? I'm asking honestly, would like thoughts on this matter. What do you feel is an appropriate salary for a PCP?

Again, it's not the absolute dollar figure that's causing the difficulty. It's the relative differential based on the valuation of the work being compensated.

If you're looking for relative numbers, there were some mentioned in an earlier link (you do read the links, don't you?) - http://futureoffamilymedicine.blogspot.com/2012/07/primary-care-subspecialist-physician.html

I'm not suggesting that we should pay civilian physicians the same as the military, and neither was the author. As he notes, it simply illustrates "how the military world values a foundation in primary care and how it values all of its doctors appropriately within its single-payer system."

Look no further than the military in regards to how payment disparities, or lack thereof, can lead to the production of more primary care doctors. Take into consideration the annual incentive pay between the different specialties within medicine. The largest payment disparity between a military family doctor with the same number years of service, rank and the same number of dependents as a military doctor who hit the ROAD (Radiology, Ophtho, Anesthesia, Dermatology) will usually be about $20,000 per year. Compare that with the civilian world where the disparity is, on average, about ten times that amount. It is no wonder why the Uniformed Services University of the Health Sciences continues to rank in the top 10 in matching its students to Family Medicine Residencies. Is this the way that civilian medicine should go in regards to paying physicians? Probably not. However, it is interesting how the military world values a foundation in primary care and how it values all of its doctors appropriately within its single-payer system.

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[deleted87716]

I don't agree that the links posted really add much to the discussion (no offense), simply thoughts from the perspective of a neurosug resident.

As opposed to...your thoughts?

Just trying to offer a little balance. Believe it or not, many specialists understand the necessity of what we're talking about, even if they don't necessarily like it.

 

[bigkahunaburger]

Drawsome, the point of increasing PCPs is basically that if you can prevent a heart attack and the disability someone goes through because of that which could cost:
http://www.cbsnews.com/8301-505146_162-39940799/how-much-would-a-heart-attack-cost-you/
(you get the idea, don't care if this is spot on accurate), you are essentially saving a lot money on healthcare. Even if you could prevent 1 out of every 10 Mcdonald's loving patient that comes through your door from getting a heart attack that would save tons of money (as opposed to having a bunch of specialist's in place to perform their expensive procedures). So no, increasing pay to PCPs will not break the system at all, and you think 200K is fair? Again, why do you think other physicians deserve double and triple that, which only helps people that have fallen through the cracks and are much less cost effective.

 

[DrAwsome]

Drawsome, the point of increasing PCPs is basically that if you can prevent a heart attack and the disability someone goes through because of that which could cost:
http://www.cbsnews.com/8301-505146_162-39940799/how-much-would-a-heart-attack-cost-you/
(you get the idea, don't care if this is spot on accurate), you are essentially saving a lot money on healthcare. Even if you could prevent 1 out of every 10 Mcdonald's loving patient that comes through your door from getting a heart attack that would save tons of money (as opposed to having a bunch of specialist's in place to perform their expensive procedures). So no, increasing pay to PCPs will not break the system at all, and you think 200K is fair? Again, why do you think other physicians deserve double and triple that, which only helps people that have fallen through the cracks and are much less cost effective.

I personally think that longer training deserves more compensation for one. No one will go into long residencies if they don't get well compensated. I do think 200k is fair for PCPs. I also think that the liability that PCPs face is significantly less than other providers given that they usually are not the ones making the final call, the numerous consultants from which they derive their treatments,etc.

Also I think we can theoretically talk all we want about how prevention this and that will help patients, but the reality is that it will not. People will never take personal responsibility, and will continue eating Mcdonalds, being overweight, sedentary, engaging in poor sexual practices, etc. and will still have bad health because of those reasons. Do you really think that you will make everyone thin, active, and healthy? I don't believe so.

I also personally believe that it is a lot easier to be a PCP than a specialist. People who I believe shold be paid more: surgeons, pathologists, OB's. If there is a limited pot of $$ that has to be distributed, I would give more $ to those people before giving to a PCP honestly. I have nothing against PCPs, but I don't personally think that their job is terribly difficult, and with all the consulting that they do, I think their job becomes a lot easier. Further, 200k for being a hospitalist and seeing 20 patients a day seems pretty darn fair to me.

Why do you think you should make the same as the orthopedic surgeon, or the anesthesiologist, or the pathologist? I think those specialties have far more skill than a PCP, and their training is far longer. This is in no way an attack on PCPs, just my personal opinions. I think for a 3 year residency 200k is quite a good salary, particularly for hospitalists working 2 weeks out of the month. How much do you honestly feel that primary care docs should be paid?

And we are re-entering the same fallacy that currently brings aproblem then. If we are saying specialists get paid too much now, it makes no sense that PCPs would make the same money that we are saying is too much for doctors.

It's like saying-well the senators get paid too much! Let's take that money and pay the governors that much. It still has the same problem-excessive salary. And in the case of PCPS, given that there are thousands, far more than most specialists, you are talking about bankrupting the system.

And then the question also becomes-why would a PCP get paid more than a specialist? Just like an orthodontist makes more than a general dentist, so does a specialist.

 

[bigkahunaburger]

Here's a post from earlier in this thread

"And, when a specialist is stuck, they send the patient back to their PCP.

"<Insert lucrative invasive procedure(s) here> is/are negative. Symptoms are not likely of <insert specialty here> etiology. Recommend patient follow up with his/her PCP."

Almost as good as the radiologist's "Cannot rule out <insert potentially serious/life threatening condition(s) here>. Clinical correlation needed."

See, we can play the game in a big circle if you want. Also, specialists go through soooo much more grueling training, right? So an anesthesiologist that does 1 MORE YEAR OF TRAINING deserves to be paid double what an IM/FM doc makes? You're right, it's cause you have to be super smart to be an anesthesiologist. Anywhoo, you completely discredit that the PCP has to completely work the patient up then the specialist sees them. Have you even been in a subspecialist's office, you really make it sound way harder than what it actually is. You act like each patient is a complex physics problem they have to solve in under 5 min without a calculator, calm down you've been watching too much House. "Do you really think you will make everyone thin..." Honestly, you're a despicable human being, but playing your dumb game I would still argue that even if all these "fat stupid Americans" don't change at all, with medical management ie. putting someone on a statin, that would still probably prevent at least 1 out of 10 heart attacks, remember how expensive those are? Nobody said PCPs should be paid more than a specialist, it's the gap in pay/discrepancy in pay that is the problem, understand that? You want an exact number on what PCPs should be paid, again, market forces will determine that, but the principle is that THERE IS TOO LARGE OF A DISCREPANCY. Really though, I applaud you, for a second there you had me fooled, but now I know that you grew up underneath power lines.

 

[elfmonkey]

I also personally believe that it is a lot easier to be a PCP than a specialist.
I have nothing against PCPs, but I don't personally think that their job is terribly difficult, and with all the consulting that they do, I think their job becomes a lot easier.

Medicine is all about differential diagnoses and sound judgement. So, with the spectrum of cases, the list of differential diagnoses and the lack of "stat" investigations, all will make it extremely difficult to have that "sound judgement" in the outpatient setting.
It is easy to become an "average" PCP but it is terribly difficult to become a good general practitioner !

 

[DrAwsome]

Here's a post from earlier in this thread

"And, when a specialist is stuck, they send the patient back to their PCP.

"<Insert lucrative invasive procedure(s) here> is/are negative. Symptoms are not likely of <insert specialty here> etiology. Recommend patient follow up with his/her PCP."

Almost as good as the radiologist's "Cannot rule out <insert potentially serious/life threatening condition(s) here>. Clinical correlation needed."

See, we can play the game in a big circle if you want. Also, specialists go through soooo much more grueling training, right? So an anesthesiologist that does 1 MORE YEAR OF TRAINING deserves to be paid double what an IM/FM doc makes? You're right, it's cause you have to be super smart to be an anesthesiologist. Anywhoo, you completely discredit that the PCP has to completely work the patient up then the specialist sees them. Have you even been in a subspecialist's office, you really make it sound way harder than what it actually is. You act like each patient is a complex physics problem they have to solve in under 5 min without a calculator, calm down you've been watching too much House. "Do you really think you will make everyone thin..." Honestly, you're a despicable human being, but playing your dumb game I would still argue that even if all these "fat stupid Americans" don't change at all, with medical management ie. putting someone on a statin, that would still probably prevent at least 1 out of 10 heart attacks, remember how expensive those are? Nobody said PCPs should be paid more than a specialist, it's the gap in pay/discrepancy in pay that is the problem, understand that? You want an exact number on what PCPs should be paid, again, market forces will determine that, but the principle is that THERE IS TOO LARGE OF A DISCREPANCY. Really though, I applaud you, for a second there you had me fooled, but now I know that you grew up underneath power lines.

You are a medical student, and realistically know nothing about the practice of medicine. Calling me a despicable human being is insulting and violates the rules of this forum. If you cannot hold a conversation with another person in this forum you should remove yourself from it, and realistically should not be in the medical profession, where you will be challenged day in and out. This is a forum where people expose their opinions. I would highly suggest you watch your words, and control your temper. It will do you well in the future, if you want to actually be able to practice.

 

[bigkahunaburger]

wait aren't you medical student as well? I mean, on top of being my mom...

 

[DrAwsome]

Medicine is all about differential diagnoses and sound judgement. So, with the spectrum of cases, the list of differential diagnoses and the lack of "stat" investigations, all will make it extremely difficult to have that "sound judgement" in the outpatient setting.
It is easy to become an "average" PCP but it is terribly difficult to become a good general practitioner !

I agree with you, but I personally believe that most PCPs these days are average at best, and rely solely on specialist diagnoses/work up. I have seen it time and time again. I remember many of my attendings early on in training simply pan consulting and expecting their consultants to diagnose/treat patients. Even when I would inquire about discharging patients, I would get the typical, "What did GI/ortho/pulmonary/psych/ENT/whatever" say? Are they ok with discharge? If so, I'm ok.

I have met very very few PCPs who actually care to work up their patients and actually come up with appropriate diagnoses/treatment. 200k for working 2 weeks a month seeing 15-20 patients is darn good imo, after 3 years of training.

 

[DrAwsome]

wait aren't you medical student as well? I mean, on top of being my mom...

No, I am not. I expect an apology from you for one, and for two, I would suggest you not call your patient population "fat, stupid, Americans."

 

[deleted87716]

I agree with you, but I personally believe that most PCPs these days are average at best

I hate to break it to you, but most specialists are equally average.

Wait...what's the definition of "average," again?

 

[bigkahunaburger]

lol, you posted "People will never take personal responsibility, and will continue eating Mcdonalds, being overweight, sedentary, engaging in poor sexual practices, etc." so, you see I actually respect our fellow citizens and was saying "fat, stupid, Americans" as a spinoff, or, summation of what you wrote, which is the reason I called you despicable, you getting me? Oh yeah, are you being sarcastic or do you really want me to apologize?

 

[DrAwsome]

lol, you posted "People will never take personal responsibility, and will continue eating Mcdonalds, being overweight, sedentary, engaging in poor sexual practices, etc." so, you see I actually respect our fellow citizens and was saying "fat, stupid, Americans" as a spinoff, or, summation of what you wrote, which is the reason I called you despicable, you getting me? Oh yeah, are you being sarcastic or do you really want me to apologize?

There is something called finesse and tact, and having good bedside manner. What I posted are facts. We have a huge obesity epidemic, among other things. Again, facts. Calling your patients "fat, stupid Americans" is not only pejorative, but will get you nowhere. Telling your patient he/she is overweight and needs to lose weight, exercise, and stop smoking is appropriate. Also, what I mentioned has nothing to do with stupidity, just a lack of personal accountability, which is completely different. Yes, I do want you to apologize. If you can't learn to have a conversation with another adult in a respectful manner, you are in for a rude awakening.

 

[elfmonkey]

Even when I would inquire about discharging patients, I would get the typical, "What did GI/ortho/pulmonary/psych/ENT/whatever" say? Are they ok with discharge? If so, I'm ok.
200k for working 2 weeks a month seeing 15-20 patients is darn good imo, after 3 years of training.

-I thinks it is a bit more complicated than just being a lazy GP, Hospitalist or EM doc. It is the system itself that will throw under the bus in a second, in case you miss something without consulting the "specialist".
I also think 200K for 2 wks/mo, is a decent salary but again, I think it`s more complicated than a just a number. Part of it is the feeling of being unappreciated by colleagues.
-A note to one of the posts above, "Never blame the sick for being sick", especially when they trust you so much to let you examine them "naked". The hierarchy in medicine exists for very good reasons.
-True, most specialists are "average" as well.

 

[deleted87716]

What I posted are facts.

No, you posted your opinion.

Also I think we can theoretically talk all we want about how prevention this and that will help patients, but the reality is that it will not. People will never take personal responsibility, and will continue eating Mcdonalds, being overweight, sedentary, engaging in poor sexual practices, etc. and will still have bad health because of those reasons. Do you really think that you will make everyone thin, active, and healthy? I don't believe so. <-- OPINION bolded for emphasis.

So, because everyone can't be helped, we shouldn't try at all...? Tell me you're joking, because the alternative is not something you want to hear.

Meanwhile, I see patients every day who have lost weight, started exercising, stopped smoking, controlled their BP/lipids/DM/etc. with my help. I don't expect to help everyone. Just everyone I can.

There is something called finesse and tact, and having good bedside manner.

Even though this wasn't directed at me, if you're going to come in here spouting nonsense and basically telling us we're all worthless and weak, don't expect to be showered in kisses. As I told another poster, you aren't my patient, and this isn't your bedside. If you can't take the heat, get out of the kitchen.

 

[bigkahunaburger]

Ok last post for a little while my head's starting to hurt, you do realize that I was not calling patients "fat, stupid Americans" right? It was you calling them that, and me sarcastically twisting your words around. I actually tend to believe people can change, which is why your words are irritating because everyone says them. Really, this is the internet, hence, I don't have to act anyway, in real life of course, here, no. You seem a little out of touch, and I'm out of time.

http://www.youtube.com/watch?v=eOO86OJV-TI

 

[DrAwsome]

No, you posted your opinion.



So, because everyone can't be helped, we shouldn't try at all...? Tell me you're joking, because the alternative is not something you want to hear.

Meanwhile, I see patients every day who have lost weight, started exercising, stopped smoking, controlled their BP/lipids/DM/etc. with my help. I don't expect to help everyone. Just everyone I can.



Even though this wasn't directed at me, if you're going to come in here spouting nonsense and basically telling us we're all worthless and weak, don't expect to be showered in kisses. As I told another poster, you aren't my patient, and this isn't your bedside. If you can't take the heat, get out of the kitchen.

No, I did not say we should not help. That's what we do on a daily basis. But the point of saying oh let's throw more money at PCPs to do something they are supposed to already be doing seems silly. Also I never said you are worthless and weak. I also do not think I am spouting nonsense. I said that I think that getting paid 200k for 2 weeks of worth out of the month is a decent salary. PCPs are important like every other specialty out there, but to somehow think that they are the end all, be all, and above specialists seems silly to me.

And unfortunately think of this. Sure for economical reasons, those going into IM/FM/primary care tend to be less competitive than people going into specialties. By that mere nature alone, you are not getting the creme of the crop, meaning that weaker doctors are going into the specialty. That in and out of itself says something.

No one is trying to offend you, but I think you have an excessive viewpoint of the role of the PCP.

 

[preDoGuy24]

No, I did not say we should not help. That's what we do on a daily basis. But the point of saying oh let's throw more money at PCPs to do something they are supposed to already be doing seems silly. Also I never said you are worthless and weak. I also do not think I am spouting nonsense. I said that I think that getting paid 200k for 2 weeks of worth out of the month is a decent salary. PCPs are important like every other specialty out there, but to somehow think that they are the end all, be all, and above specialists seems silly to me.

And unfortunately think of this. Sure for economical reasons, those going into IM/FM/primary care tend to be less competitive than people going into specialties. By that mere nature alone, you are not getting the creme of the crop, meaning that weaker doctors are going into the specialty. That in and out of itself says something.


No one is trying to offend you, but I think you have an excessive viewpoint of the role of the PCP.

Quit spouting the 2 weeks a month for 200k nonsense-most FPs don't go into hospitalist work and you are making yourself sound like a fool on this board. There are plenty of highly competitive Internal medicine and Family Medicine residencies just as there are competitive specialty ones. Ease up with the "weaker" docs dude, I have yet to see a study that shows step 1 score correlating with "strength" or "weakness" of a doc. You make yourself sound stupid by saying you aren't calling PCPs weak, then following up your argument by saying :"Oh you guys don;t get competitive students, so you're pretty weak" (highlighted) .

There isn't a more important physician to the average patient then their PCP. Period.

 

[MedicineDoc]

I agree with you, but I personally believe that most PCPs these days are average at best, and rely solely on specialist diagnoses/work up. I have seen it time and time again. I remember many of my attendings early on in training simply pan consulting and expecting their consultants to diagnose/treat patients. Even when I would inquire about discharging patients, I would get the typical, "What did GI/ortho/pulmonary/psych/ENT/whatever" say? Are they ok with discharge? If so, I'm ok.

I have met very very few PCPs who actually care to work up their patients and actually come up with appropriate diagnoses/treatment. 200k for working 2 weeks a month seeing 15-20 patients is darn good imo, after 3 years of training.

You are a medical student. In all likliehood You havent met any pcp that you are fit to judge. You don't know what you are talking about. I could do a gi guys job if I decided I liked sticking a scope up someone's rectum. I could have been a cardiologist if I decided I would enjoy doing cardiac procedures. Instead I enjoy being a true physician taking care of the whole patient and helping specialists not harm their patients while treating one organ system. As the attending physician
I decide who my patient needs to see and if they are offering what my patient needs. What they do is not mysterious or perplexing to me or difficult to understand with few exceptions. Your desire to be "special" is not met by a profession in medicine that will make you special. They are all important and specialist is all too often coming to mean technician as they refuse any type of cognitive cases as too time consiming relegating those matters to pcps. Okay for discharge is nothing but a legal cover game that everyone plays including specialists who consult hospitalists on their patients they admit themselves. Welcome to reality medical student now get in the back and keep your mouth shut and maybe you will learn something.

 

[deleted87716]

But the point of saying oh let's throw more money at PCPs to do something they are supposed to already be doing seems silly.

We aren't talking about paying more for the same thing. We're talking about paying more for better primary care.

PCPs are important like every other specialty out there, but to somehow think that they are the end all, be all, and above specialists seems silly to me.

An efficient and cost-effective health care system is founded upon primary care. At least that's the way it should be, and that's the way it works in every other first-world nation, all of whom kick our butts in terms of health measures and the per capita GNP spent on healthcare. Only in the US is the balance skewed so far in the opposite direction, and and a result, the US spends more and gets less than anyone else. You have an MPH, right? You're supposed to know this stuff.

those going into IM/FM/primary care tend to be less competitive than people going into specialties...That in and out of itself says something.

As has already been mentioned, it says that people go where the money is.

Based on your comments in another thread, you apparently understand the concept.

http://forums.studentdoctor.net/showpost.php?p=12781356&postcount=25

If derm paid the same as primary care, interest in the field would fall drastically.

 

[smq123]

Further, the mental drain of doing something like rads, rad onc, or stress levels of something like anesthesia, neurosurgery, ortho, etc is far superior to FM. Most medical students can do FM, and there is a reason why the least competitive students go into FM, much fewer can be specialists, and that is one of the reasons why there is such a significant place for midlevels in primary care, which will likely replace FM and other primary care people in our lifetime. As you can see, that's happening.

I agree with you, but I personally believe that most PCPs these days are average at best, and rely solely on specialist diagnoses/work up. I have seen it time and time again. I remember many of my attendings early on in training simply pan consulting and expecting their consultants to diagnose/treat patients. Even when I would inquire about discharging patients, I would get the typical, "What did GI/ortho/pulmonary/psych/ENT/whatever" say? Are they ok with discharge? If so, I'm ok.

I have met very very few PCPs who actually care to work up their patients and actually come up with appropriate diagnoses/treatment. 200k for working 2 weeks a month seeing 15-20 patients is darn good imo, after 3 years of training.

I understand that some people hold the opinion that primary care is easy and not mentally taxing. If that were the case, then I don't understand why so many of the MS3s and MS4s that rotated through our office sucked so bad in clinic. (And they were all AMGs, by the way). But I digress.

In any case, you are entitled to your opinion. BUT AS I ALREADY STATED, you may NOT post negative comments about a specialty in that specialty's forum. As previously stated, this is considered trolling.

As a reminder (or an FYI, if you don't already know), going into another specialty forum to make negative comments about that specialty, is considered trolling on SDN. Coming into the gas forum and saying that CRNAs can do what they do, or going into the derm forum and calling them nothing more than pimple poppers, are all equally frowned upon. The same courtesy to the FM people would be appreciated. Infractions will be given out to anyone who doesn't provide that same courtesy.

Muchas gracias.

If I have to post this again, this thread is getting closed. You've all been warned.

And as an FYI, hospitalists are NOT considered primary care. If I could see 15 patients a day for 2 weeks a month, that would be freaking awesome. But, sadly, any outpatient office that did that would go broke very quickly.

 

[DrAwsome]

You are a medical student. In all likliehood You havent met any pcp that you are fit to judge. You don't know what you are talking about. I could do a gi guys job if I decided I liked sticking a scope up someone's rectum. I could have been a cardiologist if I decided I would enjoy doing cardiac procedures. Instead I enjoy being a true physician taking care of the whole patient and helping specialists not harm their patients while treating one organ system. As the attending physician
I decide who my patient needs to see and if they are offering what my patient needs. What they do is not mysterious or perplexing to me or difficult to understand with few exceptions. Your desire to be "special" is not met by a profession in medicine that will make you special. They are all important and specialist is all too often coming to mean technician as they refuse any type of cognitive cases as too time consiming relegating those matters to pcps. Okay for discharge is nothing but a legal cover game that everyone plays including specialists who consult hospitalists on their patients they admit themselves. Welcome to reality medical student now get in the back and keep your mouth shut and maybe you will learn something.

I'm not a medical student, I already pointed this out.

SMQ MODERATOR: this person is making personal attacks to me, why is nothing being done about this?
Are personal attacks against other posters ok now?

 

[DrAwsome]

I understand that some people hold the opinion that primary care is easy and not mentally taxing. If that were the case, then I don't understand why so many of the MS3s and MS4s that rotated through our office sucked so bad in clinic. (And they were all AMGs, by the way). But I digress.

In any case, you are entitled to your opinion. BUT AS I ALREADY STATED, you may NOT post negative comments about a specialty in that specialty's forum. As previously stated, this is considered trolling.



If I have to post this again, this thread is getting closed. You've all been warned.

And as an FYI, hospitalists are NOT considered primary care. If I could see 15 patients a day for 2 weeks a month, that would be freaking awesome. But, sadly, any outpatient office that did that would go broke very quickly.

It seems that there is a bias here. Another poster, Dermpath asked for the thread to be closed yesterday, when they were being insulted. Nothing was done about it. As a moderator, there should not be bias and preferences, and this thread should have been closed yesterday.

 

[smq123]

It seems that there is a bias here. Another poster, Dermpath asked for the thread to be closed yesterday, when they were being insulted. Nothing was done about it. As a moderator, there should not be bias and preferences, and this thread should have been closed yesterday.

<sigh>

A few things:

- Posting in the thread "THIS THREAD SHOULD BE CLOSED" is not helpful. I spent the last 3 days moving across the country; checking this thread carefully was hard to do from a cellphone. I did the best that I could, but cellphone service is shoddy in parts of this country. Plus, when you spend 14 hours a day in the car, the last thing you really want to do is squint at a tiny screen.

If you have an issue with what someone has posted, please use the reported post function in the lower left hand part of the screen - it is an exclamation point inside of a red bordered triangle. That alerts me to a problem in the thread; otherwise, if I'm busy, I can't guarantee that I read these threads every single day. I'm also a doctor, and I was (until recently) a resident....sometimes life gets in the way of SDN.

- Posting a picture of Einstein with a quote is not, necessarily, an insult. You may infer it to be an insult, but it is not overtly insulting. My job as a moderator is not to attribute meaning to what people have said.

Again, however, if you have an issue with something, use the reported post function.

- Finally, how is someone calling you a medical student considered an insult? Furthermore, it is understandable that someone would assume that you are a medical student when the status under your username says, in fact, "Medical Student." If you are not a medical student, then feel free to change it to something more accurate.

I hope this clears things up.

 

[DrAwsome]

<sigh>

A few things:

- Posting in the thread "THIS THREAD SHOULD BE CLOSED" is not helpful. I spent the last 3 days moving across the country; checking this thread carefully was hard to do from a cellphone. I did the best that I could, but cellphone service is shoddy in parts of this country. Plus, when you spend 14 hours a day in the car, the last thing you really want to do is squint at a tiny screen.

If you have an issue with what someone has posted, please use the reported post function in the lower left hand part of the screen - it is an exclamation point inside of a red bordered triangle. That alerts me to a problem in the thread; otherwise, if I'm busy, I can't guarantee that I read these threads every single day. I'm also a doctor, and I was (until recently) a resident....sometimes life gets in the way of SDN.

- Posting a picture of Einstein with a quote is not, necessarily, an insult. You may infer it to be an insult, but it is not overtly insulting. My job as a moderator is not to attribute meaning to what people have said.

Again, however, if you have an issue with something, use the reported post function.

- Finally, how is someone calling you a medical student considered an insult? Furthermore, it is understandable that someone would assume that you are a medical student when the status under your username says, in fact, "Medical Student." If you are not a medical student, then feel free to change it to something more accurate.

I hope this clears things up.

I really don't understand then the basis for what's insulting or not. Posting facts about certain specialties is somehow offensive now? Then we should take issue with NRMP's posting of step scores, research, etc. for specialties. I at no point said, FM is a piece of crap or anything like that. I mentioned statements that are well known based on FACTS, not just opinions. It's as if I say dermatology really has some high step1 scores, and the pay is pretty high. Those are just facts. Since you think posting a picture of Einstein with a mention to stupidity is not an insult, then what is? Because I at no point made any overtly insulting comment. As I just mentioned, I at no point said anything pejorative about FM. Saying that working 2 weeks out of the month and getting paid 200k is insulting?? Please explain how because I don't see it.

Oh and no, someone calling me a medical student is not an insult but someone calling me stupid and a despicable human being is. I had the decency to not insult this person back, and even asked for an apology, and they came back with "it's ok to talk like this on a forum" which apparently is ok, yet giving facts about specialties is not.
Is that also not an overt insult that deserves some mention?

Also a number of other specialties were mocked (GI/cardio/rads) and not a peep was made about that. So I don't quite understand how that goes.

 

[bigkahunaburger]

http://www.youtube.com/watch?v=T8r3cWM4JII&feature=related

 

[aerodoc]

I at no point said, FM is a piece of crap or anything like that. I mentioned statements that are well known based on FACTS, not just opinions.

(cough)

I agree with you, but I personally believe that most PCPs these days are average at best, and rely solely on specialist diagnoses/work up.

(cough)

Also a number of other specialties were mocked (GI/cardio/rads) and not a peep was made about that. So I don't quite understand how that goes.

lol It's been stated twice now, what's so hard to understand?

As a reminder (or an FYI, if you don't already know), going into another specialty forum to make negative comments about that specialty, is considered trolling on SDN. Coming into the gas forum and saying that CRNAs can do what they do, or going into the derm forum and calling them nothing more than pimple poppers, are all equally frowned upon. The same courtesy to the FM people would be appreciated. Infractions will be given out to anyone who doesn't provide that same courtesy.

 

[deleted87716]

Can we get back to the subject of the thread...?

I'm re-posting the last relevant comment as a reminder of where we left off.

But the point of saying oh let's throw more money at PCPs to do something they are supposed to already be doing seems silly.

We aren't talking about paying more for the same thing. We're talking about paying more for better primary care.

PCPs are important like every other specialty out there, but to somehow think that they are the end all, be all, and above specialists seems silly to me.

An efficient and cost-effective health care system is founded upon primary care. At least that's the way it should be, and that's the way it works in every other first-world nation, all of whom kick our butts in terms of health measures and the per capita GNP spent on healthcare. Only in the US is the balance skewed so far in the opposite direction, and and a result, the US spends more and gets less than anyone else. You have an MPH, right? You're supposed to know this stuff.

those going into IM/FM/primary care tend to be less competitive than people going into specialties...That in and out of itself says something.

As has already been mentioned, it says that people go where the money is.

Based on your comments in another thread, you apparently understand the concept.

http://forums.studentdoctor.net/showpost.php?p=12781356&postcount=25

If derm paid the same as primary care, interest in the field would fall drastically.

 

[elfmonkey]

I think it would be a good idea to "redistribute" and adjust the payments because, simply, when you invest in primary care, you are going to "prevent" and and decrease the need for complicated and expensive care. It`s always better to take care of a diabetic patient by a PCP and prevent its complications than having an ophthalmologist, a vascular surgeon, a cardiologist or even an interventional cardiologist getting involved to patch up "preventable" complications.
The length of the training does not justify this gap. If so, then the gap should be terminated after the "specialist" had worked for a certain number of years, then we go back to baseline. So this notion is a bit short sighted.
Imagine how happy the doctors would be if they choose what they really like.

 

[Silent Cool]

Several things.
First off, difficulty of getting into a field has zero correlation with how "difficult" that field actually is - both in terms of physical difficulty and mental. Difficulty of getting into a field is entirely based on reimbursement rates that field is current enjoying. How said reimbursement rates were derived is the real question at hand, and if you actually took a look at how the RBRVS was created, you'll know it's riddled with errors and fallacies. Are you really going to make the argument that dermatology is "harder" than general surgery, because derm candidates had higher scores and pedigree than GS candidates?

Secondly, why do you get to go about spewing your opinions as facts, if I don't? The funny thing is that my personal experience wasn't even used as the crux of my argument. In fact, it only came up, because I asked about how you drew YOUR conclusions.

Also, I'm not going to primary care. I'll either be a specialist or administration. I have no anger or jealousy towards specialists.

Bronx, aren't you going for Rehab Med?

 

[primadonna22274]

Back on topic, to the woman who thought her husband's screening physical would have been much cheaper if done by a PA/NP: sorry, no dice. Billing codes are the same and in most cases reimbursement is the same as if done by physicians--there is an "85% rule" to allow PAs/NPs to be reimbursed at 85% the physician's rate, but it is easily gotten around (Medicare rules). I was a highly productive FM PA and often had billings higher than many of my physician colleagues, but I never made more than 1/3-1/2 their salary and was not eligible for partnership status etc. I made tons of money for the practice and was a bargain. I am typical, FYI.
Now, say we read the tea leaves correctly, and I end up going through med school and residency and amassing $150k+ more debt only to come out and supervise PAs and function more as an administrative role--fine. I like teaching and I know what PAs do and don't know, and have a very good sense of what they can do and should be able to do more.

 

[DrAwsome]

Back on topic, to the woman who thought her husband's screening physical would have been much cheaper if done by a PA/NP: sorry, no dice. Billing codes are the same and in most cases reimbursement is the same as if done by physicians--there is an "85% rule" to allow PAs/NPs to be reimbursed at 85% the physician's rate, but it is easily gotten around (Medicare rules). I was a highly productive FM PA and often had billings higher than many of my physician colleagues, but I never made more than 1/3-1/2 their salary and was not eligible for partnership status etc. I made tons of money for the practice and was a bargain. I am typical, FYI.
Now, say we read the tea leaves correctly, and I end up going through med school and residency and amassing $150k+ more debt only to come out and supervise PAs and function more as an administrative role--fine. I like teaching and I know what PAs do and don't know, and have a very good sense of what they can do and should be able to do more.

You clearly did not read what I said-I specifically mentioned that the whole billing code thing can be changed with no major issue. In addition, of course you would not have partnership status, not sure why that would be shocking. The whole idea of midlevels doing PCP care is to LOWER costs and have acute/non serious issues handled by individuals other than a physician that can see the patient at a lower cost, with easier access.

 

[DrAwsome]

I think it would be a good idea to "redistribute" and adjust the payments because, simply, when you invest in primary care, you are going to "prevent" and and decrease the need for complicated and expensive care. It`s always better to take care of a diabetic patient by a PCP and prevent its complications than having an ophthalmologist, a vascular surgeon, a cardiologist or even an interventional cardiologist getting involved to patch up "preventable" complications.
The length of the training does not justify this gap. If so, then the gap should be terminated after the "specialist" had worked for a certain number of years, then we go back to baseline. So this notion is a bit short sighted.
Imagine how happy the doctors would be if they choose what they really like.

Umm unless I missed something, PCPs are supposed to prevent complications, even as we speak. It's part of their job description, it's not something new that they are supposed to be doing. So are you saying that the PCP getting paid more will make them do a job that they are supposed to be doing now? It's as if we say oh well we'll pay the radiologist more so that he/she can read the x ray correctly/better, or pay the surgeon more so they can prevent errors in their surgeries. That's part of their job description. PCPs role is currently to do preventive care. Paying more for the same job is ridiculous imo. And like I said before-how does a PCP getting paid more prevent the patient from continuing to go to McDonalds and be obese, sedentary, etc? I'm certain that PCPs address weight, smoking, etc in their visits. How is more money going to change this?

 

[deleted87716]

You clearly did not read what I said-I specifically mentioned that the whole billing code thing can be changed with no major issue.

I would anticipate that the nursing and PA lobbies might have a problem with that, not to mention the physicians who employ and supervise mid-levels in their practices.

 

[DrAwsome]

I would anticipate that the nursing and PA lobbies might have a problem with that, not to mention the physicians who employ mid-levels in their practices.

Who cares? The gov does what it wants for one. Second, if you and PA person are billing the same, and doing the same job as a physician, in and out of itself it's an issue. It's saying that the PA/NP is the same as a physician. I don't know hwy you are not addressing this if you are wanting to have a discussion about this. What is the point of NP/PA if they cost the same as a physician? They are not meant to be physicians, but if they cost the same, might as well given them an MD/DO.

Specialists also have a "problem" with making less, it's not exactly stopping the gov from still trying to cut their salaries, is it?

It is completely illogical.

 

[deleted87716]

PCPs role is currently to do preventive care.

Actually, that's only one small part of our job. Unless we're in urgent care, most of us do primarily chronic disease management, and it's chronic diseases like diabetes, hypertension, and cardiovascular disease which are bankrupting our healthcare system.

Frankly, much of what we do with regard to prevention and counseling could be done by non-physicians within the context of the Patient Centered Medical Home. Physicians should be able to concentrate on physician-level work, and delegate more mundane tasks to staff, so that everyone works to the level of their training and expertise.

Unfortunately, the current system is not set up to reimburse for chronic disease management, and does not adequately reimburse for the investment in infrastructure and practice transformation necessary to function as a true PCMH. Our system today is designed around the face-to-face office visit and episodic care, and is working exactly as it should be expected to work based on the incentives currently in place.

 

[michaelrack]

I think it would be a good idea to "redistribute" and adjust the payments because, simply, when you invest in primary care, you are going to "prevent" and and decrease the need for complicated and expensive care. It`s always better to take care of a diabetic patient by a PCP and prevent its complications than having an ophthalmologist, a vascular surgeon, a cardiologist or even an interventional cardiologist getting involved to patch up "preventable" complications.
The length of the training does not justify this gap. If so, then the gap should be terminated after the "specialist" had worked for a certain number of years, then we go back to baseline. So this notion is a bit short sighted.
Imagine how happy the doctors would be if they choose what they really like.

For the most part, preventative care delivered by a PCP does not save the system money- it's cheaper if a diabetic drops dead from a heart attack at age 50 than if he slowly dies from CHF at age 85. Care coordination by a PCP may save $. A nation having a strong primary care system is cost effective, but not necessarily cheap.

I am all in favor of Prevention, but Prevention is not going to save the nation's healthcare system from the financial cliff it is entering.

 

[elfmonkey]

1. So are you saying that the PCP getting paid more will make them do a job that they are supposed to be doing now?
2. And like I said before-how does a PCP getting paid more prevent the patient from continuing to go to McDonalds and be obese, sedentary, etc?
3. I'm certain that PCPs address weight, smoking, etc in their visits. How is more money going to change this?

1. We all are supposed to do our best. A post-op bowel anastomosis leak is as bad as poorly managed 78yo pt on diuretics for HTN w Hypo or Hyper [K] and Hx of AF.
2. This argument can be used against Surgery=wt loss surgeries, Cardiology= Diet and smoking, EM= EtOH.
3. More money going to PCP physicians and support programs will have a significant impact on how much we are spending. The keyword is "Prevention".

Do you think PCPs being compensated "fairly", i.e., when surgeons cut, they get paid, do PCPs get compensated for doing what they are supposed to do ?

 

[DrAwsome]

For the most part, preventative care delivered by a PCP does not save the system money- it's cheaper if a diabetic drops dead from a heart attack at age 50 than if he slowly dies from CHF at age 85. Care coordination by a PCP may save $. A nation having a strong primary care system is cost effective, but not necessarily cheap.

I am all in favor of Prevention, but Prevention is not going to save the nation's healthcare system from the financial cliff it is entering.

Precisely, thank you. I'm sorry but we are a nation that does not accept personal responsibility. As I said before, people will continue to smoke, overeat, underexercise, and every other negative health habit there. People are aware of the health consequences of their actions for the most part, but will likely continue to behave the same because they can. I remember when I was a med student and I was doing my FM rotation. Attending had talked to elderly patient who had cardiac issues, was getting cardiac procedures, and had a miriad of other respiratory issues about quitting smoking. He must have talked to her every single visit, she would tell him, I know it's bad for me, but I don't really want to quit. Whether you pay a PCP 100$ or a trillion, you can;t force people to change. And paying the thousands of PCPs we have specialist salaries will bankrupt us. So let's say we are paying all PCPS 400k, PCPs are happy and giving hour long preventive care talks to patients. Now patients continue to do as they please and having to go to specialists for treatment. What happens then?

We are further in debt, and with same results.

 

[DrAwsome]

1. We all are supposed to do our best. A post-op bowel anastomosis leak is as bad as poorly managed 78yo pt on diuretics for HTN w Hypo or Hyper [K] and Hx of AF.
2. This argument can be used against Surgery=wt loss surgeries, Cardiology= Diet and smoking, EM= EtOH.
3. More money going to PCP physicians and support programs will have a significant impact on how much we are spending. The keyword is "Prevention".

Do you think PCPs being compensated "fairly", i.e., when surgeons cut, they get paid, do PCPs get compensated for doing what they are supposed to do ?

Prevention care is being done all the time, not just by PCPS but by nurses and every other healthcare person out there. So it's not about prevention really. Every patient that goes to a PCP knows about eating healthy, activity, not smoking/doing drugs, etc. It's a personal choice whether they continue to do that or not.

You still fail to explain how more money going to PCPs will help anything. There are a ton ton ton! of support programs, so I don't buy that.

I don't mind if PCPs say hey we feel undercompensated we just want more $$. I am ok with that. But claiming that more money will help prevention is not truthful imo.

Please tell me how it would be different from what's being done now, and how more moeny to them would help. Further, as bluedog said, this type of prevention can be done by midlevels-by not hire a PA/NP/nurse to say ok folks we are doing preventive care! let's address all these issues and address any questions, etc. Wouldn't that be far cheaper?

 

[deleted87716]

For the most part, preventative care delivered by a PCP does not save the system money- it's cheaper if a diabetic drops dead from a heart attack at age 50 than if he slowly dies from CHF at age 85. Care coordination by a PCP may save $. A nation having a strong primary care system is cost effective, but not necessarily cheap.

I am all in favor of Prevention, but Prevention is not going to save the nation's healthcare system from the financial cliff it is entering.

Just to clarify the terminology, the terms "screening" and "prevention" tend to refer to early detection of disease by a screening test (e.g., mammography, colonoscopy, etc.) or prevention of disease by some sort of health intervention (e.g., preventing COPD by encouraging smoking cessation). In both cases, there is no active disease at the time. Many of these interventions are mired in controversy as to costs vs. benefits (e.g., mammography, PSA testing).

When you're talking about treating something like diabetes or hypertension, however, you're not really in "prevention mode." You're in "treatment mode." Sure, there's some overlap, in the sense that a well-managed diabetic is less likely to suffer from diabetic complications, and someone who has their BP controlled is less likely to suffer a cardiovascular event (MI or CVA), but chronic disease management is a distinctly different entity from pure screening and prevention in terms of costs and benefits.

 

[deleted87716]

You still fail to explain how more money going to PCPs will help anything.

Here ya' go.

The Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies, August 2009

http://www.pcpcc.net/files/pcmh_evidence_outcomes_2009.pdf

 

[primadonna22274]

Not gonna happen...talk about taking PA practice back 40 years...

I would anticipate that the nursing and PA lobbies might have a problem with that, not to mention the physicians who employ and supervise mid-levels in their practices.

 

[DrAwsome]

Here ya' go.

The Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies, August 2009

http://www.pcpcc.net/files/pcmh_evidence_outcomes_2009.pdf

Ok, and from my skimming of that, nursing type services are being used to coordinate care and other preventive services. My question to you is now, as it was before, how does giving more money to PCPs really help with that?

I will assume that you are an extraordinary physician, so you have a ton of patients to see daily, and don't have time to do any extra prevention/coordination. Ok, we can either double your salary let's say or hire a nurse for 75k or whatever who exclusively does preventive services/coordination/follow up of discharged patients, etc. Cost savings is sigfnicaintly cheaper with midlevels, and that is my point.

I don't think it's a bad thing for PCPs to want to make more money, but I don't think it's the answer. I guess that's my point. If we are at the brink of financial collapse, our goal should be to decrease costs, not increase them. Paying PCPs a ton of money will not help us in the long term. Hiring other healthcare professionals that are far cheaper and can provide the same service to reduce overall costs though, seems logical to me.

 

[DrAwsome]

Not gonna happen...talk about taking PA practice back 40 years...

Well then you are part of the problem, who's bankrupting the system. How do you think specialists feel then?

I think this statement you just made is exactly the issue-it's not about SAVING money, it's about non-specialists wanting to make more money, in the guise that it will help patient care.

I would be willing to take a reasonable pay cut as a specialist if it meant more people being taken care of, and lower overall costs. But when I hear a PA tell me how they want to bill the same as a physician, and how "not gonna happen" then we find the problem. The role of PA's and other midlevels is to cut costs. If you are just as expensive as a physician, then there is no point, is there? If midlevels were hired to do midlevel type work with midlevel type pay, we would save millions and millions. But no, let's not do something rational.

Oh and reason why it's not going to work to pay PCP more money to do "preventive" care. I think it will be a complete and epic failure, which will indebt us to oblivion. But when did money ever get in the way of the gov doing ridiculous things? Oh well.

 

[deleted87716]

Ok, and from my skimming of that...

Y'know, when someone comes to a forum completely clueless about the subject under discussion, and doesn't even have the courtesy to read the information that is spoon-feed to them, it's really pointless to try continue the conversation.

You're certainly entitled to your opinions, however misinformed they may be. May they serve you well.

 

[michaelrack]

xxx.

 

[DrAwsome]

Y'know, when someone comes to a forum completely clueless about the subject under discussion, and doesn't even have the courtesy to read the information that is spoon-feed to them, it's really pointless to try continue the conversation.

You're certainly entitled to your opinions, however misinformed they may be. May they serve you well.

I spent a good part of my afternoon yesterday watching a Cspann show with governors from different states, drs, and other healthcare related providers talking about this. The dr. who spoke talked about what you posted, and spoke of the Geisinger model in particular. He mentioned basically what you said in very vague terms-let's provide preventive care, bla bla they will save tons of money from the system, etc. Then another rep from Hennepin county talked about "ways" that this preventive care would be done. For example, she talked about patients being ignorant of how to use their insulin, having healthcare providers go to their homes and see how patients take their meds, buying patients a fridge in case they can't store their insulin, providing patients transportation to come to appointments. It's the same thing that's been talked about time and time again, which never works.

We might as well have awhole healthcare team live with the patient to make sure they are compliant. It will never work.

There are so many reasons why it will not work it's not even funny. Just trying to put a bandaid on a huge hemorrhage without looking at what's causing it is absolutely nuts.

Sure, let's take the all the money from specialists, and let's pay PCPs double, to do preventive care, for peopel who will never take personal responsibility, while still continuing to provide ridiculous amounts of end of life care, which cost billions, and continuing to run every test known to man to make sure that we don't get sued. Awsome plan.

Oh well.

 

[elfmonkey]

Prevention care is being done all the time, not just by PCPS but by nurses and every other healthcare person out there. So it's not about prevention really. Every patient that goes to a PCP knows about eating healthy, activity, not smoking/doing drugs, etc. It's a personal choice whether they continue to do that or not.

You still fail to explain how more money going to PCPs will help anything. There are a ton ton ton! of support programs, so I don't buy that.

I don't mind if PCPs say hey we feel undercompensated we just want more $$. I am ok with that. But claiming that more money will help prevention is not truthful imo.

Please tell me how it would be different from what's being done now, and how more moeny to them would help. Further, as bluedog said, this type of prevention can be done by midlevels-by not hire a PA/NP/nurse to say ok folks we are doing preventive care! let's address all these issues and address any questions, etc. Wouldn't that be far cheaper?

1. More money for PCP`s by itself is not the answer to our problem, maybe it will make primary care more appealing. But, more money to primary care is the answer to the problem. Part of more money to primary care is more money to PCP`s. Where do we get this money from? I guess specialists payment cut would be a reasonable answer.
2. I should`ve been more careful in choosing the word "prevention". Although by well managing a chronic condition, you are preventing a ticking bomb.
3. PAs/NPs make the job of every MD easier. But to have them working on their own is simply dangerous. It is not the answer, never will be. I have nothing but respect to PAs and NPs but they are not qualified to practice unsupervised medicine.

 

[bigkahunaburger]

Hold on there now, there seems to be a huge disconnect with what's being said. So let's summarize what's actually going on:

1.) There is a massive shortage of PCPs in this country

2.) Med students aren't going into PC because of the pay

3.) Therefore, increase pay, increase PCPs

This is not about paying PCPs more to do the same job. It's about paying them the compensation they're due, as well as increasing the amount of students pursuing PC.