Declining reimbursements- Why does the data refute this common claim?

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Student189045

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My question is simple: Upon browsing historical sdn threads way back to 10 years ago all the way up until now, the vast majority of compensation threads (in general and specialty specific) complain of declining reimbursements year over year. When looking at compensation reports online, however (MGMA and medscape), this claim is directly refuted as physician incomes have risen well past inflation over the last decade. I understand that the specific value of the numbers in these reports may not be accurate, especially for small subspecialties, but the general trend after surveying tens of thousands of physicians each year must hold some weight. What gives? Obviously physicians on here aren't just lying, so where does the declining reimbursement statement come from and why is it directly conflicted by the data on physician incomes?
 
My question is simple: Upon browsing historical sdn threads way back to 10 years ago all the way up until now, the vast majority of compensation threads (in general and specialty specific) complain of declining reimbursements year over year. When looking at compensation reports online, however (MGMA and medscape), this claim is directly refuted as physician incomes have risen well past inflation over the last decade. I understand that the specific value of the numbers in these reports may not be accurate, especially for small subspecialties, but the general trend after surveying tens of thousands of physicians each year must hold some weight. What gives? Obviously physicians on here aren't just lying, so where does the declining reimbursement statement come from and why is it directly conflicted by the data on physician incomes?
Couple of things I think beyond the usual caveats of survey reliability. One is that there is increasing employment and reduced partnership jobs. Employed positions tend to have a higher starting salary compared to partnership tract but lower ceiling. This I think is the biggest factor pushing the median up.

On the other hand, practicing physicians feel squeezed constantly, even if their salary isn’t going down or even if it’s rising. This is because every year Medicare and/or insurers try to reduce $amounts paid for specific codes. For example, Medicare used to pay almost 2k for a TURP (not inflation adjusted). That has slowly been cut over decades to now where it pays closer to $400. You’ll see similar stats for a lot of procedures. This is partly offset by the fact that we can do them more efficiently over time (better tech, shorter stays, etc) allowing higher volume, and partly because newer procedures come out that pay better. This is part of why medicine seems to push the next new thing, because we are often financially incentivized to do so. So it feels like a constant battle to keep your salary up, as doing what you did last year will result in lower pay, even if you end up the same or making more.
 
Couple of things I think beyond the usual caveats of survey reliability. One is that there is increasing employment and reduced partnership jobs. Employed positions tend to have a higher starting salary compared to partnership tract but lower ceiling. This I think is the biggest factor pushing the median up.

On the other hand, practicing physicians feel squeezed constantly, even if their salary isn’t going down or even if it’s rising. This is because every year Medicare and/or insurers try to reduce $amounts paid for specific codes. For example, Medicare used to pay almost 2k for a TURP (not inflation adjusted). That has slowly been cut over decades to now where it pays closer to $400. You’ll see similar stats for a lot of procedures. This is partly offset by the fact that we can do them more efficiently over time (better tech, shorter stays, etc) allowing higher volume, and partly because newer procedures come out that pay better. This is part of why medicine seems to push the next new thing, because we are often financially incentivized to do so. So it feels like a constant battle to keep your salary up, as doing what you did last year will result in lower pay, even if you end up the same or making more.
Very helpful answer that makes a lot of sense, thank you
 
More recent changes probably aren't very reflective in aggregate data.

I can 100% promise our group's profits were at an all-time low last year. This year isn't looking much better. Reimbursement issues are a huge part of this. Many of these are state-specific and mine have made some complicated loops that need to be jumped through. Any falter results in a significant chunk of money that gets taken from us.

Insurance and gov't are taking huge shots at us. We're feelin' it. Too soon to know what the real future holds, though. Everyone and everything is bleak if you go back and read posts here from 2002. Not always the case, but sometimes...
 
Yes, salaries increase over the years but have not even close to matched inflation. The purchasing power of a physician 40 years ago makes current medicine look like a joke.
Do you have studies that show this? I was more talking about over the last decade where there is substantial evidence that salaries are rising past inflation, but I am interested in seeing data on income in the 80's and 90's to see if it really was higher (inflation adjusted of course) or if it's the brains natural revisionist history remembering the "good old days" top 5% of physicians and extrapolating it as the average income back in the day.

Edit: Although I know that education costs have raised egregiously past inflation so that alone probably makes docs worse off financially than back in the day...
 
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Do you have studies that show this? I was more talking about over the last decade where there is substantial evidence that salaries are rising past inflation, but I am interested in seeing data on income in the 80's and 90's to see if it really was higher (inflation adjusted of course) or if it's the brains natural revisionist history remembering the "good old days" top 5% of physicians and extrapolating it as the average income back in the day.

“According to AMA data, the average net income of U.S. practitioners in 1982 was $99,500. The average for practicing physicians specializing in pediatrics was approximately $70,000, while for surgeons the average was approximately $130,000. Academic physicians had earnings ranging from $42,000 to $122,500 in 1983, depending on faculty rank and method of compensation.”

So $99,500 in 1982 is about $280,000 today
 
The problem is working harder, terrible patients, and too much oversight.

Want to make the same money a radiologist made back in the day? Read 5x as many studies.

Everyone might be making the same income but it's because they are working harder. Go ask literally anyone who has been a PP attending for a 20 years.
 
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The problem is working, terrible patients, and too much oversight.

Want to make the same money a radiologist made back in the day? Read 5x as many studies.

Everyone might be making the same income but it's because they are working harder. Go ask literally anyone who has been a PP attending for a 20 years.
Ya I’d be interested in how many patients docs are seeing on average now vs 30-40 years ago. Same for paperwork
 
Yeah as others have noted the salary numbers are showing a large shift toward employed positions. I think you’d need to have better data for the 75+ percentile adjusted for inflation over the last 30 years to really see the change.

An example from ent would be sinus surgery. Back in the 90s a full endoscopic sinus surgery and septoplasty would actually reimburse $25-30k. Today you’re looking at more like $2-3k for the same work, and that’s not even counting inflation. Back in the day you could have your own practice and make a killing off this stuff (plus all the follow up debridements and in office scopes because there’s no global period), but now it’s a lot harder. The same thing continues to happen little by little each year with other procedures.
 
Wow hate to hear that payout for procedures is coming back down to earth compared to non-procedural specialties /s
 

“According to AMA data, the average net income of U.S. practitioners in 1982 was $99,500. The average for practicing physicians specializing in pediatrics was approximately $70,000, while for surgeons the average was approximately $130,000. Academic physicians had earnings ranging from $42,000 to $122,500 in 1983, depending on faculty rank and method of compensation.”

So $99,500 in 1982 is about $280,000 today
This doesn’t even account for the fact that these docs had low debt with next to nothing interest rates and they got to experience multiple crazy ass bull markets over the last 30 years.

All the docs I know who are 1) older, 2) not divorced, and 3) not stupid with their money are rich.
 
I think there’s two parallel phenomena, there’s reality which has all of the issues described above: inflation, decreasing purchasing power, changes in reimbursement schemes, differences in debt load and avg cost of living, etc. And then there’s the social phenomenon of people perceiving the world around them.

The period from the 1970s to the 1990s was not “real life” by any modern standard and it was a radically different economy. At the same time, what medicine in general could do for people was radically different from today. The period before that in medicine was much more modest.


Actually I think everyone would be surprised to know that doctors didn't really make a lot of money until the mid 80s. Before that clinical work was considered more of a public service than a business transaction.

From my copy of The Medusa and the Snail by Lewis Thomas:

"I had forgotten what things were like in the good old days of medicine, and how different...I found in the other day while glancing through the yearbook of my class at Harvard Medical School at the time of graduation, in 1937...Coons, as editor, decided to do something more ambitious for the yearbook than simply record the class statistics, and prepared a long questionnaire which was sent to all the alumni of the medical school from the classes which had graduated ten, twenty and thirty years earlier...To everyone's surprise 60 percent of the 265 alumni filled out the questionnaire and returned it...The findings of greatest interest, presented in some detail in the yearbook, concerned the net incomes of the alumni, which were, by the standards of the day, significantly higher than the AMA's figures for American physicians in general...We knew that interns and residents got room and board but no salary to speak of. We were glad to hear that Harvard graduates did better financially once out in practice...

The median net income of the group of 165 HMS graduates, ten to thirty years out of school, was between $5,000 and $10,000 a year (about 80K to 160K in today's dollars). In the ten year class, 43% made less than $5,000. Only five men earned over $20,000 (~300K c. 2015) and a single surgeon, twenty years out, made $50,000 (~700K). Seven graduates of the class of 1927 had incomes below $2,500 (below 40K).


The alumni were invited to send in comments along with the questionnaire, in a space marked "Remakrs", with the understanding that since so much of the form was directed at finding out how much money they were making they might like to say something about life in general. As it turned out, most of the "Remarks" were also about money, a typical comment being the following: 'I am satisfied with medicine as a life's work. However, I should recommend it only for the man who has plenty of money back of him. Many men never make much in medicine.' Forty one years ago, that was the way it was (LT wrote this in the 1970's)."

Everything in parentheses was written by me to provide 2015 dollars using a couple of online inflation calculators that seemed to roughly agree on those numbers. I bolded the bits I found the most interesting.

When you’re at the peak of mt Everest and looking around, every way is down. And these aren’t regular people we’re talking about, these are doctors, people who most likely chose this career precisely because they are incredibly risk averse. That doomsday tradition has continued basically indefinitely.

That’s not to say the challenges and squeeze on docs in the modern day aren’t real, they are, but if you believe the internet then medicine is going to be nothing robots, NPs, and robot NPs making the same salary as triple-boarded fellowship trained physicians in 10 years, which is also ridiculous.

I think what the doom prognosticating often fails to realize is that medicine isn’t the only part of the economy…the rest of the world has changed too. *Everyone* has less job security, fewer benefits, fewer savings, increased debt load, restrictive costs of living that exclude home ownership from most normal peoples wildest dreams in any major metropolitan area, etc. That stuff is true *for everyone*. The difference between docs and everyone is that docs are more likely to come from middle and upper class backgrounds, so being unable to completely reproduce the lifestyle of their parents or upbringing is probably felt a bit more keenly. In the grand scheme of their economy, we have very 20th century jobs that are considerably more secure and better paid than almost any other option. We also have more ways to make “extra” income than any other generation before us, and doctors are some of the few people with enough income to actually save and invest in the 21st century.
 
My question is simple: Upon browsing historical sdn threads way back to 10 years ago all the way up until now, the vast majority of compensation threads (in general and specialty specific) complain of declining reimbursements year over year. When looking at compensation reports online, however (MGMA and medscape), this claim is directly refuted as physician incomes have risen well past inflation over the last decade. I understand that the specific value of the numbers in these reports may not be accurate, especially for small subspecialties, but the general trend after surveying tens of thousands of physicians each year must hold some weight. What gives? Obviously physicians on here aren't just lying, so where does the declining reimbursement statement come from and why is it directly conflicted by the data on physician incomes?

Reimbursements for individual codes are often down.

Just as an example: a level 4 followup visit, a moderate complexity outpatient visit, reimburses $131 today from Medicare - but it actually had a pretty big increase this year. In 2020 in reimbursed $110, in 2010 it reimbursed $97.77, and in 2000 it reimbursed around $72 (I can't find a national fee schedule for 2000 - only regional ones, which vary a bit).

I went through and searched the entirety of the last 21 years, then adjusted for CPI to 2021 dollars.

YearNominalReal
2000​
$72.03​
$111.57​
2001​
$77.91​
$116.35​
2002​
$78.01​
$115.12​
2003​
$78.91​
$113.32​
2004​
$81.45​
$114.65​
2005​
$82.16​
$112.45​
2006​
$82.44​
$108.47​
2007​
$90.09​
$116.13​
2008​
$89.90​
$111.11​
2009​
$92.33​
$114.24​
2010​
$97.77​
$117.88​
2011​
$102.27​
$121.25​
2012​
$104.16​
$119.88​
2013​
$106.83​
$120.92​
2014​
$107.83​
$120.18​
2015​
$108.34​
$121.02​
2016​
$108.13​
$119.31​
2017​
$108.74​
$117.05​
2018​
$109.44​
$115.38​
2019​
$110.28​
$114.56​
2020​
$110.43​
$111.94​
2021​
$131.20​
$131.20​

As you can see, from 2000 to 2020, it vascillates from $108 to $121 (in 2021 dollars), with many years losing pace to inflation - until us outpatient docs finally got a real increase this year.

You can say that's great - reimbursement hasn't gone down, it's stayed relatively flat. Except there's another issue - there's a lot more expenses in 2021 that the practice has to pay. There's the same rent, electricity, staffing - but there's also paying the EMR, increased costs related to compliance with various quality programs, etc. So the take-home for that particular code is likely less than it was 21 years ago (it certainly was in 2020 - but we just had a big increase this year).

Similarly, you can search the Medicare fee schedule for any code you're interested in between 2000 and 2021 - Overview of the Medicare Physician Fee Schedule Search | CMS - and see that (after considering inflation), most of them have had either flat or decreasing reimbursement over time. Not all of them, but most of them. On top of that, I'm not as well versed on the non-Medicare side of things, but as I understand it, commercial payors used to be relatively even more generous compared to Medicare - but these days their fee schedules are often closer to Medicare than they used to be.

Why haven't incomes gone down with flat/declining reimbursements but increased overhead? Most doctors are working harder. That is, most people are seeing more patients, doing more procedures, or something similar. Some of those gains are from efficiency - it takes less time to do many procedures - and some of it is just from people choosing to hustle more.
 
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the private equity guys who are their employers are the ones getting rich
Yup. The value hasn’t disappeared, it’s just being funneled somewhere else. And then they run entire institutions into the ground when it doesn’t come out their way.
 
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