future of the "private practitioner"

[drboris]

I've been doing a lot of research on specialties and I have noticed one big underlying trend: all private practitioners are saying that in a few years they will call it quits because of continously decreasing reimbursement and higher overhead costs.

While I cannot yet actually fathom how bad the situation may be, it does concern me that when I graduate med school and complete my residency I will no longer job security or autonomy. Furthermore, who wants to keep working more and more year each simply to make less money?

Even one of the most autonomous and cushiest fields, optho, claim that private practice is no longer the haven that it used to be. It seems that if a hevaily driven procedural field like optho is complaining, all the other non-interventional fields will be much worse off?

I don't want to be this pessemistic, so if anyone has some wise words of wisdom, please share!

Thanks!

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[dry dre]

My useless opinions:

Relative to inflation, physician salaries continue to outpace most all other professions. And physicians start near the top in mean salary to begin with. Guys that used to make 750 now might make 500 and sound jaded and might want to "call it quits." I'd be happy at half of that...more than happy.

Job security will always, always be there in any medical field.

Reimbursements for different services in medicine changes/cycles over time. Chest-splitters get less than half of what they used to get for a CABG, and invasive cardio guys are now stenting everything they can get a cath into. Cardio seems VERY popular nowadays for med students and internal med residents...probably because stenting is so intellectual. The high reimbursements have nothing to do with it . If history is any teacher, this glut will not last for very long. Cushy fields don't stay cushy forever.

Gas was said to be dead because of CRNAs...docs quit going into anesthesiology...then there was a shortage of gas-MDs (with resultant increase in salary secondary to supply-demand economics).

If money is your goal (not saying it is)...look at history. Pick the speciality that seems like the worst to go into right now and be part of the few, the proud, the overpaid in 20 years.

 

[lurkerboy]

If any of this malpractice reform sees the light of day, I am sure the entire dynamic will change very quickly. Eg: OBGYN's in states like NJ are paying hundreds of thousands of dollars in malpractice insurance. That definitely effects the bottom line!

 

[Lonestar]

To dry dre:

In regards to your statements I have to agree with most of what you have to say, but the fact remains that most people go into the "cushy" fields for money/lifestyle. Mainly because we naturally become more materialistic as life goes on. No matter what you say the most competitive applicants WILL go into the fields with the most money and the easiest lifestyle. Much of their unhappiness comes from not living their expectations. Its almost as if what got them into the field (competitiveness/not giving in) is what hurts them when they figure out that they can't climb the ladder anymore.

As far as going into the "bad" fields right now to make money 20 years down the row, well i think i will stick with the fields that make money currently. I hate to wait 20 yrs. to pay off my $167K debt.

 

[dread]

What has happened over the past 10 yrs is that the solo private practioner who used to have one nurse and one secretary in his or her clinic is going extinct. The sad fact is that besides malpractice premiums, physicians have a ton of overhead that requires them to hire more people to sort through. A huge new problem physicians face these days is trying to get paid by the different insurance companies and government. Most practices have at least one person who handles this job, in addition to the nurse's aide and receptionist. There are tons of loopholes in terms of charting that physicians have to do in order to get paid for the work that they do, insurance companies lose money by paying physicians for providing health care so they look for any way to get out of doing it. These days, most private physicians work in groups where the overhead can be distributed and the risk of going bankrupt decreased. The larger the group, the more negotiating power you have against insurance companies as well. If your group encompasses just about every cardiologist in one state, then insurance comanies are going to have to deal with you or their customers are not going to be able to cardiology care in that state using their insurance company and will either switch companies or have to travel long distances. In the past, physicians were highly individualistic people who did not work well in groups, but this trend is shifting as physicians recognize that they day of the solo private practioner is fading and that there is strength in numbers.

 

[Energon]

If you look at some of the Wall St. Journal articles on this matter, you will see that there is a small possibility that the entire concept of ?Doctors Office? with fee for service might come back in a big way. Many physicians in less populous states/ areas are reverting back to this system. One of the examples is an EM/IM physician who left his cushy ED position to go solo. There are however a few stipulations. None of these physicians are covered for malpractice insurance. Hence, all their patients are notified in writing about the doctor?s status and some have even had their patients sign a ?non litigation pact? (promising no legal suit). Secondly, absolutely no insurance is accepted. Financially speaking, these physicians are making out pretty ok. The EP took a pay cut from $200k to about $140k. However, as a private practioner, there is no ceiling as far as income is concerned. Also his practice has just started out. Some of these physicians also provide home visits.
In terms of patient care: Most of the patient pool consists of working non-insured individuals. Their payments seem to be pretty affordable around $40 (which has to be paid at each visit) for checkup and basic blood work. Managed care costs about $70- 90 for the same work. Patients seem to be very happy with the service they are provided and each physician has a good patient load. The docs say that their services are so cheap because of the low overheads. They have absolutely no paid suits on staff only MD/DO, PA or RN?s.

 

[Energon]

Oh by the way there are limitations to this system. It only works as an outpatient setting. For a person who needs hospitalization the system fails because the non-insured docs dont have hospital privileges.

 

[Bull's eye]

One of the most innovative things that I have seen IM/FP docs do recently is the "tailored" doc. The patient pays the physican 10-15k per year base to be their private physician. He does this for 10 people, and when they need his services, he is at their beck and call and still charges insurance. I would like to see how that works out.

 

[raptor5]

Oh by the way there are limitations to this system. It only works as an outpatient setting. For a person who needs hospitalization the system fails because the non-insured docs dont have hospital privileges.

They could just contract a hospitalist couldn't they. Well if available of course. I would much rather have an IM hospitalist montoring my care at the hospital than my FP. No offense the FP does the job he is suited for but for extended care I prefer a current journal reading IM.

 

[MacGyver]

Originally posted by Bull's eye
One of the most innovative things that I have seen IM/FP docs do recently is the "tailored" doc. The patient pays the physican 10-15k per year base to be their private physician. He does this for 10 people, and when they need his services, he is at their beck and call and still charges insurance. I would like to see how that works out.

That market is already saturated. Only a few doctors can get away with this, because very, very few patients can afford to pay for "boutique" medicine.

 

[Energon]

Originally posted by raptor5
They could just contract a hospitalist couldn't they. Well if available of course. I would much rather have an IM hospitalist montoring my care at the hospital than my FP. No offense the FP does the job he is suited for but for extended care I prefer a current journal reading IM.

True that would be cool. Some of the doctors mentioned in the articles were also IM certified and previously held hospital priviliges which were later revoked due to their withdrawal from mal.
I think this entire system needs to be more looked into and further developed. However, one thing needs to be strictly maintained and that is the exclusion of paid suits. Since 1974, the # of medical trained personell has grown by 26% whereas the administrative personell has grown by over 400% (ABC news). It is pretty misleading when politicians/lawyers claim that cost of medical care is going up due to increased malpractice insurance (due to incompetent physicians)... Look into the pretty sky scraper office buildings with tons of people tapping away at computers filling em with useless "codes" and of course dont forget the HIP company of NJ who rented out a private island (sometime between 97- 99) for a year end party for the countless execs.

 

[Sanman]

Well from a political point of view doctors, especially incompetant ones, are very easy targets. Doctors are percieved as rich to the general public, whether they are or not. If you try to streamline the paperwork, you also decrease the number of available jobs, which is not a good idea politically. So if politicians don't get pressure from doctors, I doubt their positions will change.

 

[Energon]

True. Unfortunately, the TLA has really gone lightyears ahead as far as poisoning minds against the medical community. So at this point, the AMA is trying to salvage a crappy situation.