Get ready...

[2121115]

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I hope none of you took out student loans to pay medical school tuition. The bottom is about to fall out...

http://www.nytimes.com/2011/09/08/us/08docs.html?_r=1&src=me&ref=general


I will never understand why people think it is physician reimbursement that is contributing to increasing health care costs even though physician reimbursement goes down every year.

 

[pathstudent]

I hope none of you took out student loans to pay medical school tuition. The bottom is about to fall out...

http://www.nytimes.com/2011/09/08/us/08docs.html?_r=1&src=me&ref=general


I will never understand why people think it is physician reimbursement that is contributing to increasing health care costs even though physician reimbursement goes down every year.

And what would make this really grim is that it would slash insurance fees by the same amount and reduce revenue for academic practices as well as private practices by 30%.

I dont think it will happen though. Pathologists can't refuse to take Medicare but most clinicians could and I doubt the cuts would go through.

That is a good point about physician reimbursement. It has remained flat for years yet spending has gone up and up.

 

[Deucedano]

I will never understand why people think it is physician reimbursement that is contributing to increasing health care costs even though physician reimbursement goes down every year.

Its because people are ignorant, not by choice, but by this kind of BS and the rest of the media. They dont understand that becoming a physician requires years of hard work living on poverty level income to accumulate 250K+ debt at 6.8% and 7.9% interest that you cant really start paying off until your in your early 30s. Then you have malpractice on top of it.
When I speak with people who have this attitude, they quickly realize that 200K salary doesnt look nearly as much when malpractice and loan payments are subtracted from it.

 

[Thrombus]

Its because people are ignorant, not by choice, but by this kind of BS and the rest of the media. They dont understand that becoming a physician requires years of hard work living on poverty level income to accumulate 250K+ debt at 6.8% and 7.9% interest that you cant really start paying off until your in your early 30s. Then you have malpractice on top of it.
When I speak with people who have this attitude, they quickly realize that 200K salary doesnt look nearly as much when malpractice and loan payments are subtracted from it.

Not to mention the stress tha goes with it, the sacrifice of your 20's and early 30's (not to mention your late teens); the endless testing/CME; the fact that your kids will never get any kind of scholarship and will always be looked upon as "privileged sp?".

Nor do they mention that most people in medicine would not be sitting in a cubicle working for "the man" their whole life as an alternative for 50K.

Gotta love these left wingers. They are out to destroy each and every profession that "makes too much" and turn us into a 2 class system. The bureaucrats "planners" and the rest of us. Intent on destroying with regulation every profession in the country: The doctors, the bankers, the businessman, the engineer (the entrepreneurial ones anyway). Honestly what field do you recommend anymore? They are all being destroyed by the government!!!

 

[2121115]

Since I am already in it, I am going to ride it out for what's left. No way I would recommend to a young person to become a doctor now though - and definitely not my kids.

 

[sirenomelia]

In most countries outside the US, medical doctors are much closer to middle class than here, however they don't work nearly as hard. Don't kid yourself though, US Physicians (some) including pathologists are a part of the economic problems due to the silly manner in which services are paid for. You can sit for 6 hours in a derm or GI chop shop 5 days a week and bill 88305 nothings all day and make 500k/year. Our system rewards procedures- whether needed or not, and many motivated by greed take advantage of that. I know personally a gastroenterologist who shoves a scope in from above and below anyone who walks into his clinic (40-50 a day) and biopsies every region esophagus, stomach, duodenum, ileum, prox colon, transverse colon, distal colon on all of them and in 85% the tissue is completely normal. Dude clears 7 figures a year doing no medical benefit to anyone.

 

[Deucedano]

In most countries outside the US, medical doctors are much closer to middle class than here, however they don't work nearly as hard. Don't kid yourself though, US Physicians (some) including pathologists are a part of the economic problems due to the silly manner in which services are paid for. You can sit for 6 hours in a derm or GI chop shop 5 days a week and bill 88305 nothings all day and make 500k/year. Our system rewards procedures- whether needed or not, and many motivated by greed take advantage of that. I know personally a gastroenterologist who shoves a scope in from above and below anyone who walks into his clinic (40-50 a day) and biopsies every region esophagus, stomach, duodenum, ileum, prox colon, transverse colon, distal colon on all of them and in 85% the tissue is completely normal. Dude clears 7 figures a year doing no medical benefit to anyone.

I agree with you here. There are some physicians who abuse the system by taking advantage of the increasing volume = increase reimbursement/income. These people have pretty much screwed my generation who have 250K+ debt at 6.8% (thanks uncle sam!) and face lower incomes in the future.

I had no intention of being wealthy when I entered medicine; however, I am starting to question my ability to pay off loans working for an academic institution with all this talk of decreasing reimbursement. Clearly the legislators dont realize that it will drive all the good/competent people out of academics and leave no one to teach the next generation of physicians. I guess time will tell...

 

[BU Pathology]

I agree with you here. There are some physicians who abuse the system by taking advantage of the increasing volume = increase reimbursement/income. These people have pretty much screwed my generation who have 250K+ debt at 6.8% (thanks uncle sam!) and face lower incomes in the future.

I had no intention of being wealthy when I entered medicine; however, I am starting to question my ability to pay off loans working for an academic institution with all this talk of decreasing reimbursement. Clearly the legislators dont realize that it will drive all the good/competent people out of academics and leave no one to teach the next generation of physicians. I guess time will tell...

The NIH has a very attractive loan repayment program, that has as a specific category research using tissue specimens from patients. More information can be found at: http://www.lrp.nih.gov/

The program pays a portion of your loan, up to $35,000 per year. It will also pay the income tax on your loan, so that you truly can reduce your debt. If you are eligible, up to $140,000 in loan repayment can be obtained.

The payline, i.e. the success rate of obtaining funding, is also very good. Over the last 4 years, about 38% of applicants received the grants.

This was not a legislative mandate, it was a decision by NIH to attempt to increase the pipeline of phyisician scientists.

Daniel Remick, M.D.
Chair and Professor of Pathology and Laboratory Medicine
Boston University School of Medicine and Boston Medical Center

 

[Pathwrath]

Notice how the article mentioned nothing about differences in medical malpractice between the U.S. and other nations, like how we're sued over 3 times as frequently as Canadian doctors without any evidence of increased physician error, nor does it address the costs of defensive medicine (the NEJM study clocked it at 10% of healthcare spending).

That's because healthcare reform in the U.S. means decreased physician reimbursement while everything else magically remains the same--access, benefits, state-of-the-art care, drug costs, malpractice costs, med school tuition, insurance profits, everything. We want U.S.-style dream medicine and we think we're going to get it with NHS physician salaries.

There are too many goddamn lawyers in the Democratic party.

 

[Pathwrath]

"The study examined fees paid by public programs and private insurers for basic office visits and for hip replacement surgery, and found that Americans were “very low users of office visits and relatively high users of hip replacement surgery.”

Yes, because think of all those degenerated hips that could have been better and more economically treated by more office visits (maybe even with a physician extender!) rather than costly surgery.

And this is in the New York Times.

 

[KeratinPearls]

I know personally a gastroenterologist who shoves a scope in from above and below anyone who walks into his clinic (40-50 a day) and biopsies every region esophagus, stomach, duodenum, ileum, prox colon, transverse colon, distal colon on all of them and in 85% the tissue is completely normal. Dude clears 7 figures a year doing no medical benefit to anyone.

Does this dude have an in office path lab?If so, does he chain his pathologist to the scope?

 

[2121115]

That's because healthcare reform in the U.S. means decreased physician reimbursement while everything else magically remains the same--access, benefits, state-of-the-art care, drug costs, malpractice costs, med school tuition, insurance profits, everything. We want U.S.-style dream medicine and we think we're going to get it with NHS physician salaries.

^^^ This ^^^

Nobody is talking about decreasing what Medicare pays for Lipitor. There is no RUC for drug companies or medical device manufacturers. We are going to decrease physician reimbursement, hurt our profession and then still find that medical costs are spiraling out of control anyway.

 

[pathstudent]

^^^ This ^^^

Nobody is talking about decreasing what Medicare pays for Lipitor. There is no RUC for drug companies or medical device manufacturers. We are going to decrease physician reimbursement, hurt our profession and then still find that medical costs are spiraling out of control anyway.

The hospital and drug corporations are far more powerful than the professional organizations for docs. That is what it comes down to.

 

[yaah]

^^^ This ^^^

Nobody is talking about decreasing what Medicare pays for Lipitor. There is no RUC for drug companies or medical device manufacturers. We are going to decrease physician reimbursement, hurt our profession and then still find that medical costs are spiraling out of control anyway.

Yes they are. "They" talk about it all the time. If you read any health policy chatter you will see lots of discussion about drug reimbursement and how many regulations and restrictions are on it that make it much more expensive to take medications in the US than in other countries. There is also tons of chatter about medical devices and the increasing reimbursement and profit in there. And yes, there is a lot of chatter about physician reimbursement, although many make the distinction between physician "fees" (which are reimbursements before office overhead and administrative expenses come in) and physician salary.

The problem for physicians is that physician reimbursement is a relatively easy target for cuts.

There is no quick fix to increasing medical expenditures. Part of that is because everything gets more complicated every year. More drugs. More tests. More procedures, all for the same diagnosis that had fewer of all the above a few years ago.

 

[2121115]

Yes they are. "They" talk about it all the time. If you read any health policy chatter you will see lots of discussion about drug reimbursement and how many regulations and restrictions are on it that make it much more expensive to take medications in the US than in other countries. There is also tons of chatter about medical devices and the increasing reimbursement and profit in there. And yes, there is a lot of chatter about physician reimbursement, although many make the distinction between physician "fees" (which are reimbursements before office overhead and administrative expenses come in) and physician salary.

The problem for physicians is that physician reimbursement is a relatively easy target for cuts.

There is no quick fix to increasing medical expenditures. Part of that is because everything gets more complicated every year. More drugs. More tests. More procedures, all for the same diagnosis that had fewer of all the above a few years ago.

Hmm... I thought that when the health care reform package was first introduced, the drug companies agreed to a one time concession (which amounted to peanuts) in return for being off of the negotiating table during further talks. As I recall there was much uproar about this in physician circles (AMA, etc) but it was relatively quietly done otherwise. I'll have to check on that.

 

[sirenomelia]

Does this dude have an in office path lab?If so, does he chain his pathologist to the scope?

He has been trying to set-up an in office pod-lab and hire some nub runt to them read out so he can collect the professional path component too but right now the specimens get spread out to my group, quest, and some other place based on insurance contracts.

 

[schrute]

People make illegitimate international comparisons between the US and other countries all the time...physician salaries, healthcare costs, social programs, violence, Baywatch viewership, etc....

Such comparisons mean nothing in isolation...as if physician salaries occur in a vacuum... Typical, and inevitable.

 

[hpb214]

The cost of an education is what is spiraling out of control. There are far too many physicians 200K+ in the hole. With a field like path where most people do 5 years of post-graduate education (4 residency plus one fellowship) that 200K jumps up considerably in interest accrual. Then you consider physicians defer their income into their lower to mid thirties which means increased salaries, but higher taxes (and even higher in the future starting next year with a 0.9% increase in Medicare tax on you "rich" corporate jet owners making 250K or more as a family), higher disability and life insurance premiums, find they are behind the eight ball saving for retirement and their children's education, it almost does not make financial sense to become a physician anymore. Not to mention, you sacrifice a lot of your good years (20-30s) studying and preparing for examination after examination and go through evaluation after evaluation and kiss a lot of butt. Did we mention malpractice insurance and the stress of the job? Will the best and the brightest who do not have family able to support the high cost of an education continue to see becoming a physician as a viable option? With medical reimbursements decreasing, and taxes increasing, physicians will be getting hosed in the future.

 

[icpshootyz]

I go back and forth with this a lot. Let's face it, money is a motivating factor in becoming a physician for many people. If that motivation lessens, maybe those motivated by it will move on to different work, and maybe those with a genuine interest in medicine will remain. Look at what specialties are popular in medicine, many of them are higher paying with better hours. Not exactly a coincidence. I'm not saying I'm upset about the current pay, but the system is definitely broken and could use some reform.

 

[LADoc00]

Hahaha when will people understand the NY Times is more leftist than the Workers World or Communism Now! publications?

I PISS on the NYTimes. Paul Krugman is nothing more than the propaganda mouth piece of the leftist idealogues.

Bankrupting doctors has always been a very valuable goal/tool of the left ever since the rise of the Soviet.

Step 1. Bankrupt private doctors
Step 2. force state owned healthcare
Step 3. use state owned healthcare to manipulate and control the idiot masses
Step 4. profit

USSR as a state may have collapsed, but its dark tendrils are EVERYWHERE.

 

[icpshootyz]

:: rolls eyes ::

 

[Pathwrath]

I know personally a gastroenterologist who shoves a scope in from above and below anyone who walks into his clinic (40-50 a day) and biopsies every region esophagus, stomach, duodenum, ileum, prox colon, transverse colon, distal colon on all of them and in 85% the tissue is completely normal. Dude clears 7 figures a year doing no medical benefit to anyone.

You are not alone. These types are everywhere, and when fee-for-service becomes a fond memory, they will deserve the blame.

 

[icpshootyz]

Just look at dermatology. If you take a small biopsy of a small lesion, you get paid to go back again and get the rest of it. So why do a primary excision when you can do a biopsy and then have the pt back for a re-excision? Even though the only reason you have to have the patient back is because you purposefully did not fully remove the 3mm benign mole in the first place. Granted, us dermpathers reap the benefits of that, but there's no way it's not fraud. Impossible to prosecute, yes, but that doesn't make it any less fraudulent.

 

[pathstudent]

Just look at dermatology. If you take a small biopsy of a small lesion, you get paid to go back again and get the rest of it. So why do a primary excision when you can do a biopsy and then have the pt back for a re-excision? Even though the only reason you have to have the patient back is because you purposefully did not fully remove the 3mm benign mole in the first place. Granted, us dermpathers reap the benefits of that, but there's no way it's not fraud. Impossible to prosecute, yes, but that doesn't make it any less fraudulent.

Biopsy prior to excision seems logical to me, especially if excision isn't required. It does not seem like fraud.

 

[icpshootyz]

Depends on the circumstance. Purposefully taking 1.5mm of a 3mm lesion, when you could shave out or punch out the whole thing? Kinda fraudy. If the lesion comes back more malignant than you were expecting, yes, obviously you go back with a larger excision no matter what. But if you make no attempt (and most don't) to do an excisional bx (I'm talking shave or punch, not elliptical deep excision) the first time then you guarantee yourself a second office visit and second procedure, hence double the pay for the same lesion. Not to mention half-biopsying melanocytic lesions is terrible medicine when it comes to staging and prognosis of melanomas.

 

[hpb214]

I go back and forth with this a lot. Let's face it, money is a motivating factor in becoming a physician for many people. If that motivation lessens, maybe those motivated by it will move on to different work, and maybe those with a genuine interest in medicine will remain. Look at what specialties are popular in medicine, many of them are higher paying with better hours. Not exactly a coincidence. I'm not saying I'm upset about the current pay, but the system is definitely broken and could use some reform.

I understand what you are saying, but the reverse is also true. Maybe the fear of astronomical debt, along with all of the other things I have mentioned (decreased reimbursement rates for physicians, higher taxes, behind the eight ball saving for retirement and their children's education, high disability and life insurance premiums, starving lawyers) will scare outstanding candidates from becoming physicians. They may use their intelligence and compassion to do something else for society. Something that may pay more, with less stress, and much less sacrifice.

There are a lot of ways to make money, becoming a physician (now and in the future) isn't one of them. If you are entering the profession with a monetary goal as one of the main reasons, you will be sorely disappointed.

 

[icpshootyz]

It's not necessarily the main goal, but can you argue it's not high on a lot of people's lists? And if money wasn't a motivating factor, would people find dermatology and ophthalmology all that fascinating and worth killing themselves to get into? Would everyone be fighting for cardiology fellowships and abandoning primary care? I doubt it. Money and medicine are intricately linked at this point, and most of what everyone fights about is keeping their piece of the pie should reimbursement fall. We talk about needing more PCP's, but why isn't anyone doing primary care? All those reasons you mentioned. So yes, if reimbursement continues to fall and dr's make less and less, we are definitely going to scare people away. I doubt they'll end up in a very rewarding career, at least anything like being a physician. But hey, business and finance is where the big bucks are.

 

[pathstudent]

We talk about needing more PCP's, but why isn't anyone doing primary care? {/QUOTE]

Because office based primary care f***ing sucks. It would be like being a pathologist that just looks at sinus contents or tonsils or lipomas all day except worse because you have to deal with frequent annoying whiny people (well same goes for academic physicians having to deal with residents, joke) complaining about how their back hurts or they have a cold or their throat is sore.

Specialties are determined by personality. Neurosurgeons wouldn't go into family practice if it paid as much. Family practice docs wouldn't be happy being neurosurgeons.

 

[icpshootyz]

To a point, yes. I don't think someone that loves surgery is all of a sudden going to do primary care instead if the money was equal. But clinic-based medicine sub-specialties? Sure there's a procedure every now and then, but do anything 500 times and it's no longer that exciting. I would argue the larger appeal is money.

 

[Enkidu]

Specialties are determined by personality. Neurosurgeons wouldn't go into family practice if it paid as much. Family practice docs wouldn't be happy being neurosurgeons.

Yeah, but people who go into dermatology are probably not interested in dermatology. Who would be? They're interested in an income and a lifestyle. If that income was there in family medicine, then they would probably go there.

Likewise, people go into plastic surgery to make money, not because they're passionate about improving people's chances in Hollywood. They may be really interested in pediatrics, or general surgery or something.

I think it would be great if physician compensation were more-or-less flat across specialties. Then at least the most competitive specialties would at least be the most interesting ones.

If physicians didn't make any money, then nobody would want to go into medicine. If they made a million dollars a year... everybody would want to do it. If they made $500,000 a year... everybody would still want to do it. My point is not all reimbursement cuts will actually affect demand for a medical education. There's a balance somewhere in which the people most suited for medicine still go into medicine, but their salaries are lower. I'm not sure where that balance is, but it's in the best interest of our health policy (if not our physicians) to find it.

 

[TMZ2007]

There's a balance somewhere in which the people most suited for medicine still go into medicine, but their salaries are lower. I'm not sure where that balance is, but it's in the best interest of our health policy (if not our physicians) to find it.

Be prepared for the likely "OMG Socialism!" complaints.

The big problem with this line of thinking is that physician compensation is a small fraction of total government outlays for health care services.

From the 2011 HHS Budget document, page 54.

Railroading a 25% cut will serve only to piss off doctors and not significantly impact spending. Wanna actually make an impact? Raise the retirement age. Address end-of-life care issues. Limit coverage for super costly medications. Allow the government to negotiate volume discounts with big pharma. Sticking it to doctors is just not gonna get it done for you.

 

[pathstudent]

You seem to think "interesting" is an objective thing.

It is not. To me pathology was the most interesting field, but to almost everyone else in medical school it was dreadfully boring and unstimulating. Heck pathology pays pretty well among all fields of medicine and yet it is the least competitive along with psychiatry. So that sort of shoots down your premise right there.

And I don't think it makes sense at all to suggest that pediatric neurosurgeons should make about the same as general pediatricians.

Yeah, but people who go into dermatology are probably not interested in dermatology. Who would be? They're interested in an income and a lifestyle. If that income was there in family medicine, then they would probably go there.

Likewise, people go into plastic surgery to make money, not because they're passionate about improving people's chances in Hollywood. They may be really interested in pediatrics, or general surgery or something.

I think it would be great if physician compensation were more-or-less flat across specialties. Then at least the most competitive specialties would at least be the most interesting ones.

If physicians didn't make any money, then nobody would want to go into medicine. If they made a million dollars a year... everybody would want to do it. If they made $500,000 a year... everybody would still want to do it. My point is not all reimbursement cuts will actually affect demand for a medical education. There's a balance somewhere in which the people most suited for medicine still go into medicine, but their salaries are lower. I'm not sure where that balance is, but it's in the best interest of our health policy (if not our physicians) to find it.

 

[pathstudent]

Great point. Physician reimbursement has remained flat, yet healthcare costs continue to go up. Slashing physician salaries will be gratifying to university theorists but it won't do anything to control healthcare costs.

We demand death panels! If you have breast cancer over the age of 90, you get surgery and tamoxifen. That's it! No radiation, no herceptin!

If you are demented and in a nursing home, you don't get a bone marrow to figure out why your platelet count is 95k.

Like a pulmonologist once told me "Pneumonia used to be an old man's best friend. Now it is a power failure in the unit".

Google David Brooks recent column about our inability to accept the fact that all us M***** F******* are going to die.

Be prepared for the likely "OMG Socialism!" complaints.

The big problem with this line of thinking is that physician compensation is a small fraction of total government outlays for health care services.

From the 2011 HHS Budget document, page 54.

Railroading a 25% cut will serve only to piss off doctors and not significantly impact spending. Wanna actually make an impact? Raise the retirement age. Address end-of-life care issues. Limit coverage for super costly medications. Allow the government to negotiate volume discounts with big pharma. Sticking it to doctors is just not gonna get it done for you.

 

[icpshootyz]

You seem to think "interesting" is an objective thing.

It is not. To me pathology was the most interesting field, but to almost everyone else in medical school it was dreadfully boring and unstimulating. Heck pathology pays pretty well among all fields of medicine and yet it is the least competitive along with psychiatry. So that sort of shoots down your premise right there.

And I don't think it makes sense at all to suggest that pediatric neurosurgeons should make about the same as general pediatricians.

It's hard to compare pathology (non-patient contact) to fields w/ patient contact. There's few people who are interested in hands-on medicine who would choose pathology just for lifestyle/money because they really do enjoy seeing and caring for patients on a daily basis. But I would argue more people choose radiology > pathology because of money, even though staring at black and white films is hardly more interesting. But radiology can do procedures and make bigger bucks. I know several who went for it for just that reason.

And I don't think a flat salary for all physicians makes sense, no. But there's a huge disparity in some fields, and really when it comes down to it we're all working pretty hard. If I put in 60 hrs/ week in path is my 60 hrs really worth significantly less/more than any other dr's 60 hrs? And if so, why? Is 60 hrs spent operating worth 5x as much as 60 hrs spent managing outpatient health issues? Doing well checks? Reading slides? I don't know that answer, but I don't think the large disparity is good for medicine or for how people choose specialties.

 

[lipomas]

You are not alone. These types are everywhere, and when fee-for-service becomes a fond memory, they will deserve the blame.

Yes but they won't get it because they are cashing out now and will be retired or eased out.

 

[yaah]

Hmm... I thought that when the health care reform package was first introduced, the drug companies agreed to a one time concession (which amounted to peanuts) in return for being off of the negotiating table during further talks. As I recall there was much uproar about this in physician circles (AMA, etc) but it was relatively quietly done otherwise. I'll have to check on that.

No, I believe that is right. But the ACA is not the be all end all of health care funding for the next 20 years. There is always a lot of chatter about cutting various parts of medicare funding. Recent data is now suggesting that medicare part D expenditures are actually declining (or at least co-pays are, not sure about the full details) so that is removing some pressure in certain circles for having to act on drug prices.