Gloom and doom

[DrAwsome]

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So I have heard the gloom and doom scenario from multiple specialties, read about in the numerous specialty forums, and now I ask-is it real? Radiologists think they will go down and will be making primary care salaries, anesthesiologists think they will be replaced by CRNA's, FP/IM's will be replaced by NP/PA, Psychiatrists will lose out to psychologists, etc. etc.

Why is there always this mad panic about the future of our fields? Are we really that replaceable? Is this realistic of our future in medicine?

 

[Sneezing]

Read some more in the psychiatry forum.

Here's the deal, as Obamacare and the ACOs move into place rationing will increase. It will be done in a manner similar to the attempts of capitation in the 1990's, which didn't work. This time around it will be on a much bigger scale and those who are in cognitive, non-procedural specialities not-dependent upon hospitals will flourish. Just as the impulse of the "gate keeper" mentality surged a rise in PCPs in the late 1990's it will do it again. This time a two tier system will emerge with those in the government system being treated primarily by midlevels and those able to afford getting outside the system with cash to see physicians. These are generalities but will be the trends.

I'm happy in psychiatry and expect a bright future in the setting of the same rocky trail everyone will face.

 

[Law2Doc]

...

Why is there always this mad panic about the future of our fields? Are we really that replaceable? Is this realistic of our future in medicine?

I don't think always is an accurate statement -- this is a very new thing, which is the culmination of tough economic times as well as an imminent move toward universal coverage. This gloom and doom is a fairly reasonable viewpoint in light of the bad economy, the rising costs of healthcare and the governments perceived hostility toward the medical profession and backing of insurers and midlevels. To be a wide eyed optimist in the current landscape would be a bit naive. Doesn't mean the sky is falling tomorrow, but it does mean that a lot of assumptions people made based on last years numbers won't hold true in the coming years. And that can be a very big deal.

 

[LoveandHate]

Read some more in the psychiatry forum.

Here's the deal, as Obamacare and the ACOs move into place rationing will increase. It will be done in a manner similar to the attempts of capitation in the 1990's, which didn't work. This time around it will be on a much bigger scale and those who are in cognitive, non-procedural specialities not-dependent upon hospitals will flourish. Just as the impulse of the "gate keeper" mentality surged a rise in PCPs in the late 1990's it will do it again. This time a two tier system will emerge with those in the government system being treated primarily by midlevels and those able to afford getting outside the system with cash to see physicians. These are generalities but will be the trends.

I'm happy in psychiatry and expect a bright future in the setting of the same rocky trail everyone will face.

Explain the bolded part please. That seems counter-intuitive

 

[Law2Doc]

Explain the bolded part please. That seems counter-intuitive

Yeah, I think it's backwards. The procedural fields generally do better, or at least they did so under prior attempts at capitation.

 

[Valadi]

I'm continually perplexed at how physicians and physician-trainees bemoan our bleak future, but we do very little in terms of lobbying to fight this. Contrast this to the powerful nursing lobby and its no wonder the future looks questionable. Moreover, it doesn't help that the AMA largely does not represent the will of the physician majority (some studies of this online), and new physicians and med students are still doe-eyed and wish to champion healthcare on the basis of lofty ideals without significant consideration for whom the money will come from (or stop going to).

 

[gutonc]

Yeah, I think it's backwards. The procedural fields generally do better, or at least they did so under prior attempts at capitation.

I actually think s/he has a point here. If you are in a specialty like this (and psych is the best example) where all you need is a desk, two chairs, a computer and a phone (and a receptionist whom you share with a few other providers of basically any type), you can charge reasonable cash prices and make a fairly decent living. I know 3 guys who recently graduated from our psych program who are doing this...they share a single office, each works 3-4 half days a week, they have a receptionist that they share with the physical therapy office down the hall and they don't take insurance. The one I talked to most recently is pulling down $140-150K with almost no overhead and working about 25 hours a week. There is nothing in the upcoming healthcare changes that will prevent him from continuing to do this.

 

[nitemagi]

I actually think s/he has a point here. If you are in a specialty like this (and psych is the best example) where all you need is a desk, two chairs, a computer and a phone (and a receptionist whom you share with a few other providers of basically any type), you can charge reasonable cash prices and make a fairly decent living. I know 3 guys who recently graduated from our psych program who are doing this...they share a single office, each works 3-4 half days a week, they have a receptionist that they share with the physical therapy office down the hall and they don't take insurance. The one I talked to most recently is pulling down $140-150K with almost no overhead and working about 25 hours a week. There is nothing in the upcoming healthcare changes that will prevent him from continuing to do this.

Ssshhh. Don't let out the secret.😏

Those that're tied to hospital systems are essentially tied to whatever medicare reimburses, therefore if health reform cuts reimbursement for procedures, they're stuck. Low overhead cash based practices are relatively immune to this. I say relatively in that in a down economy Less people can afford to pay cash. While psychologists are a form of competition, there is always plenty of work for those that are good at what they do, and it's extremely rare for a psych NP or those rare psychologists that live in a state where they can get credentialed to prescribe actually matching the quality of a really good psychiatrist as far as medication management (though I'm sure there are exceptions).

 

[DrAwsome]

I don't think always is an accurate statement -- this is a very new thing, which is the culmination of tough economic times as well as an imminent move toward universal coverage. This gloom and doom is a fairly reasonable viewpoint in light of the bad economy, the rising costs of healthcare and the governments perceived hostility toward the medical profession and backing of insurers and midlevels. To be a wide eyed optimist in the current landscape would be a bit naive. Doesn't mean the sky is falling tomorrow, but it does mean that a lot of assumptions people made based on last years numbers won't hold true in the coming years. And that can be a very big deal.

So basically what I'm hearing is that all our work/effort/sacrifice/training is pretty much pointless then. Our reimbursement will go down to what midlevels make. Interesting. I wonder what will happen when no one makes to go to med school anymore? I really think that many specialties are already underpaid as it is, with more cuts, regardless of how much we like medicine, it becomes a huge sacrifice for little reward.

Many jobs out there already make what PCP's, peds, FP, etc make. Why are we so undervalued? What does that say about how we are perceived? I find it scary.

 

[nitemagi]

So basically what I'm hearing is that all our work/effort/sacrifice/training is pretty much pointless then. Our reimbursement will go down to what midlevels make. Interesting. I wonder what will happen when no one makes to go to med school anymore? I really think that many specialties are already underpaid as it is, with more cuts, regardless of how much we like medicine, it becomes a huge sacrifice for little reward.

Many jobs out there already make what PCP's, peds, FP, etc make. Why are we so undervalued? What does that say about how we are perceived? I find it scary.

It says that you may have to think outside the box to have the practice you want to have. Doing garden variety primary care might not be lucrative, but if you're entrepreneurial there are always good niches that you can create for yourself.

Pointless? I think not. It's easy to whine about it. Better to channel your energy into 1) getting involved in medical associations/societies, and try to make legislative changes that way
2) Figuring out what you Really want to do in your future practice, and innovate how to make that work. An example for primary care might be figuring out how to create a boutique practice, or eliminate most overhead, or sub-specialize.

Doctors are taught to think a lot inside the box, which is great. We're really good at that. Imagine what we could come up with if we tried applying that creatively.

 

[Law2Doc]

So basically what I'm hearing is that all our work/effort/sacrifice/training is pretty much pointless then. Our reimbursement will go down to what midlevels make. Interesting. I wonder what will happen when no one makes to go to med school anymore? I really think that many specialties are already underpaid as it is, with more cuts, regardless of how much we like medicine, it becomes a huge sacrifice for little reward.

Many jobs out there already make what PCP's, peds, FP, etc make. Why are we so undervalued? What does that say about how we are perceived? I find it scary.

It's only pointless if your focus is the money. There are tons of undervalued jobs out there and people still fill them because they get non monetary satisfaction out of them. There is still a huge demand for healthcare, it's just that no one in the government or insurance industry wants to pay the current going rate for the best trained person.

 

[Law2Doc]

I actually think s/he has a point here. If you are in a specialty like this (and psych is the best example) where all you need is a desk, two chairs, a computer and a phone (and a receptionist whom you share with a few other providers of basically any type), you can charge reasonable cash prices and make a fairly decent living. I know 3 guys who recently graduated from our psych program who are doing this...they share a single office, each works 3-4 half days a week, they have a receptionist that they share with the physical therapy office down the hall and they don't take insurance. The one I talked to most recently is pulling down $140-150K with almost no overhead and working about 25 hours a week. There is nothing in the upcoming healthcare changes that will prevent him from continuing to do this.

Well in a bad economy and in a setting where everyone will have insurance (both of which appear to be in the coming landscape) odds are that very few will be willing to shell out cash. If I am strapped and I already have insurance that's supposed to cover my doctor visit, I'm not opening my wallet. In a better economic time, I might have, but not now. So no, you won't be able to "charge reasonable cash prices" for long, you will get stuck with what the reimbursement is going to be for an office visit, which for time intense fields is disastrous. The folks you know who are doing well now aren't really relevant in terms of the upcoming situation -- things are changing. Which is why the nonprocedural folks probably get hardest hit -- if you get reimbursed per procedure you can try to do more of those procedures that are faster and get a better yield. If you are charging by the hour, you are stuck -- an hour can never be completed any faster.

 

[goodoldalky]

Well in a bad economy and in a setting where everyone will have insurance (both of which appear to be in the coming landscape) odds are that very few will be willing to shell out cash. If I am strapped and I already have insurance that's supposed to cover my doctor visit, I'm not opening my wallet. In a better economic time, I might have, but not now. So no, you won't be able to "charge reasonable cash prices" for long, you will get stuck with what the reimbursement is going to be for an office visit, which for time intense fields is disastrous. The folks you know who are doing well now aren't really relevant in terms of the upcoming situation -- things are changing. Which is why the nonprocedural folks probably get hardest hit -- if you get reimbursed per procedure you can try to do more of those procedures that are faster and get a better yield. If you are charging by the hour, you are stuck -- an hour can never be completed any faster.

That all depends. IMO, fields that can be considered cash-based practices will always have a certain degree of immunity from healthcare reform. If insurance premiums go down the crapper, take zero insurance. Simple.

The demand for the service may differ, however, and you've got to have it for a cash-based practice to work. Procedural based specialties who can be cash-based will fare the best. Fancy-pants ENT, ophtho, ortho guy? Cash based to fix your ACL or refill your xalatan? Cake.

PCP/cerebral specialties, such as psych and medicine, will be dependent on how difficult it is for patients to access care with their universal insurance. The demand for a conceige practice is dependent almost entirely on if there is access to healthcare for the insured. Should our healthcare system deteriorate to a wait-6-months to see your PCP or shrink, then there will be plenty of demand for a cash-based psych practice.

 

[Sneezing]

The demand for a conceige practice is dependent almost entirely on if there is access to healthcare for the insured. Should our healthcare system deteriorate to a wait-6-months to see your PCP or shrink, then there will be plenty of demand for a cash-based psych practice.

Bingo!

With the current level of physicians, there will be a wait time. Furthermore, the government will continue to cut costs and these two things will drive people to flee the government care, rightly so.

 

[docB]

I'm continually perplexed at how physicians and physician-trainees bemoan our bleak future, but we do very little in terms of lobbying to fight this. Contrast this to the powerful nursing lobby and its no wonder the future looks questionable. Moreover, it doesn't help that the AMA largely does not represent the will of the physician majority (some studies of this online), and new physicians and med students are still doe-eyed and wish to champion healthcare on the basis of lofty ideals without significant consideration for whom the money will come from (or stop going to).

It's not perplexing. Med students and residents and green attendings are too poor and busy to be activists. Nurses start making paychecks, joining lobby groups and paying union dues much earlier in their careers. And when it comes to the unions they often don't even have a choice, they become activists by circumstance.

 

[docB]

That all depends. IMO, fields that can be considered cash-based practices will always have a certain degree of immunity from healthcare reform. If insurance premiums go down the crapper, take zero insurance. Simple.

The demand for the service may differ, however, and you've got to have it for a cash-based practice to work. Procedural based specialties who can be cash-based will fare the best. Fancy-pants ENT, ophtho, ortho guy? Cash based to fix your ACL or refill your xalatan? Cake.

PCP/cerebral specialties, such as psych and medicine, will be dependent on how difficult it is for patients to access care with their universal insurance. The demand for a conceige practice is dependent almost entirely on if there is access to healthcare for the insured. Should our healthcare system deteriorate to a wait-6-months to see your PCP or shrink, then there will be plenty of demand for a cash-based psych practice.

I don't know. The example above of the psych guys doing well as a cash only, part time practice is dependant on the low overhead as Gutonc pointed out. Being a cash only general or ortho surgeon will be tough. There aren't that many people around who can afford to drop a few thousand for a gall bladder or a knee replacement. It will be hard for them to break away from the system. Those that try will be constantly trying to balance out profit margin vs. volume.

 

[rachmoninov3]

Do any of you really think that Obamacare is going to make people start seeing their PCP rather than just going to use the ER? Obamacare will not legislate behavior change. What I do foresee it doing is making every physician beholden to an ACO. Therefore except for those who can run cash practices, everyone will be an employee of banner, christus, centura, catholic health initiative, etc. Then in about 10 years when the economy turns around we'll see a resurgence of private practice. This is how it is been for the past 40+ years (talk to some of your attendings). Obamacare may look bleak right now, but just like the human body, eventually homeostasis will be achieved....just maybe not at the levels that our older attendings knew.
Finally, while we can look at nurses who make $$$ right out of a 2 year ASN program, we are still in a much better place. Our income is not based upon how many shifts we work. We never have to worry about being called off. And barring pediatricians (my apologies) we're all going to be making 6 figures with job security.

 

[Law2Doc]

Do any of you really think that Obamacare is going to make people start seeing their PCP rather than just going to use the ER? Obamacare will not legislate behavior change. What I do foresee it doing is making every physician beholden to an ACO. Therefore except for those who can run cash practices, everyone will be an employee of banner, christus, centura, catholic health initiative, etc. Then in about 10 years when the economy turns around we'll see a resurgence of private practice. This is how it is been for the past 40+ years (talk to some of your attendings). Obamacare may look bleak right now, but just like the human body, eventually homeostasis will be achieved....just maybe not at the levels that our older attendings knew.
Finally, while we can look at nurses who make $$$ right out of a 2 year ASN program, we are still in a much better place. Our income is not based upon how many shifts we work. We never have to worry about being called off. And barring pediatricians (my apologies) we're all going to be making 6 figures with job security.

Well, they probably will stop going to the ER if they can see their PCP NP 24-7 at the local CVS Minute Clinic next door, rather than go across town to the hospital, if it's covered. And some won't go to the ER if they have an actual PCP. And the ER will feel more comfortable telling people they need to go see their doctor on Monday and actually have it happen.