How do all these DOs in primary care make a living?

[Dagrimsta1]

As a medical student in my first semester, all I can say is what a fascinating thread...

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[Peach Newport]

As a medical student in my first semester, all I can say is what a fascinating thread...

I know right?

 

[Dagrimsta1]

I know right?

I honestly don't even have a clue as to what specialty to chase anymore... Oh well, might as well just study for that damn Biochem exam on monday

 

[frosted2]

Live very modestly for a few years. Same old car from med school. Cheap apartment. Just enough clothes to look professional. Put your head down and pay off your debt.

Anyone know how you couldn't pay off 400K in 3-5 years if you live on only 40K of your 180K? I mean, living on 40K is living pretty rich compared to how you live in med school and college. Plus, if you have a spouse working too, you're easy middle class lifestyle.

Alternatively, work 60-70 hour weeks, rake in that 300K and pay it off in like 1.5-2 years max.

Is this a crazy idea? I don't want to be making loan payments in my sixties. Hate having any debt, plus the longer you have it, the larger it grows.

I plan on living off of my SO's income (allied health) and putting 100% of my take home towards our loans (both his and mine). Hopefully it works out as planned!

 

[Peach Newport]

I honestly don't even have a clue as to what specialty to chase anymore... Oh well, might as well just study for that damn Biochem exam on monday

I have a handy infographic for this

 

[Dagrimsta1]

I have a handy infographic for this

Really? You can go in practice after 1 year of prelim residency?

 

[SterlingMaloryArcher]

All of your assumptions are terrible (sorry).

Your 170k estimate as a general salary was low. Then you lower it to 150k for inexplicable reasons.

25k for malpractice? I just looked at a number of random fm jobs and every single one of them provided that. Especially any job under a major clinic that is bending you over on the salary you suggested.

You have negotiated quite possibly the worst deal ever if someone is paying you 150k for a FT fm position, and you're covering malpractice to boot.

Has something changed since the last time I checked?

 

[SterlingMaloryArcher]

This is unfortunately more and more common today. Single doc with $400k+ in loans. For you likely $500k by end of residency.
I highly recommend reading www.whitecoatinvestor.com as there are articles on this specific situation of heavy loans in low paying field.

The high debt will affect all major decisions going forward (where to live, maybe even family size, ability to save for retirement, etc).
Some ideas
Live LIKE a RESIDENT for next 5years.
1. Move to low cost of living area.
At this point forget about east or west coast.
2. Get a job with loan repayment.
3. Consolidate loans with private lenders (to bring interest down to 3% or less)
4. Maximize your income (moonlight, locums to Alaska, north dakota, you get the picture)
5. Dont buy a house or lease a car or fancy vacations or private schools for kids.

Say you have $500k debt, on 10yr repayment plan at 6.8% its $5,754/mo payment.
Say you get a salary of $225k/yr with benefits. Use paycheckcity.com. Say you live in NY, single filing take home pay will be $11,414/mo.
That leaves you with $5,560/mo for all other expenses.
Let me tell you that is not much if you have a young family. This is crappy middle-class income for which many good years were spent in training.

--it can be done. But after spending your 20s in school/training you will continue to have to be frugal. You will have mid-levels outearning you and laughing all the way to the bank as they have relatively good pay and the docs cary liability for supervising their work.

--in post-residency world there are docs that are doing great (i.e. Little student loans, high paying fields, or physician couple). Then there are docs who are stuck with lots of debt, living a very much middle class lifestyle for which they spent many years in training.

Sad

 

[kubyx]

Has something changed since the last time I checked?

150k is like the absolute floor for a FT fm doc. You're probably at like a FQHC in a major city at that point, and you definitely aren't paying for your own malpractice.

I guess my point is that if you're earning that little, it's because you consciously chose to either live in an area that pays that little, or you choose working in a Medicaid clinic to help the needy.

 

[bernanke2016]

But even Kaiser is paying 240k in SoCal nowadays.

170 is either part-time or academia

Yeah my moms a socal primary care doc. 250k+ seems to be the average, not including benefits. Idk where these scare stories about poor Kaiser docs come from

 

[68PGunner]

Yeah my moms a socal primary care doc. 250k+ seems to be the average, not including benefits. Idk where these scare stories about poor Kaiser docs come from

It's more like from premeds who go into medicine for the money in the first place.

 

[Bacchus]

I just wanted to add that if you're in a typical outpatient clinic, make sure you're not 'just' billing 99213-99215 and their new patient equivalents. Don't forget your physicals (99395-97 = 1.75-2.0 RVUs), annual wellness visits (1.5-2.43 RVUs), consults for pre ops (1.34-1.88 RVUs), hospital discharge transition of care (2.11 - 3.05 RVUs).

How about those home health certification and re certification forms we all love to sign? 0.45-0.67 RVUs right there. BAM.

Don't forget concurrent billing too. Get credit for the work you do. My most productive visits are my half hour annual wellness visit, physical and chronic disease follow up appointments. 5.0 RVUs right there.

I average about 2.0 RVUs per patient encounter. Appropriate billing helps off-set my low patient volume at my lclinic. I see 12-15 patients per day and make about $240k.

Woah. Woah. Woah. Wait a freaking minute! All these visiting nurse-ish I'm signing and getting orders to review--nursing, PT, OT I can be billing for every 60 days?!?! I just read Profit Potential: Home Health Plan Certification - AAPC Knowledge Center and it seems I'm losing a **** ton of billing. I don't even need to see the patient, just have a face to face within 6 months?

So if I see the patient within 6 months and order home nursing, PT or OT and sign off on the care plan I can bill that q60d? Initially for instituting it and then if I can continue it? If they finish home services and I order in future I can bill another 'initiating visit'?

What if the patient is dc'd from hospital or SNF and gets home health services? I didn't initially order but I'm signing, I can bill??

 

[hsmooth]

Woah. Woah. Woah. Wait a freaking minute! All these visiting nurse-ish I'm signing and getting orders to review--nursing, PT, OT I can be billing for every 60 days?!?! I just read Profit Potential: Home Health Plan Certification - AAPC Knowledge Center and it seems I'm losing a **** ton of billing. I don't even need to see the patient, just have a face to face within 6 months?

So if I see the patient within 6 months and order home nursing, PT or OT and sign off on the care plan I can bill that q60d? Initially for instituting it and then if I can continue it? If they finish home services and I order in future I can bill another 'initiating visit'?

What if the patient is dc'd from hospital or SNF and gets home health services? I didn't initially order but I'm signing, I can bill??

YMMV. Definitely talk to your billing department as there may or may not be regional / state differences in how you can bill these.
Usually only the forms that say specifically "Home Health Care Certification / Re-certification" are the ones that we bill. All the other plain jane PT or OT updates or order forms, we don't.

If they completely finish home services, and say a few months later, get admitted again to home health services, I do believe you can bill another 'initial' certification. Again though, double check with your billing / coding department.

Yes, even if I wasn't the initial physician ordering for home health services after they're DC'ed from hospital to SNF... I still submit the bill. As the primary, you're the one overseeing care after discharge anyways.

They're not worth a whole lot of RVUs, but say you sign 5 or 6 of these forms a month. That's probably the equivalent of 2-3 office visits' worth of RVUs for doing what you already have been doing without getting credit all these years.

 

[Bacchus]

YMMV. Definitely talk to your billing department as there may or may not be regional / state differences in how you can bill these.
Usually only the forms that say specifically "Home Health Care Certification / Re-certification" are the ones that we bill. All the other plain jane PT or OT updates or order forms, we don't.

If they completely finish home services, and say a few months later, get admitted again to home health services, I do believe you can bill another 'initial' certification. Again though, double check with your billing / coding department.

Yes, even if I wasn't the initial physician ordering for home health services after they're DC'ed from hospital to SNF... I still submit the bill. As the primary, you're the one overseeing care after discharge anyways.

They're not worth a whole lot of RVUs, but say you sign 5 or 6 of these forms a month. That's probably the equivalent of 2-3 office visits' worth of RVUs for doing what you already have been doing without getting credit all these years.

I did. This is handled behind the scenes.

 

[Limvostov]

In Oregon the current starting for FM is about 185k. So 170k isn't too far off and actually the graduating residents about 5 years ago were getting 160-170k offers in this region for FM. IM was about 190-205K and has risen to 205-235k depending on location for hospitalist positions. There is a big regional variation in what you will get for starting salary. This does not often include loan repayment which is another huge issue... If you work for a non profit and are in a IBR repayment or similar with plans for PSLF 10 year forgiveness then you should advocate to get your loan repayment direct to yourself or to a retirement plan because any payment to the Fed on your loan is less that can be forgiven if that program holds together.

So, though loan repayment is a separate topic it is important in this issue. I was conservative on my loans and finished school with 220k debt including undergrad. Some of my class took out the maximum each semester and bought BMW's and all sorts of stuff because they are relying on this PSLF program to kick in and wipe the debt clear in 10 years. I'm also enrolled in IBR with PSLF, but took a far more conservative approach in the chance that that loan forgiveness program is modified or actually abolished all together. I did not want to finish with over 500k in loans like some of my class because that would be cumbersome to say the least. I also did not decide to stop with primary care as the salary is about 200k average between FM and IM in my region and went for a fellowship that will pay at least 50% more than that after three more years of training (for a starting salary, expected after 5 years would be double the annual pay rate of FM or IM for my region). This accomplished a few things:
-Better job satisfaction for myself
-Better pay that will surpass my colleagues in a few years after fellowship
-More years making little money to count towards the PSLF and not pay on my loans thus allowing for more benefit from the PSLF program if it goes through

The drawbacks of this plan (that I know of so far) are:
-More long hours of training
-More years of my younger life lost to training and time lost with family
-A busier career once finished with fellowship compared to colleagues who stopped with general internal medicine (so, though my annual salary may be 100% more annually once I establish my career I will work 60 hours a week compared to less as a hospitalist on average, also vacations will be more difficult to schedule and I will have a pager and clinic patients to follow -- hospitalists generally have no call and no clinic patients)
-Radiation exposure from angiograms -- this has potential to be detrimental to my overall health
-Less flexibility of job location once I finish as rural positions are not typically options (though most institutions have each doc spend a day in a rural location each week to serve that population)

There is a lot to consider when choosing this career...

 

[SLC]

…This does not often include loan repayment which is another huge issue... If you work for a non profit and are in a IBR repayment or similar with plans for PSLF 10 year forgiveness then you should advocate to get your loan repayment direct to yourself or to a retirement plan because any payment to the Fed on your loan is less that can be forgiven if that program holds together...

I worked my loan repayment funds to go to paying off my loans (~70k per year) so that I don't have to pay any actual out of pocket payments from my take home pay. Sure, It's more than IBR, meaning less benefit if and when I complete em the PSLF; but if the program collapses I'll be further ahead on the repayment that way.

 

[Postictal Raiden]

Time to gtfo of Oregon.

 

[68PGunner]

Time to gtfo of Oregon.

Let's not forget that 10% income state tax. LOL

 

[Limvostov]

Let's not forget that 10% income state tax. LOL

No doubt... And they keep trying to pass a sales tax on top of an automatic 9% income tax. Our loan political system will never be satisfied with any amout of tax. They always want more and we're always in debtor have the threat of no funding for schools, police, fire... The usual tactics.

Oregon is beautiful though. Hard to beat the lifestyle if you like the climate. Yes, the taxes blow.

 

[SLC]

No doubt... And they keep trying to pass a sales tax on top of an automatic 9% income tax. Our loan political system will never be satisfied with any amout of tax. They always want more and we're always in debtor have the threat of no funding for schools, police, fire... The usual tactics.

Oregon is beautiful though. Hard to beat the lifestyle if you like the climate. Yes, the taxes blow.

Oregon may well be the most beautiful state; and I say that as someone who grew up in utah, home of the big 5 national parks.

I hated the political establishment and the general political vibe there. There's being left-leaning, then there's doing whatever you can to spite people who lean right, even if it hurts you. Oregon does the latter quite often.

I don't take sides in the political game, but I could definitely see that Oregon, or more accurately, the I-5 corridor from Eugene to Portland, is totally off its rocker. The tax threats you highlighted are only a small part of that in reality.

But man, the landscape and the recreational opportunities are tough to beat. I don't think I've ever lived anywhere else where I was literally walking around all the time in complete awe of just how gorgeous basically everywhere I went was.

 

[68PGunner]

Oregon may well be the most beautiful state; and I say that as someone who grew up in utah, home of the big 5 national parks.

I hated the political establishment and the general political vibe there. There's being left-leaning, then there's doing whatever you can to spite people who lean right, even if it hurts you. Oregon does the latter quite often.

I don't take sides in the political game, but I could definitely see that Oregon, or more accurately, the I-5 corridor from Eugene to Portland, is totally off its rocker. The tax threats you highlighted are only a small part of that in reality.

But man, the landscape and the recreational opportunities are tough to beat. I don't think I've ever lived anywhere else where I was literally walking around all the time in complete awe of just how gorgeous basically everywhere I went was.

Besides Eugene, Portland, and Corvallis, Oregon is very RED.

 

[Staphylococcus Aureus]

Doesn't matter if the sparely populated east side is red, Oregon is one of the most anti-physician states, perhaps tying CA for the most pro-pseudoscience state as well.

 

[SLC]

Besides Eugene, Portland, and Corvallis, Oregon is very RED.

Yeah, I mentioned something to that effect in my post. In reality they're not that red, but put up against those places I can see why someone might think that.

 

[BorntobeDO?]

Doesn't matter if the sparely populated east side is red, Oregon is one of the most anti-physician states, perhaps tying CA for the most pro-pseudoscience state as well.

Cash based OMT here I come! With loan forgiveness to boot!