I appreciate your response and I have a couple of questions I would like to ask you. From what I gather across different forums on SDN, many civilian residents complain about being underpaid and having to deal with ungrateful/disorderly patients. Both of these aspects, it seems, aren't as much of a problem for military docs. I know that there's a huge piece of the picture that I may not understand until I enter medicine - which leads me to my last question.
Now that you're out, are things so much better (pay/hours/quality of life)?
Mind if I jump in here, USAFdoc?
OP:
I'd take residency out of the equation. All residents are low-wage, long hours, treated-like-dirt worker-bees who are paying their dues until graduation. Also, most residency programs are in larger cities, and the inner city population engages in many social pathologies that can make those folks unpleasant to encounter. It's once you clear residency that the punishment really begins, and it's not just in the military (the myriad problems with MILMED have been hashed out many times in this forum... I won't revisit them).
The bottom line with medicine is that despite the personal rewards, the satisfaction of helping others, the "prestige," the job security... it's really a lousy business.
Many of the problems with the business end of medicine result from the actions of third-party and government payors. Far from the fee-for-service model of medicine, where prices for services can be adjusted up or down based on local supply-and-demand, the insurance model allows third-party payors to control your revenue stream.
How? By only reimbursing a set amount for a given procedure code or encounter level, regardless of how much it costs you to provide that service. You might bill 200$ for a new patient visit, but the insurance company is only going to pay you sixty bucks. Depending on your overhead, that sixty-dollars-per-patient may or may not cover your "cost of doing business." Many insurance companies set their rates based on medicare rates (some give you a percentage of your billed charges), so everytime medicare cuts reimbursement, so do all those payors. Why do you think there's such a bitter political fight every time congress attempts to balance the budget by slashing medicare reimbursements? That's money that comes right out of your practice's bottom line. Note that we're not talking about keeping up with inflation, or the increased cost of doing business... we're talking about cuts.
"Fine." you say... "I'll just charge more, or make the patient pay the difference."
Nope. Read your managed care contract... most managed-care, insurance company, and govt. payor contracts prohibit any sort of "balance billing"... a practice wherein a physician charges the patient the difference between what the insurance pays, and what it actually costs them to perform the service. As an out-of-network provider for some insurances, you might be able to balance-bill some patients... but NOT the government (tricare, medicare, etc). In the case of medicare, tricare, etc. you get what the government pays and
that's it.
If all this is sounding like wage/price controls, you're right... you payed attention in ECON 101.
And while you
technically have the ability to negotiate your own contracts, asking for more money than your colleagues will cause the insurance company to drop you as a provider. Your patients are then forced see you as an out-of-network provider, which results in a greater cost to them, and they go elsewhere... and voila! Your practice dries up.
And forget collectively bargaining with your fellow physicians to get a reasonable reimbursement... that can get you busted under anti-trust laws.
This is only a basic overview of why many physicians get fed up with the business side of their practices, or farm out those functions to billing or managment companies (which costs yet more money).
It's not necessarily
medicine that's difficult... it's the
business of medicine that frustrates many docs.