Nephrology a potentially dying specialty...

[Atlas]

The American medical system is single handedly killing nephrology. Nephrologists actually lose money with each dialysis patient now because payments are capitated and you usually dialyze three times a week, which the reimbursement doesn't cover three treatments. Now, add to that the government and others want to take Epogen away from them! Epogen was the only thing that allowed nephrologists to MAKE ANY SORT OF PROFIT off dialysis. And we aren't talking big bucks. I'm talking like $20 per patient. I've done three renal months and just about every doc NEEDS the Epogen in order to help cover their loses from the capitated payments! This is so frustrating to me! Now, more nephrologist are working twice as hard and doing procedures just to cover their expenses. I have faith in the interventional nephrology field, but they'll take that away soon, just like they are doing with cardiac caths. I'm afraid renal medicine is dying because people are afraid that doctors, God forbid, make a dollar off their patients. I found this article and I understand that they have legitimate reasons (i.e. affecting patient care) but now nephrologists are going to have a harder time making their practice profitable. Right now, I'd stay away from renal.

http://news.yahoo.com/s/ap/20070418/ap_on_he_me/anemia_drug

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[Atlas]

Please note: I don't mean to say that patient care is not the most important thing, here. This thread was not meant to be inflammatory in any way. I am purely speaking on the business aspects of medicine. I agree that you need to do what is best for the patient. I am just frustrated with how the government lately has been picking on nephrology and it scares me because I would like to possibly do this as a subspecialty. Now, more than ever, I am thinking about being a hospitalist because this is just ridiculous!

 

[salmonella]

But nephrologists will still have a steady and excellent source of income by doing a lot of ICU/ward consults, kidney transplant clinics.

I heard average private practice nephrologists make about $300,000. Even if they cut salary by a quarter, they still can easily make >$200,000, which is pretty good money for a non-procedural, intellectually oriented specialty with relatively great lifestyle.

 

[Atlas]

Who said it was a good lifestyle?! That's not true. It may not be as bad as cardiology or critical care, but the hours can reach 60-80 quite easily. I put in 70 hrs a week on average on my renal months and my attendings were there before I got there in the AM and after I left to go home. It's not derm or even hospitalist. Plus, with doing a 2-year fellowship making the same amount as a hospitalist or internist is starting to not appeal to me. Only if you love it is it worth it. Otherwise, don't do it. You may be right - some nephrologists may make $300k but they are the ones putting in long hours. There are too many times at 2 am that you have to physically go in the hospital to dialyze someone. And fellowship is worse! Call 1:1 or 1:2. It's craziness! I'd expect (if I were you) with the epogen included to make $225K with effort. After they cut that, I'd expect to make less than $200K. Seriously. Renal is not the cash cow people think it is. It is not what it was. Go back 5 years with higher reimbursement rates, more nephrologists were making close to $300K. Oh yeah, don't listen to the job offers you read online. They are there to ENTICE you. The possibility of making $300K as a nephrologist means long hours and lots of sick sick patients. It ain't easy and it sure isn't a "lifestyle" field. This Epogen thing is another setback to a very otherwise promising field.

 

[Atlas]

Let me give you an example now that I think of it! One of my attendings and good friends is an interventional nephrologist in Akron, OH. He works approximately 70 hours a week. He covers 6 hospitals ( two of them 700+ beds), so when he is on call his days are 7am - 11pm (usually) Saturday and Sunday. He does one full day of interventional on Wednesday. Guess what he makes? $215,000. My point is made.

 

[Mumpu]

Wow, is he like living in a cardboard box on the street for $215,000 a year? Poor man.

 

[Atlas]

Sarcasm. Nice. Very professional. I think he is underpaid for the amount of training he has endured and for as much as he works.

 

[Atlas]

1.) I'm not saying that $215,000 isn't a lot of money. It is. However, it's what you do to make that money that makes it a lot or not. Working 40 hours a week at $215,000 is pretty good. Working a hundred hours a week for $215,000 may not be as good of a deal. Either way, $215,000 is a lot (I guess) in a relative term.
2.) The point I'm trying to make is that people have this idea that nephrology is a 300K a year job, when it is not anymore. Sure, you can say that $215,000 is a lot if it is a lot to you. I dunno. However, people say "Oh nephrology is payed so well...yada yada". It isn't. Look at Cards and GI pullin 500K and working roughly the same hours as a hard-working nephrologist making $250K. That's the point I'm making.
3.) I may end up being a hospitalist where $215K is probably the high end. So, am I saying that $215K is bad? NO. I'm looking at relative work and training compared to pay. For a nephrologist who works 60-80 hours a week and is on call q3-4, I don't think $215K is just.
4.) Mumpa...you must the the guy who thinks doctors make too much money! I think doctors SHOULD earn a high salary especially after 8+3 years of training. I've got loans from 8 years of school to pay back. I'm sorry but 60- $100K isn't gonna cut it. Besides nurses are making more than doctors now. That's criminal.

 

[idiotpathic]

simple.. do cardiology or gi jk

i feel its very surprising that despite changes in reimbursement in a lot of specialities over the years, one speciality which has not suffered plateaus is cardio. yes ppl will point out the current controversy with the crusade data - but u also see the boom in cardiac imaging..

no1 can take away thier business from them. not even radiologists.. are cardiologists as a whole a smarter and more practical ppl??

stay tuned

 

[maxpower75]

I am currently a renal fellow, so perhaps I am a bit more optomistic regarding the future of my speciality. Atlas is correct regarding Nephrology not being a "lifestyle" speciality, there is definately a good amount of work that needs to be done, and depending on your group you will put in >40hr work week. There is also a projected reduction in dialysis reinbursment, however declining reinbursment is a reality for all specialities. Atlas seems to have lots of information regarding reinbursment, I can provide information that I received while attending this years Renal Physician Association fellows meeting this year;
According to the 2006 MGMA survey;
Median compensation per single speciality group: 400,000
Multi specilaity group: 280,000
Overall : 260,000

By percentage:
<200K: 20% (stable over last 3 years)
200-300K: 40% (decline over last 3 years)
300-400K: 22% (increase over last 3 years)
>400K: 15% (increase over last 3 years)

These figures are for practicing Nephrologist, out of fellowship is approximately 160-200K.

I agree that one shouldn't do Renal if they do not have an interest in it, if your primary goal is earning money, there are other specialities that provide a greater income.
That being said, there will always be changes in reinbursment, financial success is based on adapting to these changes, Interventional Nephrology is one way some of these changes are being met, Nephrology is moving towards large single speciality groups that start their own access centers to increase overall revenue, and income to the members of thier group.

I doubt Renal is a dying speciality, however it is not possible to predict the future, hopefully this was helpful for anyone interested.

 

[salmonella]

I think reimbursement has a lot to do with public perception of medical specialties. Fields such as cardiology, oncology, emergency medicine, surgery, etc, will always pay well because they receive more public recognition. Pretty much everybody knows someone who has heart disease, cancer or has visited the ER once. Nephrology, on the other hand, appears to be more "esoteric" to the public and many lay people don't know exactly what these "dialysis doctors" do on a daily basis.

 

[Mumpu]

Let's not forget that a cardiologist making 500K is in the cath lab 24/7/365 and constantly exposed to radiation. GI docs make a lot due to heavy procedure load. The bean team makes sodium balance calculations and writes dialysis orders. Their salary is comparable to other non-procedure specialties like ID. The harder you work, the more you make.

FWIW, I don't think doctors make too much money, but I think they make plenty. If you are pissed because you sunk 11 years into your education, you should've quit as a premed. I'll be happy to work as an academic hospitalist on the lower end of the HM income range with a 100% controlled lifestyle, no call, working 6 months out of the year.

 

[Rocky2007]

What's happening in renal is what happens when the government controls the market and puts in price controls. The gov't sets the price/reimbursment for dialysis, not the free market. This will make nephro less desirable as a subspecialty and fewer "competitive" people will want to go into it...which I think in the long run is a detriment to the specialty (or any specialty for that matter).

 

[Atlas]

Let's not forget that a cardiologist making 500K is in the cath lab 24/7/365 and constantly exposed to radiation. GI docs make a lot due to heavy procedure load. The bean team makes sodium balance calculations and writes dialysis orders. Their salary is comparable to other non-procedure specialties like ID. The harder you work, the more you make.

FWIW, I don't think doctors make too much money, but I think they make plenty. If you are pissed because you sunk 11 years into your education, you should've quit as a premed. I'll be happy to work as an academic hospitalist on the lower end of the HM income range with a 100% controlled lifestyle, no call, working 6 months out of the year.

I am not pissed about anything. I am lucky to be in the position I'm in. I think that we should always be striving to increase reimbursements and not settle. We get dicked around enough by the government to settle. If you want to be a low-paid academic hospitalist, good for you. We need people like you. I can't help the loans I took out to do this. I have to pay them back just like everyone else. I'm starting a family, etc. So, I'm not pissed about anything. I think it's foolish when I see people on these forums (not necessarily you) saying that doctors make too much, but nurse practitioners deserve a pay raise. The laws of supply and demand don't apply to medicine. If they did, FP's and internists would be the highest paid.

"work as an academic hospitalist on the lower end of the HM income range with a 100% controlled lifestyle, no call, working 6 months out of the year." I think this is funny. There are private hospitalists with the same set-up...with twice the pay. Oh well. To each his own. Best of luck with that!

 

[Atlas]

What's happening in renal is what happens when the government controls the market and puts in price controls. The gov't sets the price/reimbursment for dialysis, not the free market. This will make nephro less desirable as a subspecialty and fewer "competitive" people will want to go into it...which I think in the long run is a detriment to the specialty (or any specialty for that matter).

Amen. That's my point. Summarized quite nicely.

 

[Atlas]

I am currently a renal fellow, so perhaps I am a bit more optomistic regarding the future of my speciality. Atlas is correct regarding Nephrology not being a "lifestyle" speciality, there is definately a good amount of work that needs to be done, and depending on your group you will put in >40hr work week. There is also a projected reduction in dialysis reinbursment, however declining reinbursment is a reality for all specialities. Atlas seems to have lots of information regarding reinbursment, I can provide information that I received while attending this years Renal Physician Association fellows meeting this year;
According to the 2006 MGMA survey;
Median compensation per single speciality group: 400,000
Multi specilaity group: 280,000
Overall : 260,000

By percentage:
<200K: 20% (stable over last 3 years)
200-300K: 40% (decline over last 3 years)
300-400K: 22% (increase over last 3 years)
>400K: 15% (increase over last 3 years)

These figures are for practicing Nephrologist, out of fellowship is approximately 160-200K.

I agree that one shouldn't do Renal if they do not have an interest in it, if your primary goal is earning money, there are other specialities that provide a greater income.
That being said, there will always be changes in reinbursment, financial success is based on adapting to these changes, Interventional Nephrology is one way some of these changes are being met, Nephrology is moving towards large single speciality groups that start their own access centers to increase overall revenue, and income to the members of thier group.

I doubt Renal is a dying speciality, however it is not possible to predict the future, hopefully this was helpful for anyone interested.

Salary surveys are very misleading. The actual pay is probably higher than what is reported. However, looking at those impressive numbers as well as other online surveys, the average nephrologist pulls $220-230K.

 

[DadofDr2B]

Wouldn't it be nice to cure kidney disease to the point that fewer nephrologists were needed?

I am an IGAN patient who was told by my first nephrologist that I would be watched until I needed dialysis and later put on a list for a transplant. I changed doctors. That was four years ago. I am now in full remission by definition for three years by undergoing treatment of cytoxan intravenously over a six month period as an outpatient. Maybe the way to make up the pay is to do some innovative treatments that save the government and insurance companies money. My treatments were under $30,000. Much less than the alternative and I will tell you a helluva of a lot better for this patient.

Finding cures could lead to less money. What would that do to your bottom line?

 

[idiotpathic]

take home message from this thread -

do cards / gi

)

jk

 

[ice_23]

FWIW, I don't think doctors make too much money, but I think they make plenty. If you are pissed because you sunk 11 years into your education, you should've quit as a premed. I'll be happy to work as an academic hospitalist on the lower end of the HM income range with a 100% controlled lifestyle, no call, working 6 months out of the year.

<rant>

I know this thread is dead, but this is bad logic to me. The rate of return on education should be on par with other professional schools with similar degrees if the government is going to set price controls on the service that doctors provide. The reason why price controls exist is because people would be willing to pay far more for the stuff that a nephrologist (for our discussion here) does, but we artificially push that amount down because we have a conscience as a society. It's economically naive to think that doctors make "plenty" if their compatriots at other professional schools (who go thru far less "graduate" training) are starting to make more on a rate of return on education basis due to declining reimbursement rates. Remember that in a free market people would be paying FAR more.

In a sense (mind you, I'm not advocating a free market approach), not only are patients getting a service at a discount relative to its intrinsic value, but the supplier of that service (the doctor) has paid an enormous amount of money (average over 130,000 in debt, some at 200,000 ==> more than the mortgage of some houses) to provide that service. Yet we'll still slam a doctor for lamenting when her salary goes down even further than it already is because she's making "plenty"?

</rant>

In other words, I understand the sentiment of the OP.

-Ice

 

[ice_23]

deleted

 

[Mumpu]

But medicine is also not "other professional schools with similar degrees". We do things and interact with people in a very different way than lawyers or MBAs. Medicine is not business plus the opportunity to legally dig in people's guts (that's called "law"). We make sacrifices in education, free time, relationships, and little bits of ourselves that die with every patient we get attached to and every bad outcome. If you don't understand that medicine is unique and not just another graduate degree, go to business school.

 

[MacGyver]

I think there is some revisionist history going on here. Some of you pretend that docs before Medicare and HMOs were substantially better off than they are today, and thats quite frankly not true. In fact, when Medicare came about in the 1960s, doctor incomes went UP, not down.

I would be willing to bet money that the average doctor income today in real terms is at least 30% higher than the pre-Medicare, pre-HMO era.

 

[tibor75]

The backlash over unnecessary Epo is the best thing to happen to this field in years. The amount of money some of these bums have raked in all in the name of getting your Hb from 11 to 13 is shameless.

 

[ice_23]

But medicine is also not "other professional schools with similar degrees". We do things and interact with people in a very different way than lawyers or MBAs. Medicine is not business plus the opportunity to legally dig in people's guts (that's called "law"). We make sacrifices in education, free time, relationships, and little bits of ourselves that die with every patient we get attached to and every bad outcome. If you don't understand that medicine is unique and not just another graduate degree, go to business school.

So you believe because we make such sacrifices, we should not dictate how we get paid?

At the very least, the rate of return on our education should match those from (from an educational standpoint) other professional degrees. Especially given the increasing cost of medical education.

I'm not certain what your point is; your argument would suggest that doctors should make more than less.

-Ice

 

[ice_23]

I think there is some revisionist history going on here. Some of you pretend that docs before Medicare and HMOs were substantially better off than they are today, and thats quite frankly not true. In fact, when Medicare came about in the 1960s, doctor incomes went UP, not down.

I would be willing to bet money that the average doctor income today in real terms is at least 30% higher than the pre-Medicare, pre-HMO era.

You're also simply defining the starting point as pre-Medicare. If you look at doctors salaries in the last 10 years, it doesn't even keep pace with inflation. (Source: http://www.hschange.org/CONTENT/851/). So it's going down in real terms relative to a decade ago because, why?

In a completely unrelated note, the top 10 largest health care insurance companies (based on revenue) that you allude to made over 11 BILLION dollars of PROFIT last year, and almost 10 billion dollars of profit the year before. Even if you look at profit as a percentage of shareholder equity, the average for last year was something like a 20 percent return which, as any investor out there knows, is an awesome return relative to the market. (Source: http://money.cnn.com/magazines/fort...ies/Health_Care_Insurance_Managed_Care/1.html)

Hmmmm....

-Ice

 

[Mumpu]

No, my argument is that doctors should not be looking at lawyers and MBAs when determining their pay.

 

[ice_23]

No, my argument is that doctors should not be looking at lawyers and MBAs when determining their pay.

Exactly what benchmark should we use then? Given that the powers that be seem unabashedly direct in how much they increase the cost of medical education and decrease future physician reimbursements?

The people who take your money in the beginning and the people who decide to give you less of it in the future seem to not have any problems using common economic methods to support their cause. Why should we not use similar methods to refute them?

-Ice

P.S. Your argument also directly asserts that a physician's life is more arduous than her professional counterparts. Hence, it would seem logical that you'd believe physicians should earn MORE for their sacrifices, no?

 

[Mumpu]

Except a large part of our income comes from the poor and the underserved. Taking care of these people and taking a financial hit because of it is part of the sacrifice of being a physician. I'm sure public defender lawyers don't make five million a year either. MDs in private practice dealing only with the well-insured patients have incomes comparable to or better than other graduate-level professions (depending on your profession of choice, you can start where a lot of MBAs and lawyers cap).

 

[ice_23]

Except a large part of our income comes from the poor and the underserved. Taking care of these people and taking a financial hit because of it is part of the sacrifice of being a physician. I'm sure public defender lawyers don't make five million a year either. MDs in private practice dealing only with the well-insured patients have incomes comparable to or better than other graduate-level professions (depending on your profession of choice, you can start where a lot of MBAs and lawyers cap).

I see what you're saying and you make a good point. But that still doesn't explain how, on the whole, a doctor's average income cannot keep up with inflation. People keep mentioning the numbers of uninsured individuals in america; that number has gone UP not down in the last 10 years. I'd understand the decrease using your logic if we suddenly started taking care of these people, but we don't even do that and STILL income decreases.

That is to say, health-care costs are constantly rising while doctors salaries decrease, uninsured patients still stay uninsured, insurance premiums rise, and returns to shareholders in private insurance stays great. Sure, a lot of that rise in healthcare cost is due to technological advances, but the lay public seems to think it's doctors driving benzes and jags that's the driving factor. And the lay public is what votes.

-Ice

P.S. And I'm not asking to make 5 million a year. I just don't see why people arbitrarily think docs should make less while conveniently forgetting that docs don't make nearly as much as they think, are held to a higher standard than many other professions, and make more financial sacrifices than any other profession with similar educational committments.