Redistribution of Physician Salaries

[LostinLift]

Why I believe physician incomes will drop, starting with the highest paid physicians (also, even if incomes just stay stagnant in the face of inflation - that's essentially a drop. Ask the middle class about that one).

• Increased need by patients
• In the near future, for the first time in history we will have more 65 year olds than year olds than 5 year olds (in 1970 > 65 year olds were 2% of the population, today they are 145. In the 1950s children under 5 were 11% of hte population today they are 14%. Today we have as many 5 year olds as fifty year olds and in 30 years we are expected to have as many people over 80 as there are under 5).
• Doctor shortages - this can be debated, but we generally don't have enough primary care doctors, could it be a distribution problem? Sure. But bottom line, we have a lot of people who don't have access to primary care. Sounds fine, until you realize these people get sick and seek specialist care - increasing costs on the system

Increased demand and decreased supply will lead to a drop in physician income?

What, in your mind, would lead to increased physician income?

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[Robinson EM]

Increased demand and decreased supply will lead to a drop in physician income?

What, in your mind, would lead to increased physician income?

This is not a free market.

The government sets our reimbursement. Increased demand and decreased supply in a bankrupt system = lower physician salaries. Midlevels will rise.

How does income go up? A completely free market might allow that. But that's impossible in healthcare. If somehow the healthcare system became insanely profitable, then doctor's salaries would go up.

 

[BurghStudent]

The issue about income redistribution falls more along these lines:

Should a primary care doc earn $170,000 compared to the $600,000 that some specialists earn?

Unfortunately for primary care physicians, they haven't garnered much support from the medical community, the AMA, the government, or even medical students.

It's no doubt somethings should be paid considerably more than primary care, but when the delta is reaching 200-300% then it becomes a problem.

Why? Primary care done well is one of the most important factors in lowering healthcare costs (aside from scrutinizing the snowballing average costs for just about anything).

My prediction is that primary care will continue to be neglected and the floodgates will open for midlevels to take over. As midlevels gain their scope of practice, they will enter specialist fields.

The primary care problems hasn't been solved by physicians, so it will be opened up to midlevels which in turn will affect most everything other than surgical specialties. By "affect" I mean lower income.

All roads don't lead to Rome, but they do lead to lower physicians salaries.

The best we can do as physicians is advocate for our patients and try to ensure that corporate pockets aren't lined with all the cuts.

I hear this all the time. But really, I haven't seen any scientific studies suggesting this, although intuitively it sounds true.

I think a lot of health care dollars could be saved if patients simply complied. I've seen a cardiothoracic surgeon implore a patient to quick smoking and lower their salt intake too many times.

 

[DermViser]

I hear this all the time. But really, I haven't seen any scientific studies suggesting this, although intuitively it sounds true.

I think a lot of health care dollars could be saved if patients simply complied. I've seen a cardiothoracic surgeon implore a patient to quick smoking and lower their salt intake too many times.

Not going to happen esp. with patient autonomy held as a value by medicine. Once P4P happens, docs will just kick people out of practices.

 

[BurghStudent]

Not going to happen esp. with patient autonomy held as a value by medicine. Once P4P happens, docs will just kick people out of practices.

I think it's philosophically unbalanced for society to put new pressures on physicians to follow some population derived protocols (detracting the from art of medicine), to put physicians at the mercy of whatever judgement patients may have on quality of care, or suffer lowered reimbursements, and have no retributive action for the patient that simply doesn't do anything to help themselves and comply.

 

[Robinson EM]

I hear this all the time. But really, I haven't seen any scientific studies suggesting this, although intuitively it sounds true.

I think a lot of health care dollars could be saved if patients simply complied. I've seen a cardiothoracic surgeon implore a patient to quick smoking and lower their salt intake too many times.

Sure. There's plenty of stuff out there.

Here's an example:

Preventable Hospitalizations and Access to Health Care
Andrew B. Bindman, MD; Kevin Grumbach, MD; Dennis Osmond, PhD; Miriam Komaromy, MD; Karen Vranizan, MA; Nicole Lurie, MD, MSPH; John Billings, JD; Anita Stewart, PhD
JAMA. 1995;274(4):305-311. doi:10.1001/jama.1995.03530040033037.

Objective. —To examine whether the higher hospital admission rates for chronic medical conditions such as asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes in low-income communities resulted from community differences in access to care, prevalence of the diseases, propensity to seek care, or physician admitting style.

Design. —Analysis of California hospital discharge data. We calculated the hospitalization rates for these five chronic conditions for the 250 ZIP code clusters that define urban California. We performed a random-digit telephone survey among adults residing in a random sample of 41 of these urban ZIP code clusters stratified by admission rates and a mailed survey of generalist and emergency physicians who practiced in the same 41 areas.

Setting. —Community based.

Participants. —A total of 6674 English- and Spanish-speaking adults aged 18 through 64 years residing in the 41 areas were asked about their access to care, their chronic medical conditions, and their propensity to seek health care. Physician admitting style was measured with written clinical vignettes among 723 generalist and emergency physicians practicing in the same communities.

Main Outcome Measures. —We compared respondents' reports of access to medical care in an area with the area's cumulative admission rate for these five chronic conditions. We then tested whether access to medical care remained independently associated with preventable hospitalization rates after controlling for the prevalence of the conditions, health care seeking, and physician practice style.

Results. —Access to care was inversely associated with the hospitalization rates for the five chronic medical conditions (R2=0.50; P<.001). In a multivariate analysis that included a measure of access, the prevalence of conditions, health care seeking, and physician practice style to predict cumulative hospitalization rates for chronic medical conditions, both self-rated access to care (P<.002) and the prevalence of the conditions (P<.03) remained independent predictors.

Conclusion. —Communities where people perceive poor access to medical care have higher rates of hospitalization for chronic diseases. Improving access to care is more likely than changing patients' propensity to seek health care or eliminating variation in physician practice style to reduce hospitalization rates for chronic conditions.(JAMA. 1995;274:305-311)

I guess one could argue, less access to care means people will die faster - making it cheaper.

And one could argue that primary care services don't save the system any money and we should just have specialists.

I haven't heard these arguments often, so it would be interesting if you could present research that says this?

I've found that SDN'ers keep asking for scientific studies (which is fair) but then I dig them up and the poster then disappears. I think if you really are interested you could spend 15 minutes searching and learn that people not having access to primary care services isn't a good thing. But as you said, I thought this would be pretty much common sense. These people just end up in emergency departments and have expensive care by the ED or specialists - now I guess that's cheaper if they end up dying young? I don't know what your argument here is.

 

[DermViser]

I think it's philosophically unbalanced for society to put new pressures on physicians to follow some population derived protocols (detracting the from art of medicine), to put physicians at the mercy of whatever judgement patients may have on quality of care, or suffer lowered reimbursements, and have no retributive action for the patient that simply doesn't do anything to help themselves and comply.

And then not have tort reform when there is a bad outcome.

 

[circulus vitios]

Am I the only one that's okay with FM docs making $175-200k/yr while specialists make $400k/yr or whatever?

 

[DermViser]

Am I the only one that's okay with FM docs making $175-200k/yr while specialists make $400k/yr or whatever?

I'm ok with that. It wouldn't make sense for specialists to make LESS than primary care. I'm sure PNHP and Doctors for America (formerly Doctors for Obama) would love it though.

 

[link2swim06]

Am I the only one that's okay with FM docs making $175-200k/yr while specialists make $400k/yr or whatever?

I'm ok with it especially when FM docs are working a fraction of the hours of a cardiologist or neurosurgeon.

 

[circulus vitios]

I'm ok with it especially when FM docs are working a fraction of the hours of a cardiologist or neurosurgeon.

I'm talking more about reimbursements and not $/hr or income. FM docs aren't performing invasive surgical procedures or managing particularly difficult or exotic medical conditions. It makes sense that their codes reimburse less because they're not as risky or complex.

 

[W19]

I'm ok with it especially when FM docs are working a fraction of the hours of a cardiologist or neurosurgeon.

I wouldn't call 52 hrs/wk, which is the average for a FM doc a fraction of 58 hrs/wk for neuro/cardio docs... These numbers are from AAMC 'career in medicine', so I don't know how accurate they are..

 

[link2swim06]

I wouldn't call 52 hrs/wk, which is the average for a FM doc a fraction of 58 hrs/wk for neuro/cardio docs... These numbers are from AAMC 'career in medicine', so I don't know how accurate they are..

I don't think a neurosurgeon works only 6 more hours than a family doc.

I'm not saying primary care has it easy...but I am saying there are specialties that are far far worse. Most tend to be specialists.

In my personal experience, I have never seen a family doc drive into the hospital at 3am for a STEMI.

 

[jdh71]

This is not a free market.

The government sets our reimbursement. Increased demand and decreased supply in a bankrupt system = lower physician salaries. Midlevels will rise.

How does income go up? A completely free market might allow that. But that's impossible in healthcare. If somehow the healthcare system became insanely profitable, then doctor's salaries would go up.

It's not a totally free market. But that is besides the point. If there is a need, hospitals and systems will cough up the cash to have the staffing they think they need, and they'll continue to increase the compensation until someone bites. There's PLENTY of money to pay physicians more. This may seem like an outlandish statement but most of the money going into healthcare ISN'T paying doctors to do what we do. There may be a point where it all taps out, but we are not there yet.

 

[Kahreek]

Pardon my naive MS1-ness, but what about the possibility of disconnecting how much a specialist can bill for with their salary?

So in other words, regardless of how much a physician bills for something, a cardiologist and an internist could be paid with a more flat salary?

Maybe I am missing the connection between purely billing and the salary from it. The reason I am advocating for this is trying to reason a possible solution to the PCP shortage being to redistribute the salaries since this is a huge reason why medical students oppose primary care.

that is what happens in many countries outside us, but US is insurance based and so procedures and coding have weight.

 

[syma]

I love our NHS. I love what it can offer when working well.

But with recent BS in the ironically right winged media has left the public foaming at the mouth. At this point I want to say screw it and make the whole thing private.

I don't think I have an opinion of whether a PCP should be making more or less than a specialist. But it kind of makes sense to me how it is now. But the general public would rather if doctors didn't make any money. You should be doing it for the love of caring for others. So...

 

[eglaurencio]

Physician salaries are NOT the problem in regards to the current U.S. healthcare debacle. For a little perspective...look at how much hospital administrative staff are paid, many of whom seek complete control of even the physician's style of work in a clinical setting. In my opinion, one of the only ways that physicians may be helping add to the healthcare woes are when they practice a more defensive style of medicine. In the United States, you can literally sue for anything. It's not surprising if a given MD or DO in a clinical setting decides to just be sure that the patient does not have X condition by ordering a CT or an MRI. Obviously it's better to be safe than sorry but to ensure that this cycle doesn't perpetuate itself, the best prevention of malpractice suits for physicians is to establish rapport and honesty with their patients.

Replying to the original post.... primary care physicians have been belittled for so long and neglected from respect that they deserve. I've met doctors who practice primary care that know surgeons personally who actually don't understand what a primary care physician does differently than other mid-level providers (PAs, NPs, etc). That is sad. For a layman, primary care physicians and physician extenders may seem to have identical roles. Superficially..they do basically do the same things. But it's clearly more complicated than that. The number 1 solution to mending this "primary care crises" we have on our hands is by either significantly reducing medical school tuition (will not happen considerably enough in my opinion) AND/OR constructing a viable student loan forgiveness program specifically directed towards those who desire to practice primary care medicine. No matter what specialty you are....you have to realize the costs of NOT having primary care physicians nationwide. Let's take for example an instance where all primary care physicians were replaced by NP and PAs. Access to care? Well, either it wouldn't change much or it COULD increase (NPs and PA programs take less time and money). And, NPs and PAs also are reimbursed less so this could make insurance companies very happy. However, 7 years of training for a primary care physician (assuming general internist or family practitioner) dominates the considerably less training that PAs and NPs have. Not only does the time/experience factor weigh in here but PA and NPs are not trained like doctors. They don't think like doctors. They can be excellent at patient care but will they be able to be on call every weekend and/or nights? Would these physician extenders be willing to sacrifice their family time and schedule to be where their first priorities are? There is a difference between an MD/DO and a NP and PA. Supervision in most states is required for NPs, though they have gained freedom for independent practice in a few states. The result? In the end NP-only appointments produce more ordered tests (have less knowledge base for disease processes and how physiological systems are interrelated in a sick patient) and this would then possibly lead to unnecessary referrals or referrals to a specialist who might not have needed to see the patient had a primary care PHYSICIAN attended the patient.

You have to look at the big picture when it comes to how important primary care is for our nation's health. We shouldn't ask if they deserve more money or not. I can guarantee that anybody would be much more attracted to the idea of serving our population in a primary care model IF and ONLY IF the costs to obtain a medical degree in this country wasn't so prohibitive. I mean ask a young student or child that's interested in medicine who they look up to or imagine as their ideal physician. I bet most would first think of primary care physicians....now considered a dying breed unless we change our medical school model. In my opinion, it will either take a long time to accomplish the OBVIOUS answer to replenish our primary care physician numbers or we will see an increasing number of NPs and PAs take over the domain which will inevitably lead to rising healthcare costs...again.

 

[DermViser]

Replying to the original post.... primary care physicians have been belittled for so long and neglected from respect that they deserve. I've met doctors who practice primary care that know surgeons personally who actually don't understand what a primary care physician does differently than other mid-level providers (PAs, NPs, etc). That is sad. For a layman, primary care physicians and physician extenders may seem to have identical roles.

It doesn't help when those in our own profession validate what you are saying isn't true.
Who am I to argue with a Family Med doc from UCSF?

http://www.nbcnews.com/health/healt...actitioners-fill-doc-shortage-gap-f6C10849957

“To me, nurse practitioners could be a huge, huge solution to this problem of primary care shortage,” said Dr. Thomas Bodenheimer, a professor of family and community medicine at the University of California, San Francisco, School of Medicine.

NPs, as they’re sometimes known, are registered nurses who hold graduate degrees and can perform virtually all of the functions of front-line family doctors -- depending on the laws of the state they’re in.

“They can do 90 to 95 percent of what the docs can do,” said Bodenheimer, a medical doctor who practiced primary care himself for three decades.

 

[MalibuPreMD]

“They can do 90 to 95 percent of what the docs can do,” said Bodenheimer, a medical doctor who practiced primary care himself for three decades.

They can do 90-95% of what most primary care docs can do while ordering 90-95% more tests than most docs do.

 

[DermViser]

They can do 90-95% of what most primary care docs can do while ordering 90-95% more tests than most docs do.

Who are we to argue with a Family medicine doc from the esteemed UCSF? He's the one who said it. Why not believe him?

 

[Meh.meh]

Who are we to argue with a Family medicine doc from the esteemed UCSF? He's the one who said it. Why not believe him?

I'm fairly certain you're being sarcastic, but just for fun.

1. Nobody has created a good, objective comparison between the two. Studies so far have used surrogate measures like BP management and patient satisfaction. So at best, he is giving expert opinion. It's hardly conclusive evidence.

2. The minimal amount of training a family doc. receives far outweighs the minimum possible for a NP. The law shouldn't address what a "great" physician can do vs a "great" np. It should address minimum standards in both professions. The potential minimum for reaching independent practice as a NP should scare everyone ATM.

Somehow, independent practice for midlevels has pushed past rigorous standards we normally hold in medicine. Any drug entering the market requires years of testing and exploration of potential side effects. Yet for some reason, the same standard is not being held for the people who prescribe said drugs.

Whether or not a patient has his/her blood pressure controlled for a 6 mo. period is not a "hard" outcome. Patient mortality, hospitalizations, and cost would be more interesting, but hardly conclusive. The question of midlevel safety could take decades to answer conclusively.

We have allowed the discussion to put us on the defense, with questions like "why shouldn't we allow midlevels to practice." The more appropriate question is "How have they proven themselves safe enough for practice?"

The burden shouldn't be on us, but on them. We would never allow a new drug to enter the market on the basis that "it hasn't killed anyone yet."

IMO, midlevels are useful and could help expand access to care. What they shouldn't be is a low-barrier-backdoor to independent practice.

Some day, they may indeed prove equivalence in certain settings. Until then, they should receive maximal oversight. Anything else is unethical.

 

[Psai]

I love our NHS. I love what it can offer when working well.

But with recent BS in the ironically right winged media has left the public foaming at the mouth. At this point I want to say screw it and make the whole thing private.

I don't think I have an opinion of whether a PCP should be making more or less than a specialist. But it kind of makes sense to me how it is now. But the general public would rather if doctors didn't make any money. You should be doing it for the love of caring for others. So...

yeah caring for others...that's before they actually see who comes into doctor's offices and hospitals. hard to care for people who don't care for themselves

 

[syma]

yeah caring for others...that's before they actually see who comes into doctor's offices and hospitals. hard to care for people who don't care for themselves

I completely agree. Should have made my sarcasm more obvious (if it was missed)

 

[circulus vitios]

I wanna be a hospital administrator when I grow up.

 

[Frazier]

I wanna be a hospital administrator when I grow up.

No, Bobby. When you grow up, you will sell propane and propane accessories.

 

[Robinson EM]

It's not a totally free market. But that is besides the point. If there is a need, hospitals and systems will cough up the cash to have the staffing they think they need, and they'll continue to increase the compensation until someone bites. There's PLENTY of money to pay physicians more. This may seem like an outlandish statement but most of the money going into healthcare ISN'T paying doctors to do what we do. There may be a point where it all taps out, but we are not there yet.

Agreed.

 

[DermViser]

Have you considered the fact that many people just don't consider primary care to be very interesting?

How dare you!!

 

[wjs010]

OP didn't ever do any research about the percentage of healthcare costs going to physician salaries and how it's NOT the biggest problem in costs. Congrats OP I am disappointed in your post lol

 

[Robinson EM]

Honestly I have no idea at what you're getting at. Your post says a lot without an overarching point. You mention all these procedures in multiple posts. What procedures, why are they unnecessary?

I remembered your response and found some more excellent reading for you on this topic.

What is an unnecessary procedure?

Read below, but the key here is the unnecessary procedures account for 30% of healthcare costs and that they are mostly due to facility fees. The thing that most medical students don't understand is that facility fees may or may not go to doctors. This is the reason you see ophtho earning 250k to 700k or orthopedic docs earning 400k - 800k, a lot of the upside of income for physicians is due to facility fees.

Full article below explain everything, but some key ideas:
- Knee replacement costs vary from $1,800 - $32,000
- Hips? $2,600 to $32,000

Imaging costs also drastically vary.

This is why some people will say, the cost difference isn't paid to physicians - which is mostly true. But enterprising physicians have figured out how to get in on the facility fees via private ownership.

https://www.clinicalkey.com/info/blog/facility-fees-cause-healthcare-costs-vary-wildly/

October 13, 2014
Facility fees cause healthcare costs to vary wildly
A 2012 report from the Institute of Medicine estimated the U.S. healthcare industry wastes $750 billion dollars annually in unnecessary medical spending, or about 30 percent of the industry's overall expenses. When the topic is broached within the guise of healthcare reform, experts usually focus on redundant or ineffective tests and diagnostic procedures that do not improve quality of care or patient outcomes.

However, according to Change Healthcare's most recent Healthcare Transparency Index, which measures the cost variability of medical services across different sites, physicians and networks, the fees charged by individual facilities vary so wildly that prices can fluctuate by tens of thousands of dollarsfor nearly identical procedures. If healthcare reform is ever to tackle the issue of unnecessary spending, facility fees should be a primary focus.

Tackling facility fees
The HCTI report looked at procedures conducted in quarter one 2014 and identified joint replacement surgeries as the most inconsistently priced operation in healthcare. Depending on the facility, the cost of knee replacements varied by 1,687 percent - $1,803 to $32,225 - and hip replacements fluctuated by 1,132 percent - $2,613 to $32,190.

In comparison, fees charged by physicians varied only by 127 and 151 percent.

Joint replacement surgeries were not the only procedures that suffered from inconsistent and borderline predatory pricing behaviors. Costs for CT scans, ultrasounds and vaginal deliveries all varied by more than 300 percent.

"We often hear that doctors' fees are to blame for escalating healthcare costs," Doug Ghertner, chief executive officer of Change Healthcare, told Health Data Management. "In truth, it's the facilities that exhibit the most significant variance in costs - often varying by hundreds or even thousands of percentage points."

The HCTI report illuminates a significant issue in healthcare reform, but the U.S. Centers for Medicare and Medicaid Services had known about the problem for a while. In 2013, the CMS announced tighter restrictions on how medical facilities can bill Medicare for additional fees based off of their abilities to provide certain services, Modern Healthcare reported.

The CMS proposed replacing a variable rate system, which paid about $50 for a low-level patient visit and up to about $345 for serious incidents, with a flat fee of $212.90 for all emergency department visits regardless of severity. The policy went into effect January 1, 2014, though some officials claimed that it would unnecessarily hurt hospitals that are already facing budgetary restrictions.

The differences in joint replacements are ridiculous and shameful, whether it's corporations or private ownership.

 

[Instatewaiter]

Specialists make more money because the procedures they do and advanced care they provide is more expensive than what PCP's are capable of. IE a cardiologist bills more for an EKG than a PCP can bill for a simple physical. "Redistribution" of money towards primary care physicians means the patient would have to pay MORE for primary care, which will never happen.

No they don't. A cardiologist bills $8 for an EKG.

 

[loltopsy]

The FM guys I've shadowed, although technically worked 50+ hours per week, were not really working 50+ hours a week. They spent over half their day sitting in their office waiting for the next patient to arrive at their office. While in their office, roughly half of that was spent doing actual work (calling pharmacies/patients, filling out paperwork), and the rest was spent chatting with the staff about some movie that just came out.

I'm sure that's not every FM doc ever, but if you look at actual work time, it's probably way, way less. When I've shadowed surgeons, they've all been working way more and playing around way less. They also generally had longer clinic and surgery hours on those days.

 

[DrBodacious]

I remembered your response and found some more excellent reading for you on this topic.

What is an unnecessary procedure?

Read below, but the key here is the unnecessary procedures account for 30% of healthcare costs and that they are mostly due to facility fees. The thing that most medical students don't understand is that facility fees may or may not go to doctors. This is the reason you see ophtho earning 250k to 700k or orthopedic docs earning 400k - 800k, a lot of the upside of income for physicians is due to facility fees.

Full article below explain everything, but some key ideas:
- Knee replacement costs vary from $1,800 - $32,000
- Hips? $2,600 to $32,000

Imaging costs also drastically vary.

This is why some people will say, the cost difference isn't paid to physicians - which is mostly true. But enterprising physicians have figured out how to get in on the facility fees via private ownership.

https://www.clinicalkey.com/info/blog/facility-fees-cause-healthcare-costs-vary-wildly/

The differences in joint replacements are ridiculous and shameful, whether it's corporations or private ownership.

I am not trying to dissect all of the inconsistencies and weak data here, but for anyone following the thread I would like to point out:

1. There is no data in the linked article showing that 30% of healthcare costs are from unnecessary procedures
2. Physician reported salaries do not include income from investments in surgery centers, where they would gain a share of facility fees, therefore this does not explain the range in reported salaries
3. The reimbursements for facility fees and physician fees are contracted with insurance companies through a fee schedule. The insurance company chooses to agree to a contracted price. If they do not contract with providers, an insurance company may pay much higher out of network fees to satisfy the agreements they make with their insured patients. The implication that this is ridiculous and shameful is naive.
4. He is implying that physicians have "figured out how to get in on the facility fees via private ownership." The main way this happens is via surgery centers or maybe other similar ambulatory care centers. For any given procedure, surgery centers receive a much smaller payment relative to hospitals. For medicare, currently, I believe the surgery center reimbursement is 58% of what a hospital gets. This is a great way to decrease health care spending. Who is it that you think should be owning surgery centers if physicans are not allowed to own surgery centers? I am a surgery center investor, and I can tell you that it is much better run than any hospital. Having practicing physicians owning and managing the center is precisely why it works so well from both an efficiency and quality standpoint.

 

[IlDestriero]

Agreed. Exactly what I feel, and you have med students making threads advocating for it. I swear it's almost like that's part of the grand scheme: pitting us against each other lol.

If the next generation wants to work for less that's fine. I'd be happy to hire them for 30% less. Everyone is happy.

 

[deleted500612]

The FM guys I've shadowed, although technically worked 50+ hours per week, were not really working 50+ hours a week. They spent over half their day sitting in their office waiting for the next patient to arrive at their office. While in their office, roughly half of that was spent doing actual work (calling pharmacies/patients, filling out paperwork), and the rest was spent chatting with the staff about some movie that just came out.

I'm sure that's not every FM doc ever, but if you look at actual work time, it's probably way, way less. When I've shadowed surgeons, they've all been working way more and playing around way less. They also generally had longer clinic and surgery hours on those days.

This is far from the experience I've had. Every FM I've seen has patients backed up in the waiting room and is at least 20-30 minutes behind schedule, usually skipping breaks to try and catch up on work with barely a moment of down time throughout the day.

 

[Graywolf]

This is far from the experience I've had. Every FM I've seen has patients backed up in the waiting room and is at least 20-30 minutes behind schedule, usually skipping breaks to try and catch up on work with barely a moment of down time throughout the day.

This is right. I work full time in FM now and the doctors never get a break. From making triaging decisions, reading through progress notes, imaging reports, and keeping up with thousands of lab results that patients expect the next day reviewed, they are frantically trying to keep up for 8 to 10 hours per day. The rest of the staff is working just as hard to facilitate all this work. This is required in FM to stay afloat. The clinic makes a dollar for doing a flu shot - high volume turns a profit this day and age...

 

[DrBodacious]

No they don't. A cardiologist bills $8 for an EKG.

Many PCPs I know do EKGs, also.

 

[thesauce]

End of life care, especially, is fundamentally broken.

How would you fix it?

 

[DermViser]

How would you fix it?

The govt. is doing that now. They'll say no to paying for any further care which they believe isn't worth it.

 

[anbuitachi]

We all know how little PCP's make compared to Specialists.

For those of us learning healthcare in MS1 for the first time are being exposed to some of the cost problems of healthcare. It seems that Physicians being overpaid is definitely one of them.

Personally, I consider myself as fairly fiscally conservative and generally opposed to socialism, but in light of PCP salaries vs Specialty salaries, I think there is problem here.

Can someone justify why some specialists make so much more than PCP's?

I don't buy the "Because it's longer training and worse hours", because if we look outside of the medical field there are so many problems with that argument and if most of America is down to redistribute the wealth, why would the medical field be opposed to redistributing physician salaries?

Too lazy to read the rest of the thread lol.

But like probably already mentioned, specialists make more because of liability + technical skill. If a PCP prescribes the wrong HTN drug, or forgets to prescribe it all together, what will most likely happen? Probably nothing for a while... If an anesthesiologist stabs into the spinal cord by accident, then things wont turn out well. Anesthesiologists take these types of risks on a daily basis, which is why they get paid more. Plus, they work more hours than PCP.

Longer training is another factor. PCP is only 3 years... and you just need to know the information. It doesn't really require any technical skills. Pretty much any specialty that pays well need technical skills (including high paying IM subspecialties).

Personally i think specialists SHOULD be paid much more, or few would be willing to go thru the extra years of training, and the added risks.

But you can also earn a LOT as a PCP. My PCP earns 300k++ working 6 days a week in his clinic and he isn't even swamped or anything. My primary care attending appears wealthy (owns RR, bentley, porsche) but he works 7 days a week like crazy..

I think specialty salaries shouldn't be decreased to compensate. Instead all of our salaries, PCP included should go up. They can do this by getting rid of setting up a government run non profit insurance in my opinion.

 

[Greenberg702]

We all know how little PCP's make compared to Specialists.

For those of us learning healthcare in MS1 for the first time are being exposed to some of the cost problems of healthcare. It seems that Physicians being overpaid is definitely one of them.

Personally, I consider myself as fairly fiscally conservative and generally opposed to socialism, but in light of PCP salaries vs Specialty salaries, I think there is problem here.

Can someone justify why some specialists make so much more than PCP's?

I don't buy the "Because it's longer training and worse hours", because if we look outside of the medical field there are so many problems with that argument and if most of America is down to redistribute the wealth, why would the medical field be opposed to redistributing physician salaries?

If PCPs made only slightly less than specialists (say 350K instead of 400K to compensate for length of training) I still wouldn't even consider it. I believe that the majority of people simply don't find it sufficiently intellectually stimulating. It has nothing to do with the money and everything to do with the pathology, technology, and research potential in the field.

 

[DermViser]

If PCPs made only slightly less than specialists (say 350K instead of 400K to compensate for length of training) I still wouldn't even consider it. I believe that the majority of people simply don't find it sufficiently intellectually stimulating. It has nothing to do with the money and everything to do with the pathology, technology, and research potential in the field.

Not to mention the govt. feels that primary care can be done by PAs and NPs, with physicians in an administrative role. Why would someone go into a specialty in which they are not appreciated by others?

 

[W19]

If PCPs made only slightly less than specialists (say 350K instead of 400K to compensate for length of training) I still wouldn't even consider it. I believe that the majority of people simply don't find it sufficiently intellectually stimulating. It has nothing to do with the money and everything to do with the pathology, technology, and research potential in the field.

What?

 

[Robinson EM]

I am not trying to dissect all of the inconsistencies and weak data here, but for anyone following the thread I would like to point out:

1. There is no data in the linked article showing that 30% of healthcare costs are from unnecessary procedures
2. Physician reported salaries do not include income from investments in surgery centers, where they would gain a share of facility fees, therefore this does not explain the range in reported salaries
3. The reimbursements for facility fees and physician fees are contracted with insurance companies through a fee schedule. The insurance company chooses to agree to a contracted price. If they do not contract with providers, an insurance company may pay much higher out of network fees to satisfy the agreements they make with their insured patients. The implication that this is ridiculous and shameful is naive.
4. He is implying that physicians have "figured out how to get in on the facility fees via private ownership." The main way this happens is via surgery centers or maybe other similar ambulatory care centers. For any given procedure, surgery centers receive a much smaller payment relative to hospitals. For medicare, currently, I believe the surgery center reimbursement is 58% of what a hospital gets. This is a great way to decrease health care spending. Who is it that you think should be owning surgery centers if physicans are not allowed to own surgery centers? I am a surgery center investor, and I can tell you that it is much better run than any hospital. Having practicing physicians owning and managing the center is precisely why it works so well from both an efficiency and quality standpoint.

I always enjoy how easy it is to "dissect all the inconsistencies" of the data presented and the calls for data or research to be listed, yet I never ever see any response with a research paper or evidence proving otherwise. I hear lots of statistics and reasons why the data is incorrect, but I never see response links or research papers - evidence - presented otherwise.

Did you really need a link. A google search will bring it up immediately.
http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=13444

Date: Sept. 6, 2012


FOR IMMEDIATE RELEASE


Transformation of Health System Needed to Improve Care and Reduce Costs


WASHINGTON — America's health care system has become too complex and costly to continue business as usual, says a new report from the Institute of Medicine. Inefficiencies, an overwhelming amount of data, and other economic and quality barriers hinder progress in improving health and threaten the nation's economic stability and global competitiveness, the report says. However, the knowledge and tools exist to put the health system on the right course to achieve continuous improvement and better quality care at lower cost, added the committee that wrote the report.


The costs of the system's current inefficiency underscore the urgent need for a systemwide transformation. The committee calculated that about 30 percent of health spending in 2009 -- roughly $750 billion -- was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best performing state.


Incremental upgrades and changes by individual hospitals or providers will not suffice, the committee said. Achieving higher quality care at lower cost will require an across-the-board commitment to transform the U.S. health system into a "learning" system that continuously improves by systematically capturing and broadly disseminating lessons from every care experience and new research discovery. It will necessitate embracing new technologies to collect and tap clinical data at the point of care, engaging patients and their families as partners, and establishing greater teamwork and transparency within health care organizations. Also, incentives and payment systems should emphasize the value and outcomes of care.


"The threats to Americans' health and economic security are clear and compelling, and it's time to get all hands on deck," said committee chair Mark D. Smith, president and CEO, California HealthCare Foundation, Oakland. "Our health care system lags in its ability to adapt, affordably meet patients' needs, and consistently achieve better outcomes. But we have the know-how and technology to make substantial improvement on costs and quality. Our report offers the vision and road map to create a learning health care system that will provide higher quality and greater value."


The ways that health care providers currently train, practice, and learn new information cannot keep pace with the flood of research discoveries and technological advances, the report says. How health care organizations approach care delivery and how providers are paid for their services also often lead to inefficiencies and lower effectiveness and may hinder improvement.


Better use of data is a critical element of a continuously improving health system, the report says. About 75 million Americans have more than one chronic condition, requiring coordination among multiple specialists and therapies, which can increase the potential for miscommunication, misdiagnosis, potentially conflicting interventions, and dangerous drug interactions. Health professionals and patients frequently lack relevant and useful information at the point of care where decisions are made. And it can take years for new breakthroughs to gain widespread adoption; for example, it took 13 years for the use of beta blockers to become standard practice after they were shown to improve survival rates for heart attack victims.


Mobile technologies and electronic health records offer significant potential to capture and share health data better. The National Coordinator for Health Information Technology, IT developers, and standard-setting organizations should ensure that these systems are robust and interoperable, the report says. Clinicians and care organizations should fully adopt these technologies, and patients should be encouraged to use tools, such as personal health information portals, to actively engage in their care.


Health care costs have increased at a greater rate than the economy as a whole for 31 of the past 40 years. Most payment systems emphasize volume over quality and value by reimbursing providers for individual procedures and tests rather than paying a flat rate or reimbursing based on patients' outcomes, the report notes. It calls on health economists, researchers, professional societies, and insurance providers to work together on ways to measure quality performance and design new payment models and incentives that reward high-value care.http://national-academies.orgor http://iom.edu. A committee roster follows.

Additional Resources:

• Report in Brief

• Project Page

Contacts:

Christine Stencel, Senior Media Relations Officer

Luwam Yeibio, Media Relations Assistant

Office of News and Public Information

202-334-2138; e-mail [email protected]

___________________________________________________________________________________________

Pre-publication copies of Best Care at Lower Cost: The Path to Continuously Learning Health Care in Americaare available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet athttp://www.nap.edu. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).

# # #


INSTITUTE OF MEDICINE

Institute of Medicine Executive Office


Committee on the Learning Healthcare System in America


Mark D. Smith, M.D., M.B.A.1 (chair)

President and CEO

California HealthCare Foundation

Oakland


James P. Bagian, M.D.1, 2

Director

Center for Healthcare Engineering and Patient Safety, and

Professor

College of Engineering and Medical School

University of Michigan

Ann Arbor


Anthony S. Bryk, Ed.D.

President

The Carnegie Foundation for the Advancement of Teaching

Stanford, Calif.


Gail H. Cassell, Ph.D.1

Visiting Professor

Department of Global Health and Social Medicine

Harvard Medical School, and

Vice President of Scientific Affairs and Distinguished Lilly Research Scholar for Infectious Diseases

Eli Lilly and Co. (retired)

Carmel, Ind.


James B. Conway, M.S.

Adjunct Lecturer

Harvard School of Public Health, and

Senior Fellow

Institute for Healthcare Improvement

Woburn, Mass.


Helen B. Darling, M.A.

President

National Business Group on Health

Washington, D.C.


T. Bruce Ferguson Jr., M.D.

Professor and Inaugural Chairman

Department of Cardiovascular Sciences

East Carolina University

Greenville, N.C.


Ginger L. Graham, M.B.A.

President and CEO

Two Trees Consulting,

President and CEO

Amylin Pharmaceuticals, and

Group Chairman

Guidant Corp.

Ventura, Calif.


George Halvorson, M.B.A.

Chairman and CEO

Kaiser Permanente

Oakland, Calif.


Brent C. James, M.D.1

Chief Quality Officer and Executive Director

Institute for Health Care Delivery Research

Intermountain Healthcare Inc.

Salt Lake City


Craig A. Jones, M.D.

Director

Vermont Blueprint for Health

Burlington


Gary Kaplan, M.D.

Chairman and CEO

Virginia Mason Health System

Seattle


Arthur A. Levin, M.P.H.

Director

Center for Medical Consumers

New York City


Eugene Litvak, Ph.D.

President and CEO

Institute for Healthcare Optimization

Newton, Mass.


David O. Meltzer, M.D., Ph.D.

Chief

Section of Hospital Medicine, and

Director

Center for Health and the Social Sciences

University of Chicago

Chicago


Mary D. Naylor, Ph.D., M.S.N.1

Marian S. Ware Professor in Gerontology, and

Director

NewCourtland Center for Transitions and Health

School of Nursing

University of Pennsylvania

Philadelphia


Rita Redberg, M.D.,M.Sc.

Editor

Archives of Internal Medicine, and

Professor of Medicine

School of Medicine

University of California

San Francisco


Paul C. Tang, M.D., M.S.1

Vice President and Chief Innovation and Technology Officer

Palo Alto Medical Foundation

Palo Alto, Calif.


STAFF


Robert Saunders, Ph.D.

Study Director

____________________________________

1 Member, Institute of Medicine

2 Member, National Academy of Engineering

They've taken the time to write a 400 page book on this, I'm sure if you're interested you can read it. It's difficult for me to just discount it because you say so. If you can present a counter research paper or 400 page book or anything saying otherwise, that we have ____% unnecessary procedures or none, whatever - any other evidence, that would be great.

Now I'm sure you can sit around and pick this apart. Heck, the research articles we use to make major treatment changes by big pharma are often easy to dissect with major inconsistencies - which we learn about after drugs are pulled off market or shown to have little to no measurable difference in previous medications.

But with that said, please present your research papers or evidence proving what you just have asserted, specifically:

• Less than 30% are unnecessary. Great. What % are unnecessary? 5%? 29%? 14.5%? Can you present evidence showing this?
• "physician reported salaries do not include income from facility fees". What physician reported income? From every salary survey in America? MGMA, bls, medscape, etc? Can you present evidence that this is true for all the surveys? You have no linked data for this claim
• Insurance pays via a fee schedule. Ok, great. I hear this all the time, it's not really $32,000 - it's a fee schedule. Can you tell me this? How much of that $32,000 is paid? I would like to see actual evidence rather than you just stating, "Oh, it's not $32,000 - it's less than that". Because I'm unable to find it. I found one comprehensive study showing the actual costs based on agreed upon payments. Guess what? America was still incredibly higher! I.e. the range from $2,000 - $32,000 - some companies were able to get 15-20k and the average costs are incredibly higher. But let's have you present evidence showing us exactly what % or approximately what % they are getting paid, sure it's different depending on the contract - but we don't really know if it's 50% or 80% of the billed cost.
• You then go on to say surgery centers are the main way physicians do this (please present research or evidence for this claim) - i.e. what % are doing this with surgery centers?

Why do I say it's shameful, because the act of charging people $32,000 for a joint replacement prevents other people from receiving healthcare. Sure, it's good for the surgeon and the corporation or private ownership, but it hurts our nation overall. This is a screwed up market. Insurance companies agreeing to pay more just jacks up insurance costs. That's why we spend so much on healthcare. For you to say, "Oh, it's the insurance companies decision if they want to pay more." Well, they don't really lose any money paying more - they just pass the bill on to other American families who can't afford insurance. So this "free decision to contract" doesn't prevent insurance from paying executives millions, having the same profits year after year and then just charging more and more in premiums.

All the while the middle class and poor are shafted into paying more and more for premiums with little choice and little competition in these insurance markets. This isn't a free market when a company is agreeing on a fair price they chose to pay - they are passing the bill on to people who can't afford it while they continue to roll in the $$$. That is shameful. These are the same companies who will screw over patients at the drop of a hat to earn more money.

Sorry if you think that is naive - but it's not. It's an actual understanding of who is harmed by these greedy practices. What goods do you know that have range of cost of $2,000 - $32,000 for the same thing?

You end by stating that having physician owned and managed centers is beneficial. I agree, I've seen recent evidence on this to state they spend less than corporate operated hospitals. I'm not an enemy of physicians, I think corporate greed has done the worst for this system. Yet to sit around and think that 100% of physicians wear white hats and have no responsibility in these greedy business practices is naive.

Anyway, I look forward to you presented some evidence that I've had difficulty finding. Specifically on % payments that are agreed upon and how no physician salary surveys include any ownership income or facility fees. I know this is unlikely and you're more likely to respond with why it is illogical for you to gather this evidence or it's not possible. I just find it interesting how no counter evidence is ever listed on this site, just people who like to pick apart what you've listed.

I don't think it's naive to look at the waste in our system that is placed as a burden upon those with the least ability to pay and wonder why we can't fix that system.

 

[Greenberg702]

What?

I'm using the word people to refer to allopathic medical students.

 

[DermViser]

What?

You're an M1. You'll realize it soon enough.

 

[thesauce]

The govt. is doing that now. They'll say no to paying for any further care which they believe isn't worth it.

That is how they're ADDRESSING it, but how can we FIX it? The government has never done a good job of fixing things. Every initiative they undertake ends up being a big money pit and bureaucratic nightmare.

I deal with these issues routinely and I have to say that it's difficult to know when patients are truly at the end of their life. I've had patients live with metastatic cancer for 10 years. Good thing they got treated. Although this isn't the norm, 2-3 years happens routinely. It's not an easy issue to address yet alone fix.

 

[W19]

You're an M1. You'll realize it soon enough.

 

[DermViser]

It's true - as later you'll be exposed to medicine in an academic medical center.

 

[Robinson EM]

Not to mention the govt. feels that primary care can be done by PAs and NPs, with physicians in an administrative role. Why would someone go into a specialty in which they are not appreciated by others?

I think PC's main problem, more than being less mentally stimulating (this is an argument, obviously it's not Rad Onc, but I'm sure some of the best primary care physicians in America are using very good problem solving to help their patients. Remember, some people have 5-6 chronic health issues and psych issues - if that's not a challenging patient to deal with in a short session, I don't know what is) - but the main issue is that we need MORE providers across the country and we aren't training enough fast enough.

As for midlevels, this is a sensitive topic - as physicians will obviously be biased in their opinions on them. Now that I've worked with some excellent PAs and NPs, I have no doubt that those with years/decades of experience, who also are excellent and constantly improve, would have no problem treating many of the conditions that doctors treat. I remember reading they taught some midlevels to perform simple hernia surgeries at a proficiency as good as or better than general surgeons due to specialization. So with that said, I think it's undeniable that excellent midlevels can do nearly all what physicians in some specialties do. Primary care has the biggest target right now because it has the most need - other areas like psych also will face issues. The easiest to train and most need will be attacked by the government first. The issues is, once it starts the dominoes will fall and it will effect multiple areas in medicine.

I truly believe it's inevitable at this point. And it also might be best for our country to allow midlevels to do some basic primary care. If someone has some real reasons why not I would love to hear them. There seems to be more evidence now in support of allowing them to deliver some basic care especially in rural areas.

 

[Robinson EM]

That is how they're ADDRESSING it, but how can we FIX it? The government has never done a good job of fixing things. Every initiative they undertake ends up being a big money pit and bureaucratic nightmare.

I deal with these issues routinely and I have to say that it's difficult to know when patients are truly at the end of their life. I've had patients live with metastatic cancer for 10 years. Good thing they got treated. Although this isn't the norm, 2-3 years happens routinely. It's not an easy issue to address yet alone fix.

+1

2 great points. Government can't manage much well and how do we know when the end has come?

These are 2 ideas are going to play critical roles in the next few decades. I wish we had a competent government because a efficient and well-managed single payer while it has tons of downsides could fix a lot.