Rheumatology Workforce Shortfall

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drfunktacular

ANA ≠ SLE
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Bad and getting worse

Hopefully more residents and students become interested in the field, and more funding can be allocated for training spots. On the other hand, it will be a good time to be a rheumatologist (although a bad time to need one :()


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http://www.the-rheumatologist.org/a...cialists-predicts-future-workforce-shortfall/

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Keep the supply low so the demand stays high


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Supply and demand don't apply in medicine since there are no actual market dynamics at play

We have way more spine surgeons than we need, and way fewer pediatricians than we need. Even so, the pay differential between them is about 5-6x and expanding

From my standpoint the main benefit to rheumatologists will be the ability to spend your time exclusively on inflammatory diseases and dismiss all the non inflammatory stuff (fibro, OA, back pain, etc) that PCPs should be managing
 
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I'd imagine a collaborative model where rheum practices have an NP to handle OA, fibro, back pain, etc. Does that seem reasonable?

Regarding supply and demand - even if medicine did function normally, keeping supply low with a fixed demand wouldn't increase demand in a classic economic sense. It'll cause an increase in price.

https://en.m.wikipedia.org/wiki/Supply_and_demand


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Also, I would bet more concierge practices spring up. If it takes three months to get in to see a rheumatologist, rich areas would be able to sustain a subscription type model, where you pay a fee per year in cash to have more access. Whether that's right or wrong / good or bad is another issue.


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I'd imagine a collaborative model where rheum practices have an NP to handle OA, fibro, back pain, etc. Does that seem reasonable?

Yes; many do this already. But I suspect most rheumatologists would rather not have to mess with it and spend their time on more "interesting" problems

Regarding supply and demand - even if medicine did function normally, keeping supply low with a fixed demand wouldn't increase demand in a classic economic sense. It'll cause an increase in price.

That is what I meant; I suspect a big part of the reason trainees are not more interested in rheumatology is the relatively low compensation compared to other specialties. So in that sense if the "price" (compensation) of a rheumatologist increases, more people will be interested in the specialty who otherwise might have decided against it. But that isn't the way compensation actually works in our system, so I'm not sure it will happen.

Also, I would bet more concierge practices spring up. If it takes three months to get in to see a rheumatologist, rich areas would be able to sustain a subscription type model, where you pay a fee per year in cash to have more access. Whether that's right or wrong / good or bad is another issue.

I think rheumatology is actually very well-suited to this type of practice; it is not heavily dependent on capital-intensive resources like a cath lab, endoscopy suite, etc. Infusions could be done (risky) or else farmed out to a private infusion center. One obstacle though is that rheumatology is heavily referral-dependent; most people are not self-referring to a rheumatologist. So a successful retainer rheumatology practice would have to be in an area where you have referring providers who understand what you are doing and will work with you on it.
 
These numbers are only a net positive for rheumatologists. However, saturated locations will still be saturated.

One extra boon for rheumatologists is that it isn't a field that is readily open for midlevel takeover. Sure, NPs can see your OA, fibro, and very simple RA, but overall I've realized that the rheumatology patient population is generally less accepting of a non-MD managing their disease than many other fields.
 
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These numbers are only a net positive for rheumatologists. However, saturated locations will still be saturated.

One extra boon for rheumatologists is that it isn't a field that is readily open for midlevel takeover. Sure, NPs can see your OA, fibro, and very simple RA, but overall I've realized that the rheumatology patient population is generally less accepting of a non-MD managing their disease than many other fields.

Excellent point about the patients. Also, I think the patients have excellent reasons for feeling this way.

Besides cases where diagnosis is *abundantly* clear,
most PHYSICIANS seem to know little of rheum outside the extremely common,
and EVERYONE seems unable to make any but the most common rheum diagnoses with any certainty,
and most can't properly interpret most of the most common panels

A lot of rheum dx's have systemic effects that most non-specialists don't want to touch with a ten foot pole - lupus and kidney failure? Not something I want to play with.

Couple the diagnostic uncertainty, complexity, lack of experience, potential for random systemic extreme badness,

Not to mention - the treatments for a lot of this?
PCPs can be loose with steroids and methotrexate,
but I don't see anyone wanting to touch any of the rest of the immunosuppresants.

Anything past those, the risk of PML and agranulocytosis - basically everyone wants rheum to write for rheum dx's
(aside from the specialists that do it if for their scope of practice, GI w/ Crohns, Derm w/ Psoriasis, etc)

I think rheum is at, or should be near, the bottom of any list of specialties that are ranked,
"Hey I'm a doctor or a midlevel I think I can wing this, especially since it's not procedure heavy"

TLDR:
I will say this, in my training at least, it seemed like rheum was the turf no one wanted to play on, like, ever.
I think that was a good thing, actually, and well deserved.
 
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I suspect what will happen if the shortage worsens as predicted is that we will have to operate more similar to the way European rheumatologists do. See the patient once or twice to confirm the diagnosis and start a treatment plan, then send the PCP instructions on how to adjust/monitor and see the patient for rheum follow-up once a year or so.
 
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I suspect what will happen if the shortage worsens as predicted is that we will have to operate more similar to the way European rheumatologists do. See the patient once or twice to confirm the diagnosis and start a treatment plan, then send the PCP instructions on how to adjust/monitor and see the patient for rheum follow-up once a year or so.
You think they'll be down with that?

90% of my non-chemo requiring hem/onc patients could do with this treatment plan but I get so much pushback from referring/primary docs that I just quit trying.

I was trying to make life easier/cheaper for my patients (do they really need another appointment just so someone can look at a CBC and order a CT scan?), but it got to be more trouble than it was worth.
 
I think rheumatology is actually very well-suited to this type of practice; it is not heavily dependent on capital-intensive resources like a cath lab, endoscopy suite, etc. Infusions could be done (risky) or else farmed out to a private infusion center. One obstacle though is that rheumatology is heavily referral-dependent; most people are not self-referring to a rheumatologist. So a successful retainer rheumatology practice would have to be in an area where you have referring providers who understand what you are doing and will work with you on it.
I don't see this as a barrier at all to a direct payment model for rheumatology. From what I've seen so far, rheumatologists will have bigger problems trying to sift through all the primary care referrals for things that we don't want to treat.

What I can envision is that you can take consultations for a certain cash payment. If a diagnosis can be made, then you can offer a yearly retainer for your services. Honestly, I would go for this business model simply to get out of the regulatory red tape that is popping up like wild fire for all clinicians. Imagine you, an office, and one support staff. No insurance companies. No billing department. No documentation Nazis breathing down your neck.
 
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You think they'll be down with that?

90% of my non-chemo requiring hem/onc patients could do with this treatment plan but I get so much pushback from referring/primary docs that I just quit trying.

I was trying to make life easier/cheaper for my patients (do they really need another appointment just so someone can look at a CBC and order a CT scan?), but it got to be more trouble than it was worth.

I agree in that I've attempted similar arrangements and been obstructed by PCPs. Some of them refuse to even refill NSAIDs when they know the patient is seeing a rheumatologist :laugh:

I think they'll be more open to it when it takes 6 months to get someone with active RA in with a rheumatologist...
 
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That is what I meant; I suspect a big part of the reason trainees are not more interested in rheumatology is the relatively low compensation compared to other specialties. So in that sense if the "price" (compensation) of a rheumatologist increases, more people will be interested in the specialty who otherwise might have decided against it. But that isn't the way compensation actually works in our system, so I'm not sure it will happen.

Is the lobbying power of Rheumatologists not great enough to bump up compensation for the field? With all the Rheum drugs I see being pumped out on TV, I would've thought this would help the lobbying power of the field because of Pharma's clout. No disrespect to general internists or PCP's, but as a specialty field, and given the workforce deficit, Rheumatologists are deserving of a higher compensation than they currently receive. And the fact that the average Rheum patient can take a much longer time to work up than others, should not be a disadvantage to Rheumatologists' reimbursements.
 
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Is the lobbying power of Rheumatologists not great enough to bump up compensation for the field? With all the Rheum drugs I see being pumped out on TV, I would've thought this would help the lobbying power of the field because of Pharma's clout. No disrespect to general internists or PCP's, but as a specialty field, and given the workforce deficit, Rheumatologists are deserving of a higher compensation than they currently receive. And the fact that the average Rheum patient can take a much longer time to work up than others, should not be a disadvantage to Rheumatologists' reimbursements.

you somehow think that talking to pt is compensated appropriately....
 
Is the lobbying power of Rheumatologists not great enough to bump up compensation for the field? With all the Rheum drugs I see being pumped out on TV, I would've thought this would help the lobbying power of the field because of Pharma's clout. No disrespect to general internists or PCP's, but as a specialty field, and given the workforce deficit, Rheumatologists are deserving of a higher compensation than they currently receive. And the fact that the average Rheum patient can take a much longer time to work up than others, should not be a disadvantage to Rheumatologists' reimbursements.
*shrug*

Pretty much everyone gets paid the same for a f/u visit as anyone else. Without procedure codes to throw in there, your initial consult is worth the same as anyone elses and so is your f/u visit. If your patients are more complicated you'll bill a higher proportion of 5s relative to 4s, but there's no level 6. Infusion centers can make some money, but unless you're the one who owns it, it's going to make money for the hospital (or the oncologist who owns the place you send your patients to).
 
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Pretty much everyone gets paid the same for a f/u visit as anyone else. Without procedure codes to throw in there, your initial consult is worth the same as anyone elses and so is your f/u visit. If your patients are more complicated you'll bill a higher proportion of 5s relative to 4s, but there's no level 6. Infusion centers can make some money, but unless you're the one who owns it, it's going to make money for the hospital (or the oncologist who owns the place you send your patients to).

I read an article some time ago in which the author was explaining that Rheumatologists lose out on a good chunk of revenue due to inefficient billing. I'd imagine this happens in other fields too though. I'm not yet a physician so I don't know the intricacies/validity of this
 
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Is the lobbying power of Rheumatologists not great enough to bump up compensation for the field? With all the Rheum drugs I see being pumped out on TV, I would've thought this would help the lobbying power of the field because of Pharma's clout. No disrespect to general internists or PCP's, but as a specialty field, and given the workforce deficit, Rheumatologists are deserving of a higher compensation than they currently receive. And the fact that the average Rheum patient can take a much longer time to work up than others, should not be a disadvantage to Rheumatologists' reimbursements.
Lol, what do TV commercials got to do with anything?

The bottom line here is that non-procedural specialties are just limited by the lack of reimbursement dollars going into E&M. As far as compensation is concerned, it's all about # patients X $ per visit. And furthermore, unlike other specialties which are crucial to the functioning of large health care corporations (such as EM or hospital medicine), a shortage of rheumatologists doesn't force the hand of these entities. In other words, a healthcare corporation would never subsidize a rheumatology group like they do for hospital medicine. If a hospitalist group peaces out, they will shut down half the hospital the next day. If a rheumatology group is gone, then it just means a few people in the community will have synovitis for another few months.

But don't sweat this stuff. It's still better to be in demand than to NOT be in demand. Once MACRA and/or whatever other monstrosity the CMS has in store for us rolls around, many of the proceduralists will be hurting. And when compensation equalizes, would you rather be the guy who is dime a dozen, or one who is in short supply? I live in a large midwest city and our rheumatology division has a wait time of 4-5 months. For cardiology, people can get in within 2-3 weeks.
 
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Yes as Raryn and bronx said above the problem is not with the field specifically but with the healthcare system generally.

People who do lots of CPT-billable procedures get paid. People who do boring thinky stuff like rheumatologists and endocrinologists get much less paid. This is why surgeons spend all day in the OR and leave the "easy stuff" like office visits and follow-ups to their midlevels. Of course anyone who receives baffling/terrible referrals from said midlevels knows how "easy" non-procedural clinical decision-making actually is...

But the bottom line is: doing pays, thinking doesn't.
 
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