"Safest" fields (financially)

[H_Caulfield]

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Any slightly cynical pre-med seems quick to note that providers' near-monopoly over the payment of physicians for their services, in conjunction with the general humanitarian consensus that capitalism and free-trade are exempt from scenarios where human lives ("souls") are on the line, is going to ultimately result in the attitude that, regardless of ability to pay, any living person has a right to the knowledge/ability that every physician has so rigorously accrued. (I don't necessarily believe this, but I'm trying to paint as vivid a picture as have a few people I've spoken to recently.)

I myself have already chosen cardiology, and I'm much less interested in the pay than in the well-being of my soon-to-be patients. It's just fascinating to see the discrepancy in attitute: med students think they're on their way to the soup kitchen, and the rest of the world is talking about the great demand and job prospects for doctors, given the aging population and so on and so on.

Sorry to use you all to help in settling a dispute between myself and a couple of friends, and I know that there are plenty of threads here concerning whether the above-mentioned is actually happening, but...what fields do you think would be least affected by this?

Would it be Dermatology? I don't think that insurance companies are paying for (and restricting payment for) a whole lot of face lifts.

Surgery? Those unwilling to pay doctors could get anesthesia from nurse anes's? (not sure about the extent to which this is true). Chiropractors for aching backs instead of orthos, PAs instead of FP MDs, and so on. But SURGEONS? Who can replace them?

What do you guys think?

 

[frostynorthwind]

My guess would be that elective procedures that managed care organizations typically don't pay for now, yet remain attractive to those who can afford them, will continue to be highly lucrative. Many of these procedures fall in the realm of dermatology and non-reconstructive plastic surgery. Doctors who perform these non-essential, "elective" procedures often require out-of-pocket payment at the time of treatment by the patient. Consequently, these doctors rarely deal with managed care and the growing financial constraints MC organizations might impose to try to cut costs and increase their own profit. The icing on the cake comes in the relative immunity to malpractice suits compared to other specialties. Many plastic surgeons require a patient waiver of his/her right to pursue indemnity claims after an elective procedure. This isn't to say that dermatologists and plastic surgeons don't perform essential medical procedures nor am I implying they aren't needed. However, I would doubt the majority of dermatologists or plastic surgeons would take many medicare/medicaid patients unless they were feeling particularly generous at the time. Why would they need to? It certainly makes one wonder why more people don't pursue these specialties... wait a minute...

 

[MissMuffet]

My guess would be that elective procedures that managed care organizations typically don't pay for now, yet remain attractive to those who can afford them, will continue to be highly lucrative.

But aren't they also the least recession-proof?

 

[cdql]

But aren't they also the least recession-proof?

That's what I was thinking as well. But there will always be those with money trying to "better" themselves. I've even heard of insane cases where the patient was poor but actually went out and borrowed money to pay for cosmetic procedures.

Also, cosmetic procedures aren't the only things done by dermatologists and plastic surgeons. If those cases drop off, they can always be replaced with other patients. (e.g. skin cancers, psoriasis, reconstructive surgery, etc...)

 

[cdql]

I also think it depends on the quality that the physician provides.

For instance, the casual onlooker could say that psychiatrists could be easily replaced. All they do is talk!

But there are probably patients out there who would prefer to pay more money to speak with a great psychiatrist as opposed to paying minimal money for just some run of the mill psychiatrist.

Or another example is an eye doctor. There must be plenty of doctors who perform LASIK surgery now. But I know if I were getting it done, I would rather pay for the surgery out of my own pocket if I knew I was getting it done by a very proficient doctor as opposed to letting the insurance company pick the cheapest ophthalmologist for me.

I think as long as you are good/great/the best! at what you do, there should always be a spot for you out there!

 

[Law2Doc]

I also think it depends on the quality that the physician provides.

For instance, the casual onlooker could say that psychiatrists could be easily replaced. All they do is talk!

But there are probably patients out there who would prefer to pay more money to speak with a great psychiatrist as opposed to paying minimal money for just some run of the mill psychiatrist.

Or another example is an eye doctor. There must be plenty of doctors who perform LASIK surgery now. But I know if I were getting it done, I would rather pay for the surgery out of my own pocket if I knew I was getting it done by a very proficient doctor as opposed to letting the insurance company pick the cheapest ophthalmologist for me.

I think as long as you are good/great/the best! at what you do, there should always be a spot for you out there!

Psychiatrist and ophthalmologist are probably bad examples of recession proof medicine because these are two fields in which non-MD/DO professionals also exist, and although the scope of their work, education and abilities is not the same, they most importantly charge less. So during hard times patients without the more serious issues that could only be handled by physicians are likely to make do with psychologists and optometrists, respectively. In horrible economic times, folks don't go to the best -- they go to the best they can afford, I'm afraid.

 

[cdql]

Even for something as delicate as eye surgery? (Although that's probably a bad example seeing as LASIK is an elective procedure)

 

[aamartin81]

Another issue for you to consider: the increasing prevalence of Health Savings Accounts. Where many of the plans present today subject any work done in an office to a copay only (with the deductible being applied to surgery/outpatient procedures), the HSA accounts are only used in conjunction with high deductible plans which are applied to all service, regardless of place of service (some have routine coverage limits prior to meeting deductibles).

How does this affect you? Where you would typicaly only collect copays and coinsurance amounts in the past, you are now responsible for collecting full payments of deductibles (think of trying to collect $25 vs $485). Instead of being in the business of helping patients, you have found yourself in the collection industry. This is an ingenious plan by insurance companies. It transfers the responsibility of collection to the provider while also cutting back the likelyhood that payments will be made on the policy. A typical family HSA has a deductible of $1500-$3000/year. How many families utilize that amount of service in the absence of an emergency?

Food for thought.

 

[deleted87716]

Instead of being in the business of helping patients, you have found yourself in the collection industry.

Just require patients to keep a credit card number on file. Hotels do it. 😉

 

[aamartin81]

The problem with this idea is assuming that people have the money to pay in the first place. According to your model, you would have to know exactly how much time the physician will see the patient (determine the proper visit CPT code), then know any additional tests that will be done (X-rays, Ultrasounds, Mamm, Lab, etc..) to determine the allowable amounts as negotiated under 1 of possibly 50 or more insurance plans your office accepts/participates with. Then, you must obtain the credit card for pre-authorization. Meanwhile, the uninformed patient who has insurance coverage under an employer who just changed policies is only expecting to pay their $10-$40 Copay. Do you turn them away (=no revenue), or set up a plan to take whatever they can pay today and collect additional payments in the future?

As a side note, medical bills are the second leading cause of bankruptcy in the US (slight second to divorce).

 

[deleted87716]

Tmedical bills are the second leading cause of bankruptcy in the US (slight second to divorce).

I doubt anyone's going bankrupt from primary care office visits. 😉

And people really do need to understand how their insurance works. When they don't, my office manager does her best to explain it to them. Many of them are surprised to learn that it doesn't work like they thought it did.

Here's how the credit card thing works. The credit card number is kept in a secure file (not in the patient's chart). Any co-payments and known non-covered charges are collected at the time of service, and the rest of the bill is submitted to the patient's insurance company. When the EOB comes back, any remaining portion that is not covered by the insurance company is then charged to the patient's credit card, and they're sent a copy of their statement along with the credit card receipt. Simple.

And yes, this assumes the patient has a credit card in the first place.

 

[aamartin81]

You can doubt whatever you like, the facts are there (not every MD wants to go into primary care). As for retaining a credit card on file, what happens when it is canceled (collections)? How do you deal with a denied credit card (collections)? How do you go about pre-screening potential patients based on the availability and/or willingness to submit such information along with obtaining accurate information regarding credit limits (this information is available only to those listed as account holders)? In theory, the idea could be applied to a patient base of moderately to highly affluent indviduals/families. But the fact of the matter is that this is not always representative of your patient population (especially in primary care).

 

[deleted87716]

But the fact of the matter is that this is not always representative of your patient population.

I hope you're not presuming to know more about my patient population than I do. 🙄

As for your "what if" scenarios, you simply mail the patient an invoice for their remaining balance. Nonpaying patients are dealt with on a case-by-case basis.

 

[aamartin81]

Nonpaying patients are dealt with on a case-by-case basis.

You have illustrated my point perfectly.

Imagine how many more of the "case-by-case" scenarios will occur when deductibles change from $250-500 being applied only to surgery/outpatient services to $1000-4000 being applied to all services. This "case-by-case" situation is called collections.

 

[deleted87716]

You have illustrated my point perfectly.

Glad to help. I only wish I could say I knew what your point was. 😉

 

[Ypo.]

I doubt anyone's going bankrupt from primary care office visits. 😉

People w/o insurance don't usually go to primary care offices to begin with. They wait until they have an emergency and then they go to the ER.

But if they DID go to a primary care office, I think we can assume that between prescriptions and office visits, it could easily bankrupt a low-income patient.

 

[akpete]

People w/o insurance don't usually go to primary care offices to begin with. They wait until they have an emergency and then they go to the ER.

But if they DID go to a primary care office, I think we can assume that between prescriptions and office visits, it could easily bankrupt a low-income patient.

Absolutely. I made the mistake of going to my pre-med school physical on my old insurance and not waiting for the one the school requires to start. My standard physical with a few labs was over $800. I had insurance with a $2500 deductible because it was the best insurance I could afford. No wonder people don't show up at the doctor until something gets really bad. I didn't even have anything wrong with me!

 

[Titans81]

Glad to help. I only wish I could say I knew what your point was. 😉

As I stated in the first post, potential doctors should consider that as insurance companies shift the structure of plans (increased deductibles through Health Savings Accounts), an increasingly significant amount of time will be spent on collections versus seeing patients. This will affect your profitability/ability to treat patients. With each new piece of legislation, medical practices become more of a business, be ready for it (that's it).

To the second poster, uninsured patients (in a private practice setting - can't speak for emergency rooms/hospitals with which I have no experience) are actually easier to address than application of deductibles, as they are aware that all service costs are born directly by them alone.

 

[Ypo.]

To the second poster, uninsured patients (in a private practice setting - can't speak for emergency rooms/hospitals with which I have no experience) are actually easier to address than application of deductibles, as they are aware that all service costs are born directly by them alone.

I'm more concerned about how the uninsured will get their health taken care of, actually. I plan on working at a sliding-fee clinic.

 

[deleted87716]

People w/o insurance

The discussion underway wasn't about people without insurance. It was about people with high-deductible insurance plans. I agree with you, however.

 

[deleted87716]

With each new piece of legislation, medical practices become more of a business, be ready for it (that's it).

We're ready for it, don't worry. 😉 You do know that I'm in private practice, right (it's in my profile)? I deal with this stuff daily.

 

[SuperTrooper]

We're ready for it, don't worry. 😉 You do know that I'm in private practice, right (it's in my profile)? I deal with this stuff daily.

KentW, I love your avatar!! 😍 😍

My parents have a blue dog print hanging up in their kitchen. Cost them a bunch of $$$ tho.

 

[deleted87716]

KentW, I love your avatar!!

Thanks! 🙂 I visited George Rodrigue's gallery in New Orleans a couple of years ago...great stuff, very expressive. Thought about buying something, but if you think his prints are expensive, you should see the prices of his originals!

 

[deleted87716]

My standard physical with a few labs was over $800.

Wow...what all did they do? I've had a couple of patients get stuck paying 100% of a CPE when their insurance didn't cover it (read the fine print in your insurance contracts, people!), but the bills "only" came to about half that. Most of it was from the lab, not my office.

 

[akpete]

Wow...what all did they do? I've had a couple of patients get stuck paying 100% of a CPE when their insurance didn't cover it (read the fine print in your insurance contracts, people!), but the bills "only" came to about half that. Most of it was from the lab, not my office.

Well, the insurance co. is supposed to pay $125 per year for preventive medicine. And so far, the clinic has only billed me for ~$355. However, I just received a statement, not a bill, from the insurance co. showing the remainder of the charges that of course they're not paying for. So I'm really expecting another bill from the clinic any day now to pay the rest. This appointment was way back in July.

Dr fee = $142
Labs = $680 including BUN, creatinine, potassium, CBC and other standard blood stuff, TSH, and then titers to prove I had vaccinations against things for the med school and TB test.

 

[deleted87716]

titers to prove I had vaccinations against things for the med school

Oh, titers...yeah, those are expensive. Bummer. 🙁

 

[azzarah]

Psych...one can pretty much work until one dies or becomes demented. No lawsuites & constant supply of patients plus it's so intellectually fascinating!

 

[cdql]

Does insurance cover psych visits? Or does the patient pay out of pocket?

 

[jjmack]

most psychiatrist just have patients pay usuallay. Getting insurance to pay is a big hassle.

 

[deleted87716]

most psychiatrist just have patients pay usuallay. Getting insurance to pay is a big hassle.

Of course, not being able to pay is one of the biggest reasons patients give for not following up with their psychiatrists.