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>> respect that is not extended towards, say, their accountant.
And that will help pay your loans and mortgage how?

I don’t think you understand social medicine. In the UK I am free to choose my PCP within the area I live, or go to someone else when I’m out of town. Social medicine is funded by the tax system and usually has budgetary constraints which actually causes other issues. And what do you think Medicare is?

So you think people are free to choose their provider – what do you base that on? Someone who is going to pay totally out of pocket has that choice. But, for those people with (and without) insurance they cannot simply choose who to see. If you're right then I wasted 20 minutes of my afternoon finding a psych consult for a 15 year old - took me that long to find a group who would take Cigna.

>>Who or what is "forcing us into a high volume triage system"?
That would be insurance companies, medicare, and the need to make a living. When you are seeing between 25 and 30 patients a day you simply don’t have time to deal with all of the issues. Therefore I will refer compliants to specialists that I would otherwise have dealth with myself if I had more time. Why do you think concierge medicine is gaining momentum?

>>the average person would preferentially seek care from a PA or CRNP >>instead of you
You’re not paying attention – the average person will not have a choice – unless they’re paying out of pocket.

>>As far as being a high volume triage system, that totally depends on what >>kind of doctor you want to be.
One that can pay my bills and eat.

>>I just don't see it.
Then you can’t see through the cloud of smoke from whatever you’re smoking.
 
KentW said:
Please confine the discussion to the topic, not the participants.
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Kent,

You know that on SDN no thread is complete until it has been reduced to ad hominem attacks.
Oh, and Kent? You're ugly and your mom dresses you funny. J/K 😉
 
racerx said:
Oh, and Kent? You're ugly and your mom dresses you funny. J/K 😉
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You-Are-Have_balls.jpg


Squirrel.jpg


😉
 
McDoctor said:
How about the perk of being a well respected and trusted member of the community? When I see patients outside of the workplace, I am greeted by them with a unique sense of respect that is not extended towards, say, their accountant or their car mechanic.
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Thats a very expensive perk.
 
McDoctor said:
How about the perk of being a well respected and trusted member of the community? When I see patients outside of the workplace, I am greeted by them with a unique sense of respect that is not extended towards, say, their accountant or their car mechanic.
Click to expand...

They don't greet their car mechanic they rather punch him because he reminds them of the $1000 cash for labor that he just charged them for work which only took half a day to complete, or they don't get their car back. They like you cuz they only paid a $10 copay. I suppose we could try to hold their medical records hostage for the rest of what you are rightly owed but will never see but that is probably some sorta Hippa violation. :laugh:
 
George85 said:
I don't think you understand social medicine. In the UK I am free to choose my PCP within the area I live, or go to someone else when I'm out of town.
Click to expand...

However, you're not free to choose covered care other than that which is provided by the government, nor is your doctor free to choose to accept payment from anyone other than the government. Socialized medicine is not freedom of choice...it's freedom from choice.

The U.S. system is not without its faults, and there's plenty that could be improved upon, but most people have the freedom to choose their employer, their insurance plan, and their PCP. And, unlike in socialized systems, doctors have the freedom to choose whether or not they wish to participate with any given third-party payer, including the government.

I'll take our current system over a pure single-payer system any day, warts and all.
 
George85 said:
>>
Someone who is going to pay totally out of pocket has that choice. But, for those people with (and without) insurance they cannot simply choose who to see. If you're right then I wasted 20 minutes of my afternoon finding a psych consult for a 15 year old - took me that long to find a group who would take Cigna.

>>the average person would preferentially seek care from a PA or CRNP >>instead of you
You're not paying attention – the average person will not have a choice – unless they're paying out of pocket.

.
Click to expand...

Last time I checked, there were plenty of choices for consumers in choosing a primary care doctor in most parts of the country. There is not one major insurer in the country whom restricts its customers to seeing a CRNP or PA instead of a physician for their primary care. If this statement is false, please post a link or source with evidence to the contrary.

I acknowledge that probably there are underserved regions where midlevels are filling a role in primary care due to a shortage of primary care doctors. But any doctor can move here, hang out a shingle, and attract loads of business away from these midlevels. The medical degree would virtually sell itself.

Specialists are a different ballpark. Patients often are followed by midlevels for their specialty care. I tell my patients who want referrals in my area to an endocrinologist for their diabetic care or to a GI specialist for their IBS, that they are essentially going to be followed by a midlevel. This is what I see happening. So I agree, that patients have no choice in this, because there are limited number of specialists in certain fields in certain areas. Your example with psych doesn't translate to primary care.

Look, I'm an optimistic third year FM resident. I enjoy what I do. I haven't had an occasion to become dissatisfied with my job or my life. Scoff at that all you like. But your exposition on midlevels replacing family doctors is fear-mongering wholly unsupported by the facts, plain and simple.

Sell your alarmist propaganda, paranoia, and discontent someplace else; we're all stocked up here.
 
KentW
>>not free to choose covered care other than that which is provided
>>by the government
Not so. Google BUPA and Nuffield hospitals in the UK. There is choice, except the alternative choice from socialised medicine means paying for it, something most people don’t want to do.

>>nor is your doctor free to choose to accept payment from anyone other >>than the government.
Yes they can. They can work in private hospital and clinics. They can even do that part-time while being employed within the National Health Service (NHS)

>>Socialized medicine is not freedom of choice...it's freedom from choice.
Not at all. What a social medicine system does is create a climate of expectation. Consequently, people don’t expect to pay. Managing peoples expectation can be one of the biggest hurdles in medicine. And we see it here all the time, from explaining that we can’t manage 5 complex complaints in a single 15 minute visit to the insanity of a system that will spend thousands on the last month of a 90 year old's life while denying millions access to health care.

I’m not saying that socialised medicine is the way to go, but it’s certainly no worse than the US system – both systems have their issues.

MyDoctor
>>There is not one major insurer in the country whom restricts its customers >>to seeing a CRNP or PA instead of a physician for their primary care.
No, and it probably won’t happen. Certainly not as long as primary care is as poorly paid as it is. The point you are missing is that people can now see a physician but the primary care physicians are being paid at mid-level provider rates. So, to the insurance companies we are already the mid-level providers. And so long as there are enough IMG’s to fill FM programs then everything will carry on as is. I havn’t seen this year’s match figures but I bet there are fewer US grads entering FM than ever before. And if insurance companies were forced to pay primary care docs a reasonable rate then they would find a way to introduce a 2 tier system to encourage patients to use PA’s ARNP’s.

>> But your exposition on midlevels replacing family doctors is fear-mongering >> wholly unsupported by the facts, plain and simple.
We have become the midlevels. And the facts are in your face. That’s what this thread is about – primary care salaries, or more specifically family medicine, because the other “primary care” specialities, such as ob/gyn and peds have far more scope and potential, such as fellowships, etc. And again, it’s not about the money per se, it’s about the attitude that the salary levels reflect.

>>Sell your alarmist propaganda, paranoia, and discontent someplace else.
I’m not discontent with my choice of FM. I made an informed decision for very specific reasons, a decision that I am still comfortable with. My situation is much different from the average American who will have large loans and work in the US the whole of their career. I am discontent with my residency training, as it is a reflection of where the US health system sees me as a primary care physician.

Paranoia is an excessive anxiety or fear concerning one's own well-being. I have no personal concerns. It’s just frustrating to see such a messed up health system in the world’s richest country, with so many people excluded from care. The system needs to be primary care driven. And, those people who enter primary care should be making an informed decision as the road ahead is a rocky one for primary care in the US.
 
George85,

In general, I would consider pediatrics to be a more troubled field in primary care in terms of low pay and an identitiy crisis. But, you're right, there are more fellowship opportunities in peds, but in doing these fellowships you are essentially leaving primary care. OB/Gyn is much higher paid, but the malpractice and the lifestyle are both horrid.

I feel your frustration with low reimbursement. I think the current climate presents some major obstacles for docs fresh out of residency to start their own practices right out of the gate. I think that some busy practices are more likely to bring in a midlevel to pick up the slack than hire a new doctor for financial considerations. I've seen this happen in my own job search.

In the end, however, I just don't see myself at a competetive disadvantage against midlevels. Primary care is mainly an academic and cognitive endeavor. CRNP's and PA's just don't stack up with their limited training and inferior education relative to mine as a physician. The level of care will never be equivalent. Patients and major insurers will figure this out, if they haven't already.

The main problem, as I see it, is large practices, motivated purely by profit, which hire midlevels and allow them to function as independent providers. Sooner or later, like all forms of insurance abuse and medicare abuse, I think legislation will crack down on this practice.

I also think we will see a bump in reimbursement when healthcare reform takes place after the 2008 election, regardless of how it manifests. Historically, major reforms in healthcare policy (i.e. formation of medicare, formation of medicaid, employer sponsored insurance, etc...) have provided bumps in physician income, albeit some more short-lived than others, by widening the public's access to healthcare. This is just an opinion, and I'm not really interested in debating it since healthcare reform is already debated ad nauseum on these forums.

As far as the current state of Family Medicine goes, I think we'll have to agree to disagree. I share some of your frustrations but am more optimistic about the future.
 
McDoctor said:
George85,

I also think we will see a bump in reimbursement when healthcare reform takes place after the 2008 election, regardless of how it manifests.
Click to expand...

Oh No!!!!! Not Hillary-Care. Whether (R) or (D) --They're politicians first which means they all lie.
 
KentW said:
Want a glimpse of socialized primary care? Take a look at the debate on GP incomes in Britain.
Click to expand...

I'll quote the article...

Family doctors saw average earnings increase to around £100,000 after the introduction of a contract that linked payments to the services they provide, such as cholesterol checks and flu jabs.
Click to expand...

100000 british pounds are like $199179.81 So GP are BETTER paid in the UK.

So it aint bad for gps.
 
KentW said:
Only recently. And now, some people think they're making too much money. Ironic, isn't it?
Click to expand...

I am surprised there is so much demand to go to the US still despite the insane salary and great lifestyle of GPs in the UK. Apparently the word has not gone around the world enough times.
 
KentW
The article and topic you refer to has more to do with salaries than with socialized primary care. And the UK has socialised medicine, not just primary care. One of the reason GP’s were able to negotiate such a jump in pay is because it is a primary care driven system. There is a move to expand GP’s scope of practice to relieve the pressure on hospitals, which translates to GP’s being more valued and having more options.

In the UK the difference between GP’s and specialists salaries is minimal. Consequently, people make their post-grad choices based on what really interests them as money is not a major factor – no big loans to pay off either. GP’s work can be much more varied and interesting than here. The result of these factors is that competion is high for GP training places. Imagine that – having to go into anesthesia or derm because you couldn’t get a Fam Med spot.

Faebinder
>>I am surprised there is so much demand to go to the US
That’s because it’s so much easier to get into the US. Many of the offshore schools recognised by the ECFMG are not recognised by EU countries. Also, there has been a recent shift towards favouring other EU countries over traditional ties. For example, the UK recently changed immigration laws which now makes it difficult for Indian physicians to work or train in the UK. Guess where they’re headed now. Which is just as well, as there are plenty of Fam med spots that need filling – each one comes with it’s own complementary J1-visa.

>>Apparently the word has not gone around the world enough times.
That’s because most Americans think that America is the world.
 
I think I want to move to the UK.
 
iatrosB said:
I think I want to move to the UK.
Click to expand...

Just bring your galoshes and stay away from anything resembling a "meat pie"...

Oh, and for Kent:

Wow, those salaries sure are crazy-high over there. Too bad we don't have higher salaries in the US for physicians. Sometimes I wonder if I'd make a higher salary if I was a CRNA!!

😉
 
Faebinder said:
I'll quote the article...

100000 british pounds are like $199179.81 So GP are BETTER paid in the UK.

So it aint bad for gps.
Click to expand...

Yes, but cost of living is probably proportionately higher. I remember groceries being quite a bit more expensive there, and London now has the highest rents of any city in the world.
 
sophiejane said:
Yes, but cost of living is probably proportionately higher. I remember groceries being quite a bit more expensive there, and London now has the highest rents of any city in the world.
Click to expand...

But our taxes are higher not to mention we do have our share of insane living expenses like NY, NJ and CA.
 
And you don't have to live in london.

British countryside is amazing.

But you better like stout beer and FOOTBALL. ( I did not use the S word).
 
Faebinder said:
But our taxes are higher not to mention we do have our share of insane living expenses like NY, NJ and CA.
Click to expand...

Are they really higher? This site says for 100K British pounds salary, you'd pay 35k in taxes:

http://www.listentotaxman.com/index...axcode=&period=1&ingr=100000&Submit=Calculate

(Note the hefty sum for national insurance. Socialized medicine is not free, my friends).

Seems pretty similar to ours, but then, I haven't actually earned money or paid taxes in 4 years, so I could be a little fuzzy on that! 😉
 
ajce9 said:
And you don't have to live in london.

British countryside is amazing.

But you better like stout beer and FOOTBALL. ( I did not use the S word).
Click to expand...

British country side, beer, football...where do I sign up?!👍
 
sophiejane said:
Are they really higher? This site says for 100K British pounds salary, you'd pay 35k in taxes:

http://www.listentotaxman.com/index...axcode=&period=1&ingr=100000&Submit=Calculate

(Note the hefty sum for national insurance. Socialized medicine is not free, my friends).

Seems pretty similar to ours, but then, I haven't actually earned money or paid taxes in 4 years, so I could be a little fuzzy on that! 😉
Click to expand...

You're not seeing the true tax percentage cause you are married and I presume file jointly (which drops it like 5% or something depending on where you are in the total income bracket). The regular single folks are pretty much at about 30%-35% tax.

Nope socialized medicine is not free but it's funny to say, primary care in the US would hardly be affected if tomorrow Hillary or any other democrate decided its time to make the healthcare system universal. The specialists wont be happy.
 
See its all good.

A little "football", a littel "beer', and a little "socialized primary care medicine" with a view of the British country side.

AND, instead of just T time, you also get "tea time". 🙂 Bloody good ain it.
 
Taxes are about the same, possibly a little lighter here, although property tax here is totally outrageous - UK property tax is generally 15-20% of US levels. Sales tax is called VAT and is 17.5% across the board. And of course gas is expensive, but when comparing don't forget that a US gallon is 3.8 liters, a UK gallon is 4.5 liters - who said everything was bigger in America?

Winter's are tough. Gets dark at 3.30 in December. And you know it's summer when the rain warms up.

Not related to salaries, but amusing http://news.bbc.co.uk/2/hi/health/3159813.stm
PFO is Pissed (as in drunk), fell over.

Back on the topic if salaries. I was always under the impression that procedures were where the money is. If that's the case why does (non-interventional) diagnostic radiology do so well? All they do is sit behind a screen, so how/why the high salaries? Any ideas?
 
thats because there are less rad docs and rad res spots to go around, so by supply/demand, in the capitalistic society, the few gets paid more. I wonder if FP spots are reduced by half the amount it'll drive our salaries higher ;-)
 
George85 said:
Back on the topic if salaries. I was always under the impression that procedures were where the money is. If that's the case why does (non-interventional) diagnostic radiology do so well? All they do is sit behind a screen, so how/why the high salaries? Any ideas?
Click to expand...

Radiologist incomes are primarily tied to reimbursement for the professional component of radiology services. The technical component goes to the facility, although radiologists can also benefit from that if they have an ownership stake in the facility. These have traditionally been well-paid...however, rads reimbursement under Medicare took a big hit this year.
 
George85 said:
Taxes are about the same, possibly a little lighter here, although property tax here is totally outrageous - UK property tax is generally 15-20% of US levels. Sales tax is called VAT and is 17.5% across the board. And of course gas is expensive, but when comparing don't forget that a US gallon is 3.8 liters, a UK gallon is 4.5 liters - who said everything was bigger in America?

Winter's are tough. Gets dark at 3.30 in December. And you know it's summer when the rain warms up.

Not related to salaries, but amusing http://news.bbc.co.uk/2/hi/health/3159813.stm
PFO is Pissed (as in drunk), fell over.

Back on the topic if salaries. I was always under the impression that procedures were where the money is. If that's the case why does (non-interventional) diagnostic radiology do so well? All they do is sit behind a screen, so how/why the high salaries? Any ideas?
Click to expand...


They get 30 to 60 dollars for every study they read. some do it in their PJs on the ranch doing telemedicine.

but we all know that using your brain doesnt always pay well. Lets look at some examples.

Ortho, (should I go into plumming or carpentry , hmmmm, 😉 )

Anesthesia 🙂sleep: no need to say more)

GI ( this brings us right back to plumming)

Derm ( we know who really makes the diagnosis, his name is MR. Pathologist 😉 )

Radiology (If I have to see another patient again I will quit medicine, wait I can go underground) The dark side of medicine. :idea:


Fell free to add to the list. No one is exempt. 😍
 
Back to salary, I'm finishing up my residency so I don't know the real world yet. But I guess how much money you make is based on your scope of practice.

There are a lot of private community FPs at our hospital who is making >$250K per year. Their offices are near by and they have low threshold of admitting people into the hospital (they follow their own patients). Some of them also have contracts with the government so they will admit prisoners into the hospital where the reimbursement is pretty much 100%. At the same time, they do some cosmetic procedures and acupuncture (even cosmetic acupunture). They also have a panel of nursing home patients who they see once per month.

So I guess it's really up to you in terms of how hard you want to work or how smart you want to work...
 
Doctor Grim said:
Back to salary, I'm finishing up my residency so I don't know the real world yet. But I guess how much money you make is based on your scope of practice.

There are a lot of private community FPs at our hospital who is making >$250K per year. Their offices are near by and they have low threshold of admitting people into the hospital (they follow their own patients). Some of them also have contracts with the government so they will admit prisoners into the hospital where the reimbursement is pretty much 100%. At the same time, they do some cosmetic procedures and acupuncture (even cosmetic acupunture). They also have a panel of nursing home patients who they see once per month.

So I guess it's really up to you in terms of how hard you want to work or how smart you want to work...
Click to expand...

It all depends on how busy you want to be and the area you are in. If you want to live in a big city and work in that big city you may not get 250 per year. In fact that most likely won't happen. But lets say you live in that big city of 1/2 hour outside that city and work one hour outside that city. Now, you may get much more than if you worked in the big city. You kinda of the best of both worlds.

But if you insisit on living in a big city work there you most likely will make around 150 to 170 and your cost of living will be inflated so that 150 might look more like 120.

Hope that helps.
 
That is an interesting article.

In order to see more patients there has to be more patients to see. So if someone is in a big city where the competition is high there may not be an opportunity to see more patients.

If you are solo, hospital medicine can really take a toll. The call could be harsh.

So, it makes sense to move out to the suburbs or even a little further out in order to increase your value and see more patients. Also, overhead is less the further out you go. This is mostly true for Lease rates or if you choose to purchase a building the purchase price.

I have always thought that it is more than possible to make at least 200 K in FM. It all depends on volume and organization in your office. But the patients have to be there.

There was a point made in the article about contract negotiation. I think that is the hardest part. First, what do you negotiate and how much can you push the envelope and second if you have not done it before who can help you with it.
 
ajce9 said:
There was a point made in the article about contract negotiation. I think that is the hardest part. First, what do you negotiate and how much can you push the envelope and second if you have not done it before who can help you with it.
Click to expand...

At present, solo physicians and small practices have little leverage with insurers, unless they bring something unique to the table. Larger groups definitely have an advantage when it comes to negotiating favorable fee schedules with payers. In the future, the ability to generate outcomes data using EMR and (if it's done right) pay-for-performance may help level the playing field. We'll see.
 
KentW said:
At present, solo physicians and small practices have little leverage with insurers, unless they bring something unique to the table. Larger groups definitely have an advantage when it comes to negotiating favorable fee schedules with payers. In the future, the ability to generate outcomes data using EMR and (if it's done right) pay-for-performance may help level the playing field. We'll see.
Click to expand...


Yeah, I agree.

Also, the more I hear and read about pay for performance, the less I like it.

1. There are way too many variables and very difficult to get accurate data.
2. The people who are collecting the data can skew the statistics in their favor and there is no reason to think that they would not.
3. Physicians can't control what their patients do. If they happen to have a bunch of patients that don't comply or can't afford meds or any other reason that leads to them not getting good outcomes, it becomes the physicians fault. Medicine in not auto mechanics. Even half the studies we do end up being wrong or partly wrong after more studies and several years later.
Some simple examples include vioxx and hormone replacement.

As physicians we want to move towards evidence based medicine and pay for perforamance is part of that movement. However, we can't forget that a huge part of medicine is not evidence based. Its ART. Just ask how many physicians perscribe meds off label. So, until we can quantify ART, which I don't think that will happen, then we will not be able to accurately quantify performance in medicine.
 
The article that KentW references makes for depressing reading.

When I referred to radiology salaries thedman888 stated "thats because there are less rad docs and rad res spots to go around, so by supply/demand, in the capitalistic society, the few gets paid more."

In other words, there is a shortage of radiologists. By the same reasoning, there is not a shortage of FP docs - although, we keep hearing that there is.

122 pt's a week means long hours. It's not just the "seeing", it's all the associated paperwork that goes with it. For every 10 pt's I see I probably have 3 or 4 that need extra work, such as follow up phone call, speaking to another doc, etc. All this takes time and is unpaid. The amount of refill requests and other requests in my inbox on a daily basis is huge.

Again, contrast this to radiology or anesthesia, where their paperwork overhead is much lower - it means they get paid for what they do.

Also, seeing a 122 pt's a week is not practicing quality medicine. Concierge medicine is the way to go. That way, pt's get the time they need, and primary care docs made a good living without the system screwing them.
 
George85 said:
The article that KentW references makes for depressing reading.
Click to expand...

I dunno...the little box at the end pretty much describes my practice (except for the part about doing hospital and working longer hours.) 😉
 
what does it really matter anyways? start your own business and then you make more money. we will never make anywhere near as much doing whatever we do if we are working for some random boss person. work for yourself.

cant believe i actually started this thread...
 
KentW said:
For those of you who haven't seen it before, this is an excellent article.

What Makes a High-Earning Family Physician?
Click to expand...

Also very interesting that seeing more Medicare patients is a feature of high-earners (though this apparently varies by state).

Goes back to a previous thread where someone who will remain unnamed declared in effect that only bleeding heart Mother Theresa types take Medicare anymore...

Sign me up for that.

Love,

Your Friendly Neighborhood Tree-Hugging Bleeding Heart 🙂
 
sophiejane said:
Also very interesting that seeing more Medicare patients is a feature of high-earners (though this apparently varies by state).

Goes back to a previous thread where someone who will remain unnamed declared in effect that only bleeding heart Mother Theresa types take Medicare anymore...

Sign me up for that.

Love,

Your Friendly Neighborhood Tree-Hugging Bleeding Heart 🙂
Click to expand...

how about walmart customers?


WALMART CLINICS
 
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