Who's right about the future of FM?

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zambo

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I would like to hear your thoughts about what the future likely holds for FM. Some say the situation will worsen, while others say the pendelum will swing the other way and the future will be bright. So who's right and why are they right?
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zambo said:
I would like to hear your thoughts about what the future likely holds for FM. Some say the situation will worsen, while others say the pendelum will swing the other way and the future will be bright. So who's right and why are they right?
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That's the million dollar question. Unfortunately, there is no answer.
 
Well, since the latest change in the reimbursement scheme (E&M) increased the pay for the average FP doc by about 5% and decreased such specialties as radiology and anesthesiology by 6-7%, I would say that the pendulum is swinging, baby!
 
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Tn Family MD said:
Well, since the latest change in the reimbursement scheme (E&M) increased the pay for the average FP doc by about 5% and decreased such specialties as radiology and anesthesiology by 6-7%, I would say that the pendulum is swinging, baby!
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The forthcoming CMS E&M updates, if implemented, could increase reimbursement to primary care physicians an average of 12-15%. That's real money, folks...and it's going to come from someplace.
 
Ah....I love hearing stuff like this....

And just once before I die I'd like to see discussion threads like this on SDN:

"Am I competitive enough for Family Medicine?"

"People who go into FM JUST for the MONEY!!"

"I really want FM, but I'm afraid I might have to scramble into Rads or Gas"

:)
 
Well, shoot...look at family medicine objectively.

1) Relatively short residency
2) Relatively low malpractice incidence and insurance costs
3) Virtually limitless job opportunities
4) Broad scope of practice that you can tailor to what you enjoy doing
5) Wide variety of pathology (undifferentiated patients)
6) Regular hours (no nights and weekends unless you want to do them)
7) As much vacation as you can afford to take
8) Easy to work part-time, if that's what you want to do
9) Ability to perform cosmetic procedures, if you want to
10) Readily transferrable skills to other fields (urgent care, public health, hospitalist, etc.)

I could go on. IMO, FM is the ultimate "lifestyle specialty" already. It's amazing to me that more people don't realize it. ;)
 
KentW said:
Well, shoot...look at family medicine objectively.

1) Relatively short residency
2) Relatively low malpractice incidence and insurance costs
3) Virtually limitless job opportunities
4) Broad scope of practice that you can tailor to what you enjoy doing
5) Wide variety of pathology (undifferentiated patients)
6) Regular hours (no nights and weekends unless you want to do them)
7) As much vacation as you can afford to take
8) Easy to work part-time, if that's what you want to do
9) Ability to perform cosmetic procedures, if you want to
10) Readily transferrable skills to other fields (urgent care, public health, hospitalist, etc.)

I could go on. IMO, FM is the ultimate "lifestyle specialty" already. It's amazing to me that more people don't realize it. ;)
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I agree here. The biggest news currently are two awesome trends for FP:
1)FP is in GREATEST demand, more than ortho, more than cards. This translates into real dollars-big sign-on bonuses and higher salary guarantees.
2)Looks like CMS will be INCREASING the RVU component for E&M's. Salaries will rise SIGNIFICANTLY.

The latest MGMA salary survey pegs avg FP income at $169k. What other profession can you go ANYWHERE the heck you want and make $169k. Sure, some of our MD brethens make more, but that is equalizing quickly.

Lastly, most urgent care centers, medical director jobs, administrative roles SEEK or will ONLY accept FP docs. Why? We understand adult care, pediatrics, GYN, OB. NO OTHER field can say this. Like Kent I really do not understand why students buy into the $100k FP that works 80hrs/wk. I assure you our lifestyle is MUCH easier than 75% of specialists.
 
KentW said:
Well, shoot...look at family medicine objectively.

1) Relatively short residency
2) Relatively low malpractice incidence and insurance costs
3) Virtually limitless job opportunities
4) Broad scope of practice that you can tailor to what you enjoy doing
5) Wide variety of pathology (undifferentiated patients)
6) Regular hours (no nights and weekends unless you want to do them)
7) As much vacation as you can afford to take
8) Easy to work part-time, if that's what you want to do
9) Ability to perform cosmetic procedures, if you want to
10) Readily transferrable skills to other fields (urgent care, public health, hospitalist, etc.)

I could go on. IMO, FM is the ultimate "lifestyle specialty" already. It's amazing to me that more people don't realize it. ;)
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:)

This is just exactly what I needed to see the night before my Step 2...seriously...I'm already calmer! At this point, I just need to pass the sucker and there's no way I won't get into a great program and on to a great career...

Maybe that's why I like hanging with the FP crowd. Nobody gets their panties in a wad about too much of anything--at least as far as residency goes.

Nice to hear about the part-time thing too--I suspected that but wasn't sure how many people pull it off.
 
Three weeks into FP residency. This thread is cheering me up significantly. :)
 
If you believe the fundamentals, buy low, sell high. The best time to get into something is when it is on its knees and absolutely unpopular, especially when you believe in something and not the hype. By the time things recover, you'll be perfectly positioned.

My answer to the OP: Everyone is right. If you believe, you will gravitate towards the specialty. If you don't, you should stay away if you have a choice. Once everyone in the specialty is a believer, we can move and control our very own fate.

(Well, fingers crossed anyways. That's what I was hoping when I made my decision a couple of years ago...)

... but for the time being, I'm ok with thinning the herd. Sometimes things just have to get to a crisis point...
 
KentW said:
The forthcoming CMS E&M updates, if implemented, could increase reimbursement to primary care physicians an average of 15-17%. That's real money, folks...and it's going to come from someplace.
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What's the ETA for this?
 
Wow, Kent, I didn't think it was by that much. I can't recall where the article was that I read, but it said about 5% increase for PC Specialties and 6-7% decrease for rads and anesthesia specifically and less of a decrease for other things such as cards, ortho and other specialties.
 
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Tn Family MD said:
Wow, Kent, I didn't think it was by that much. I can't recall where the article was that I read, but it said about 5% increase for PC Specialties and 6-7% decrease for rads and anesthesia specifically and less of a decrease for other things such as cards, ortho and other specialties.
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The 12-15%* estimate is extrapolated based on typical family medicine coding, where the majority of visits are 99213/99214. I don't have a link for that figure, as it was part of a presentation at a conference I went to recently.

There's little doubt that the money is going to come from procedures, as they're also revising the way they're paying for procedural work.

Don't forget that since most commercial insurance plans peg their fees to Medicare, there will be a ripple effect outside of Medicare, as well. :thumbup:

Here's something I found online:
Medicare law requires CMS to assess the accuracy of the relative values it assigns to physician services every five years. CMS last changed the work RVUs assigned to the E/M services in 1997. In a proposed rule, to be published in the Federal Register on June 29, 2006, CMS proposes increases be implemented January 1, 2007.

The increases in work RVUs proposed by CMS, based on the Relative-value scale Update Committee's (RUC) recommendations, would include increases for some of the E&M codes most commonly billed:

* The work RVU for a mid-level established patient office visit, 99213,
would increase by 37%.
* The work RVU for the highest-level initial hospital visit, 99223,
would increase by 26%.
* The work RVU for the mid-level subsequent hospital visit, 99233,
would increase by 31%.

By law, CMS must offset the total increases in work RVUs from the five year review with a separate adjustment so that 2007 expenditures are roughly equal to their 2006 level. Even after the budget neutrality adjustment is applied, 2007 Medicare payments for many E/M services would increase significantly, assuming continuation of the current 2006 conversion factor. For example:

* For CPT code 99213 the 2006 fee is $52.68, the 2007 fee would be $59.42.
This is a 12.8% change.
* For CPT code 99223 the 2006 fee is $157.29, the 2007 fee would be $173.27.
This is a 10.2% change.
* For CPT codes 99233 the 2206 fee is $79.21, the 2007 fee would be $90.95.
This is a 14.8% change.
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Here is another document that includes a summary of the effects of the proposed changes on each medical specialty (it's a PDF file...look at the table at the very bottom of the document): http://www.hospitalmedicine.org/AM/...mplate=/CM/ContentDisplay.cfm&ContentID=10204

When the changes are fully implemented in 2010, the biggest losers will be Clinical Psychology (-15%), Clinical Social Work (-14%), Chiropractic (-11%), Anesthesiology (-10%), Nurse Anesthesia (-10%), Interventional Radiology (-8%), Nuclear Medicine (-7%), Pathology (-7%), and Ophthalmology (-6%).

I'm not sure why the mental health fields took such a hit. Even Psychiatry, an almost purely cognitive specialty, is -1%. That doesn't seem right, given the already abysmal state of mental health services in this country.

Family medicine isn't the only cognitive field that gets a positive bump. Several internal medicine specialties receive comparable increases. In particular, Infectious Disease is listed as +10%, and Dermatology is +7%. Interestingly, reimbursements to Independent Laboratories also increase by 19%, which should help physicians who have invested in diagnostic labs.

* I just checked my notes, and it's 12-15%, not 15-17% as I typed earlier. My bad.
 
raptor5 said:
Dermatology +7%. As if they need it.
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I'm not sure what's up with that. Derm had, far and away, the largest bump (+12%) in the 10-year PE (Practice Expense) RVU Changes column, bested only by Independent Laboratories (+21%). No other specialty even came close. Family Medicine only got a 1% bump in this area. It's hard to believe that Derm's current PE RVUs are that undervalued compared to everyone else's.
 
Here's another article on the subject: http://www.familypracticenews.com/article/PIIS030070730673482X/fulltext

It gives one possible explanation why there may be some disparities in the current numbers:

some specialties are complaining about the way practice expense changes were calculated. The agency put out a notice asking various specialties to submit their own data for consideration by CMS. One member of the Practicing Physicians Advisory Council, which advises the CMS on issues affecting physicians, took the agency to task at the council's May meeting for allowing only some specialties to submit new data.

“I am more than a little frustrated that there [already] was a data set which admittedly was old, but it was collected from all specialties at the same time,” said Dr. Tye Ouzounian, an orthopedic surgeon from Tarzana, Calif. “Now some specialties have selectively submitted new data, which is 10 years newer, which is probably going to be more extensive. Those societies are being allowed to use new data, whereas other societies were not allowed to use new data, and that's not fair.”
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KentW said:
I could go on. IMO, FM is the ultimate "lifestyle specialty" already. It's amazing to me that more people don't realize it. ;)
Click to expand...

Have never heard it better said! :thumbup: :thumbup:
 
Hey all,
I'm a future med student interested in family practice. This thread is extremely encouraging. As a little aside, could anyone recommend some resources to familiarize myself with the ins and outs of medicare/medicaid? I have a firm grasp on the insurance world, but the more and more I read, this thread included, it seems like CMS ends up setting the pace for reimbursement schedules in all sectors. Any recommendations to help wade through the acronym wonderland would be appreciated.
 
derm is to take a -5% hit. the source came from CMS in the AMA news front page article. i have to stay it looks as if CMS is finally getting their s*** together!! the AAFP and ACP really pushed and worked hard on this. its looking better and better for primary care which is the way it should be.
 
dr.smurf said:
derm is to take a -5% hit.
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That's only in the first year. As I mentioned previously, they're +7% by 2010. See the aforementioned links for data tables.
 
KentW said:
The forthcoming CMS E&M updates, if implemented, could increase reimbursement to primary care physicians an average of 12-15%. That's real money, folks...and it's going to come from someplace.
Click to expand...


Can someone give us the quick and dirty on what this exactly means? For those of us who are too ADD/busy procrastinating/etc. to get through the links?

What's CMS? E&M? RVU?

Are we talking about just medicare/caid or are these for all insurance reimbursements?

Does this mean salaries will be 12-15% or will the actual take home increase be lower?
 
KentW said:
I'm not sure why the mental health fields took such a hit. Even Psychiatry, an almost purely cognitive specialty, is -1%. That doesn't seem right, given the already abysmal state of mental health services in this country.
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This is very bad indeed. Maybe we better implement more psych requirements for FM residency. Most I've seen don't have much at all...
 
sophiejane said:
Can someone give us the quick and dirty on what this exactly means?
Click to expand...

CMS=Centers for Medicare & Medicaid Services (a.k.a. Medicare, "the Government")
E&M=Evaluation and Management (relates to coding for clinical encounters)
RVU=Relative Value Unit (factor used in pricing of medical services)

Work RVUs determine how much "value" the work you do has, and Practice Expense (PE) RVUs supposedly account for the costs involved in providing services. RVUs are used to calculate payment amounts for the various types of clinical encounters (E&M services).

We're talking about Medicare at this point. However, since commercial insurers base their reimbursements on Medicare, there will be a "trickle-down" effect that should increase reimbursement across the board as contracts come up for renewal and negotiation.

The net effect on an individual doctor's bottom line will depend on the type of services they provide (coding, billing, payer mix, etc.), but the average projected increase in collections for family medicine physicians (at least, according to what I'm hearing) should be in the 12-15% range.

Hope that helps.
 
KentW said:
The net effect on an individual doctor's bottom line will depend on the type of services they provide (coding, billing, payer mix, etc.), but the average projected increase in collections for family medicine physicians (at least, according to what I'm hearing) should be in the 12-15% range.

Hope that helps.
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Let's see, 15% of $169,000 (the avg FP salary) = $25,000, making new avg salary $195,000! And even better for those of us already above the $169k average :)
 
My undergrad was a small school in Santa Barbara, CA. The campus was located on a hill that overlooked stunning CA sunsets dipping into the Pacific Ocean. Because there were so many trees, though, you had to go to the top of campus to see the view. Wonderfully positioned at the pinnacle of the campus was one of the 8 dorm buildings.

For some reason, this dorm was considered the LEAST cool place to live on campus. All the cool people tussled with each other to get into another dorm located at the foot of the college grounds. I thought this was insane. The "cool" dorm was old. The furniture was metal, the carpet old and nasty. After years of humid summers, it made the entire dorm smell musty and gross. And, the worst insult...their foosball tables were unbalanced!

So, I had little difficulty living multiple years in a dorm with new furniture, overlooking the Pacific Ocean and Channel Islands, and watching CA sunsets over my O-chem book. I'm told that this dorm is now regarded as the best place to live on campus. I'm only glad it got discovered AFTER I graduated. I'm anticipating the same for FM, although I'm not too concerned either way. The sunsets are great, weather anybody knows about them or not.
 
secretwave101 said:
My undergrad was a small school in Santa Barbara, CA. The campus was located on a hill that overlooked stunning CA sunsets dipping into the Pacific Ocean. Because there were so many trees, though, you had to go to the top of campus to see the view. Wonderfully positioned at the pinnacle of the campus was one of the 8 dorm buildings.

For some reason, this dorm was considered the LEAST cool place to live on campus. All the cool people tussled with each other to get into another dorm located at the foot of the college grounds. I thought this was insane. The "cool" dorm was old. The furniture was metal, the carpet old and nasty. After years of humid summers, it made the entire dorm smell musty and gross. And, the worst insult...their foosball tables were unbalanced!

So, I had little difficulty living multiple years in a dorm with new furniture, overlooking the Pacific Ocean and Channel Islands, and watching CA sunsets over my O-chem book. I'm told that this dorm is now regarded as the best place to live on campus. I'm only glad it got discovered AFTER I graduated. I'm anticipating the same for FM, although I'm not too concerned either way. The sunsets are great, weather anybody knows about them or not.
Click to expand...


:thumbup: :thumbup:
 
secretwave101 said:
My undergrad was a small school in Santa Barbara, CA. The campus was located on a hill that overlooked stunning CA sunsets dipping into the Pacific Ocean. Because there were so many trees, though, you had to go to the top of campus to see the view. Wonderfully positioned at the pinnacle of the campus was one of the 8 dorm buildings.

For some reason, this dorm was considered the LEAST cool place to live on campus. All the cool people tussled with each other to get into another dorm located at the foot of the college grounds. I thought this was insane. The "cool" dorm was old. The furniture was metal, the carpet old and nasty. After years of humid summers, it made the entire dorm smell musty and gross. And, the worst insult...their foosball tables were unbalanced!

So, I had little difficulty living multiple years in a dorm with new furniture, overlooking the Pacific Ocean and Channel Islands, and watching CA sunsets over my O-chem book. I'm told that this dorm is now regarded as the best place to live on campus. I'm only glad it got discovered AFTER I graduated. I'm anticipating the same for FM, although I'm not too concerned either way. The sunsets are great, weather anybody knows about them or not.
Click to expand...

:love: Can I use it as my personal statement? Instead, I overlook NY sunrise sticking out of Atlantic Ocean.
 
sophiejane said:
And just once before I die I'd like to see discussion threads like this on SDN:

"Am I competitive enough for Family Medicine?"

"People who go into FM JUST for the MONEY!!"

"I really want FM, but I'm afraid I might have to scramble into Rads or Gas"

:)
Click to expand...

Considering you need to know a little bit about everything to be a Family Physician, I'm shocked it's not been said before.

That said, I first completed an Ob/Gyn residency because I really didn't think I could deal with having to know about everything.

Now I enjoy the fact that I do :)
 
This thread has been just brilliant to read, thank you so much everyone.
 
M. Platini said:
This thread has been just brilliant to read, thank you so much everyone.
Click to expand...

Yeah man, I agree. It's great to see a thread like this in FP!
 
KentW said:
When the changes are fully implemented in 2010, the biggest losers will be Clinical Psychology (-15%), Clinical Social Work (-14%), Chiropractic (-11%), Anesthesiology (-10%), Nurse Anesthesia (-10%), Interventional Radiology (-8%), Nuclear Medicine (-7%), Pathology (-7%), and Ophthalmology (-6%).
Click to expand...

So I guess in the future, the acronym ROADs might not be as popular as it is today?
 
Does this mean I will stop getting the patronizing smile when I say I want to do family medicine?

It's that little half-smile with the head cocked to one side that seems to say, "Aw, you're so cute and selfless, and you must want to save the whole world, for practically no compensation! That's so admirable!"
 
I don't want to burst any bubbles but don't hold your breath guys. Just because the cpt codes give you more does not mean that the employee is going to do the same.

Also, don't think your going to make 195 k out of residency. the 169 average is a national average. If you live in california it's more like 145.

It's also not going to be 15%. It's more like 10%.

I'm not trying to be negative I just hate to see people get their hopes up to high.

The 10% change is a step in the right direction. I think there needs to another 10% in five years or so.
 
The aafp did very little for this change. The change came because fewer people went into fp and it became obvious to medicare that if they wanted to have their patient seen by a primary care doctor they needed to increase the insentive to have more primary care doctors.

aafp is a joke mostly.
 
erichaj said:
The aafp did very little for this change.
Click to expand...

CMS doesn't operate in a vacuum, and it doesn't make changes to reimbursement out of generosity. The RVU updates are largely the result of the collective efforts of a number of lobbies, including the AAFP, over the past two years.
 
I recently wrote an editorial for the CAFP, due later this year. I'll share a snippet of it here -- it explains how CMS makes its RBRVS decisions.

Even with the recent increase (closer to 5% per CMS, much less than the original recommendation from the RUC), we're getting the short-end of the income stick and we should be pissed. It is my opinion that our previous leaders didn't do enough to protect primary care's income during the late 90s and into the early 00s.

Tom Bodenheimer, MD from UCSF gave an enlightening presentation [at the recent CAFP Board Meeting] which details why primary care is suffering. Our current situation is a combination of clever planning by specialists, failure of organized family medicine, and a change in public sentiment.

The Resource-Based Relative Value Scale (RBRVS) is skewed to favor specialists. Each year there is a fixed pot of money available from the Centers for Medicare and Medicaid Services (CMS). Payments are made to physicians based on Relative Value Units (RVUs) of billing codes. RVUs are designed to try to keep CMS within its allotted annual budget.

RVUs are updated every few years based on recommendations from the AMA’s Relative Value Update Committee (RUC). The RUC is made-up of 29 members named by specialty societies. Of the 29 members, only 4 represent primary care. The remaining 25 members represent specialists.

These 25 specialists frequently vote together to increase RVUs which favor themselves. The results are clear: between 1995 and 2004, primary care incomes have increased 21%, while all specialists’ income has increased 38%. Adjusted for inflation, primary care physicians earned 10% less in 2003 than they did in 1995.

Major problem – what solution?

Some suggest pushing for a single-payer model; expand Medicare to our entire population. I’m not certain that’s a good idea, but it has merit. However, until the RBRVS model is changed, it might not improve our situation.

The specialist skewed RUC exists because we allow it to exist. It’s time family physicians reject this specialist controlled committee. Primary care represents 50% of CMS visits; we should represent 50% of the RUC.
Click to expand...
 
Lee Burnett said:
I recently wrote an editorial for the CAFP, due later this year.
Click to expand...

Interesting. I look forward to reading your article. I'm glad that you're getting involved. :)
 
I read that by federal law, Medicare's payments to providers must be held flat. Otherwords, its a zero sum game. If FPs get paid more, then it means somebody else must get paid less. Medicare doesnt allow RVUs to increase across the board.

My question is does Medicare factor population growth and inflation into the equation? Because if not, doctors are screwed over hte long term. The number of docs increases every year, if there is no increase in overall payments to docotrs it means that over the long term, each individual provider gets paid less and less.

Another thing to think about is that the midlevel providers take money out of hte same pie that doctors get. Midlevels are expanding like crazy. There are 10 NP and PA schools for every MD/DO program. The expansion in midlevels means that everybody will get paid less money unless Medicare factors in population growth and inflation.
 
MacGyver said:
I read that by federal law, Medicare's payments to providers must be held flat. Otherwords, its a zero sum game. If FPs get paid more, then it means somebody else must get paid less.
Click to expand...

That's the premise of "budget neutrality." I don't think anyone believes that this is a long-term solution, however.
 
From the editorial: "Failure of organized family medicine," I think, explains much of the problem. Seems we have a very weak lobby, although I'm still just getting my feet wet on these things.
 
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