why do Derm have high $$$?

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coco09

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why does Derm have one of the higher rates of compensation? They work less, but make more? Is it because of out-of-pocket services? If I had a predominantly medical derm practice, would I be making considerably less ~comparable to PCP?
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I'll take a stab at it:

low supply, high demand could be one reason

If you note the average income though, it is still quite lower than a lot of specialties out there. (Probably because they work ~40 hrs/week)

Out-of-pocket services? Another reason why pay is quite good despite the low work hours.

Predominantly medical derm? You would be making considerably more than a PCP. There are many dermatologists out there who refuse to have a cosmetic component to their practice and they are still up to their eyeballs in patients. You might not make as much but then again, you also don't have to deal with some of the negatives of "those cosmetic patients".

See: Dr. 90210 for a (probably exaggerated) glimpse of how irritating those people can be
 
Also, the volume of patients seen per hours is higher than most other doctors. I know a derm guy who triple books...can see about 12 pts per hour with his ancillary staff, takes all insurance including medicaid...makes for a long day but early retirement.
 
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Egon said:
Also, the volume of patients seen per hours is higher than most other doctors. I know a derm guy who triple books...can see about 12 pts per hour with his ancillary staff, takes all insurance including medicaid...makes for a long day but early retirement.
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I've heard this as well. Once spoke with a dermatologist who said, "If you aren't happy seeing a patient every 15 minutes, find a new field."
 
It is volume and procedures.... yes with cosmetics (out of pocket) you can make a bundle but in general any specialty that involves procedures pays well.... another thing.....hire a PA-C or a NP and pay them a third of an MD derm's salary or less (and they are likewise doing procedures) and you can make loads of money.
 
I agree with the supply and demand. . . but I've been told that some of it is just politics. Subspecialties own the medical lobby in Washington - a family doc can perform the same procedure and get paid less by medicare simply b/c that's how the policies are written up.

One can only speculate that these pork-barrel politics are a big reason for rising medical cost.
 
BobA said:
I agree with the supply and demand. . . but I've been told that some of it is just politics. Subspecialties own the medical lobby in Washington - a family doc can perform the same procedure and get paid less by medicare simply b/c that's how the policies are written up.

One can only speculate that these pork-barrel politics are a big reason for rising medical cost.
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c'om on, dude! doctors should be making bank, after all they go through and the enormous responsibility they have in medical practice. It's the evil insurance companies that contribute to rising medical cost
 
coco09 said:
why does Derm have one of the higher rates of compensation? They work less, but make more? Is it because of out-of-pocket services? If I had a predominantly medical derm practice, would I be making considerably less ~comparable to PCP?
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Cause beauty is only skin deep.
 
One can bill about the same for a 15 minute new patient visit/biopsy than he can for a new patient hour visit in neurology. More procedures + cosmetics = high pay. It's not that tough a formula to work out.
 
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BobA said:
I agree with the supply and demand. . . but I've been told that some of it is just politics. Subspecialties own the medical lobby in Washington - a family doc can perform the same procedure and get paid less by medicare simply b/c that's how the policies are written up.

One can only speculate that these pork-barrel politics are a big reason for rising medical cost.
Click to expand...

Yes...I have personally gone to Washington and lobbied for family docs to get paid less for doing procedures that I will do as an attending because I'm an evil subspecialist (not because, you know, of the years and years of dedicated, intense training in performing these procedures and managing issues specifically related to my specialty). Hey, it's easy and anyone can do it--it's just my evil, twisted desire to keep family docs down that led me to do a 6 year residency instead of a 3 year residency, all just so I could opress FP's. All of us blackhearted, politics-obsessed subspecialists are like this.

discontinuebed said:
See: Dr. 90210 for a (probably exaggerated) glimpse of how irritating those people can be
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That show is not an appropriate (or even exaggerated) representation of anything. Not aesthetic surgery, not plastic surgery, not medicine, and not even normal human beings.
 
You are all forgetting the supply and demand is fixed by the govt! So you can't apply normal market economics because supply would increase given the demand, but it doesn't since the number of derm spots is fixed.

Also...I wonder how derm reimbursement would/will change under a universal (or a single-payer) health care system.
 
*Dear infant baby Jesus, all cuddled up in your manger crib, please encourage all of these bright and enthusiastic medical students, residents, and grads to research and understand the system better. Amen.*

Market, free, socialized, fixed, blah, blah, blah....

Fellas,

AMA RUC sets an RVU value to every service. Many things go into this, but the "demand" and "supply" never enter the equation. FP, IM, peds, GS, PRS, ENT, whoever -- perform a 17000, 11000, 17311, etc, for a medicare patient in a given locale and all will be paid the exact same. Derms don't get paid any better for any given procedure.
 
MOHS_01 said:
*Dear infant baby Jesus, all cuddled up in your manger crib, please encourage all of these bright and enthusiastic medical students, residents, and grads to research and understand the system better. Amen.*

Market, free, socialized, fixed, blah, blah, blah....

Fellas,

AMA RUC sets an RVU value to every service. Many things go into this, but the "demand" and "supply" never enter the equation. FP, IM, peds, GS, PRS, ENT, whoever -- perform a 17000, 11000, 17311, etc, for a medicare patient in a given locale and all will be paid the exact same. Derms don't get paid any better for any given procedure.
Click to expand...

I like to picture Jesus with eagles' wings, singin' lead at a Lynyrd Skynyrd concert. And I'm in the front row, and I'm hammered...what, I like to party, so I like my Jesus to party.
 
dear 6 pound 8 ounce baby jesus...

i like to think of jesus as a muscular gymnast..
 
MOHS_01 said:
*Dear infant baby Jesus, all cuddled up in your manger crib, please encourage all of these bright and enthusiastic medical students, residents, and grads to research and understand the system better. Amen.*

Market, free, socialized, fixed, blah, blah, blah....

Fellas,

AMA RUC sets an RVU value to every service. Many things go into this, but the "demand" and "supply" never enter the equation. FP, IM, peds, GS, PRS, ENT, whoever -- perform a 17000, 11000, 17311, etc, for a medicare patient in a given locale and all will be paid the exact same. Derms don't get paid any better for any given procedure.
Click to expand...

Please spare me the patronizing comments. In fact, I have an MPH in health policy and management and have spent years working in public health. So--with all due respect for your own years of experience-- I pray that YOU think twice before making assumptions about the knowledge and experience of your colleagues.

With that off my chest... Yes, RBRVs and DRUs determine reimbursement for MEDICARE patients (and medicaid, in some instances). However, these reimbursement schedules do NOT always represent the actual cost of the service and they are NOT reflective of private sector fees.

Dermatologists, as a whole, see a disproportionate number of insured patients. One reason they are less likely to see patients without insurance (with medical) is because these patients have less access to primary care referrals. Those with immigrant status or lower socioeconomic status are more likely to be uninsured and less likely to have access to specialty care.
 
Bito42 said:
Please spare me the patronizing comments. In fact, I have an MPH in health policy and management and have spent years working in public health. So--with all due respect for your own years of experience-- I pray that YOU think twice before making assumptions about the knowledge and experience of your colleagues.

With that off my chest... Yes, RBRVs and DRUs determine reimbursement for MEDICARE patients (and medicaid, in some instances). However, these reimbursement schedules do NOT always represent the actual cost of the service and they are NOT reflective of private sector fees.

Dermatologists, as a whole, see a disproportionate number of insured patients. One reason they are less likely to see patients without insurance (with medical) is because these patients have less access to primary care referrals. Those with immigrant status or lower socioeconomic status are more likely to be uninsured and less likely to have access to specialty care.
Click to expand...

Read MOHS's post more carefully. You are not disproving or even disagreeing with anything MOHS said. I'm sure he (I think MOHS is a he...I apologize in advance if I am incorrect) is quite capable of detailed discourse on the difference between Medicare reimbursements and private insurance reimbursements, as well as the proportion of each patient population seen by primary care docs vs. specialists.

The way I read that post is that Medicare has a set reimbursement schedule for a given set of services, no matter what type of physician provides these services. I'm pretty sure he was trying to clear up a misconception (common to med students and residents) about Medicare, and left out the consideration of private insurance in the interest of remaining concise and relevant. It's educational, and definitely not patronizing.

It's not like MOHS is saying "If you don't chew Big Red then f*** you" or something.
 
Bito42 said:
Please spare me the patronizing comments. In fact, I have an MPH in health policy and management and have spent years working in public health. So--with all due respect for your own years of experience-- I pray that YOU think twice before making assumptions about the knowledge and experience of your colleagues.

With that off my chest... Yes, RBRVs and DRUs determine reimbursement for MEDICARE patients (and medicaid, in some instances). However, these reimbursement schedules do NOT always represent the actual cost of the service and they are NOT reflective of private sector fees.

Dermatologists, as a whole, see a disproportionate number of insured patients. One reason they are less likely to see patients without insurance (with medical) is because these patients have less access to primary care referrals. Those with immigrant status or lower socioeconomic status are more likely to be uninsured and less likely to have access to specialty care.
Click to expand...


Bito,

No real offense intended. If you read many of the posts on this and other boards you will find that there exists a widespread misunderstanding of the true in's and out's of our system.

Since you brought it up.... payor mix is largely determined by demographics and provider supply in a given area. As a student of public health I am sure that you know that certain specialties (ophtho, derm, IM to name a few) service a much higher percentage of MC compared to many specialties due to disease mix. My personal MC percentage is consistently 30-35%.

Regarding RVU's (and this is not directed at you, just those who may not have as great a command of the situation) -- they are the foundation for the vast majority of payments, public or private. The system is not perfect, but is the best construct to date that has been proposed. It is somewhat erroneous to say that they do not reflect practice costs as well. RVU values are periodically revalued (MC mandates q5yrs); three major components go into the final figure: work, expense, and malpractice. What has not kept up with practice costs are FEES, which result from a calcuation (of which RVU values are only one component). Medicare has its own tool for measuring practice costs (Medicare economic index); MC fees have not kept pace with the MEI for several years.

It is true that private insurers determine their own fee schedule. Some set it as a straight percentage of MC, some have a fee schedule that jumps around a bit, while a precious few base their payment upon a percentage of charges (up to the "usual and customary" fee). These "precious few" decline in number year in and year out due to the consolidation that is occurring in the healt insurance industry, and are in large part the reason for the ridiculous fees that are charged by all providers (physicians, hospitals, etc).

Regarding the last thought in your post -- I (as well as many of my colleagues) do see MA and self pay patients. Economic forces dictate that we must limit MA to a set percentage, but we do see them. Also, since we advertise in the phone book, if they can read, they can find us rather easily... and everyone gets an appointment (wait times vary).

As an aside -- it is much harder to get an appointment with a PCP in my neck of the woods than it is to get in with most specialists... and the PCP's tend to be much more selective in insurances seen, quit participating in MC (at a minimum limit the number), etc.
 
DrDre311 said:
Read MOHS's post more carefully. You are not disproving or even disagreeing with anything MOHS said. I'm sure he (I think MOHS is a he...I apologize in advance if I am incorrect) is quite capable of detailed discourse on the difference between Medicare reimbursements and private insurance reimbursements, as well as the proportion of each patient population seen by primary care docs vs. specialists.

The way I read that post is that Medicare has a set reimbursement schedule for a given set of services, no matter what type of physician provides these services. I'm pretty sure he was trying to clear up a misconception (common to med students and residents) about Medicare, and left out the consideration of private insurance in the interest of remaining concise and relevant. It's educational, and definitely not patronizing.

It's not like MOHS is saying "If you don't chew Big Red then f*** you" or something.
Click to expand...

I'm not sure that Talledega Nights play was recognized....

I feel like the Big Red commercial, but I would not ever say that out loud....
 
MOHS_01 said:
Regarding RVU's (and this is not directed at you, just those who may not have as great a command of the situation) -- they are the foundation for the vast majority of payments, public or private. The system is not perfect, but is the best construct to date that has been proposed. It is somewhat erroneous to say that they do not reflect practice costs as well. RVU values are periodically revalued (MC mandates q5yrs); three major components go into the final figure: work, expense, and malpractice. What has not kept up with practice costs are FEES, which result from a calcuation (of which RVU values are only one component). Medicare has its own tool for measuring practice costs (Medicare economic index); MC fees have not kept pace with the MEI for several years.

It is true that private insurers determine their own fee schedule. Some set it as a straight percentage of MC, some have a fee schedule that jumps around a bit, while a precious few base their payment upon a percentage of charges (up to the "usual and customary" fee). These "precious few" decline in number year in and year out due to the consolidation that is occurring in the healt insurance industry, and are in large part the reason for the ridiculous fees that are charged by all providers (physicians, hospitals, etc).

Regarding the last thought in your post -- I (as well as many of my colleagues) do see MA and self pay patients. Economic forces dictate that we must limit MA to a set percentage, but we do see them. Also, since we advertise in the phone book, if they can read, they can find us rather easily... and everyone gets an appointment (wait times vary).

As an aside -- it is much harder to get an appointment with a PCP in my neck of the woods than it is to get in with most specialists... and the PCP's tend to be much more selective in insurances seen, quit participating in MC (at a minimum limit the number), etc.
Click to expand...

Ok, so you are saying that people are reimbursed for a procedure/service by "fees". Fees are determined by a calculation of RVU's (which are determined by work, expense, and malpractice), plus other things. And then there is also the consideration that Medicare bases all the above on "practice costs" which it has it's own system for. Wow. You're right, it's so simple. I appreciate your post, but it's really not simple, at all.
 
I understand that RVU's are the same whether a dermatologist or a PCP performs the service. And I understand that Medicare is paying less and less for the same service each year. And I understand that RVU's are based on some semi-subjective data that includes intensity/difficulty of service peformed, cost of service, and malpractice involved. That's about all I understand.
 
Strength&Speed said:
Ok, so you are saying that people are reimbursed for a procedure/service by "fees". Fees are determined by a calculation of RVU's (which are determined by work, expense, and malpractice), plus other things. And then there is also the consideration that Medicare bases all the above on "practice costs" which it has it's own system for. Wow. You're right, it's so simple. I appreciate your post, but it's really not simple, at all.
Click to expand...

S&S,

It can be simple if someone (who actually understands it) explains it well, with diagrams illustrating what is going on, something that is very difficult to do in this forum. One clarification -- the MEI is not factored into the annual conversion factor update. Practice "costs" are a component of the RVU determination for any particular code; updates are made as part of the 5yr cycle.

Don't fret -- this will be covered in a better way *hopefully* sometime soon (I am crazy covered up with work and home life, but I have recruited help to get this little project up and running).
 
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I like to picture Jesus as a changling or a shapeshifter
 
AMA RUC sets an RVU value to every service. Many things go into this, but the "demand" and "supply" never enter the equation. FP, IM, peds, GS, PRS, ENT, whoever -- perform a 17000, 11000, 17311, etc, for a medicare patient in a given locale and all will be paid the exact same. Derms don't get paid any better for any given procedure.[/quote]

THANK YOU.

Moderators: is there some other thread, like the business one, where excellent comments like these can be stickied?

It is true in my field, too (I'm not derm.) It's true in EVERY field.
 
Egon said:
Also, the volume of patients seen per hours is higher than most other doctors. I know a derm guy who triple books...can see about 12 pts per hour with his ancillary staff, takes all insurance including medicaid...makes for a long day but early retirement.
Click to expand...
I agree with this as well as the supply and demand explanation. This is one of the reasons dentistry has become one of the most sought after fields nowadays and premeds are becoming predent. The ADA will not allow many dental schools to open (there might be a total of 21 with one new one opening soon). They do not want the market to be saturated with dentists, keeping their income extremely high. It seems like dermatology foundations are doing the same. Also, the last dermatologist I did a rotation with was seeing over 100 patients a day (with only med students helping him out and 1 backup nurse), pretty sick.
 
.
 
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coco09 said:
why does Derm have one of the higher rates of compensation? They work less, but make more? Is it because of out-of-pocket services? If I had a predominantly medical derm practice, would I be making considerably less ~comparable to PCP?
Click to expand...

What are dermatologists making on average right out of residency? And after 10 years of practice?
 
.
 
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SDN9876 said:
Depends on the location, type of practice

What's the problem our kind sir? He is wondering probably due to curiousity. All students and colleagues wonder about compensations and have a right for many reasons:

1. Knowing compensations to compare with other specialities.
2. Knowing compensations to give advice to siblings or friends who are thinking of pursuing certain fields and would like to know compensations.
3. Knowing compensations to know what is commonplace in the world when searching for employment and not being take for a joyride.
4. Knowing compensations for pure curiousity.

Please refrain yourself from sarcastic comments. Thank you.
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I ask you this: would he/she show up to a derm rotation and ask it this bluntly?

No, so why is it okay here?

I thought so.
 
SDN9876 said:
I've asked this in medical universitet and I have no problem with it. I do not think there is anything wrong with it. What is this "taboo" with salary/compensation? You are uptight.
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:rolleyes:

It helps to spell university correctly.

It also helps not to lie. If you're truly interested in derm and had the gall to go up to your attending and bluntly ask, "How much should I expect to make once I'm done with training?", then I applaud you. Bravo. I'll also think you're a liar.
 
SDN9876 said:
I have asked my superiors about payscales after and during derm training. I'm sorry but universitet is correct in my language, sorry english isn't the only language in the world. Typical amerikan trash.
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:laugh::corny:
 
leagueelbow said:
:rolleyes:

It helps to spell university correctly.
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Really? How much does that increase his salary? Oh...wait... you would never ask that. Pu$$y.

It also helps not to lie. If you're truly interested in derm and had the gall to go up to your attending and bluntly ask, "How much should I expect to make once I'm done with training?", then I applaud you. Bravo. I'll also think you're a liar.
Click to expand...
Perhaps attendings are more relaxed in Sweden. Dress code is more relaxed- everything is more relaxed.
 
Please keep it civil everyone. This thread is close to being locked. There are ways to discuss issues like this without resorting to insults or flames.
 
yaah said:
Please keep it civil everyone. This thread is close to being locked. There are ways to discuss issues like this without resorting to insults or flames.
Click to expand...

But... but... he used the phrase "typical amerikan trash" on a predominantly US-based forum. That's far too hilarious to lock. :laugh:
 
SDN9876 said:
I am glad my language/cultural barrier caused you some humour.:thumbup:;) Thank you for attending this forum board.
Click to expand...

Unsure if you're being sarcastic, but I'm amused at the blatant insult that blanketed the majority of SDN members, not the language thing.

By all means, spell things as you spell them. Your command of English is probably better than quite a few native speakers here. My mediocre understanding of only one other language besides English (yeah, I know) doesn't mean that I don't appreciate linguistics. :D
 
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