Will Physician Salaries continue to go down?

[MacGyver]

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I do not see PA's or NP's ever being able to successfully defend themselves as sole providers in court -

Are you freaking kidding me? NPs are ALREADY SOLE PROVIDERS IN MANY STATES. Go to a rural ER or clinic in North Carolina and I guarantee you they will have NPs practicing totally independently. NO supervision, no sharing revenue with MDs, total independent operation.

Maybe it hasnt happened in your state yet, but I guarantee you they are lobbying for it.

The court issue is irrelevant, because the state nursing boards have revised their practice standards to encroach on MDs scope of practice. Yes, they can be sued, but they wont because they dont have the deep pockets like the hospitals do.

You are in serious denial if you think lawsuit issues are going to prevent NPs and PAs from further encroaching on turf and working independently. That ship has sailed.

it will simply never happen as long as there are licensed medical doctors in practice. This is why each state has their own medical board, and there is a national board of medical examiners to ensure that MD's are certified and credentialed as the final entity in healthcare. What others are suggesting on this board is that midlevel providers will supplant MD's in the workforce. The credentialing, training, and legal issues with solo PA or NP practice alone make this impossible. Further, just as the AAMC regulates the credentialing of medical schools and the RRC/ACGME regulate post-graduate training, the philosophy of midlevel training institutions can never accomodate such huge credentialing requirements.

You dont understand how NPs are reworking hte laws to their advantage. First off, the state medical board is NOT the sole authority for practicing "medicine." IN most states, the state nursing board has full authority to set their own scope of practice.

This is not really about supplanting MDs, its more about wage deflation. MDs have the most training, they can always get a job, regardless of NPs. However, the problem is that NPs will introduce artificial wage suppression due to their turf encroachment. An NP will gladly take a 60k per year job, almost no MD would accept that.

Rest assured that right now PAs are running CABG 95% unsupervised, with the attending only stepping in for the most crucial 15 or 20 minute segment of the surgery.

 

[MacGyver]

So sheltered tower here - I've worked in all hospital settings. Believe me - there will never be a "physician equivalent" status between midlevel providers and physicians. The legal climate of our country will never stand for it...

The legal climate has ALREADY tolerated it. How do you think NPs got the regulations changed?

YOu are naive if you think lawsuit threats will hold them back. Just because they screw up doesnt mean they will get sued. Depends on how deep their pockets are. Sueing an individual NP, even if they killed somebody, does not make much sense for a lawyer when they have thousands of MD clients they can go after and get millions.

Do you really understand what NPs do? You do know that by state law, they can run a full blown ER, with no doctor oversight? YOu do know that they are allowed to script ANYTHING a doctor can script with zero oversight?

 

[bigtimesmally]

Rest assured that right now PAs are running CABG 95% unsupervised, with the attending only stepping in for the most crucial 15 or 20 minute segment of the surgery.

That's a little hard to believe. Can you tell me where that is happening?

 

[fuegorama]

OK so we've identified some big threats to physician income. Liability, decreased reimbursement, encroachment by PEs, increasing reliance on gov't etc...
What can we as future docs do to protect a healthy fiscal future?

I'll start.
1. EM will be the first place for federal funding as the "safety net". EMTALA creates the mandate, now will come the funding. ACEP et al have quietly muttered about the unfunded demands of EMTALA, but they haven't gone public for good reason. With funding in place, comes more govt. control including salary caps, work restrictions, more beauracracy. (oh yeah it CAN get worse).
When the reimbursement apocalypse comes, EPs need an agressive lobbying effort to guarantee a solid salary, tuition reimbursement, work hour restrictions that benefit docs and assurance of specialist (read still privatized) compliance w/consultation.
2. We have a pub in the white house, pubs in the legislature, a right leaning judiciary and we still can't move on tort reform. We need a radical wake up for the country. Either:
A: Everybody...I mean everybody go bare or
B😀emand face to face arbitration up front before starting care. Require a joint agreement to end run lawyers before entering an agreement to service.


Somebody else.

Who's next?

 

[NinerNiner999]

What we need are two or three large judgements and payouts against NP's and PA's and the hiring entity (read hospital) who gave them autonomy. Then, we need to see an increase in NP and PA individual malpractice insurance (which we will). When these hits happen (and they will as long as midlevels continue to practice with autonomy), hospitals will reconsider their decision to fund these providers. MacGyver - you stated that "Sueing an individual NP, even if they killed somebody, does not make much sense for a lawyer when they have thousands of MD clients they can go after and get millions." Actually, it makes even more sense because the lawyers can go directly after the hospital (or hospital system, or megagroup, etc) with LESS legal resistance than an MD with a well-covered malpractice policy. An MD might have the ability to settle for $200k on a case, but a hospital won't have the ground to stand on when they justify an NP who botched a CABG without an accredited, board certified CT surgeon. I'd bet that same case would settle for $5 million at the minimum.

The lobbying efforts of midlevels do have a huge push for autonomy (I am well aware of this), but the accreditation entities that license them are not directly involved in this push - perhaps because quietly they realize that would involve an overhaul and expensive government regulation that is on par with MD training (which currently costs about $800k to $1 million per MD graduate, plus subsidization for residency training). In short, they may want the title without the training but they are sure not equipped to pay for it either.

Any way you slice it - the problem with our medical system isn't the fact there aren't enough doctors, its that there aren't enough doctors to keep up with the number of patients who are getting sick (and growing in number in year). Medicine is a volume-driven industry, and midlevel providers allow us to treat the volumes of patients we need to see, not take away from our profit margin. BTW - I do not support the advancement or "equivelancy" of midlevel providers, I do support their ability to assist the MD, as their employment is intended to be 😉

 

[MissMuffet]

Isn't the threat of PA encroachment different/less than the threat of NPs?

In my reading of various forums, I often see NPs and CRNAs telling AAs and PAs that, because they (NPs) are licensed by the state nursing boards, they have much more potential for autonomy than the PAs.

According to them, PAs will never be a real threat, because they are licensed by the state MD boards, who control their scope of practice. ? There also seems to be a less adversarial attitude among PAs toward MDs, I think.

 

[NinerNiner999]

In the grand scheme of things, yes, I would think that the bigger "threat" (if there is one) would come from the NP's. However, while the nursing board may set state-by-state policies, they cannot supplant MD's as the final authority (or the state board of medical examiner's) for autonomy. Hospital policies may permit NP's (via legislation championed by the nursing boards) to have autonomy of their patients, but their liability protection will never be as extensive as MD's.

 

[Mumpu]

In my experience, patients don't trust NPs. When in doubt, they ask MDs and MD opinion always overrules. From the lay viewpoint, the NP is always a "nurse" and the MD is always a "doctor." The NP has to explain they are a special kind of nurse with more certification and autonomy. All the MD has to say "Hi I'm Doctor So-and-so." The difference between these terms has a very powerful context in all societies. We are talking about the world's second-oldest profession (someone had to treat the VD 😛) here versus a 21st century American invention.

Having said that, I fully support using NPs and other midlevels to fill the need for healthcare providers in medically underserved areas.

As for the attending not supervising the CABG, isn't that what happens in residency anyway? "The procedure was done under the supervision of Dr Attending who was present during the entire surgery" is the biggest lie since "I'm not a crook."

 

[MacGyver]

As for the attending not supervising the CABG, isn't that what happens in residency anyway? "The procedure was done under the supervision of Dr Attending who was present during the entire surgery" is the biggest lie since "I'm not a crook."

The natural conclusion of your statement is that PA training is equivalent to residency. If thats the case, how can you justify going 100k in debt, spending 7 years in training when a PA can do exaclty the same job for 1/3 the time and debt

Also, the PAs would jump all over your statement as an excuse to advance their cause. They would say "why dont we get autonomy when our training is identical to what residents get"

 

[MacGyver]

In the grand scheme of things, yes, I would think that the bigger "threat" (if there is one) would come from the NP's. However, while the nursing board may set state-by-state policies, they cannot supplant MD's as the final authority (or the state board of medical examiner's) for autonomy. Hospital policies may permit NP's (via legislation championed by the nursing boards) to have autonomy of their patients, but their liability protection will never be as extensive as MD's.

You still dont get it. NPs ALREADY HAVE FINAL AUTHORITY in some states. LIke I said, go to a clinic in North Carolina and look at their medical charts. All are signed by NPs with no MD cosignature. Hell there wont even be an MD in the whole damn clinic. These clinics are owned and operated 100% by NPs. ERs in rural counties are exaclty the same way. You wont find any ER docs in there, just NPs doing everything with no MD oversight

As for the state medical board, NPs found an ingenious way to get around that.

Most state laws simply say that "medical boards set the practice of medicine, nursing boards set the practice of nursing."

So the NPs went out and wrote their expanded scope as "nursing" practice and therefore immune to any oversight by the state medical boards. They define scripting meds as "nursing" practice. They define delivering anesthesia and nerve blocks as "nursing" practice. They define minor surgeries as "nursing" practice. The state medical board has no say over what they do because they define everything in terms of "nursing" practice. There is no authority over the boards who determines the actual scope of practice. Whatever the state nursing boards decide to write into nursing code IS the law, MDs have no say over it whatsoever.

 

[NinerNiner999]

Mac - what don't I get - NP's may have their own authority - I know this. I am suggesting that it will not last long. One major lawsuit will change this....

 

[fuegorama]

Mac - what don't I get - NP's may have their own authority - I know this. I am suggesting that it will not last long. One major lawsuit will change this....

That's hopeful, but not realistic. Medicine must exploit the errors we discover commited by these midlevels. As unsavory as it sounds this is what will make the difference. We need documentation and a conduit.

Unfortunately, NP errors usually fall into a doc's lap to rescue. Once a physician gets involved in a case, he is sharing in the care of an evolving disaster. He then shares the meal of bad outcome w/whatever "provider" caused the issue. Docs will fall all over themselves to avoid this kind of scenario. That includes protecting the PE responsible.


I feel a bit chicken littlish talking like this, but 99er, you keep reiterating the arguments that I have heard for years. I'm realizing there is no greater threat to healthcare in general, and my future income specifically, than this encroachment.

 

[APACHE3]

Well placed ad campaign to all CEO, Hosp. Admin, etc. will scare the hell out of them and those autonomous PE's will begin disappearing fast. Oh wait, that's why we pay millions in dues so they AMA can do this for us!!! Wake up guys before its too late!!!

 

[Mumpu]

AMA is a joke. We get free membership as med students and it's going bye-bye the moment it's no longer free. How can they expect to reform healthcare if they can't even get rid of Step 2 CS. Talk about effete.

 

[Sinnman]

APACHE3, fuegorama, MacGyver, you guys are dead on. This is a serious threat to the practice of medicine. I've watched this whole thing unravel for many years. I used to think to my self "midlevels will never pose a serious threat to medicine" but I was completely wrong. Slowly buy surely they are gaining autonomy and power.

Interesting trends I have noticed:

1) The NPs have definitely positioned themselves politically to do WHATEVER they want. There is no physician or state medical board oversight in many (probably most) states now. I've seen this develop first hand. They get tired of pushing for increased rights from the state medical boards so they convince a few state legislators to change the board of nursings scope and presto, they regulate themselves, completely autonomously. They could conceivably state that performing neurosurgery is under the auspices of advanced "nursing practice" and be completely legal. Don't think it could happen? This example is pretty far fetched but who would have thought NPs would be the only provider in EDs or acting as hospitalists or staffing all these "NPs in box" that are starting to pop up everywhere? Have you seen the Wal-Mart or Target clinics? Don't believe that this trend will stop.

2) The nursing organizations have been trying to diminish the authority of physicians for years. In one the first classes that nurses take in nursing school they emphasize that nursing is equal to medicine and that doctors are have no authority over nursing practice. They purposefully foster an antagonistic attitude toward physicians. This same political indoctrination continues all the way through to the NP curricula. They truly believe that they are on equal footing with physicians when it comes to patient care management decisions. A lot of the "old school" nurses I know even make comments on how the new grads have such a horrible inflated attitude.

3) Like the previous poster said about the titles on the name badges, who do you think runs the hospitals? Guess who runs the daily tasks of most healthcare policy organizations like JCAHO? If you think that physicians still have the power to reverse this encroachment?

4) Healthcare in this country is experiencing so many problems that the time is ripe for all these people’s agendas. Think about it, what factors favor halting the progression of the midlevels? The insurance companies would love to pay somebody a fraction of the cost of a physician to do the "same" job. The government and CMS are facing huge budget constraints and the midlevels are touting that they can help cut costs and provide more "efficient" care. Rural communities believe that midlevels can solve the problem of attracting providers (until they head toward the cities because they don't want to live in the sticks either). Even physicians like the midlevels now because they can make $$ off of them and reduce their scut work.

Sorry but Pandora’s Box is open. There are simply too many pressures working against physicians. This is a HUGE threat to both our practice and our patients. If I hadn't worked in healthcare as long as I have, I would think this is very Chicken Little-like but I can assure you that these issues are very real and we need to get on the ball to fix them.

 

[OUsooner]

Sinnman has hit the head on the nail. Primary Care Physicians are a dying breed. I have heard several nurses spout off about how they are better clinically than docs but "admit" they don't know the pathophysiology, which many of them consider unnecessary. Not only are PCP's on their way out, but anybody who has seen the attitudes of nurses in several (but not all) cath labs etc could easily see a future in which these nurses have a far greater role in specialized fields.

 

[Whodathunkit]

4) Healthcare in this country is experiencing so many problems that the time is ripe for all these people’s agendas. Think about it, what factors favor halting the progression of the midlevels? The insurance companies would love to pay somebody a fraction of the cost of a physician to do the "same" job. The government and CMS are facing huge budget constraints and the midlevels are touting that they can help cut costs and provide more "efficient" care. Rural communities believe that midlevels can solve the problem of attracting providers (until they head toward the cities because they don't want to live in the sticks either). Even physicians like the midlevels now because they can make $$ off of them and reduce their scut work.

From seeing some of the "salary quotes" that some NPs and PAs spout off as to what they are making(sometimes on par or sometimes more than FPs make) I find it hard to believe that the goverment thinks that they are getting a deal. The midlevels are definitely making out like bandits as they dont have to expend as much time or money in education to make a similar if not more.

Physicians(and physicians in training) need to be more proactive instead of reactive.

 

[smugtroll]

Someone said that family docs salary won't decrease forever. I think they will continue to decline..

I read that in France the avg. doc makes only $55,000 per year.

That sux

 

[Coastie]

MacGyver is the Tom Tancredo of SDN.

Are you freaking kidding me? NPs are ALREADY SOLE PROVIDERS IN MANY STATES. Go to a rural ER or clinic in North Carolina and I guarantee you they will have NPs practicing totally independently. NO supervision, no sharing revenue with MDs, total independent operation.

Maybe it hasnt happened in your state yet, but I guarantee you they are lobbying for it.

The court issue is irrelevant, because the state nursing boards have revised their practice standards to encroach on MDs scope of practice. Yes, they can be sued, but they wont because they dont have the deep pockets like the hospitals do.

You are in serious denial if you think lawsuit issues are going to prevent NPs and PAs from further encroaching on turf and working independently. That ship has sailed.



You dont understand how NPs are reworking hte laws to their advantage. First off, the state medical board is NOT the sole authority for practicing "medicine." IN most states, the state nursing board has full authority to set their own scope of practice.

This is not really about supplanting MDs, its more about wage deflation. MDs have the most training, they can always get a job, regardless of NPs. However, the problem is that NPs will introduce artificial wage suppression due to their turf encroachment. An NP will gladly take a 60k per year job, almost no MD would accept that.

Rest assured that right now PAs are running CABG 95% unsupervised, with the attending only stepping in for the most crucial 15 or 20 minute segment of the surgery.

 

[Miami_med]

Salaries are actually rising, they are just not rising in line with inflation. I suspect that this will be the norm.

 

[deleted87716]

Someone said that family docs salary won't decrease forever. I think they will continue to decline.

I read that in France the avg. doc makes only $55,000 per year.

The United States is not France.

http://ezraklein.typepad.com/blog/2006/04/on_doctors_sala.html

One can think of several reasons why physician compensation in the United States is relatively more generous than elsewhere. First, physicians in most other nations face a powerful single buyer (monopsony) for health services. As the McKinsey Global Institute and Mark Pauly have shown, market power (or regulation) translates into relatively lower prices for health services, including the services of physicians. Second, U.S. physicians must make a larger financial investment in their education than their counter parts in many other countries do; they must recover the debt they incur as part of the educational process. Third, [Ed: and most importantly] the incomes of highly skilled health care workers—notably physicians—are determined partly with reference to the incomes that equally able and skilled professionals can earn elsewhere in the economy. Because the U.S. distribution of earned income for all occupations is wider than it is in most other OECD countries, the relatively high incomes offered skil led professionals in the United States may well have served to pull up the incomes of American physicians relative to the incomes of their peers abroad.

 

[MacGyver]

I remember this thread. I wonder if ninerniner still thinks midlevels arent a threat.

I noticed he is at Hopkins. I rotated there awhile back. He should check out the hospitalist service on Halsted 5 or the HIV clinic on Carnegie 3. Both services have NPs on them that are totally and absolutely independent. No chart review, no cosignatures, absolute script authority, etc. The MDs on that service no longer have the auhtority to bill for their services. So that nice revenue stream they got from the midlevels is gone.

Maybe they havent made their way to the Hopkins ED yet where ninerniner works, but they will eventually.

 

[Brigade4Radiant]

So sheltered tower here - I've worked in all hospital settings. Believe me - there will never be a "physician equivalent" status between midlevel providers and physicians. The legal climate of our country will never stand for it...

hellooo? Will you re-read fuegorama's post one more time! It's a much more eloquent rebuttle to your insistance that the chairs on the Titanic do look better if rearranged! I remember one hospital I rotated at the doctors did not have MD after their names, but the nurses, PT's etc, had every initial since girl scout badges, after their names. Since the nurses run the hospital administration/HR they made the decision to take off the MD, and nothing the docs could do. Not that it matters, but as one resident told me, just another way to marginalize the docs, and reassert that the nurses are the patient advocate to protect them from the...doctors!!!! 99'r with your line of thinking, you're a shoe in for vice-president or even pesident of the AMA. So out of touch its really scary. I need not say more..fuegorama's post is perfect! and TRUE! Oh I also heard that PA's now want to be called Physician Associates, not assistants anymore. Again, where does it stop. whew, I'm out of breath...

PA's were originally called Physician Associates and then the name got changed. I think it is for the best because they often get confused with Medical Assistants...

 

[deleted6669]

Maybe they havent made their way to the Hopkins ED yet where ninerniner works, but they will eventually.

hopkins em pa residency program....🙂
http://www.appap.org/md.html#two

 

[NufinButTheToof]

In my experience, patients don't trust NPs. When in doubt, they ask MDs and MD opinion always overrules. From the lay viewpoint, the NP is always a "nurse" and the MD is always a "doctor." The NP has to explain they are a special kind of nurse with more certification and autonomy. All the MD has to say "Hi I'm Doctor So-and-so." The difference between these terms has a very powerful context in all societies.

What about when the Nurse anesth or NP aquires their Doctor of Nursing degree and they walk in the room in their white coat and say, "Hello, I'm Doctor so and so your anesth provider". Do you think the patient will know the difference then?

Example:
http://www.sahp.vcu.edu/nrsa/faculty/mfallacaro.htm

 

[Faebinder]

What about when the Nurse anesth or NP aquires their Doctor of Nursing degree and they walk in the room in their white coat and say, "Hello, I'm Doctor so and so your anesth provider". Do you think the patient will know the difference then?

Example:
http://www.sahp.vcu.edu/nrsa/faculty/mfallacaro.htm

There is a law against that now... you cant claim a doctor in the medical setting unless MD or DO.... but I am sure they will say 'anesthetist'.

 

[Taurus]

As long as the cost pressure is there, the midlevels will enjoy their day in the sun. Yes, they will make mistakes. Yes, physicians will be there to save their butts. But will that stop their rise? Nope. It always comes back to $$$. As long as they can save more money than they cost in litigation, then they are worth it.

How do we as physicians respond to this? We have to differentiate ourselves from them. Know or do things that are so much greater than what a 2 year master's degree can offer. We have to keep moving up the food chain. Fighting to keep our turf in primary care or anesthesia is futile. Midlevels have already shown they can do a "good enough" job in those fields and that's all the politicians and insurance companies really care about. Maybe "good enough" doesn't sound like good patient care to you, but it is to the politicians when you have an impending Medicare and Social Security budget crisis. It's medicine on the cheap or as I like to call it the "dumbing down" of medicine in this country.

One last thing, if a new midlevel group tries to invade your turf, have no mercy and squash them like a bug.

 

[jubb]

I think in some ways physicians salaries deserve to go down. We are relying on technology to do so much of the work that used to be done by the physician, that we are actually doing less of the hardstuff. The money that used to be handed over to us exclusively now has to be divided out to the tech people who invented all the modern medical machines we use today and keep them running and with all the new imaging technologies it has to go to someone to read it.

Believe me, I don't want to make less money or give poorer quality care, but I don't think our fellow citizens are willing to pay for the increases in quality of care they are getting. Yeah, they may demand it of their insurance companies, but then the rates go up and more and more people can't afford insurance.

I just think it's funny how much people whine about their co-pay and then go pay hundreds to thousands of dollars out of pocket for dermatologic or plastic surgery.

I fear it's going to get a lot worse before it starts to get better. There will be a shortage of doctors a lot sooner than people think.

Justin

 

[Hallm_7]

There's a lot of doom and gloom here, but the fact remains that physicians are taking home (on average) more than ever in dollar amounts. When you correct for inflation physician salaries haven't kept up with other professions, but salaries have NOT dropped. The individual reimbursement for procedures and E&M codes have dropped, but the payouts of Medicare to physicians has kept on increasing. Physicians have made up for the drop in reimbursement with an increase in volume.

Also look for the SGR to be repealed in the next couple years. The Senate and House both have large majorities signed on to get rid of it, but for some reason they just haven't voted on it. The SGR was part of the Balanced Budget Act in the 90s and would cut physician reimbursement when Medicare spending outpaced GDP growth. Fortunately the cuts have never materialized. Congress has always either maintained the previous year's reimbursement levels or given an increase of ~1.5%. That's where these projections that physician reimbursement will drop by 20% in 5 years come from. It's not gonna happen though.

Physicians are in the driver's seat. If you want to just be a doctor and bring home a respectable salary (but nothing too much) then you can do that. However, if you want to be a highly successful doctor then you have to innovate the way a practice is run. One way to do that is by not accepting any type of health insurance or medicare payments at all. Go completely to a pay for service system. This is beginning to catch on in a few locales with family practice. Another avenue is the so-called "boutique" practices in wealthier areas. Charge a yearly fee and then provide a very high level of service to those patients (spend a minumum of 15 minutes with a patient, give a yearly physical of 1 hour, guarentee same-day service, etc). Another development is the creation of large physician groups. Large physicians' groups can negotiate reimbursement rates with insurance companies without risk of anti-trust litigation. I personally know of physician groups that flat-out dropped an insurance company for failing to increase their pay.....the company increased their pay. There are also benefits to large groups in regards to call schedules, malpractice rates, and tax structure.

Someone said that physicians can't unionized. That's just incorrect. There are numerous examples around the country of physician unions. Besides, it doesn't even take a union to get what we want from Medicare. A work stoppage will go along way with the government. Just see what happened when Ontario physicians stopped working several years ago when the provincial government wouldn't pay them enough

 

[smugtroll]

The United States is not France.

http://ezraklein.typepad.com/blog/2006/04/on_doctors_sala.html

good article👍

ps. i've got a Ranger tat. on my shoulder from Iraq x2, so I'm aware the the United States is not France.

 

[LADoc00]

good article👍

ps. i've got a Ranger tat. on my shoulder from Iraq x2, so I'm aware the the United States is not France.

I heard that new Matt Damon movie Shooter is based loosely on your life.

 

[NDESTRUKT]

The subject of PA/NP providers has been covered on this thread greatly, but I would like to add something from personal knowledge. It was said earlier that NP's don't have as high malpractice due to less lawsuits - but I personally know a nurse midwife (specialty NP) that has ridiculous malpractice costs in the state of Indiana (one of the best states for medicine). She has never in her 20 years of experience had a lawsuit, but is paying crazy costs for her malpractice. In addition, she once told me that if they're ever sued, the insurance drops them right away - even if they end up winning (obvs due to the court costs, etc). Along that line, all her patients are Medicare. Does anyone think an NP can take away higher paying patients from the MD's? Perhaps in certain situations, but trust me...most people would send their loved one or themself to an MD they've never met > a PA/NP they've never met. My mom is an NP and she's awesome, but they're not all as good as her. How would I know the NP that my loved one is sent to will be good? It's so variable across the board. While on SDN we have PA's who are pretty darn competent in their field, are they all like that? From my personal experience, no. An NP/PA with >10 years experience is probably functioning pretty well, but an MD after residency would beat an NP/PA out of the gate for the most part.

MD's also enjoy worldwide recognition. Go to any country in the world, and a US MD will be acknowledged. You can't do the same with NP/PA. Sure many advanced countries are using mid levels like we do, but at the same time the majority of the world aren't. Asian countries don't even recognize NP/PA's as care providers.

My argument isn't whether or not NP/PA's are good enough to help out - I know plenty who are competent. My point is that MD's still share some great personal benefits. For one thing, we're still the benchmark all the mid levels are comparing themselves to ("I'm just as good as an MD.", "I can do everything an MD can."). I feel that will continue for many years to come.

 

[Taurus]

While on SDN we have PA's who are pretty darn competent in their field, are they all like that? From my personal experience, no.

I would agree with this. One of the problems with midlevel education is that it is too short. Too many bad or incompetent ones "fall through the cracks" and enter the system. Because physicians are in training and supervised for such a long period of time, the bad and incompetent ones are weeded out. Not everyone who enters medical school makes it to the other side. Does it get them all? No. But the probability of an incompetent provider is higher with a midlevel than with board certified physician. That's why I only recommend my loved ones to go to a physician and not a midlevel.

 

[PediBoneDoc]

i remember when i thought PA's and NP's would be a problem .... worried about them taking our jobs ... now, not so much .... i think most refer to them as physician extenders ... in my practice, we have both an NP and 2 PA's to go along with the 3 residents that rotate on service every month ...

there are a couple of reasons my thoughts on the midlevel provider have changed ...
1. i am a surgical subspecialty the more patients seen, the more surgeries ... and PA's and NP's can see patients alone. in most states, NP's can see a new patient and no supervising physician needs to be present (meaning in the building); PA's can not see a new patient and may or may not need the supervising physician to be present.
2. with the 80 work week ... who will fill in the time voids? i spoke about the 80 work week on my BLOG and how it makes the med studs and residents soft ... i received several responses that said things like residents need a life, they are not going to sacrifice themselves for a specialty ... well that's all very well ... but if the physician is not going to do the work ... who will?
3. on the PA end (not sure for NP's) the reimbursement is 80% of the physicians on an E&M code ....
4. most midlevel providers know their place .... you get the occasional PA who thinks he is a doctor (usually male) ... an the occasional NP ... but it happens with many of the nurses after a while ...

so, i would recommend you embrace the NP and PA, it will make you life easier and give you to ability to expand you practice without incurring the cost of another physician.

pedi out

 

[schwartz818]

I am starting college right now and am very interested in the field of medicine. However I want to make atleast 300K or whatever would be equivilent to 300K after inflation. I know many doctors right now are able to make more than that. Do you guys think it would be possible to make that much in the next 15-30 years. If so what specialties do you think will be most uneffected by these cuts

 

[mdjobexchange]

It is only a matter of time before either medical school applications take a dive, or medical student quality takes a dive. There will be a shortage and salaries will go back up. I saw this happen beginning in 2000 in anesthesia. Salary increases for anesthesia have leveled off somewhat, but I know average salaries for both locums and permanent anesthesia jobs are higher than 6 or 7 years ago. Primary care may have some price pressure secondary to midlevels. If Americans are not going to value their primary care docs, that will be their loss.

Most professionals in this country have been seeing salary increases, especially IT and accounting. Dentists make good money, as do pharmacists. Why go to medical school when you can do so many other things? Especially without taking on the huge amount of debt. Sure, there will be the people who had their lives changed by an experience and want to do nothing other than medicine. I don't think most doctors fall into that category.

It may take 5 to 7 years for the whole thing to play out, but I believe it will happen.

 

[UMED122]

It is only a matter of time before either medical school applications take a dive, or medical student quality takes a dive. There will be a shortage and salaries will go back up. I saw this happen beginning in 2000 in anesthesia. Salary increases for anesthesia have leveled off somewhat, but I know average salaries for both locums and permanent anesthesia jobs are higher than 6 or 7 years ago. Primary care may have some price pressure secondary to midlevels. If Americans are not going to value their primary care docs, that will be their loss.

Most professionals in this country have been seeing salary increases, especially IT and accounting. Dentists make good money, as do pharmacists. Why go to medical school when you can do so many other things? Especially without taking on the huge amount of debt. Sure, there will be the people who had their lives changed by an experience and want to do nothing other than medicine. I don't think most doctors fall into that category.

It may take 5 to 7 years for the whole thing to play out, but I believe it will happen.

Agreed. I was shocked to learn that in the city where I grew up, teachers are now making nearly as much as primary care docs after about 7 years of teaching experience. That's teaching experience, not school, as in, they're getting paid for the experience while pcp's in training are going 300k in the hole. I'd like to think the decreasing salaries in medicine are nearing a breaking point.

 

[nowanmd]

A significant portion of the healthcare dollar is consumed by administrative expenses and health insurance company profits. Having numerous health insurance companies creates very expensive duplication of administrative expenditures ( data processing, billing, marketing etc.) Having a single payer (but not socialized medicine) will significantly increase efficiency and just possibly enable physicians (especially primary care)-the ones who actually do the work- to make a fair living.

I believe this is fundamental to rational health care reform.

 

[UMED122]

A significant portion of the healthcare dollar is consumed by administrative expenses and health insurance company profits. Having numerous health insurance companies creates very expensive duplication of administrative expenditures ( data processing, billing, marketing etc.) Having a single payer (but not socialized medicine) will significantly increase efficiency and just possibly enable physicians (especially primary care)-the ones who actually do the work- to make a fair living.

I believe this is fundamental to rational health care reform.

You're right about all the extra admin expenses with private insurance. But correct me if I'm wrong...aren't doctors paid even less by medicare and medicaid? In a single payer system, that's the only way physicians can be paid, I think.

 

[Faebinder]

You're right about all the extra admin expenses with private insurance. But correct me if I'm wrong...aren't doctors paid even less by medicare and medicaid? In a single payer system, that's the only way physicians can be paid, I think.

I am continuously surprised to find out that medicare pays more than other insurances. Medicaid pays lower than everything usually. It's almost like a single payer system except that the adminstration sucks the money from the physicians. I wouldn't be surprised that people want a switch to socialized medicine but i dont see it happening soon. Insurance companies wont let it happen. Primary care wont suffer much (if any really) from socialized medicine. Heck they might even see a rise. The subspecialties on the other hand will see a significant drop in pay.

 

[LADoc00]

Do you guys think physician salaries will continue to go down in the next 10-15 years (Family Practice & Specialties)?

Of course, my gut impression is that primary care will begin on the average to be less than nursing in a mere 5 years. In many communities nursing is already better compensated than the average Peds doc.

Surgery will continue to drop bigtime, probably getting a 30-40% haircut within the next 10 years. To compensate, surgeons will do cases far more quickly and work much longer hours.

The result will be fields like general surgery, ob, primary care will be nearly 100% FMGs by 2020. Of course insurance companies will laugh all the way to the bank on this one.

You will also see very very few MDs working more than 40 or so hrs a week. More lifestyle choices will be made. Derm will be by far the most competitive residency before the floodgates are opened and med schools realize they have to train 10x more dermatologists then they are now because no one wants to do anything other than that (ie no AoA will choose surgery, surgical subs, gas or IM).

Derm compensation will continue to grow because more and more are opting out of insurance.

Eventually the dam will burst and burst big. Of course my plan is to have 3-4 million in the bank by the time it does...

 

[Taurus]

Derm will be by far the most competitive residency before the floodgates are opened and med schools realize they have to train 10x more dermatologists then they are now because no one wants to do anything other than that (ie no AoA will choose surgery, surgical subs, gas or IM).

Derm compensation will continue to grow because more and more are opting out of insurance.

Med schools don't control the number of derm positions. Like many highly prized fields, derm keeps its slots low to maximize income. It's all about supply and demand. Funny thing is that only the US seems to value derm. Physicians from other countries in Europe and India think derm is the bottom of the barrel.

In the future, I see derm getting more competition from FP, internists, and NP's. As most derms will admit, an FP can do 80% of what a derm can do. These FP, internists, and NP's will simply drop Medicare patients and begin to accept all cash for derm-related visits. I know that's what I would do if I were in one of those fields.

When I was doing my FP rotation, I was surprised to learn that FP has a derm fellowship. If FP expanded the number of these fellowships, then derms could be hurting in the future. It comes back to supply and demand.

 

[schwartz818]

So from what ive been hearing specialties like cardiology, radiology, oncology urology will still make a good living in the next 30 years because no midlevel or any other field will be able to replace the work they do. They seem like they will be the least hurt by future cuts

 

[latinfridley]

I am starting college right now and am very interested in the field of medicine. However I want to make atleast 300K or whatever would be equivilent to 300K after inflation. I know many doctors right now are able to make more than that. Do you guys think it would be possible to make that much in the next 15-30 years. If so what specialties do you think will be most uneffected by these cuts

All specialties will be affected by cuts in pay except some of the private practice plastics docs and the other odd ball who does not accept govt insurance.
There is no guarantee in medicine as far as compensation is concerned except to say that you will be making more than 90,000 and you have great job security.

 

[nima123]

This article talks about how health care reforms are lowering physician reimbursements and suggest how doctors can fight back:

http://www.facs.org/ahp/pubs/whatsurg0207.pdf

I think by the time I finish residency and start practicing, doctors would be considered POOR if the trend doesn't change!

 

[wanabdoc]

When HMOs started taking over, everyone said that physician salaries would start drastically dropping.

Here is a chart of what has happened from 1982-2000. You can find this information in almost all medical school libraries. I will get 2006 data as soon as I locate a reputable source.

Physician Salaries

 

[nowanmd]

We really should start thinking like we did when we were kids- it's MY basketball I'm gonna go home and take it with me GAME OVER

There are only a limited number of doctors-you gotta go to med school get licensed and do a residency-we should stand together against hospitals,insurance companies and the government- they'll shout antitrust, collusion-but that's what they do to us- they dictate our reimbursement and compensation and collude- we need to act in unison- to make a fair living- I'm sure there's no programmed decreases in insurance company executives' pay- wake up my colleagues- you have nothing to lose but your stethoscopes(chains).

 

[Faebinder]

We really should start thinking like we did when we were kids- it's MY basketball I'm gonna go home and take it with me GAME OVER

There are only a limited number of doctors-you gotta go to med school get licensed and do a residency-we should stand together against hospitals,insurance companies and the government- they'll shout antitrust, collusion-but that's what they do to us- they dictate our reimbursement and compensation and collude- we need to act in unison- to make a fair living- I'm sure there's no programmed decreases in insurance company executives' pay- wake up my colleagues- you have nothing to lose but your stethoscopes(chains).

We gotta be able to unionize. The weakest links right now are indivisual practioners. AAFP and the AMA have been talking about this. How the insurance companies dictate to individual practioners what they will pay them. I think individual practioners of a specialty in a city should be able to form a negotiating union, otherwise there is no way counter the large monopoly of insurance companies other than out right refusing to take insurance (in which case they go to the ER where the EMTALA will save them).

 

[Winged Scapula]

When HMOs started taking over, everyone said that physician salaries would start drastically dropping.

Here is a chart of what has happened from 1982-2000. You can find this information in almost all medical school libraries. I will get 2006 data as soon as I locate a reputable source.

Physician Salaries

While physician salaries may be higher than they were 25 years ago, so are expenses. Frankly, the minimum wage is 57% higher today than it was in 1983. Surgeon salaries for example have fallen 7% when adjusted for inflation (ie, compared to how everyone else's salaries have risen).

 

[Taurus]

We really should start thinking like we did when we were kids- it's MY basketball I'm gonna go home and take it with me GAME OVER

There are only a limited number of doctors-you gotta go to med school get licensed and do a residency-we should stand together against hospitals,insurance companies and the government- they'll shout antitrust, collusion-but that's what they do to us- they dictate our reimbursement and compensation and collude- we need to act in unison- to make a fair living- I'm sure there's no programmed decreases in insurance company executives' pay- wake up my colleagues- you have nothing to lose but your stethoscopes(chains).

I agree with this. However, med schools don't encourage this type of thinking. They want students who will sacrifice anything and everything for medicine. They want the person who will do missionary work in Africa for practically nothing. Students don't appreciate how medicine is under assault until they're off practicing in the real world.