Category: Physician Income

AMNews: June 29, 2009. AMA meeting: Don’t shortchange specialists to fund care model … American Medical News

AMNews: June 29, 2009. AMA meeting: Don’t shortchange specialists to fund care model … American Medical News:

“Chicago — In the discussion of how to pay for coordinated care under the patient-centered medical home model, the AMA House of Delegates agreed that primary care physicians should not be rewarded at the expense of specialists.

“At its June Annual Meeting, the house voted to advocate that additional pay to physicians for operating a medical home should not come from a reduction to the pay of specialists. Delegates approved language that medical home payments not be subject to requirements for budget neutrality in Medicare, where an extra dollar spent somewhere means a dollar has to be cut elsewhere.

“The house also approved recommendations that private plans and the Centers for Medicare & Medicaid Services develop one standard for a medical home, and that specialty practices as well as primary care practices should be able to serve as that home.

‘Primary care needs more help. It just shouldn’t come at the expense of specialists,’ said Kim Williams, MD, a cardiologist from Chicago and a delegate for the American College of Cardiology.”

I am aware that, in the House of Medicine, it is impolite to disagree with this notion that primary care physicians should get more money but there should be no adjustment of specialist reimbursement. It is not just impolite, it is also likely to start fights. I expect that the notion of knocking down the uber-specialists reimbursement lurks in the darkest places of the hearts of many a PCP and psychiatrist, the class-warfare-that-must-not-be-named.

But, consider the incomes of internists starting at $150K or so and neurosurgeons, radiologists (nuclear medicine), thoracic surgeons, invasive cardiologists and orthopedic surgeons starting at between $400K and $600K, it is hard not to wonder whether the economic disincentive of going into primary care can ever be overcome by raising PCP income by 20 or 30 or 40 per cent or more. Value is relative and simply increasing PCP income a bit and still having one’s peers making vastly more explicitly marks the value we place on primary care.

Societies generally reward physicians with good incomes, but except for the incomes of specialists in the Netherlands, nowhere near as highly as we do. But, on the other hand, no country saddles their young doctors with the massive debt that we do. Heavily subsidized tuition is the norm, not the exception, and so young doctors around the world do not feel the economic imperative to enter the best paid fields as we do here. Nor do other countries have the massive overhead of physicians beyond debt: malpractice insurance, billing staff to fight with insurers and so on.

I expect that if we graduated medical school with debt similar to those of our non M.D. peers, incomes more comparable to our international peers would be more acceptable.

Median Physicians’ Salaries – Health Blog – WSJ

Median Physicians’ Salaries – Health Blog – WSJ:

“Good news for med students worried about their debt loads: Physicians coming out of residencies last year reported increases in their starting salaries in many specialties, according to a survey by the Medical Group Management Association, a trade group for medical groups.

“Here are the specialties with the biggest jumps in 2008 from a year earlier based on data from 3,520 physicians:

Neurology: $200,000 to $230,000 –- up 15%

Non-invasive cardiology: $350,000 to $400,000 – up 14.29%

Anesthesiology: $275,000 to $312,500 – up 13.64%

Emergency medicine: $192,000 to $215,040 – up 12%

Internal medicine: $150,000 to $165,000 – up 10%

“And as if we needed any more reminders about why there’s a shortage of pediatricians and family practitioners, the report also contains data on the extremes: The lowest starting salary in 2008 was for pediatricians — $132,500. The other lowest-paid specialties, in ascending order: family practice, geriatrics, urgent care, internal medicine and infectious disease.

The highest specialty salary was for those starting out in neurological surgery — $605,000. Others at the top of the heap, in descending order: radiology (nuclear medicine), thoracic surgery, cardiology and orthopedic surgery.”

I’ve blogged about this before, but coming out of medical school in massive debt, knowing that you are going to make low wages for your three to seven years of training, and still choosing one of the lower income specialties requires some significant altruism. God bless everyone who does this.

But, this should not be such a stark decision. We really do need to do something about reducing or eliminating the cost of medical school to encourage (or at least make it not an economically crazy thing to do) students to enter primary care and other lower paid specialties.

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker:

A damning look by Atul Gawande at the way we pay for medical care in America. The final three paragraphs of this must read article.

“Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

“In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”

“As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.”

I went to the Dartmouth Atlas web site myself and found this interesting tid-bit:



I think it fits in well with the ethos described in Gawande’s article.

It is much easier to continue aggressive treatment rather than spend time having an honest discussion about the benefits and burdens of continuing treatment.


Thanks to whoever put the link up on the Howard Dean Webinar tonight!



UPDATE: This recent Archives of Internal Medicine article is particularly apporpriate:
http://archinte.ama-assn.org/cgi/content/short/169/10/954

This also, perversely, can make the hospital statistics in mortality look good, as well. As an intensivist, I can get almost ANYONE out of the the ICU and subsequently out of the hospital if I ignore the true outcome for the patient and the family: additional suffering, minimal prolongation of a life at its end, and so on.

My colleagues who do practice best EOL practices know that our ICU and hospital mortality numbers suffer, but I have no doubt that having honest discussions with my patients and families is the right thing to do. You may have heard this for your patients, “Thanks for the straight talk, Doc,” or “Nobody talked to me about my prognosis before.”

Of course, this is not new information, but we still need to do better as physicians:http://www.chestjournal.org/content/128/1/465.full?ck=nck

COST: Is This What They Went to Med School For? | New America Blogs

COST: Is This What They Went to Med School For? New America Blogs:

Excellent summary by Joanne Kenen at New America:

“Two new studies released this week online by Health Affairs examine how health care providers, particularly physician practices, interact with insurers. One study found that doctors personally spend the equivalent of three full weeks a year on billing and related insurance information. The overall cost to their practices (their time as well as other medical and clerical personnel) was about $31 billion a year (in 2006)—which as study author Larry Casalino noted, was about six times what we spent at the time on the State Children’s Health Insurance Program and nearly 7 percent of total national expenses on physician and clinical services. Primary care practices spent more time on these administrative tasks than specialists. Very little of the data—only about two hours a year for the doctor—pertained to quality data.

“The second study looked at the billing and insurance-related activities at one large multi-site, multi-specialty California group practice. The cost (in physician and clerical time) turned out to be $85,276 per physician, or 10 percent of operating revenue. (And that excluded the time the doctors spent recording procedure and diagnosis codes). And this California practice isn’t bogged down in paper; they already use electronic medical records for both clinical and billing data. (Some older studies, before medicine began its slow and not always so steady migration to Health IT, showed even more time and money spent on administration in the days of pure paper.)”

Additionally, from the second paper:

Impact of complexity. Previous reports have suggested that the complexity inherent in the current multipayer financing system is responsible for increasing the administrative burden associated with medical groups’ transaction processing.15 During our interviews, informants frequently described the contributions of complexity in the payment system to billing and insurance burden. For example, the patient population of our study site is covered by hundreds of insurance plans, each with its own rules about benefits covered and under what conditions, payment rates, and often billing procedures. This complexity adds burden to billing and insurance tasks, including procedure coding, drug formulary authorizations, discussions with patients, submission and appeal processes, and receipt of payments. The complexity also increases the chance for error and dispute, increasing the likelihood of payment follow-up and collections. Even high-deductible plans, which might appear to avoid administrative burden for initial services during the year, impose billing/insurance costs because each service, including those within the patients’ deductibles, must be evaluated and processed.

I’ve also classified this under Physician Income and Physician Autonomy, because these burdensome duties and their concomitant expenses impact both significantly. If you think your PHIs are paying you more than Medicare, you need to factor this into the equation.

Health at a glance: OECD indicators 2005 – Google Book Search

Health at a glance: OECD indicators 2005 – Google Book Search

I was looking to find the prevelance of Nurse Practitioners elsewhere in the world and found the entire OECD “Health at a glance 2005”

Very interesting.

Who has the highest paid specialists? The Netherlands.

Where do PCPs and specialists get paid the same? Portugal.

Most MRIs? Japan. CTs? Japan.

And who pays the most? Oh, you know this one!

Shortage of Doctors Proves Obstacle to Obama Goals – NYTimes.com

Shortage of Doctors Proves Obstacle to Obama Goals – NYTimes.com:

“Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors — the very ones needed to coordinate the care of older people with chronic conditions like congestive heart failure, diabetes and Alzheimer’s disease.

““Primary care physicians are grossly underpaid compared with many specialists,” said Mr. Baucus, who vowed to increase primary care payments as part of legislation to overhaul the health care system.

“The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists.

“Dr. Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, said: “We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way.

““If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.””

So, do we have the beginnings of class war in medicine? Our spending is unsutainable, we spend it in the wrong places quite often, and the specialties with something to lose ( high reimbursement rates) are not going to take this lying down.

The article also goes on to point out that as we bring more people into the ranks of the insured, waiting times will go up. Gee, where have I heard that before?

What Doctors Make, and Why – New York Times

What Doctors Make, and Why – New York Times:

“In “Sending Back the Doctor’s Bill” (Week in Review, July 29), you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid. A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.

Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.

Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.

This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.

Uwe E. Reinhardt, Princeton, N.J., July 30, 2007″

OECD Study of Physician Income in 14 Countires

“The Remuneration of General Practitioners and Specialists in 14 OECD Countries: What are the Factors Influencing Variations across Countries?
(Published 22-Dec-2008)”

This link takes you to the full PDF file of the document. It is interesting.

For primary care, most coutries get between $106k to $121K, US is $146K. Interestingly, the dreaded NHS of the UK is the $121, and France is a low outlier at only $84K! But keep looking through the graphs, they are interesting. For example, US PCP’s are payed 3.4 times the average wage of our countrymen, and this is in line with the top half dozen countries or so.

Turns out the Netherlands has physician income for specialists higher than ours, by quite a bit ($290K vs $236K). But the rest of the countries fall off fairly quickly. They do not have the large disparity of specialist vs PCP income that we do.

I don’t have the data (nor the skills!) to do the analysis, but I would be very interested in how wealth accumulation differs among the countries. Considering the large expense of American colleges and Medical Schools, I would make a guess that we are so far behind the eight ball when we finish our educations and training, that we probably don’t catch up with our international peers until we’re in our forties or fifties, except for the highly payed specialties.

So, would it be wiser to do as other countries do and heavily subsidize our educations so there is not so much pent up delayed gratification? And would that also lead to more PCPs and less income disparity among specialties?