Healthcare, health policy, cognitive science. , and the path to Universal Healthcare..
The Health Care Blog: POLICY: Oh Canada
“This article is about Canada’s health system and its relationship to the US health policy debate. It is not meant to be an endorsement of Canada’s system, or an endorsement of single payer for the US.”
Very well done, but a few years old. Most of the information is still pertinent. Very nice, very detailed compare/contrast piece on US vs. Canadian Healthcare systems.
An Egalitarian Culture [at the Mayo Clinic]
You may have heard that at Mayo, doctors collaborate. But did you know that after their first five years all physicians within a single department are paid the same salary? During those first years, physicians receive “step raises” each year. After that, they top out ,and “he or she is paid just the same as someone who is internationally known and has been there for thirty years,” says Patterson. (“Most could earn substantially more in private fee-for-service practice.” he adds.)
“It doesn’t matter how much revenue you bring in,” Patterson explains, “or how many procedures you do. We’re all salaried staff—paid equally. This is very good for collegiality, and people working together,” he adds. “The culture here at Mayo doesn’t encourage egos. There is not the same cult of personality that you find at other places.”
At Columbia, by contrast, the pecking order is quite clear: even the furniture on the floor where a physician works tells him where he stands. “The floor we were on was perfectly fine,” Patterson recalls. “But if you walked up a few flights to ENT (ear nose and throat) surgery, it was a different world—dark wood paneling, different furniture… These surgeons bring in a much higher return for their time,” he points out, “and they do some things that require remarkable skill and training. At the same time, if a psychiatrist spends two hours with a patient, he may get $200, while all a dermatologist needs to do is get out the liquid nitrogen…”
The dermatologist can make $200 in a matter of minutes, just by zapping the harmless crusty brown patches on the back of a middle-aged patient commonly known as “barnacles of age.”
That celebrity turns on how much money a doctor brings in hardly unique to Columbia. “Traditional medical centers are much more hierarchical,” Patterson notes.
The article goes on to say how the filthy socialists have significantly lower spending and excellent care, they value the patient over the revenue generated per procedure, thinking and taking care of patients is valued more than one’s “revenue stream.”
BBC NEWS | Health | GP salary surge goes into reverse:
“Inflation-busting pay rises for many GPs in recent years have been halted – with the average salary falling in 2006/07, NHS figures show.
The average salary for 85% of GPs was £104,000, a fall of 2.4%.
This comes after sharp rises following a new GP contract in 2004 – as much as 58% on average , according to a spending watchdog.
The British Medical Association said most earned under £100,000, and further falls could risk damaging morale.”
The exchange rate is about two to one, so, GPs are making the equivalent or $200K. Not too shabby. The downside is that their salaries seem to be so much more dependent on the prevailing political and economic winds than are ours. But, as we saw with the recent battle to prevent across the board Medicare cuts, we face this pressure as well.
Out of curiosity, I checked to see where this income fits in British households. The top quintile for household income in the UK starts at £72.9K
TH – Top News Article:
“The Georgia study suggests changes to insurance reimbursements hurt primary care by rewarding the delivery of diagnostic tests and medical treatments, instead of rewarding time spent communicating with patients.
‘What has happened with the physician payment system historically is that it has given a higher value to procedures over cognitive care,’ Hubbard said.
Family medicine physicians have the lowest average salary ($185,740) of the doctors studied, compared to radiologists and orthopedic surgeons, who had an average salary of more than $400,000.
‘When a medical student chooses a specialty, potential income is becoming more and more of a factor in that decision,’ Hubbard said.
Knox fears access to care could become restricted if a primary care shortage continues.
Physician assistants and nurse practitioners can fill some of the gaps left by a dearth of primary care physicians — to a point.
‘There is a higher level of qualification required to provide some of the services that physicians provide,’ Tracy said.
Pechous said the economics of training and retaining new physicians is complex.
The debt load facing medical school graduates is one of the impediments to enlarging the pool of primary care doctors. For M.D.s, that debt is pushing $130,000, Tracy said.
‘It is like a second mortgage.'”
Another interesting statistic:
“At the University of Iowa’s Roy J. and Lucille A. Carver College of Medicine, 37 percent of the incoming class entered the family medicine field in 1996. By 2006, that number had dropped to 10 percent. In the early 1990s, Iowa graduated nearly 45 family doctors per year. By 2006, that dropped to 12.”
Thanks to Dr. Pechous for writing this. The solution, really, is obvious. Pay more for the behavior you want and less for the behavior you don’t want. Higher reimbursement for primary care services, lower for procedures. This is not “class warfare” for physicians, it is simply facing simple economics and the consequences of reimbursement rates.
Physicians, health, burnout Salon:
“I’m tired. Really tired. I’ve been seeing patients continuously — one every 15 minutes — for five and sometimes six days a week. The pace is nothing new for me or most primary care doctors. But lately it all feels like a game of Jenga, with patients stacked on top of one another like wooden blocks, ready to come tumbling down.”
I’m posting this, not so much for the article itself (about physician burnout), but for the responses/letters. To all doctors, read the letters by clicking “Editor’s Choice” first, so you don’t get too angry or depressed. Then read all the letters.
I just found it very interesting both the animosity and admiration physicians generate among the public. And another common thread is that the public seems to understand that we, too, are entrapped in a lousy system — but also wonder, then, why we aren’t getting the AMA to finally back serious reform.
Cheers,
Need Some Botox With that Flu Shot? : NPR:
“Primary care doctors say they’re having more and more trouble making ends meet. They’re drowning in required paperwork and getting paid less than specialists. So, a growing number of general practitioners are adding cosmetic procedures to their offerings as a way to bring in more money.”
No surprizes in this story, except at the end there is a bit of discussion of the reimbursement differential among procedure-based specialties and the rest of us.
And NPR really seems to be giving healthcare the full coverage blitz lately. Lots of stories about healthcare including this one on Morning Edition documenting the travails of two patients with MS. The first in the “new and improved” NHS in Britain and the other, a man in Philadelphia who thought he had good healthcare insurance.
And here is a link to their “Health Care for All” home page.
Keeping German Doctors On A Budget Lowers Costs : NPR:
“How Doctors Get Paid
Nearly all hospital-based doctors are salaried, and those salaries are part of hospital budgets that are negotiated each year between hospitals and ‘sickness funds’ — the 240 nonprofit insurance companies that cover nearly nine out of 10 Germans through their jobs. (About 10 percent, who are generally higher income, opt out of the main system to buy insurance from for-profit companies. A small fraction get tax-subsidized care.)
Office-based doctors in Germany operate much like U.S. physicians do. They’re private entrepreneurs who get a fee from insurers for every visit and every procedure they perform. The big difference is that groups of office-based physicians in every region negotiate with insurers to arrive at collective annual budgets.
Those doctor budgets get divided into quarterly amounts — a limited pot of money for each region. Once doctors collectively use up that money, that’s it — there’s no more until the next quarter.
It’s a powerful incentive for doctors to exercise restraint — not to provide more care than is necessary. But often, the pot of money is exhausted before the end of the quarter.”
Interesting piece from over the Fourth holiday. It was mostly about the last paragraph above: Namely that physicians have to decide whether to continue to provide service until the end of the quarter when the budget is already exhausted. Seems bizarre to physicians here, except that we do the same thing, only play the game differently.
The way we do it is not quarterly, but on an ongoing basis. Most of our patients have insurance that pays us (more or less) what we expect, but a certain percentage have Medicaid or are uninsured altogether or have crappy insurance that doesn’t cover whatever you just took care of, and so on. So the net effect is similar.
But another intersting tidbits is the salaried nature of hospital based physicians. It would be interesting to see what the contracts look like in terms of benefits, vacation, salary, etc.
Doctor shortage worsens as student debt rises:
“the debt burden on graduates is daunting, especially given that they must spend at least three more years on post-graduate residency training that pays about $44,000 to $45,000 for the first year, according to the Association of American Medical Colleges.
While in their residencies, many future doctors choose to defer their school loan payments, so their arrears grow even larger as they accrue interest, Black said.
That option will be gone, however, beginning in July 2009, when the U.S. Department of Education ends medical school payment deferment — a move that could further put aspiring doctors in a financial bind, said Chromy, who helped author the resolution.
‘We’re required to do this residency, but we can’t defer,’ she said. ‘If we’re trying to increase the supply of physicians, the answer is not to make it harder to make physicians.’
The resolution estimates that the average monthly payment on debt of about $160,000 starts at $1,400 a month on a 25-year repayment plan — or about 50 percent of the post-tax income of a resident’s salary.
In his two years of medical school at Wayne State, Joseph Khouri has racked up about $140,000 in debt, a figure that includes out-of-state tuition and loans to pay for living expenses.
‘I mean, this is ridiculous,’ said Khouri, who is from Cleveland. ‘Medicine isn’t about money and it never was about it for me. But graduating $280,000 in debt is intimidating.’
It could be worse for future medical students at Wayne State Medical School. One report by the medical college association projects debt for graduates could rise to about $750,000 by 2033.”
This is the new social contract we have accidentally made. We tell our students to suck it up and pay extraordinary tuition to become doctors. Then we tell them they should be going into primary care, where they would be doing the most good caring for patients, but will never catch up to their peers in income, accumulation of home equity, retirement funds or wealth in general.
The saying that “it’s just as easy to fall in love with a rich man as a poor man” comes to mind. While in training, it is just as easy to fall in love with a handsomely reimbursed specialty as it is a poorly reimbursed one.
Health Blog : Some Nurses Land Higher Salaries Than Primary Care Doctors:
“The Merritt Hawkins figures for the nurses are higher than some other sources. The Medical Group Management Association, which tracks health-care salaries, puts nurse anesthetists’ median compensation at $140,000 per year — still pretty good, from where we sit. Miller said the discrepancy may be due to the fact that fewer employers go through recruiters to hire the nurses, and those who do are willing to pay top dollar.”
Essay – Fed Up With the Frustrations, More Doctors Change Course – NYTimes.com:
“Not long ago, fed up with what he perceived as a loss of professional autonomy, Dr. Bhupinder Singh, 42, a general internist in New York, sold his practice and went to work part time at a hospital in Queens.
“I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.”
When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.
“But managed care is like a magnet attached to you,” he said.
He continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ””
But if they were Government Bureaucrats, now that would be intolerable…
BTW, I included this post with the category of Rationing Healthcare because it does become rationing by attrition. Physicians often are so frustrated by the battles they fight hourly with Private Insurers, they cave in and provide less than optimal care.