Do today’s doctors feel they owe anything back to society?

Many physicians now see taking Medicare and Medicaid as providing charity care. Relative to private insurance, it usually is. Anon 11:16am, that’s precisely why fewer and fewer physicians ARE accepting Medicare and Medicaid patients, and terminating those contracts.
In addition, Federally Qualified Health Centers (community health clinics) are there to provide a societal safety net, so the individual physicians in private practice don’t have to feel that they are the last resort.

I wonder if the author of the first comment has heard of EMTALA? To have a medical practice in most specialties (particularly surgery) you must have hospital privledges. Now, with that comes mandidated ER call as hopitals by law must have a call schedule for specialties that practice there. Part of ER call is EMTALA. That is to say, if a patient hits the door of the hospital, you can be called in to treat, stabilize, etc. In fact, you pretty much inherit that patient for the extent of their care. This is not for free, as if they are uninsured you lose income as you have to cancel your paying patients to take care of what came in on call. Additionally, people who go to the ER are usually really sick and have a high potential for bad outcomes which leads to lawsuits.

We are trying to be like attorneys and get the hopsital to help pay for call. Court appointed attorneys for those that can not afford their own at least get something for payment, we get the chance to be sued. Oh, I actually saw an attorney in the Emergency Room last night at 2:00am. He wasn’t called in at the request of a client, he was drunk and hit a tree with his volvo.

One thing that is often forgotten when discussing the income of physicians is that the income doesn’t start until long after most other professionals have begun earning, and with high debt burdens as a result. Many 20 year olds have more stashed in their Roth IRA’a from summer jobs, than I had in my retirement accounts when I was 31 years of age. Furthermore, a physcian, to earn that money, makes an investment in a business, but really only to own his own job, as it is still a personal service that only earns money when he is working it. My attorney uses “value added pricing” and my accountant charges me as if he were doing my taxes when what actually happens is his employee puts the numbers in the program. The result is that they both “earn” hourly fees for hours they aren’t putting in. I, on the other hand, bill for fewer hours than time spent as only face-to-face time with patients is billable.

In short, it is enough money–I am not griping on that account–but it is no gravy train and the end result is about the same as other professions as engineers, solo shop attorneys (the big group practice guys leave us in the dust), and CPA’s all of whom put a lot less into the educational process. The social contract in which physicians were free to charge what they wanted to those who could pay but treated the poor for little or nothing was broken long ago by the rest of society. I realized that when I found myself treating elderly wealthy persons at Medicare mandated discounts that amounted to charity care, even though they were far wealthier than I could ever hope to be.

Society broke the contract long ago, it is silly to ask us to hold up one side of it.

If Warren Buffet is enrolled in Medicare to which he is entitled, then all but the few opted out physicians are required to treat him at a charity care discount rate.

I have a fantasy of a practice with Reciprocity Billing:

You are a trial attorney: you sign over 40% of your earnings the rest of your life if you survive the treatment.

You work for a billable hour hog law firm, I send you a bill for our time, for my lunch while I was thinking about your case, for the time I spent reading journals that relate to your case, and for typing up the bill.

You work for a University, you pay 20,000 for a year of regular visits in advance which is non-refundable. I expell you from the practice if you are non-compliant with homework and you don’t get your money back.

You are a physician: I give whatever professional courtesy you give.

You are a preacher: You tithe me 10% of your income year after year whether you use the service or not.

You work in insurance: I charge you monthly fees, and cancel you when you get sick and make an appointment.

You work for public schools: I bill you for sloppy care, demand more if you complain about the service, and take a stress sabatical if you complain again-but you still get billed.

You work for a cell phone company. I charge you a monthly bill pumped up with mystery charges and don’t talk to you when you call.

You are an elected official: I promise you everything. Get your personal identifying information. Then strip you naked, lock you in the basement, and max out your credit cards and empty your back accounts laughing while you rage about my lies.

You are a member of that dying race, an American who produces useful goods or services that make life better, only get paid when you produce product, and never take nothing for nothing: then I charge you staight hour for hour exchange.

happyman, I don’t know how happy you are but you are certainly a funny man.

If you actually belive the guy running the corner gas station makes more than Drs. you are out of touch with reality. Why do you think all those gas stations now sell so many nickle and dime items inside? Its because thats the only profit they make. And, it is penny profit! Now if you were to say you wish you had been an oil man who could then screw everyone from the gas staion owners to the consumers on prices, then you might be on to something.

So, why not just give up medicine and go buy a gas station? But, you better watch out for those gallons that you buy at 3.35 a gallon and have to sell at 3.15 a gallon because thats what speedway down the street is selling at. Trust me. You won’t take home any paycheck that month!

“my point is that there are plenty of small businesses where one can earn a 6-figure income with little investment compared to medicine.”

Such as. . . ? I mean, a great salesman can make money doing anything, but which businesses do you think are so much easier and require so much little investment than being a physician, and still have average salaries of $150K a year like physicians?

Do you have any clue what the capital investment of buying or starting a gas station is? And the ROI? It doesn’t appear so.

“1- EVERYBODY makes you show participation with medicare/medicaid, from commercial insurers to hospital administrators to malpractice carriers.”

This is simply untrue – there are physicians out there who have completely dropped out of that game – I think Kevin’s even linked some of their blogs.

“2- “high standard”? if you are in primary care, you are SOLIDLY MIDDLE-CLASS after umpteen years of education making $100,000/yr starting in your thirties while everyone else was building a business/ spending their young adulthood having fun / etc. “

Do you really not think an average salary of $150K, or $250K for surgeons, is not upper middle class? If you don’t, then you need to take a hard look at what the rest of the country makes and how hard they work. I don’t think you’re in touch with reality.

Are you joking with the motel line? Seriously, I would encourage you to stay a physician – you have no concept of how the world that doesn’t get all its payments from large companies and the government works.

thanks a non 10:00am.

You are right, and this discussion shows just how little understanding laypeople have of actual medical practice now.

And, anecdotally, I have heard the average investment in a mcdonalds or dunkin donuts franchise is about $200,000. This is certainly less than than the time & money it takes to become a practicing primary care doctor (not to mention you don’t have to worry about acing endless tests). And I have heard (again I admit, anecdotally) that these franchises net the owner well into the six figure range.

I’m not saying that running a franchise is easy – it most certainly isn’t. But all the same hassles of running a small business also apply to a medical practice, as well as malpractice issues, third party reimbursement, on-call responsibilities, etc.

And as far as what the rest of the country earns, that doesn’t matter. When you train for so many years, most would agree that it’s reasonable to except to be (at least) upper middle class.

“The latest ACGME rules (2003) put the resident work hour limits at 80 hours/week (before that it was not unusual to see surgical/medical residents working over 100 hours/week. That’s the fact.”

How much work do you think a motel owner or a new franchise owner does? And his debt ain’t student loan 4% debt that you can defer. It’s due and payable every month, at prevailing rates.

“With respect to your statement about the ease of dropping out of medicare, it is NOT easy. Besides the time requirement, the fact is unless you are a concierge PCP, dermatologist, or plastic surgeon, medicare patients are (almost) a necissary.”

No one said it is easy, but it’s still your choice. We all make them, in every job and profession, so get over yourselves.

It is rare for comments on this blog to cause me to laugh out loud, but this one did it. The general level of clue here is, I regret to say, pretty low.

My father, grandfather, and great-grandfather were all doctors, so I’m well aware of how time-consuming and difficult the practice of medicine is. But it also taught me that doctors can have difficulty appreciating how time-consuming and difficult other professions and businesses can be.

I’m an engineer. I attended a top-ranked engineering school where I worked my ass off. Even so, while there I teamed up with a couple of other students to build a product. (Doing so didn’t exactly help my GPA.)

After who knows how many hundreds of hours of work, we eventually graduated and started our own business to sell our product. Of course there was no income to begin with so we all had “day jobs”. (Well, to be fair, one of us went on to get a PhD in mathematics. As if that’s an easier course…)

Fast forward six years. Our business was a complete flop and none of us had earned a dime, not because we didn’t have a well-built product (we did), but because we built the thing we were interested in building rather than something that lots of people actually wanted to buy. Oops.

We were forced to change directions, essentially abandoning all the work we had done (the documentation alone was well over 1,500 pages). It makes me sick just thinking about all that work swirling down the drain.

We got lucky the second time and built something that sold. Soon we all were able to quit our other jobs and work for our own company, but with that came management headaches. We were smart enough to know that we were out of our depth and managed to hire, with the help of an executive recruiter, a CEO. But all that meant is that instead of 100-hour work weeks running the business we switched back to 100-hour weeks doing the engineering work that wasn’t getting done when we were running things.

We eventually sold the company (by then with about 50 employees), but I still work on the product and I still work 80+ hour weeks 25 years after we began.

Other people I know who did the same sort of thing were not nearly as lucky as we were. There’s a guy who lives down the street from me who, after 20+ years of those 100+ hour weeks, still hasn’t managed to turn the corner with his little startup. But at least he’s still there – another friend was forced, after years of effort, to declare bankruptcy.

And to be fair, some were luckier. One friend sold his company at the top of dot-com boom. He’s set for life and then some.

Of course I’m talking about true startups here. Franchises are safer propositions in most ways, but as others have pointed out, the amount of up-front money required can be very large and even franchises can go bust.

From time to time now people approach me asking if I’m going to start another business. I always smile and say something polite but negative, but what I’m thinking is, “You must be freakin crazy! No way am I going to do that again!”

In summary, don’t confuse the ability of a few to be in the right place at the right time doing the right thing with the general ability of anyone who starts a business to succeed. A lot more startups fail miserably than succeed to the point of making their founders wealthy. And never, I repeat NEVER, underestimate the amount of time you’ll have to devote to a business regardless of type. It’s always more than you think it will be, and unfortunately it is sometimes more than you’ve got to give.

Of course ned a total fallacy in your argument is we are talking about the “average” doctor or resident compared with someone else. You give your example, but do you truly believe the average engineer works 80 plus hours a week? The average medical/surgical resident does work upwards of 80 hours a week (and probably more if they are lying on their time sheets which IMO is far from infrequent. There is a big difference betwen one particular case 9yours) and the mean. Think about it.