A physician surplus?

A refreshing take. The argument here is that there are not enough physicians in primary care:

Increasing medical school enrollments isn’t going to solve the problem. You’ll just end up with proportionally more cardiologists, more gastroenterologists, more cardiac surgeons to flood an already supesaturated metropolitan market. Until we compensate primary care/family practice in such a way wo make it financially appealing to medical students, there’s still going to be physician shortages in South Dakota and Southern Ohio and Rural Kansas.

Comments

Anonymous
Sorry, but primary care is permanently dead in the USA, thanks entirely to government. Who in their right mind or short of sainthood, can put up with endless bureaucratic abuse that PCPs suffer, ever declining reimbursement, and over-regulated micromanagement by the federal and state governments?
Ed Sodaro MD
The Happy Hospitalist
Chalk one up from the land of common sense. I couldn’t agree with you more.
One comment argued that as supply of specialists increased, their salaries would go down.
In a market economy, this would be true. But Medicare is not a market economy.
It guarantee’s $200 for a 13.5 minute screening colonoscopy. The incentive to do specialized medicine is guaranteed by the discrepency in payment when compared with primary care.
The market CAN’T drop the price because there is no market. There is only Medicare. And Medicare policies are driving specialty medicine.
If the reimbursment rates of specialists were poor, medical students, who pick their specialties by market economics, would would not enter them. That is your key to adequate reimbursment rates.
And right now, procedural specialities are thriving. A hunger to fill with a steady stream of newbies. But not primary care. The money is gone.
If the market decided, maybe a colonoscopy would only paya $50, or $100. We will never know because the spigot of money aka Medicare B is unrelenting.
Imagine what would happen if Medicare B payed $200 for a mid-complex outpatient follow up visit.
It’s about money and will always be about money.
Your shortage just disappeared. Primary care would thrive.
Barbara K.
I had a conversation the other night with a senior executive of a large veterinary hospital. They are facing the same problem — a growing shortage of PC vets.
Anonymous
first of all the ‘salaries’ of specialists are not derived specifically from the reimbursement rates, but based on overall revenue less costs. the argument made was that there are too many specialists, resulting in competition for patients. the lower overall volume of procedures per specialist will lower the net ‘salary’ of the specialist.
second, as you know, the reimbursement rates are dropping. i can assure you the specialists are looking for additional revenue streams so that their ‘salaries’ don’t take a hit.
and of course there is a market for medical services. some specialties don’t have medicare serve as their sole provider. private insurance rates still need to be negotiated even if cms pays for most of the patients. i certainly agree with you that most providers aren’t happy with their arrangements.
i can’t disagree that economics dictate medical student choices. but i can say most specialists don’t sit around thinking how good they have it compared to primary care. they complain just as bitterly
Anonymous
What’s the per capita number of primary care physicians that is a threshold for a “shortage”?
And how much more do they need to be paid in order to alleviate the “shortage”?
If you can’t answer the first question, how do you purport to tell us about how traumatic this “shortage” is?
The Happy Hospitalist
anonymous, all points are points well taken.
However, the creep away from primary care has resulted in essentially the vast majority of students entering declared specialties.
By nature of their agreement to enter specialties, they are saying the reimbursment is still good enough for them. The day medical students walk away from specialty medicine is the day all medicine dies. IE, no medical students at all. They will avoid the field entirely.
While I agree reimbursment rates for all doctors has declined through the years, the basis of your starting points are ridiculously skewed.
Instead of making 1.5 million a year as a cardiologist 15 years ago, maybe you make 1/2 that ( not unreasonable numbers).
It’s a matter of perspective. And the perspective says that medical students are still willing to accept 750K a year. (as would most).
Are cardiologists upset that their reimbursment rates have gone down? Probably. Nobody likes to have their income decline.
Do I feel a deep sorrow?
Nope. The starting and ending figures don’t allow me to feel sorry. The economic incentive for specialized medicine is still very attractive and well intact, I suspect, even if it dropped in 1/2 for some fields.
I disagree that more specialists mean less procedures for everyone.
I argue just the opposite. Just as reimbursment rates have gone down, more procedures are performed to make up that difference.
The only question that matters is when that reimbursment comes close to cost of business. That’s when the procedure goes the way of the dinasaur.
That’s where primary care is right now. Revenue and cost curves are quickly crossing each other.
Double booking, triple booking. Hurried medicine.
Anonymous
HH:
All pretty much true. In my specialty, one does only what can be considered viable either by direct reimbursement or as an essential support for an activity that is viable and for which the reimbursement can globally compensate for the net costs of ancilary support. If it is a loser in toto, we simply don’t do it.
The very simple answer to the “shortage” question is to eliminate the Medicare “allowable” limits and permit unlimited balance billing. Do that, and this talk of “shortages” will become a laughable memory.
Doctors will have to compete on price and service when patients pay cash. The fact is, they always have. They will have to get far more used to providing price quotes. Smart doctors will offer services with “cost not to exceed” guarantees. Patients will have to respond in turn by guaranteeing payment on time.
Sure, patients will have to adjust their thinking about personal responsibility for paying their doctor’s bills. They will also learn to treat the insurance companies with the same degree of scrutiny and accountability as everyone else they do business with.
Anonymous
What has not been discussed here are the noneconomic factors that drive students away from primary care. Many arguments I have seen about PCP shortages center upon reimbursement- but I feel that this is a relatively minor issue for most students.
In fact, the shorter residencies of FP and IM, get students on a decent earnings track much faster than the specialties.
The problem is that students look at primary care as the bottom rung of the medical ladder. This is reinforced by academic medicine, which is highly specialty driven. Student’s see the “common cold care” of primary practice and long for intellectual challenge and insulation of the specialties.
I can see a future of triage-based medicine where screening RNs simply refer the outpatient directly to a specialist, no PCP needed.
Anonymous
thanks for your comments. i enjoy your happy hospitalist blog very much actually.
i’m not sure whether medical students with 200k in debt are saying specialty medicine is still good enough, or just that it is the best option left given the debt load of 200k to pay off and no one else is offering a job paying 200k+ (iow, screwed if you do, screwed worse if you do primary care). med school applications are up, so that is promising.
as far as making 750k, i know of very few people who have take home pay of 750k. most are plastic surgeons or people who have very unique niche markets and cash only situations. certainly there are only a handful of cardiologists pulling in that money at this point. i think we are closer to the threshold of being nontenable than you, given the ever increasing debt load of current graduates. what fields do you think people can expect to take home 750k? or 500k?
of course physician income is dependent on a lot of things, and a lot of complaints i hear are about business management issues which of course affect take home pay. and, frankly, a lot of small groups need to merge and develop better business plans in order to survive. today they really have to address the business half of the practice of medicine head on. if you run your business poorly, pay employees too much, don’t control other operating costs, don’t negotiate reimbursements well, then you will take home less pay at the end of the day. you really get kicked in the balls if your reimbursements are cut at the same time.
certainly there is probably a normal bell shaped distribution regarding procedure volume and number of providers. the specific area of medicine, where you live, and local practice realities dictate whether adding another provider adds procedures to the community or just redistributes procedures that would have been done anyways. can we ever really know whether too many angioplasties are done because the technology has improved to make it easier and safer to do than ever before or whether we just have too many practicioners looking to take home more money?
but if you just sit as a fly on the wall, most (all?)of the specialists i hear don’t ever feel that they need more practioners in the area to do the procedures, they need them for call coverage or other issues.
there are many new medical schools being planned and existing medical schools are expanding. what will we offer those graduates? we can force them into primary care by not expanding other training opportunities. i totally disagree with that concept but thankfully i’m not a policy maker. in some ways it isn’t so different than now. you can’t just decide you are a cardiologist because you want to be. you have to convince some academic @sshole that you deserve the slot more than 20 other people. it’s just that the competition for those slots may be more extreme and the penalty for not getting it is *gasp* primary care or some other less lucrative (interesting?) specialty.
as always, ymmv. jmo. etc.
Anonymous
“What has not been discussed here are the noneconomic factors that drive students away from primary care. Many arguments I have seen about PCP shortages center upon reimbursement- but I feel that this is a relatively minor issue for most students.”
I respectfully disagree. Money is typically the major motivator in eliminating some professions from consideration. It’s difficult to feel fulfilled in a career where you’ll never be free of monetary concerns. What most seek is enough compensation to be secure, and work that they find fulfilling. Compensation is a primary driver in narrowing the pool, no escaping it.

Previous post: "Meager financial incentives do not significantly change physician behavior"

Next post: The obese are being denied surgery

A physician surplus?

Related Stories

More in Uncategorized

Comments

Site

Channels

Subscribe

Related Stories

More in Uncategorized

Comments

Site

Channels