1) In response to declining primary care numbers, Bernie Sanders (Ind.-Vt.) proposed expanding funding for government programs to forgive loans for physicians that agree to practice primary care in under-served areas.
My take: That’s like using a thumbtack to plug a bursting dam. The solution needs to be significantly more dramatic to gain the attention of medical students gravitating towards better paying specialties.
Two things need to happen: i) all student loans need to be forgiven for new doctors choosing to enter a primary care specialty, regardless of setting, and ii) salaries between generalists and specialists need to be fairly reconciled.
Expect nothing to change unless those points are addressed.
2) Despite spending more money, patients with spinal problems feel worse in 2005 than they did in 1997.
My take: Another example where more medicine may be less. Patients have a hard time understanding this. The public is conditioned that “something needs to be done” for their symptoms, and the fact that less treatment may have equivocal results is a hard concept to grasp.
3) Blue Cross of California asks physicians to rat out patients lying on their insurance forms.
My take: Insurance companies expect physicians to do their dirty work for them. What insurers really need some basic lessons in PR. But I guess when you’re already at rock bottom, there is nothing to lose by pulling a stunt like this.
Related posts:
- Patients feeling the primary care pinch
- Primary care access
- Where’s the money to better pay primary care doctors going to come from?
- Academia responsible for the primary care shortage?
- Do patients think there’s a primary care shortage?
- Op-ed: Shortage of primary care threatens health care system
- Matthew Mintz: As psychiatry goes, so will primary care
{ 22 comments }
So let’s see here: Cardio Versus Primary Care under your plan
200K medical school + 600,000 lost income (4 years more training than primary care)
= 800,000 dollars in extra benefits to primary care
Average Cardio Specialist –> 310
Average Primary Care –> 180K
Career Length 25 Years
4.5 million (at 180k)+ 800K = 5.3 million
Career Length 21 Years (4 extra years training)
6.5 million (at 310k)- (200-400K) (school loans + interest) = 6.1 – 6.3 million
I agree about paying off the school for primary care, but I do not believe that they should also get more salary. The total income is almost equal in these situations! What do you think these years of life lost in the hospital are worth kevin!
Now you may point out that there are outlier cardiologists who make 1000000, but they are rare. I could also point out that there are primary care docs in my area of the country that make over 500K easily. So let’s just stick with the averages.
Loan forgiveness carries its own problems. The agreement usually commits the new physician to taking Medicaid and Medicare for years. That will be an increasing burden on these young physicians as those systems will face even more pressure to cut costs.
Loan forgiveness will only delay specialization if primary care is as bad at the end of these loan agreements as it is now (unless they’re dumb enough to enter family medicine which rules out future fellowships).
The payers have promised patients more than they can pay for and will need to continue to squeeze primary care docs until enough of us retire or opt out of third party payment that the shortage causes beneficiary or taxpayer problems for the payers.
Until then, these band aids are just for show.
A Family Doc
There is no free lunch. Let society pay off your loans and society will think it owns you.
To the first commenter: I’m not a doctor, so I have no specific personal interest here, but don’t your own numbers contradict your point? Minimally, you’ve found a cardiologist makes $800,000 more than a primary care provider–which, eyeballing it, is close to 20 percent of total lifetime income. You also appear to factor in the additional training time twice by first calculating the lost time separately and then adding it into your second calculation which also factors in for the time training difference. Unless I’m misreading something.
“these bandaids are just for show”
Yes. Indeed. Served in the NHSC (one of those “loan forgiveness” programs). Totally hosed because the United States government doesn’t give a crap about doctors in public service except as pawns on a chessboard.
Again, any resident physician considering loan repayment for service should read my blog.
I think the supposed $600,000 in lost income is off base. Last I checked, cards-disease fellowships are 3 years, not 4. Plus, you will be paid about $50,000 per year in fellowship. If you spent those three years as a practicing PCP and earned $150,000/yr (I think your 180k figure could be disputed… you need to look at what a brand new doc would be earning anyway), then you are essentially losing 100k per year or $300,000 altogether.
As far as sticking with averages… I have to believe that the average physician has more than a 21-25 year career. Assuming you go a straight path through undergrad/med school you can finish cardio fellowship by age 32 comfortably. How many of them will really retire by age 53?
Let’s assume a PCP starts at age 28and a cardiologist at age 32. There’s no reason one couldn’t/shouldn’t expect to work until age 65. Recalculate using 37- and 33-year careers and you’ll now find an enormous disparity in pay.
I do not believe PCP and specialist pay should be equalized by any means, but I do think the disparity is a little too great right now.
The reason cardiologists ought to make more isn’t because they trained longer. It’s because I don’t remember the last time we paged a FP to come in at 1am on Christmas or on Sunday to cath someone.
Perhaps your FP’s would still be coming in on Sunday or Christmas to admit their own patients if they received a reasonable reimbursement for doing so. The 1 AM cath still pays pretty well last time I checked.
Regarding treatment for spinal care, in addition to the fact that we are paying a lot of money for no improvement (in fact worse outcomes), we are not paying for inexpensive things that work. Most studies for back pain show that all treatments are pretty much the same, and that improvement is minimal. However, things like weight loss and ergonomic changes which cost substantially less are rarely reimbursed by insurance. If instead of paying $100 a month for Celebrex (200mg) we spent the same (or less) money on a gym membership or trainer for back stretching/stengthening and cardio for weight loss, we would at least have the same outcome, and likely have a better return on investment for other improvements such as lower risk for heart attack and stroke. See the link to my blog for more on this. study.
Perhaps. But what happens if the family doctor doesn’t come in compared to if the cardiologist doesn’t come in.
1. Student loans: Yes.
2. Cardio-Lover: Learn math, and learn the facts to avoid embarrassing yourself.
3. Wellpoint gets what they deserve…and the pain will last longer than they think. Morons.
As a family practitioner, this debate between us and cardiologists is non-productice. Even though I admittedly suffer from specialist-envy, it is not directed towards cardiologists, who, like us, are also on the “front lines” and work extremely hard. I would also say similar things about surgeons, ob-gyns and other medical specialties.
Just think of who sops up too much of the medical dollar:
1) anesthesia,who do better than surgeons (where’s the logic in that?)
2) radiologists, who do not even have to get calls anymore in this era of tele-imaging yet still make more money than ever
3) pain management makes a truckload of dough to do facet joint injections that don’t even work that well
As the pie has gotten smaller, resentment has increased. The era of saying we’re all in this together is over.
Underpaid in New York
Oh, come off it, Dr. Whiney Underpaid. When you were in med school, you had a choice. Go for primary care, surgery, rads, or whatever. If you did not know then that there were large discrepancies in the paychecks of the various specialties, you may have been the only high school graduate in the USA that was ignorant of this. You spent several weeks on a clinical rotation with the surgery residents, who worked their asses off but somehow seemed to be having a good time, and decided, I can not/do not want to do this for 5 years, and then for a career. I made the same decision regarding my specialty (general surgery). The relative increase in income is nice, but not the deciding factor. Yes, the anesthesiologist does do much less work, for more money than I make, but what a boring way to earn a living. If you go into a specialty because of money, you will have money and misery To me, sitting in a darkened room mumbling into a dictaphone (i.e., radiology) would be a form of torment, despite their lofty incomes.
No one in this economy is underpaid. You get up every morning and voluntarily go to your place of employment for whatever paycheck you draw. Unless someone is holding a gun to your head, you are trading your time and expertise for money on a voluntary basis. It’s up to you to make yourself more valuable to someone, anyone, so you will not be “underpaid.” Until then, shut up and get to work.
how much does a 1 am cath pay?
the reimbursement differences need to account for the call frequency and intensity, and also account for risks of practice, including radiation exposure, and liability.
another point to consider is the opportunity cost of the lost compound interest of 401k’s over 35 years and savings for those 3-4 years for the 35 years and add the compound interest of the loans accruing for an additional 3-4 years paid over the 30 year repayment schedule.
there are a lot of ways to massage the numbers to prove whichever point you believe in.
i also believe that many small primary care practices lack the time and resources to be reduce overhead and run business as efficiently as larger groups. it is just that small subspecialty groups can afford to do it and don’t get as much attention.
In response to jb:
Thanks for your constructive feedback.
It is nice to know you are so happy in your career choice. Quite frankly, the most unhappy physicians I have ever known are the general surgeons.
As far as my career choice, it is true for me, as well as you, that money was not a deciding factor. However, in 13 years of practice, things have gone from ok to bad to worse to pathetic, while the specialists have stood by and said nothing.
But your advice is well taken, if I could change I would. But with med school loan and other debt, I feel somewhat trapped. It is very disconcerting to be losing money in medicine.
Underpaid in New York
“unless they’re dumb enough to enter family medicine which rules out future fellowships”
It doesn’t rule out a sleep medicine fellowship
jb,
I suspect you’re just a troll but I’ll take the bait. The problem isn’t us whining, that just clogs up blog comments, big deal.
The problem is that we’re retiring, quitting, or reducing our scope of care (no more 1 AM runs to the ER as above) because we can’t stay in business. Remember that when you or your parents are in the golden years and can’t get in to see a doc for weeks unless you go to the ER.
A Family Doc
family doc,
…and you’ll wait 12 hours to see a real live doctor in the ER because everyone else is in the same boat.
But don’t fret, you may be able see a “physician extender” somewhere, somehow, once all the doctors have decided it isn’t worth it anymore. 1/2 the training at 2/3 the cost. What a deal.
Now when they tell you your problems are “too complex” and you need a specialist, back to square one.
“”unless they’re dumb enough to enter family medicine which rules out future fellowships”
It doesn’t rule out a sleep medicine fellowship
10:39 AM”
It doesn’t rule out Sports Medicine either. I’m sure there are a few others.
Family Doc-
I’m not a troll, I’m a real live general surgeon. I agree that it’s a problem that so many docs are getting out of clinical medicine, but that was not my point. My point was that MDs who make an informed choice to enter a relatively low paying specialty have no standing to then whine about what a low paying specialty they are in.
My fervent wish is that MDs of every specialty, but especially the low paid ones, will open cash based practices in which the doc will get to keep 70-80% of the fee instead of the current ~30%. She will earn a much better income, be able to give much better care, and everyone will be better off except the insurance companies. That model appears to be quite practical in primary care, where encounters can be < $100 per if the doc does not have to have an army of insurance clerks and a significant investment in computer hardware and software to keep the insurance people at bay. That's certainly the way I would do it if I were in FP or IM. It's not too practical for a surgery practice where the encounters generally start at $500 and go way up from there- that is truly what insurance is for- infrequent, high cost, and unpredictable events.
I will need you to stay in business. You will not be able to stay in business under the current scheme, no matter how much whining you do.
As a fp for 18 years I take great issue with the comments by jb and the cardiology ex. I chose FP because you really won’t get bored with work and AT THE TIME I GOT OUT OF RESIDENCY THE PAY WAS MUCH BETTER compared to my specialist colleagues. This disparity is what many primary care drs. are “whining about”. In my community the disparity goes beyond pay but also to resources our health system devotes to health care. We are on our third construction project for orthopods, we subsidize anesthesia to an average of over 300,000 a year, but we must be “whining” to jb if we try to get the system to give 25000 for loan forgiveness for an fp.
That being said any “generalist” i.e. FP, IM, PEDS, GEN SURG,and even to some extent OB/GYN are the providers that are suffering. I’ve spent 10 years in med staff leadership and these practices have been squeezed the most. My FP group still bucks the trend and do inpt with its call etc. All those specialties id’d perform a great deal of scut that “consulting” staff doesn’t do, do a lot of highly compensated but clinically dubious procedures, then sign off. A consult from a specialist shows no thought any longer except to trot out a great deal of expensive work. We in these “general fields” need to get to work at our grass root institutions and force our boards to recognize that we need to address the cost of our care to be able to assert any real political control.
I may get irritated at the comments jb left, but I am irritated that at my hospital an appy may pay him @ 1000, whereas a crna/ or anesthesia gets 1500!!!! for passing the gas . Unless the workhorse specialties are paid better to attract more/better talent, this country is going no where in health reform.
jb,
Sounds like we agree on most things.
I don’t know of any family docs who feel we should make as much per hour as the longer trained specialties, but I whine plenty when 70-80 hour work weeks are needed to stay afloat financially and the hourly income works out to less than most plumbers and nurses earn.
family doc
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