Should doctors be forbidden to complain about money?

Should doctors be forbidden to complain about money?The Patient Centered Medical Home is supposed to be the solution to our primary care woes.

Endorsed by both the American Academy of Family Physicians and the American College of Physicians, this new model of primary care creates a team-based approach to patient care, with a cadre of care managers and nurses assisting physicians to manage patients with chronic disease. If the model is widely implemented, it would keep patients out of the hospital, save money, and divorce doctors from the dreaded fee for service payment system.

But getting from here to there is proving to be an arduous task.

The Wall Street Journal detailed one practice which made such a transition. Unfortunately, equipping today’s practices with the necessary technology and workflow changes is expensive. And the financial incentives meant to transform these practices barely makes up for the cost.

According to the piece,

For a five-doctor practice, the Advisory Board Co., a health-care research firm, projects the total first-year cost at between $126,000 and $346,500, including two added nurses.

The upshot: Doctors fear a squeeze as they try to ramp up changes in tandem with evolving reimbursement schemes. “You’re asking a practice that may be only marginally viable as a business to invest in significant infrastructure,” says Glen Stream, president of the American Academy of Family Physicians. “Is the payment model going to be there to support that?”

Progressive-leaning pediatrician and health policy expert Aaron Carroll doesn’t like the slant of the piece, saying that in today’s recession-recovering economy, doctors shouldn’t complain about money:

Every time I see a piece in the media about doctors complaining about money, I cringe. What the article fails to mention is that the clinic is “struggling” because it’s also likely paying its physicians a nice six-figure salary. There seems to be this feeling that many (not all) doctors share that they are “entitled” to large salaries. Yes, they have a high cost of education, and yes, the years of training they had to go through is extreme. But still, when your nice six-figure salary becomes a slightly lower six-figure salary, you don’t get to go around complaining that you’re “struggling to make ends meet”. It’s sad for you. It’s going to make your lifestyle a little less awesome, likely. I’m not unsympathetic. But consider your audience.

Well, maybe. It’s true that physicians who plea that they “struggle to make ends meet” will be met by an unsympathetic public ear. But there’s a general public belief that most doctors are rich, drive luxury cars, and hang out at the golf course. In primary care especially, it’s a caricature that’s far from the truth.

Despite what Dr. Carroll calls a “sob story,” it’s still one that deserves to be told. The public shouldn’t be shielded from the real-world financial decisions facing today’s small, independent primary care practices. It’s the only way to puncture the myth of the “rich” doctor, which in primary care, is a slap in the face.

is an internal medicine physician and on the Board of Contributors at USA Today. He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.

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  • Matthew Mintz

    I think part of the issue is that among those six figure salaries there are real disparities among physicians, particularly in primary care. Looking at census data (link below), there seems to be two big cut offs.  Households making greater than $135K are in the top 10% and spread out pretty evenly until you hit greater than $200K which is the top 4%. (Worth pointing out that few physicians are in the top 1% that make over $500K, so most of us are the 99%).  Only primary care physicians hover around that $200K mark, many making substantially less.  It is very likely that based on these numbers, the lifestyle of the top 4% is very different from the top 90-96%.   In other words, a cardiologist making over $300K maybe should have less to complain about since a $50K loss would still keep them in the top 4%. However a PCP making $180K, a $50K loss is still alot of money, and better than most, but puts them out of the top 10% earners. It is no wonder that few of our students are choosing primary care specialties.
    P.S.  Didin’t notice any “more students matched to Primary Care” headlines today. Haven’t looked closely at the stats yet, but suspect news is not good.

    http://en.wikipedia.org/wiki/File:Distribution_of_Annual_Household_Income_in_the_United_States.png

    • http://profile.yahoo.com/5K3LXDV4P4HQLTFLJ4EGJJBD7M Sarah Stone

      I saw this article this morning regarding the match and primary care.  You can’t match more students if you don’t increase the number of slots!

      http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/31697

      • Matthew Mintz

        Yes, we absolutely need more residency slots, especially for Primary Care.  However, even if we got these, unclear that our students would be choosing them based on the current system.

  • http://www.thehappymd.com/ Dike Drummond MD

    The investment of time in education (your entire twenties) and the amount of hours required to generate the 6 figures in primary care equates to a shockingly low hourly “wage”. Aaron Carroll should spend a week in his primary care doctor’s shoes and check it out.  And in our current healthcare “system” it is possible to drive doctors out of business. Money is important. If anything, doctors don’t concentrate enough on the financial realities of practice … preferring to focus on being with their patients and practicing good medicine.

    The bigger challenge is doing something effective when financial reality threatens your practice … not just complain … and certainly not within earshot of Mr. Carroll

    my two cents,

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

    • http://www.mywhitecoatisonfire.com/ Lumi St. Claire

      Thank you Dike for making a very important point.  It’s not about complaining – it’s about clarifying the issues that are actually at hand.  Physicians today simply do not all have the two vacation homes, three cars, and money coming out of their ears that the layperson often assumes we enjoy.  As a physician who was in academic primary care for over a decade, I actually (in a very self-masochistic moment) calculated my hourly salary one week taking into account my nursery coverage and weekend call duty, and came up with the very sobering number of $12.76 per hour.

      Additionally, I think it’s worth mentioning that even our own organizations don’t take into consideration whether we are specialists or PCPs when it comes to paying our annual dues.  I was walloped with over two grand this year alone in board certification renewal and national academy dues.  (Not that I’m complaining, Dr. Carroll….)

      We need honest discussions about the economics physicians actually face these days.  Appreciate this post.

      ~lumi
      http://mywhitecoatisonfire.com

  • Anonymous

    We are the Ninety-nine %.

  • Anonymous

    Perhaps Dr. Carroll rather than pointing to his colleagues as the problem ought to provide example capital and operating budgets for a 5 doc owned PCP with complete cost and revenue breakdown for his envisioned PCMH. 

    If the numbers work for the partners … great!   But let’s see them.  If they don’t work for the partners … then PCMH is dead before launch no matter how much whining from the Dr. Carroll’s.

  • Anonymous

    It’s not an admirable emotion, but schadenfreude is sweet.

    It was obvious 5 years ago to anyone familiar with basic arithmetic that the PCMH would be a financial disaster for practicing physicians 

    The leadership of the AAFP and the ACP have been grossly irresponsible in pushing this half-baked form of practice management on their members.

    Those of us who asked, over and over again, for data to support the extravagant claims made for medical homes were first ignored and then ridiculed. 

    Well, you can only hide the truth for so long – but I expect the primary care leaders to do a good job of ignoring it. 

  • http://twitter.com/livewellthy Stewart Segal

    The medical home is one of those great sounding ideas that
    academics come up with in their spare time. 
    In reality, it is one more black hole. 
    Today’s reality is that physicians are being required to purchase and
    maintain EMRs (yes, there are exorbitant monthly fees after purchasing), face
    ever lower reimbursements for service rendered, deal with continually
    increasing overhead, and still have to pay exorbitant malpractice fees in order
    to stay in practice (no tort reform in sight).

    While Medicare continues to threaten large cuts in payments
    to physicians, insurers and Medicare increase the workload needed just to get
    reimbursed.  Add the cost of implementing
    ICD 10 and the private practice of medicine is doomed. 

    Some would say that the intent of the medical home, ICD 10,
    and ever increasing government and insurer instituted regulations is to foster
    corporate run medicine by forcing independent medical practices to fold under
    the ever increasing financial strain. 

    As to those who take offense at doctors whining about lost
    income, remember those docs are the ones who wake up in the middle of the night
    to meet your family’s healthcare needs. 
    Also remember, you receive those services free of charge.  When you figure in the cost of getting a
    medical degree, please don’t forget to count the 80-hour plus work week, night
    and weekend call, and the stress of being responsible for other people’s lives.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    A doctor comes out of training with little or no business experience or saavy. He or she attends business classes often conducted by a division of the AMA or ACP or AAFP. They decide to start a practice and sit down and plan a budget.  They come up with a business plan, borrow money or invest their own money into starting this business, taking risk and make projections based on current expenses and reimbursement levels. They build a home budget and lifestyle plan based on their business projections and models and most are quite conservative in generating home expenses. They start to practice and stay within their budget and projections. Then the government comes along and reduces reimbursement for procedures and visits. In my state, Florida, where Medicare is king, the private insurers who actually control the patients then pay the physician the same 75% of Medicare allowable fees that they always did but now at the reduced rate.  The physician is then left with a short fall of income which Dr Carroll doesnt want practitioners to complain about?   Everything is relative. As a primary care doc its easy to say if a specialist gets cut 10% off his million dollar income that is no big deal. It is a big deal if that specialist buiild a sane business plan and budgeted his loan repayments and home expenses correctly and by the stroke of a pen the rules changed in the middle of the game. Money becomes an overwhelming stressful issue when you do not have enough of it to meet your projections in medicine or in any other life situation. Most of those doctors complaining about money donate time, and money pro bono to patients and causes routinely. Altruism isnt the issue. The issue is being able to cover your costs without resorting to beginning procedures and sales of products that generate income but have no proven efficacy as so many practices have been forced to do to make ends meet

  • John Henry

    Most people who are patients have no experience and little understanding of small business of any kind. Even those that do, many do not know what is required to qualify as a medical doctor or to operate a medical practice. Many people who have insurance are not competent to understand their explanation of benefits or may want to believe the doctor was paid in full when the statement may show the opposite. 
    They may see some charge that was steeply chopped down and think somehow, magically, that is what the doctor received anyway. And preconceived notions and stereotypes are habits of laziness that have long colored doctors as all being rich. Very few people are sophisticated enough to understand consider the opportunity costs of medical practice when hearing of a doctor’s income. To them it all seems excessive.

    Even though many doctors do not receive any meaningful business education in medical school or residency, many are quick enough learners. There are a large number of successful practitioners wh make ends meet. It is dishonest for critics to decry doctors’ refusing to do professional work on manifestly disadvantageous terms, as with Medicaid and lousy commercial plans, and now Medicare, as being greedy and unsympathetic, yet offer up the “lousy businessman” argument when doctors who do accept those plans find themselves struggling with practice finances. You can’t have it both ways.

    Doctors have as much a right to complain about money as anyone else who does business, and maybe more so since it is so much more difficult to raise prices to match rising costs with Medicare price controls in the majority of the so-called market.

  • Anonymous

    The easy answer? We need more Health Care Centers that operate like WalMart. Is going to WalMart like going to Nordstrom? Not even close! But the problem for the vast majority of patients in America is this. WE CAN NO LONGER AFFORD NORDSTROM STYLE HEALTH CARE! We need to gather all of the health care “experts” under one management organization and make them all salaried employees in a single system that has a single goal in mind. A team approach to wellness and good outcomes. We can no longer reward just volume. We need to reward wellness as measured by the patient. At the end of the day, if you have a healthy patient, you have a less expensive patient. That should be the goal. Not volume! If traditional fee-for-service providers do not like this idea and want to remain in the status quo. That’s fine. More power to them. As for people like me that are slowly going broke trying to survive in that broken and expensive status quo model, I’ll choose WalMart style health care any day of the week! What do we have to lose? It’s already broken beyond repair. We need to throw out fee-for-service health care completely and start over with a new model. 

    • Matthew Mintz

      Dave you may be 100% correct and the ACO/PCMH model may solve many of our health care problems.  (I hope you are right!)  However, the WalMart model is entirely about volume.  People shop at WalMart because they have lost of choices, and because WalMart has huge purchasing power, they customers can get most stuff at great prices. The down side of shopping at WalMart is trying to find a salesperson to help you, trying to figure out which of the many choices you have is right for you (though at least the prices are clear), and trying to get your questions answered.  This is what good health care is all about, and it requires people. WalMart functions on few employees per customer, paying them all very low wages. If you want the WalMart/ACO/PCMH to work; you are going to need qualified primary care physicians.  In order to do this, you are going to have to pay them.  Would you expect a young adult with a college and business or law degree to bypass a lucrative legal or business career and go work at WalMart? If the ACO/PCMH models is going to work, it is still going to have to increase reimbursement to primary care, and though everything I have seen on this model emphasizes the importance of primary care, nothing that I have seen on this model spells out how primary care physicians are going to be compensated better.
      P.S. If you think we don’t need MD’s and can rely on PA’s or NP’s; these students are not going into primary care either.

      • Anonymous

        A Walmart store has everything under one roof. They have an in house business office. They have in house cleaning and maintenance people. They have one HVAC system to keep hundreds of people comfortable. They have one computer system and one phone system. They have in house IT and phone system people. They have the financial resources to purchase and run state of the art diagnostic tools and even an have an in house medical lab should they decide to offer primary health care. They already do prescription drugs under the same roof and they can negotiate the prices unlike Medicare Part D. Compare this to hundreds of small single doc offices in the same geographical region that need all of the above on a smaller scale. How can that be cost effective? How many doctors do you know that are dragging their feet on purchasing and employing an EMR system? Not WalMart! They will have the best EMR system money can buy. The key here is to focus on the benefits of economy of scale. Volume? Yes! Gobs of volume! Why? Because they can! And they can do it without sacrificing the quality that will be required in a patient centered rating system. When all is said and done, health care delivery is changing. It will look much different ten years from now. Smart folks will adapt. 

        • Matthew Mintz

          Dave, I don’t disagree with you that economies of scale can work for health care.  However, the Walmart analogy is somewhat flawed because health care is not a product industry (we don’t sell TV’s, detergent, widgets, etc.) but a service industry.    When you are selling things, your Walmart analogy works well. The proof is that the days of mom and pop businesses are essentially done. People would rather go to Walmart to get prescriptions because they can get generics for $4, then to the corner pharmacy where they can actually talk to a pharmacist who knows them and their doctor. Bottom line is that when you are selling products (especially the same product), in today’s economy price trumps convenience and value.  However, health care is a service not a product, and selling services is essentially selling people and time. You have to have quality people that have the time to provide quality service.  This costs money. Now it is possible for Walmart health care to work (in my opinion) if 1) primary care physicians play a central role 2) they are freed from the common day to day paper work hassles and can focus on taking care of patients and 3) they are properly reimbursed for their time and expertise. However, there is nothing I have seen in the ACO literature that clearly lays out how this will happen.  Lip service is given to #1 and #2, but nothing is ever said about #3. 

          • Anonymous

            I don’t pretend to ever be as smart as you. You seem to know everything about everything. All I know is this. If big-box health care isn’t in our future, then why are so many hospitals on a buying spree when it comes to snapping up as many small physician practices as they can in a particular geographical region. There seems to be a huge effort by hospital groups to be prepared to compete on opening day of ACO season. Why don’t you do a web search for…

            “Why hospital groups are buying physician practices”

            Then, as you always seem to do, come back and explain your version of that phenomena. My PCP is in the process of negotiating the sale of his small practice to one of these massive hospital organizations. If all goes as planned, he will become a salaried employee in this ACO at some point in the future. I’m sure he’d be very interested in you sage advice about how the whole idea of ACOs and big-box health care is doomed. 

          • Matthew Mintz

            Dave,
            You have a lot of great thoughts and ideas, and can contribute significantly to the discussion.  I don’t know why you feel the need to be sarcastic and rude. It is your right to disagree with me, and in fact I enjoy reading your responses because you have good ideas.  I have been as professional as possible to you.  I don’t really see the need for name calling.
            That out of the way…
            Hospital groups are buying physician practices because 1) docs are finding it hard to survive on their own in the current system and 2) hospitals aren’t sure what’s going to happen, but buying practices somewhat ensures them a steady stream of referrals and
            3) if the ACO thing does work out, then it’s a good investment.

            This doesn’t necessarily mean that ACO’s will actually work.  The hospitals are buying PCP practices, not the docs. Nothing stopping them from leaving, retiring, etc.  This same exact thing happened about 10 years ago, although it was the hospitals that dropped the practices.

            Also, the other trend in health care is in the exact opposite direction of hospitals buying up practices.   It’s all about simplifying things, being “nimble” and moblie. Read some of David Chase’s pieces on Direct Primary Care, or see some of the things Dr. Jay Parkinson is doing/has done.

            In general, while I hope the whole ACO thing works out, I remain very skeptical. Not sure what you do or what field you are in, but if you have been in health care for a while, you will know that the whole managed care thing sounded great too. The promise was focusing on prevention and incentivizing physicians to use resources wisely.  We all know how this turned out. ACO sounds a lot like managed care 2.0. Current data on both PCMH and ACO’s are mixed at best, and no one has really spelled out the logistics of how PCP’s will be reimbursed.  

          • Anonymous

            Yeah! Right! Fact is, what you seem to be forgetting, each time you post a comment, is that the ACO model is not a fee-for-service model. I know it sounds too good to be true but the ACO concept throws our broken fee-for-service health care delivery model completely out the window. The ACO adopts an entirely new concept. You might say it’s a “fee-for-satisfaction” model without any fees. You might be asking yourself by now, how in the world will doctors survive without their tried and true fee-for-service model that made them so wealthy? Have you heard what the Cleveland Clinic is doing? Maybe you should do a web search for the following video…
            Cleveland Clinic Adapts to Health-Care Overhaul

          • Matthew Mintz

            Dave,
            All that video says is that hospitals will be reimbursed by quality measures,including patient satisfaction. The problem is that ACA does not spell out the details of how this will actually work. Will doctors be paid entirely on quality?  ”Sorry Dr. Johson, I realize you spent a long time on that operation, but your patient wasn’t happy so you get nothing.”  Clearly, this is not gong to be how it works. My sense is that there will be some mix of fee for service and some per member per month payments.  My guess is that the total dollar amount will not change, and in fact may go down, but doctors can prevent their fees from going down if they reach certain quality measures, including satisfaction.  I am guessing this will happen because this is exactly how meaningful use is spelled out in the ACA.  Doctors who do not implement EHR’s with meaningful use will soon see their payments go down.  You would expect that due to this all docs would be rapidly switching to EHR’s, and many have.  But few meet the meaningful use standards because the way the whole thing was set up was so complicated, virtually no practice can meet meaningful use criteria. Thus, most docs will see revenue go down, and it is possible that docs who invested heavily in EHR’s may go under because they will not see a return on this investment.
            Finally, Cleveland Clinc is a bad example. They have huge research dollars that fund a lot of programs so they are able to invest in making patients happy even if the whole thing doesn’t work. The bottom line is (like managed care before it), all of this sounds really good. And again, I hope it works. However, the devil is always in the details, and I have seen nothing yet that spells this out clearly that gives me any indication that this will work out for primary care. 

          • Anonymous

            Clearly, you sound like you have a lot to lose if things change. 

          • Matthew Mintz

            Actually, I think Primary Care docs like me have the least to lose.  One  scenario is that you are right/  ACO’s work and PCP’s get reimbursed appropriately and enjoy taking care of patients again.  Another scenario is that this fails miserably, and PCP’s look elsewhere.  Several alternatives that some PCP’s have gone to because they are not willing to wait for the outcome include cash only practices, direct primary care practices and retainer practices.  PCP’s are in high demand and because few students are choosing this career path will continue to be in high demand. Again, I would love the first scenario to work out.  However, because of the many reasons I have listed above, I have cause for concern. 

          • http://pulse.yahoo.com/_GXO5UT3MGTPBRYKXHHFG6NCRO4 S

            Rather hilarious that walmart, an organization that is infamous for not providing a large number of it’s employees with insurance is used as an example by the peanut gallery. Less than 50% of Walmart employees even have employee health. Dave, maybe you think it is a good idea that Walmart cost shifts to taxpayers such as you and me in the form of medicaid. Just keep on buying the cheap chinese made crap and tell yourself what a great deal you are getting.

          • Anonymous

            Actually, what is really “hilarious” is people who only read part of the conversation. The WalMart reference was used only to describe the size of future ACO groups, not that WalMart itself would become one. But, then again, l need to constantly remind myself to consider the intelligence of my audience. 

          • Anonymous

            Besides, you are suggesting that  WalMart could make  health care delivery worse than it already is today? Is that possible?

    • http://twitter.com/Chakrabs S.C.

      As a student about to graduate med school, I certainly didnt spend the last 8 years working towards becoming a Walmart employee. I’m offended that anyone would equate that the best I could hope for after this much time and effort that I put in to be a lowest-common denominator form of medicine. 

      • davemills555

        Maybe you didn’t understand my post clearly. The operative words are “Health Care Centers that operate like WalMart”. You need to understand that solo-doc practices will not be able to compete with the future of big-box health care centers. More and more single docs are being gobbled up by hospitals groups and insurance companies. Doctors are selling out and signing on as salaried employees. Is it the end of Marcus Welby style health care delivery? I’d say there will always be a market for the wealthy 1 percent. I suggest that you do a web search for the following…

        “ACOs Multiply As Medicare Announces 27 New Ones”

  • http://twitter.com/Chakrabs S.C.

    I’ll admit, that as a graduating medical student, I am ignorant of the realities of being a full-fledged physician dealing with reimbursement issues. However, I do feel that I deserve every last penny I earn and charge. No other business in the US has to deal with someone paying them less than what they charge for a product or service. When was the last time you went into Home Depot and walked away paying $50 bucks for a tool listed at $100? When Walmart allows that, then I’ll be satisfied with the travesty that is the way doctors in this country are paid. 

  • soppendeuff

    Yes, please. Stop complaining. An MD is not a license to make money. And it’s unseemly when so many people are unemployed.

  • http://www.facebook.com/chris.lillis Chris Lillis

    I think we need to be careful of all the lumping together this short piece is about.  All physicians are not paid equally.  Primary care doctors do operate businesses that have small profit margins, and take home pay for PCPs are certainly lower than many professions with less training – think financial industry or attorneys.  So – policies such as advanced payment models that provide capital to PCP practices to ramp up to make medical homes reality should be part of the conversation.  But there are some specialists who make over a million dollars every year, and many more who make over half-a-million dollars.  It is not productive to speak of PCPs and specialists in the same way.  There needs to be incentives provided for cognitive based primary care, and less incentives for procedural based specialty care if we are ever going to get a handle on health expenditures in our country.  If there was more parity in the pay between PCPs and specialists (PCPs more and specialists less) than Aaron’s opinion likely would change.  I would love to see you use your considerable influence to write about this more, Kevin.  

  • cooper2012

    if they are highly recommnded and they do a good job then he or she should get a good paid. We dont need a doctors to carry they pataints around up tp ten visit before they cure them. dats reaping out they money.

    • davemills555

      I agree…

      If they are consistently rated excellent by their patients in a documented forum that can be clearly measured, they deserve to be given a bonus. If not, they should be fired! That’s how the real world works! That’s how things will be in the future when we have more and more ACO models all across the country. Salaries and bonuses based upon a documented patient rating system. It’s called accountability! 

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