Pay me like a French doctor. You know you want to.

Pay me like a French doctor.  You know you want to.

Whenever new physician salary data is released, reporters and policy experts often compare doctor salaries in the United States to those of other countries: most notably, France.

And on cue, Vox’s Sarah Kliff — normally an excellent health care writer, by the way — is uncharacteristically lazy in framing physician salaries through a biased lens.

After presenting the data, she writes, “Primary care doctors in the United States, do tend to earn a lot more than their counterparts abroad. One 2011 study, which looked at doctor salaries from 2008, found that the average primary care doctor in France earns about $95,000, compared to the $186,000 that physicians net in the United States.”

For a site that prides itself on providing context to the news, these numbers require a bit more, well, explaining.

The clear implication is that American physicians are paid too much, and disproportionately contribute to our rising health costs. In fact, Kliff says it outright: “Doctor salaries are a pretty significant part of the reason why the United States spends more per person on health care than any other developed country.”

Really? According to pediatrician and the New York Times’ The Upshot contributor Aaron Carroll,

In 2006, physician salaries accounted for $138 billion in costs, which is nowhere near 56% of health care spending. Plus, some of that is to be expected. Calculations by McKinsey pegged “excess spending” on physician salary, or that which was above what you’d expect given the wealth of the US, at $64 billion.

That’s not an insignificant amount of money. But it’s not the major cause of our over-spending on health care.

And listen to celebrated Princeton economist Uwe Reinhardt, also writing in the New York Times:

Cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.

This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

What most fail to include when comparing physician salaries across countries is the cost of medical education and medical malpractice.  Let’s consider France, the go-to country when pointing out how expensive health care is in the United States.

Medical education in France is government subsidized versus a median 4-year cost of a private American medical school of $286,806.

Medical malpractice in France is based on a national no-fault compensation scheme versus an American medical malpractice system where OB/GYNs in some New York counties pay annual malpractice premiums of $227,899:

Pay me like a French doctor.  You know you want to.

Comparing physician salaries with those in other countries is fine.  Even saying American physicians get paid too much is okay.  But if you want to cut physician pay in the United States, also reform the cost of medical education and medical malpractice to match systems of those abroad.  Don’t pick and choose numbers to fit an agenda.

If you want to pay me like a French doctor, also give me the French cost of medical school and the French medical malpractice system. Any takers?

Pay me like a French doctor.  You know you want to.

Kevin Pho is an internal medicine physician and co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is on the editorial board of contributors, USA Today, and is founder and editor, KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • buzzkillersmith

    Well done Kevin.

    Cutting doc salaries by 20% won’t save much money, but it will give a substantial number of Americans joy at our suffering. So let’s not forget that benefit.

    If you really want to save the big bucks, you have to cut income for all workers in health care by a substantial percentage–nurses, PTs, etc. And let’s not forget pharma.

    Another option might be to try to slash the more than 20% of each HC dollar sucked down the administrative rat hole. Good luck with that.

    • Dr. Drake Ramoray

      Doctors. Disorganized low hanging fruit. Statistics, numbers, rational thought don’t matter when arguing against the caricature of the greedy doctor driving one his Mercedes on the way to his second vacation home.

      Every resident I work with I tell them to pay off their debt as fast as they possibly can. Live like your still in residency, especially if they don’t have children. Excellent articles like this one aside, the pay isn’t gonna last. None of it will matter. The writings on the wall. Prepare.

      • Suzi Q 38

        “……..Every resident I work with I tell them to pay off their debt as fast as they possibly can. Live like your still in residency, especially if they don’t have children. Excellent articles like this one aside, the pay isn’t gonna last. None of it will matter. The writings on the wall. Prepare.”

        Good advice.
        I am not sure that doctors will listen.
        I agree that the pay is not going to last.
        Physicians will be a “target” because their salaries will be considered quite large as far as the total costs.

    • safetygoal

      I agree 100%. Don’t forget the administrators. When we have to cut back the first thing they do is lay off housekeepers and dietary aids, the cheapest staff they have. Then they get upset because the HCAHPS scores are down because the patients’ rooms are dirty and their food is cold. For the price of one do-nothing AVP, we could have another hospitalist.

      • Suzi Q 38

        This is so true.
        I had my c-spine surgery at one of the better teaching hospitals in my state.
        After my surgery, I was put in a patient room with a roommate, who was a nurse. We were both “invalids,” but luckily I was more mobile and she was more outspoken.

        When we fully woke up after our surgeries and felt well enough to look around, I saw how dirty our room was.
        I could literally see the dirt on the floors, the trash still in the trash cans, the dust and dirt on the furniture. The bathroom was also dirty. Gross.

        We couldn’t get a nurse after several attempts. Good thing I had insisted several hours previous to have my catheter removed. I was handed a bedpan. I told her that was not what I asked for, LOL. She grudgingly did what I asked. Anyway, this allowed me to be more mobile.

        When my roommate or I couldn’t get the attention of our nurses (who were visiting nurses), I simply walked outside to the nurses station with my I.V. pole in tow.

        I teased them about not answering our calls. I told them “What if there was a medical emergency?” “You don’t even answer our calls. If someone doesn’t come to help my roommate, I am going to call the patient advocate.”

        Anyway, I did complain.
        I was told that they sent a “team” of marketing people down to my very room. They agreed that it was filthy.

        No wonder I got out of there as soon as I could.

        • safetygoal

          I’m so glad you spoke up! It seems the bigger the hospital, the less attention the patient receives. I’ll stick to a small hospital if/when I need to be admitted. :)

  • liberty4awl

    I’d love to, actually I don’t know what French doctors make but I’d love to pay you a comfortable wage as I think my health is worth it, but I’d love to just be able to pay you out of pocket but I can’t. Well, of course technically I can, but have you ever tried? It’s a joke, there is no set payment for anything, it’s a nightmare. Insurance companies have a strangle hold on healthcare and i don’t see them going away anytime soon. We have over legislated healthcare and its a mess that nobody seems to want to clean up. As a nurse, I’m constantly disgusted by the way we ration out care in hospitals based on the patient’s insurance status. I’m so glad you docs went to school for years and accrued horrible debt so that you could be told by an insurance company what kind of care your patient can receive. Healthcare in the US is a mess that is never going to change because people don’t seem to understand how it works. I hear people constantly complain about doctors constantly, not realizing that you guys aren’t even calling the shots anymore. You can’t have good patient care when the hospital administration wants to run the place like a business and only worry about the bottom line. One hospitalists can not cover a 30 bed med-surg floor and the ICU at the same time, but hey that happens at my hospital all the time. And my patients wonder why the doctor doesn’t show up til 3 pm to see them and do you know who they blame, not the administration that has over booked the doc but the doc, cause obviously they are out golfing or riding around in their Mercedes cause the media tells them that’s all they do with all the cash they are raking in! As much as I can’t stand that my doctor no longer looks me in the eye but at their computer screen and only has 10 minutes to do a whole health history, I know it’s not really their fault, they are a product of our broken health care system and until the doctors and nurses raise up and demand change it’s never going to happen and sadly I don’t think it ever will, because nurses and docs are too busy doing paperwork on the patients they barely get to send any time with and just trying to make a living and bill their bills. I hope I’m wrong and some day it will get better, cause as of now I’m unable to encourage anyone to go into the healthcare field.

    • buzzkillersmith

      Yep, you get it.

      HC won’t get better. It will get worse. There is money to be made by admins and other folks. They’re not feeling our pain or our patients’ pain.

    • HopCare

      When insurance started acting as a payor for every single healthcare need, even the most routine and common, we moved away from anything that resembled a normal marketplace. No prices available for the person receiving care and thousands of codes for the doctor’s office to handle. We don’t have car insurance for a broken headlight and we shouldn’t have health insurance for strep throat.

    • Suzi Q 38

      Liberty4awl,
      You make some very good points.
      It has been helpful to me to hear about what has happened to our healthcare system.
      I hear about it mostly on this website.
      I simply had no idea. Now I understand what has happened, and realize that hospitals are so different than what I thought they were.
      I used to feel that us patients were safe when we got to the hospital. I realize now that we are not, and we just have to do our best and look out for ourselves. The hospitalist is not going to do it.
      Here I envisioned my former teaching hospital as one of the premiere hospitals for cancer. I thought when my doctor did have the answers, he would call on his “team of health professionals and together, they would work out a solid plan for me. After all, I had PPO insurance.
      After my surgery, when my mobility and health kept declining,
      there was no team of experts (like they advertise on the radio and television) to help me.
      Yet when they figured out that my sister and I might have Lynch’s syndrome, they were all over it, asking us to submit to a litany of tests. I had to say “”STOP,” you haven’t figured out my my legs are so weak after my surgery…..”
      I don’t think my doctors are rich, I just think that specialists make a good living, so stop complaining.
      There are more med students who would want their job someday.
      As far as the GP or primary care doctor, they have a lot to be unhappy about. I agree…they are not being paid enough.

  • T H

    Mainly preaching to the choir, but this is an outstanding essay. Funny that the Post, Vox, Bloomberg, or some other major news outlet hasn’t picked it up.

    Wait. It’s not really funny.

  • Markus

    Let’s see now. Med school in France is free, but it costs $300k in the US. American primary care doctor makes $90k per year more than French doctor. In three and a half years the American can pay off this difference, and it is all gravy thereafter.
    The incomes reported are net.
    The low malpractice rates reflect the social network in place in France versus the US. If I am damaged by a French doctor, I don’t have to add in the cost of my kids’ college in my loss calculation.
    Do you really want French income? It comes with a whole social system that Americans generally say they reject.

    • FriendlyJD

      It’s true, annual salary snapshots aren’t too helpful here. I’d love to see a lifetime analysis, with adjustment for malpractice premiums and, say, $300,000 in loans at an average of 6% interest.

      • Markus

        The salaries are net…after malpractice, etc. The absolute difference at 90k per year is $7500 a month. Amortization of $300k at 6% over thirty years is $1750 a month which leaves the US doc with an extra $5750 each month. This sum is close to the income of a experienced high school teacher for comparison purposes.
        The French doc does have some monetary and non-monetary advantages. The bread is better, retirement is secure, and they are closer to Catherine DeNeuve.
        My main point is that societies are not available a la cart. There is a whole social infrastructure which few American doctors would want to switch.

        • Dr. Drake Ramoray

          Some of us are willin to switch. I have looked before and am again considering moving to Australia, Canada, or New Zealand. My issue is not lack of desire for a better system, but for disbelief that it is something the US government can do correctly.

          • Suzi Q 38

            Is Canada, that much better?
            I remember visiting there at least a decade ago, and their taxes were a full 45% of people’s income. I met a couple on a cruise, and he said this was true.
            Also, nurses were striking because of poor wages, I am sure that physicians do not have it that easy either, unless you could convince me otherwise.
            In the US, at least our taxes are in the 25%-30% range.

            If things have changed, let me know.

          • Dr. Drake Ramoray

            Cost of living is higher, taxes are higher, and it sure is cold. Money isn’t everything and the Endos from Canada I have met at conferences are some of the happiest ones there. I will take a pay cut (in the US or overseas) to work in a better system if it is easier to do what is right for my patients.

            From a strictly practicing medicine standpoint, it is an English speaking first world country who has happier physicians. I’m not setting the bar particuarly high, it’s more a reflection of how unpleasant it is here. No place is paradise.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          The French docs have another advantage too. Nobody is trying to put them out of business or forcing them to sell their little practices. There must be some value attached to having full autonomy and being your own boss……

          • buzzkillersmith

            Hi M. This is critical. They are trying to put us out of business and trying to force us to be the serfs of CorpMed. Autonomy is huge here, especially for us nonproceduralists who are probably on average less greedy than some docs.

            I made a lot more money working for CorpMed. It was absolute hell.

          • https://www.facebook.com/arobert6 Alice Robertson

            “They” being your colleagues in conglomerated medicine?

          • buzzkillerjsmith

            Kaiser certainly would like to do that.

            But it’s mainly the feds and CorpMed itself.

        • Suzi Q 38

          “…..Amortization of $300k at 6% over thirty years is $1750 a month which leaves the US doc with an extra $5750 each month……”

          Is the total amount borrowed $300k? Doesn’t anyone work part time during med school and residency? Do med students receive any financial help for joining the armed forces after?
          I have two friends in high school who wanted to be physicians but their families had no money.
          they joined the Air Force.
          We paid $100K for each child to get their undergrad. Maybe some families can afford to help with the tuition.

          If the worse case scenario is $300K, and doctors make an average of $200K or more, wouldn’t it be a good idea to live frugally like you did before and pay off the loans with most of your income until they were completely paid off? Stretching the payoff date to the full 30 years is not the greatest of ideas. There would be way too much additional interest to pay.

          Waiting 30 years would be a choice, albiet a poor one.

          • Dr. Cap

            Again, most of us are in our 30s when we start practicing. With families. Kids. Mortgage. And most are probably living what you would call “frugally” driving the same Honda we did through residency.

          • Suzi Q 38

            Good for you and your husband.
            It sounds like you knew what to do and how to systematically pay the debt down before your children needed money for their college tuition.
            Not everyone thinks like you do.
            I still say it can be done, at least way before the debt becomes a huge albatross. Waiting 30 years to pay anything off is not a good idea.
            You drive the same Honda, but not every physician is so thrifty and wise.

          • FEDUP MD

            I finished training in my 30s. I have 2 kids whose daycare each costs more than public college tuition in my state (this is common, see recent NYT article about this). I’m not too excited about us all living in a one bedroom apartment on Ramen until the kids are 10.

    • Dr. Cap

      Yeah if you live in a box and eat cat food. Seriously? By the time most of us collect salaries we have, um, families and stuff.

      • Suzi Q 38

        Is your husband a physician, too?
        Are you both GP’s and FP’s, or are you specialists?
        If you are specialists, you may have on the negative double the school loans. On the positive side, you have double the salary, yet you are sharing the same house.
        If you have children and have to pay a nanny or daycare, those years of paying for such does not last forever. I know from experience it feels that way, but when they get into first grade, you only need part time care.

      • https://www.facebook.com/arobert6 Alice Robertson

        You know sometimes you need to know your audience. The audience on this board is too well informed for this to go unchecked. When doctors drop off the of the majority of the top 20 earners in the states then you may make headway in convincing us that live in a cat colony awaits the most educated people in the land. Until then we aren’t worried about you eating cat food when the average patient is making far less than a doctor, has their own student debt and by-the-way they know cat food ain’t cheap:)

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Oh, but they are…. :-)

    There is a very good paper by David Cutler (particularly Table 2 on page 12), that sheds some light on this conundrum.
    http://stevereads.com/papers_to_read/the_paper_work_of_medicine_understanding_international_medical_costs.pdf

    What is happening in the US now is that doctors are seeing their income relative to other high-earners slipping. The reason it is slipping is because physician income is anchored to the income of most people, or GDP per capita, and due to increasing inequality this number is moving farther away from the incomes of the rich.
    So for the umpteen time: doctors for the poor cannot become wealthy. If physicians want to see their income go up, they better start advocating for reducing inequality and poverty among the patients they serve. This may or may not work, but it is the one and only way.

    • Dr. Drake Ramoray

      I am not going to dispute the concentration of wealth in this country and the destruction of the middle class, I am however going to point out that physician salary being anchored to middle class income is a simplification if not incorrect analysis of the problem. Costs are actually going up while doctor salaries are going down moslty due to the consolidation of payers (less competition amongst private payers) and because they are increasingly becoming employees of big corporations.

      The cost of care isn’t goind down, it’s increasing. More and more money is going into the system, however it is not going to doctors. Now the money is going to big pharma, big insurance, EMR Vendors, consultants largely made up of doctors who used to see patients and big hospitals. Both the doctor and the patient are being squeezed, in part due to facility fees amd regulations and red tape that isn’t supported by patients or independent doctors.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        It is indeed a simplification. You are aptly describing the means by which physicians are being nailed to the middle class as it’s being sunk. Similar strategies have been used against all sorts of other professions in the past, quite successfully.
        I think physicians for some reason were convinced that their fate (and fortune) was inextricably connected to the upper echelons of income. As the groups are parting ways in this country, doctors are discovering that those who make a living with their hands are classified as labor – knowledge labor and extremely high-skilled and high-payed labor, but labor nevertheless, and as such slated for servitude and barred from fair compensation.

        • Dr. Drake Ramoray

          Agreed. I appreciate the clarification. Doctors are also notoriously poor buisnessman. I remain amazed at some of the contracts my colleagues have signed.

          I don’t lament the loss of income as much as many of my colleagues and I am looking for a better way to practice medicine as I have described elsewhere even if it means a loss of income. My primary concern is autonomy and what is best for patients.
          Money aside, I am more suprised at physicians failure to react to loss of autonomy on so many levels. From agreeing to work for corp med, to the generations ago shift of physicians billing the insurance company directly, doctors have not been effective at advocating for themselves or their patients for generations. If I had the sociology qualifications it would be something I would study.
          I remain steadfast in my desire to be independent and do what I think is best for my patients, even at a significant cut in pay. But I fail to understand why those who have given up and joined the machine don’t have the desire to unionize.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I completely understand. I do however think that the loss of autonomy is a first and prerequisite step in taking away your income (it may be a small fraction, but it’s a pretty good amount in total), and your ability to trigger spending on your patients. It really all boils down to minimizing the amount of money “wasted” on patients without ROI in the form of increased workforce productivity.

          • Dr. Drake Ramoray

            It’s always good to talk with you Margalit. I have to admit though when I do I remind myself to seriously consider moving over seas to practice medicine. I say this not from just a physician perspective because this is not the country that I grew up in and like generations before that came here, I fear for the future of my children and grandchildren. This is not the country that my parents emigrated to and of my childhood.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Good to talk to you too Dr. Joey :-) I do share your apprehension, but I am hopeful that our children’s generation will be able to fix the mess we are bequeathing them. I like their generation a lot…..

          • Suzi Q 38

            Why can’t you doctors just ask your patients to bill the insurance company themselves and pay you in full before or after services are rendered?
            Yes, we may have to pay more than the insurance company would pay, but that would be fair in my opinion. If the visit charged was too much, I would have a talk with your receptionist who works with the insurance companies.
            When I had my knee surgery, I that to pay the deductible and copay upfront, which was about $2K. I think the whole surgery cost a little more than $10K. It would have been too difficult for me to come up with the entire amount at the time of the surgery.
            Office visits, though are far less as far as cost, so I could consider paying upfront, then billing my insurance company.

          • querywoman

            That’s what we use to do, when the standard was a $200 deductible and then pay in advance and get 80% reimbursement.
            Very few doctors around here would take insurance assignment and kept increasing their frees.
            Then insurance went mostly to a small copay with no deductible. And a lot of doctors started running all kinds of tests when I was just paying a small copay.

          • Dr. Drake Ramoray

            Depending on the particular contract that is a possibilty, although not popular among patients. You can’t do this for Medicare/Medicaid though. It’s called balanced billing and its against the law.

          • buzzkillerjsmith

            Gotta unionize. Unions would be transformative for CorpMed docs.

        • azmd

          Yep. As a friend of mine from a very upper-class background once said to me “Doctors are the hired help.” She was actually speaking of a mutual friend of ours who was a successful ophthalmologist; in her mind, he was a tradesman. I frequently tell my friends that I see myself as a skilled worker not unlike a plumber.
          The problem is that most doctors are too immersed for too long in the arduous training that it takes to become a doctor, and they don’t have the social awareness or the time to notice nuances like these, or how their lives are being affected by them. Those who are savvy enough, are either going into, or planning to go into non-clinical fields.
          Patients should be worried. Very worried. In a generation, we will probably have a healthcare system like Russia’s.

          • Dr. Cap

            Too bad you can’t charge like a plumber. And collect like a plumber. And fix pipes any damn way you think is best… say it with me…
            Like a plumber.

          • Suzi Q 38

            My brother is a very successful plumber.
            He lives in an upscale neighborhood, amongst physicians and other highly regarded professionals.

          • Dr. Cap

            Just stating aloud that skilled professionals are skilled. My husband was an apprentice plumber (for which I have thanked God countless times). My point (assuming you misread me) is that other professions get to charge and collect what the market will bear, do their best job or nobody would recommend them, and the paperwork consists of an invoice. We as physicians should be so lucky.

          • Suzi Q 38

            Yes, I did misread you. Thanks for your clarification.
            After paying about $1K in plumbing bills last week, I realize that they charge a lot.
            I also have to pay “on the spot.”
            No stretching the payments out like I have done with past physicians and my insurance company.

          • querywoman

            Yeah! Like the old joke about the doctor who called a plumber and complained to the plumber about what he charged for his plumbing time as compared to his own charges.
            And the plumber, “I know. That’s what I made when I was a doctor.”

          • buzzkillerjsmith

            When I worked at Kaiser I was a highly trained professional treated like a worker at McD’s.

            Would you like any antibiotics with your postal service work excuse today?

          • querywoman

            I wonder how badly Kaiser treated its doctors during its brief stay in Texas?

    • querywoman

      Doctors for the poor in the US really need salaried positions with public clinics, hospitals, and medical schools to be able to make a living.

      • buzzkillerjsmith

        True, but who the heck wants to work in that chaotic and abusive environment? Follow one of those docs around for a few days. You will be mortified, absolutely stunned by the horrible job.

        Most docs would rather do almost anything than work in a community health center.

        • querywoman

          So would most patients.
          But some doctors have the mentality for it.

        • ersmom

          I did 3 years in a community health clinic. It was like residency but better paid. And I completely burned out, took 6 months off. Now have a job working part-time in a hospital practice. My boss keeps asking if I want to work more. I just laugh at him.

  • NewMexicoRam

    This is rich.
    I don’t have time to look up the source, but practice expenses are also higher here is the US.
    There’s a lot that can be done to lower health care costs, but starting with the docs is a big waste of time.

  • JR

    Is it really fair to compare tuition (France) vs estimated cost of tuition, room and board (US) like you did above? Does France cover tuition, room and board at 100%?

    Is it really fair to estimate what an average person pays for medical school by the estimated cost of the school? That’s like estimating the average cost of a medical procedure by looking at what the hospital bills rather then the payments they receive.

    The “average” student gets scholarships, grants, work studies… or even tuition reductions. Work provided assistance (Even McDonalds has a tuition assistance program). Assistance from parents, grandparents, or other providers. The amount listed in the catalog isn’t an accurate gauge of what people are actually paying.

    It seems like it’s safer to go off the average debt per student to see what the students themselves (and not their parents) are spending, but of course those costs also include loans taken out for room and board along with their undergraduate costs… and it seems that’s coming out at a total of $180k for undergrad + medical school… tuition, room and board, a lot smaller than a number like $280k just for med school tuition no? Not that $180k isn’t an insane number.

    • FEDUP MD

      Med school isn’t college. There is almost no downtime, other than MAYBE a 4 week break between years 1-2. Which usually people fill with research for applications to residency. It’s not like you can bust out f of anatomy lab or walk off your 24 hour shift in the ED to go to your shift at McD’s. Generally the first two years you are in class all day long, unlike college, and it is necessary to study all evening and weekend just to pass. During the last 2 years, you are typically on a resident type schedule, about 80 hours per week, not including studying time at home, or doing applications and travelling around on interviews. I say this as someone who had tons of free time in college for whom med school was quite the culture shock.

      • buzzkillerjsmith

        Med school is a totally different ballgame. Everyone is wicked smart and very motivated. You take what they give.

      • JR

        I wouldn’t wish med school on my worst enemy.

        … ok well, maybe my worst enemy… … hmm

        But still, I think that if we are going to look at the cost of an education we have to realize that the “sticker value” doesn’t really equal the cost.

  • ninguem

    And when the insurance payment gets ratcheted down too low, you can balance bill like a French doctor:

    The French term is “dépassements d’honoraires”

    https://www.mutuellemgc.fr/depassements-d-honoraires

    http://www.radiancehumanis.com/conseils-sante/comprendre-la-mutuelle/remboursement-depassements-honoraires

    It is possible to go too far. These docs balance-billed over triple the official insurance rate.

    http://www.lefigaro.fr/conjoncture/2014/03/05/20002-20140305ARTFIG00198-trois-premiers-medecins-condamnes-pour-des-depassements-d-honoraire-excessifs.php

    • querywoman

      There’s something about government payee systems that invite fraud.

      • cerf-volant13

        So d#mn right ! People over here do medical shopping, get free medication which they send over to their family abroad ( I voluntarily do not mention any country ) where nothing’s free. Or even better : the family comes over, and uses the social security card of the registered family member to get their check-up. And if the over-using of a certain social security number arouses suspicion : you’ll never guess who gets controlled and even fined !!!

    • cerf-volant13

      Ninguem, don’t be fooled : these “dépassements” are only permitted to a limited number of doctors, and can only be paid by a limited number of patients. An OB/GYN – friend of mine, working in Marseille, has over 90% of his patients on CMU , which is a sort of wellfare-medecine, and you may not refuse to treat these patients. For these patients EVERYTHING medical is free, they don’t have to advance any money, the physician is paid by the government… after all the necessary paperwork has been filled out. And believe me : bureaucracy is a french word ! You ask for 5€ in advance, you risk being suspended for 3 weeks to 3 months !
      These “dépassements” are used by the media when they want to go out for some “doctor-bashing”. The abusive billing is done mostly by physicians working in the public system, and who provide a waiting-list bypass for their more wealthy ( or better insured ) patients. In a private practice, unless you have a concrete reputation, you can not ask for an unreasonable surplus unless you want to retire soon. But it’s these doctors that are taking the rage of the general public.
      25 years ago, I did a summer clerckship in Eastern europe ( I wanted to get an “edge” by making my resume seem more adventurous ). I was informed by an english speaking patient that in order to get the REAL doctor to operate on him, he had to bring a small envelope with about half a months salary ( he came in for a diaphragmatic hernia ). In view of the physicians actual salary and his personal investment, this did not really shock me . I find the actual situation in France far more shocking : we have done so much with so little for so long, tomorrow we are forced to do everything with nothing.

  • Dr. Cap

    *thunderousapplause*

  • ninguem
    • querywoman

      So they don’t want irresponsible poor patients either. Big deal!

      • ninguem

        You understand that, query.

        But people really think these problems are fixed in France. No they’re not.

        • querywoman

          Yeah. The poor are still the poor and can be a pain.
          And other people write that doctors can be blackmailed into seeing patients sooner in countries with socialized medicine.

  • ninguem

    See Médecins Sans Frontières – Doctors Without Borders, see the work they do in France, in Belgium, in Switzerland. for the people exclused from their own healthcare systems.

    http://www.doctorswithoutborders.org/about-us

  • querywoman

    Picking out one issue like a medical salary from a more socialized society is unrealistic. Taxes are higher in all of Europe. There is more public transportation. There are more generous programs to keep people in homes and better nursing home.
    Once when researching Prez Sarkozy, I learned that French politicians are supposed to above money and in it for higher purposes. Maybe French businessmen an politicians have to pretend to not like money.
    The love and pursuit of money are part of the American capitalist system, our higher goal.

    • cerf-volant13

      I’m living in France, and believe me : they’re all in it for the money. Sarkozy was somehow more honest, because he didn’t hide his love for luxury. Maybe it’s the eye of the expat , but I’ve noticed that when looking at the french politicians , there’s one thing that’s very striking : the so-called right wing ( liberal, capitalist, free market oriented ) are mostly self-made men, entrepreneurs, who know what it means to work, and who want to lower taxes to get more investors. The left wing ( socialist, central-government oriented ) are all coming from extreme wealthy families, never had a day of honest work in their lives. Their election program always wants to make the rich middle class pay. NOT the rich UPPER class, that’s themselves !!! So you get a system where the minister of finances and taxes ( Cahuzac ) is found to have laundried money into a swiss banc account, another one lobbies to leave artwork out of the taxable patrimonium ( Fabius : his parents own for BILLIONS of antiques and art ), and the national mascotte, DSK , is gently put aside but gets “hired” for astronomic amounts of money as an advisor. Others who are known to have src€w#d -up, get golden government jobs ( probably to keep their mouths shut ). Personally, I don’t mind telling that I work to earn money. But I must be lacking in hypocrisy.

      • querywoman

        Thanks for telling us all about France!
        So President Nick was obvious and that’s one of the things that got him controversial! I liked him, because he loves Diet Coke and candy.
        If doctors are part of the “upper middle class” in France, then they pay plenty of taxes.

  • JW

    I have some docs I really appreciate. I want doctor pay to increase, not be cut. All the articles I read say being a doctor is a really poor financial decision, but we actually need more doctors.

    We need to do something differently, to incentivise doctoring and especially primary care.

    And to change the rules so doctors can practice medicine, not be directed by insurance and government agencies.

    I want good doctors (and I assume that’s most of you) to feel appreciated and to have a decent salary.

    • Suzi Q 38

      I still say that becoming a physician is still considered very desirable. Medical schools are highly selective. People simply would not be lining up to do this profession if it was so bad.

      I think they earn their pay.
      This idea that there are not going to be anyone left to treat us in our lifetime is proud and self serving.

      • FEDUP MD

        For now at least.

      • buzzkillerjsmith

        Becoming a physician. That’s right. Actually being a physician sucks eggs. This leads to part-time work, demoralization and bad pt care.

        People are lining up for a bad profession because they don’t know or don’t want to think about how bad it is. The endless parade of unhappy humanity and the egregious abuse by CorpMed and others takes its toll. Often in just a few years, as the younger docs here can attest.

        There will be people left to treat you. Primary care docs who are demoralized and give crappy care. And over-refer, leading to spiraling costs.

        And who won’t see followup pts from the hospital because those pts are too much work for too little money so that the pts wind up in the hospital again and lead to spiraling costs.

        And the NPs and PAs won’t help much here. Not enough of them and they don’t like primary care much more than we do. The ones I work with would get out if they could and be orthopedic assistants.

  • Suzi Q 38

    Yes.
    Here he never graduated from college, and he is living amongst physicians and other upper class professionals in a very upscale neighborhood.
    He told me he has almost paid off his house, and he is about to buy another rental for income when he retires. He has several houses, and his plumbing skills come is handy.
    He has done the best with what he had, even with a wife at home who never worked outside their some since they got married.

    It appears that most doctors are good at making money, but many do not appear to have what it takes to grow their money.

    • https://www.facebook.com/arobert6 Alice Robertson

      Good on your brother!:). I think the comparison of a doctor’s wages to a plumber’s is often unequal. Overall doctors are paid more (Dept. of Labor stats). Plumbers have poor hours, and lots of equipment to buy, and they do house calls. If a doctor had a traveling business and did house calls then you could compare on a wages only basis.

  • NormRx

    My two cents. If there is one common topic on all of these threads on physician pay it is, wait for it!!! BLAME THE OTHER GUY. Doctors blame pharma, not just pharma it is BIG PHARMA and BIG HOSPITALS. Hospitals blame BIG PHARMA and DOCTORS (we haven’t gotten around to calling doctors BIG DOCTORS yet) and of course pharma blames doctors and hospitals, and all three groups blame insurance companies. Until doctors, hospitals and pharmaceutical companies unite for their common good instead of blaming each other you are all going to be screwed.

  • ak123

    Forget malpractice, forget cost of education. Can someone point out number of hours worked? Amount of non-compensated overtime? Amount of free call overnight we take? How about retirement benefit?
    Oh, and lest we not forget, how about the income distribution in france? Minimum wage there is 60% of hourly mean wage, i.e. the U.S. equivalent minimum wage would be $15 an hour. US is hard work = big success, or at least it was.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    This is really interesting data. Thank you!
    May I ask a few more questions?
    Are there doctors that work in both systems? Seeing how the public structure is only 35 weeks, I would think that supplementing the income with private patients may be interesting….
    Approximately, what portion of charges does the government cover for private patients, if any?
    And finally, are most doctors in the private system? and does it vary by specialty?

    • cerf-volant13

      When patients come to the public hospital, everything is free. When they go to a private structure, the government covers the same amount : this is quite interesting for the structure itself, but not ( anymore) for the doctors : it has been about 30 ( ! ) years since the fees for every operation have been readjusted to the cost of life. So every practitioner who wants to give good care, needs to ask for extra money. (e.g. : for an appendectomie, the surgeon gets about 100 $ , the anesthetist 72 $… this is not a joke !!!) This comes out of the patients pocket, unless he’s got a good health insurance. You may not believe this, but most of the patients don’t even know what their insurance covers ( and most of the time it covers only the supplement for a single room, cable TV and telephone. Good medical care is clearly not the issue ).The only thing that has been upgraded, is the fee for a consultation : standard = 28 € ( or about 34$ ,) , complex = 46€ ( 55 $). Most practitioners will then go for 30 and 50 €, which is not that bad, but there’s the catch : the public see you making 50€ in 15 minutes, for a “chat”, so they imagine that for every medical act you get thousands. My closest neighbour once asked me – informally – how much I made for every anesthetic : ” 400€ ? 500€ ? ” When I showed him the figures, he first laughed and refused to believe me. And he’s an intelligent man !
      As for working in both systems : In the public sector it’s 35h a week, not 35 weeks a year (!). Indeed, some doctors work in both systems, but not as you may expect : it’s mostly the private sector who lends a hand in the hospitals when their structure is closed for maintenance or summer holidays… or lack of personnel : here’s another paradox : the nurses are paid far better – and for less work – in the hospitals ! And the hospital won’t hire unless you’ve got some experience. So a freshly graduated nurse, no experience, gets hired in the private sector. She has to learn everything the hard way ( I cannot overstate “hard” ), and so as soon as she can get out and flee to the public system, she does.( in 2002, we had 8 OR nurses. The hospital started hiring, and in less then 2 months we were down to 3…)
      As for proportions : about 2/3 of the doctors are in the public system, 1/3 private. And still lesser doctors go into the private sector, because , well, working hard doesn’t pay anymore. It does vary by specialty, but I don’t have enough data about that. Why go in private practice, you may ask. Good question. For me, the only advantage is to be able to work with the people I chose to work with, and to not have a supervisor who tells me what to do and how to do it. But maybe I’m paying to high a price…

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Thank you so much for the response. I guess the problem is much more universal than we think here in the U.S. I am not surprised really, but I will have to mull this over a bit…. before I “unleash” another blog post :-)

  • Karen Ronk

    If you have a good doctor who really cares about you and does their best to help you, then you are happy to see that doctor make a good living. If you have had a lousy doctor who is incompetent and arrogant and you believe they stole someone’s identity because they cannot possibly be a real doctor, then you would love to see them living in a box and eating cat food.

  • Eric W Thompson

    A good portion of the blame for student debt is the cost of University education. It has risen at a much greater clip than healthcare; but students just pay. Building palatial & ornate buildings and dorms then charging the students to cover the costs. Not to mention the large increases in administrative staff with negative impact on ratio of those teaching to support employees. Higher education is a much poorer deal than 40 or 50 years ago with arguably lower quality output. Blame is then put on the government for not subsidizing education enough; though with would only increase the cost inflation.

  • Dorothygreen

    Why do you compare to France. Switizerland is much better to compare to on all accounts.

  • morebuzzkills

    This is an outstanding article with great debate in the comments section. I would also argue that everyone is missing one of the most important arguments when it comes to medical school, debt, and physician repayment. In general, I have found that most patients hope to have the best and brightest as their physicians. With that said, it is, from a purely financial perspective, practically suicide to go into medicine. This is because of two main issues: the time value of money and the debt required to become a physician. First, the student chooses to sacrifice the first four years of a potential post-college career (and associated earnings) to medicine. These four years are literally the most important years in terms of saving for retirement. I know that the societal norm is to not save during this time…but remember that we are talking about the best and brightest that go into medicine. One would assume that many of these students could realize the importance of these four years and work to save during this time. Second, the student must sacrifice anywhere from seven to twelve years after college for training. Four of these years typically cost the student anywhere from $100,000 to as high as $550,000 (that is the largest amount of debt I am personally aware of). So, once the person finishes training, a large portion of what they could be saving goes into paying back debt. Finally, the length of any career is inherently cut short by the duration of training. This means that there are fewer years at the end of one’s career when one is presumably earning the maximum amount. Just to illustrate the time value of money, assume this very HYPOTHETICAL example: student A (medical school material, but chooses a career in banking) graduates from college and manages to save $10,000 per year invested at 8% and has a 40 year career; student B (medical student material, becomes internal medicine physician) graduates from residency and manages to save the same $10,000 invested at 8% but has a 30 year career. The 10 year difference is astonishing. Student A has retirement savings of $2,590,565.19 while student B has retirement savings of $1,132,832.11. This incredibly simple example shows that all things being equal, medicine can end up having a $1.5 million dollar consequence. I truly hope that the time value of money and opportunity cost of becoming a physician is not lost on the readers of this blog as well as patients throughout the country. Most people go into medicine because they want to take care of patients. It is sad that most are not able to do so because of a system that does not properly incentivize this. Most people who go into medicine also become aware of the incredible lost opportunity cost of medicine. This is something to keep in mind the next time your doctor seems stressed or overwhelmed.

    • Matthew

      For once, you either chose to look at the whole perspective or know a medical student, and for that I thank you. I just finished up my first year of medical school and unfortunately I know exactly what I got myself into. In reality the best and brightest get into medical school with a vision of making a difference in the lives of those around them. Unfortunately, physicians are inundated with an overwhelming number of patients that they need to see to keep a roof over their head and, have let the system dictate how much and when they will get paid. Some of the most highly skilled and educated people in our country and the hospital CEO makes the most????? And the fact that people have the audacity to get on here and say that doctors make too much money, yet I finished my first year and already 70k in debt. So maybe we should look at trimming the fact on the insurance and hospital side of things, before you start talking about trimming how much a physician makes.

      • morebuzzkills

        I wasn’t even necessarily talking about how much physicians make on a purely salary basis…I was referring to the incredible sacrifice they make by basically signing up for a minimum of 10 years (likely many more) in six-figure debt at an interest rate that would make many hedge fund managers salivate. Imagine what physician salaries would be if this sacrifice were specifically calculated and incorporated into the salary of physicians. The common US citizen does not understand this time value of money conundrum. We are very much a surface-level society, but that is just the way that things are and you have to get used to it. Furthermore, it’s not just the time value of money that is sacrificed. Being a medical student, you are well aware that it is also time with family and friends, hobbies, social activities, etc. In short, it is a sacrifice that people outside of medicine do not really understand. That is why the sympathy card does not go very far.

  • Jerome Bigge

    I fail to see “why” we can’t do as France, Germany, and other developed countries do. They make the necessary “investment” in advance by paying for physician’s education. On the other “free market” US doesn’t, making it necessary that the doctor to be pays for his or her own education. Our malpractice system is out of control thanks to no limits upon the number of lawyers who graduate from law school and then have to find a means of making a living. The only thing “exceptional” about the USA is how stupid and “short sighted” we are relative to the rest of the developed world…

    I should add here that French doctors do not have to bill insurance companies. They collect the money from the patient, who then bills his or her insurance company. This means that the French doctor only needs an “office nurse” instead of the big staff that you see in American medical offices.

    Also, French health insurance is non-profit. There are no investors demanding a big dividend or stock that grows in value every quarter.
    Thus the cost of health insurance is less. Drug prices are controlled. Instead of the “monopoly pricing” US drug companies charge here.

    All of this adds up. There is nothing “magic” about how France, Germany, the rest of Europe does it. There is also the major difference that their governments are “democratic” and exist to serve the people. Our own government on the other hand mainly exists to benefit the wealthy and corporations. That is another difference between the US and the rest of the developed world. It isn’t just health care that is different there, its a whole lot of things, most of which at least one of our political parties is opposed to.

    • querywoman

      There is no such thing as a nonprofit government, either!

    • Suzi Q 38

      What you say about France sounds idyllic.
      There must be a few drawbacks….maybe they limit the number of medical school students, or restrict who gets to become a physician.
      I have no idea.
      If it was so good there, doctors would be leaving the U.S. and lining up to work there.

  • Suzi Q 38

    Thank you for your explanation.
    Are you a GP or an FP?
    If so, you have something to complain about.

    In the end, it is still your choice to become a physician or not, based on the cost, projected future earnings, and most of all, choice of career.

    I am just saying that if it was so bad financially as a choice of career, there probably wouldn’t be so many college graduates lining up to get into the various medical schools.

    I am just thinking that physicians will not do as well as they did in the past as far as pay, but there are a lot of other professions that have taken a salary “hit.”
    If a an MBA graduates from the Haas Business School, h/she was also paid quite a bit for h/her education.

    Undergrad would have cost about $100k alone.
    I am guessing another 2 years for their undergrad…the tuition alone for graduate school is much higher, so about 70K a year. Plus living expenses…..add another $50K for the two years.

    We are now nearing $290K in loans so far, and those $150K jobs for people w/MBA’s are not the norm.

    I can see the bitterness as far as GP’s and FP’s.

    The pay adjustment should be made with the specialists giving up some of their pay and the GP’s getting more to even things out.
    If not, I can see where GP’s will not want to work for that much less than the specialists.

    There is a young man from our neighborhood who has decided to become a GP. I was just “floored.”
    With all this talk about the low wages and high medical school costs, I wondered about his choice….I realized that by now he knows what the pay is, doesn’t he? In that case, I hope he knows not to second guess himself. The facts are already there.

    • Harry

      At the end of the day it does come down to one’s decision to enter into a medical career or not. I sincerely hope that students continue to pursue these careers, even if the financial return on one’s educational investment appears dismal. With stagnant salaries, yet unregulated costs of medical education, I fear many who choose medicine as a career will find themselves in a position of indentured servitude (borrower is slave to the lender). And with average medical student debt approaching $200K, that shoul definitely grab prospective students’ attentions.

      As far as trying to compare student loan debt and earnings between various professions, people seem to either forget or downplay what physicians do. While it may be fairly easy to compare student loan burden and incomes on the surface, the responsibility and liability that physicians have to deal with in a daily basis, with every single patient encounter (whether face to face or indirect), cannot and should not be ignored. Each and every decision that physicians make regarding patient care has the potential to heal or harm an individual that has entrusted his/her care to that physician. The potential ramifications of malpractice lurk in every nook and cranny of a physician’s psyche. So, on the surface, it may seem easy to compare average debts, time investments, and earnings between various professions, but when we look a bit deeper, we should hopefully realize that significant differences exist that should justify higher physician salaries vs other professionals (no offense to any attorneys, MBA’s, CPA’s, PhD’s, or others who have also invested in their careers).

  • querywoman

    Other people besides doctors have most of these expenses too. Remember, you cannot pick out only the cost of a French medical education from the rest of their society.

  • Suzi Q 38

    A good friend of mine is a pediatrician.
    She is in her early 40′s, so all of her loans are paid off.
    She works part-time, about 3-4 days a week.
    She treats mostly medicare, and consequently has to see about 40+ patients a day. Her boss pays her extra to input patient information on the EMR.
    She said she is not making much. Her husband has an MBA, but has not been able to keep the same job for long periods of time.

    The economy has been rough in the last 20+ years, and so MBA jobs are not plentiful nor are they lucrative like they were in decades past.
    My point being that salary has not been great for the MBA’s, either.

    I hear what you are saying.
    My friend said she has competed WITH NP’s and PA’s in interviews for jobs.

    Law careers are not “all that” either.
    Ask the unemployed 30 year old across the street.
    She went through her undergrad, then law school, then studied for the bar and got a job. That first job was not stable, and the firm closed down. She has been a temp lawyer ever since. That was 3 years ago. Her student loans are still accruing interest plus principle.

  • gomerblog

    They also get 3 months off and short work days.

  • Wack

    That means take home difference of about 90k will take care of additional spending of 300k for school in less than 4 years!!

    And dont look at salaries of general practioners. Compare how much more our cardiologists, oral surgeons, anaesthesiologist, oncologists, gastro enterologists, radiologists etc make compared to rest of the world for delivering the same results.

    And american software engineers can not complain that they spend 50k per year in top school and engineers from india who came here to work spent only 500$ per year.

  • telemachus

    Your first figure, $286,806 (US) vs near zero (France), is incorrect. The 286806 figure is for tuition and living costs. France only subsidises fees, not living costs.

  • Wack

    Except for medical field where numbers are controlled by medical boards and board certifications are not allowed without residency even though foreign medical grad is capable of passing toughest board exams we can have, every other profession in US has to compete with rest of the world for job and their salaries are changing accordingly. If we allow to import doctors and other healthcare professionals and let them work right after they pass board exams, US doctors salaries will come down and ultimately merge with rest of the world.

    And again, you are looking at only salaried physicians salaries. Compare for other specialists i mention and you will see a huge difference in what they earn and what doctors earn in other countries. And those doctors are equally qualified and deliver same results.

  • anshublog

    Doctors say they are not overpaid. Surgeons say they are not overpaid. Insurance companies say they make only market returns. Hospitals say they are almost going out of business.

    Someone is making too much money. I would argue Doctors have created artificial supply constraints.

    Everyone is making too much money. We need to cut our healthcare costs by 50% – to be in line with world’s best.

    This means everyone has to take a cut.

    And let’s start with medical schools. What a scam!

  • tggudge

    As the Author points out, these cross-border comparisons are misleading at best and should not frame an entire argument. There is a lot more going on behind the French data than even the authors of the original report let on.

    I’m an American MBA who has lived in France for almost 10 years and the comparison of how personal income is reported in France and the US has been kind of a pet project for me and an Economist friend of mine here.

    The salary data in the report was “Self-Reported”. When a French Physician (or any French employee) cites take-home pay they are often citing their “Salaire Net” which is their net take-home not including social security contributions which are paid by their employer. This is a big cultural difference in the way salaries are quoted that too often goes unaccounted for in reports like this.

    Total mandatory social security contributions in France are roughly 100% of the salary figures being quoted in self reported data. So if self-reports show that French Physicians are taking home $95K, as the study claims, that means in reality their Gross Wage Cost to the Hospital or Clinic where they work is closer to $190K ($95K salary + ~$95K payed into the social welfare system) which is much closer to the gross cost of employing a US Physician.

    Of course I’m over simplifying but essentially the French Physician is paying for his “Free” education and frictionless malpractice system with each pay check… he just doesn’t account for it when reporting his earnings because those transactions take place inside the magical black box of the French Social Welfare system (which by the way has its own major systemic problems to deal with.)

    As the author points out comparisons like this are lazy and typically fraught with error. US journalists would do better to leave cross border economic analysis out of arguments over domestic issues like US healthcare costs. I can think of many more interesting areas of inquiry closer to home for them to investigate.

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