Grumpy doctors, but is it really worse now?

An essay in the NY times explains how terrible life is for doctors. Reimbursement is down, more time is spent arguing with managed care companies, there are more restrictions on the what they can prescribe, etc, etc.

Now I understand that primary care is in crisis, but overall physicians’ salaries in the last couple of years have gone up, and the first doc in the article is a cardiologist. Cardiologists, as this salary survey suggests, tend to make more than double what a primary care doc gets. And of course, fewer docs are primary care only now, and more are specialists (who make more money!). But whether or not physicians are getting paid less than they were, their perception surely is that that’s the case.

I am surprised that the burden of operating a practice and the demands of “managed care” are felt to have increased. Most observers would suggest that insurers have, since the days of Len Abramson & US Healthcare in the 1990s, backed off the extremes of medical micro-management. In fact, the most profitable health plan of recent years (Aetna) has bent over backwards to appear to be physician friendly. Whether or not it’s just window dressing is less certain.

If a doc living in the 1970s was forced into a 1990s world, I would understand the depression. And the surveys I was part of in the 90s indeed showed dismay at what was happening for them. But we’re now more than 10 years on from those times, and (as the politicians say) is it really worse now than it was four or five years ago?

Answers on a post-card (or at least in the comments), please!


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  1. I’d like to present a different perspective.
    I am not a military health care recruiter nor have any specific interest in convincing other physicians that the grass is greener in my clinic. However, as an Army Family Physician for the past 5 years, I would not describe my life as “terrible.” This includes my time spent deployed to Iraq in support of the War on Terror, as well. I can only speak to my experience, but I think it’s worth sharing.
    For me, this attitude stems from working with an incredible group of Americans–Soldiers, their families and retirees. It is an honor to serve them and gives me the satisfaction of doing something meaningful despite issues with pay, staffing shortfalls, frequent deployments away from my family, and administrative inefficiencies similarly found in civilian practices.
    In my current assignment, I primarily see a population of motivated patients who prescribe to a fairly healthy lifestyle including regular exercise and fitness. They are brave and selfless, committed to our nation, and since most want to remain healthy, are good partners in health. Certainly my job is not perfect, but I am satisfied to be involved in what I feel is a noble cause – caring for our country’s warriors. And at the end of the day, that really matters most to me.
    The views expressed in this statement are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.

  2. In New York State over the past 5 years you can see that the profits for the major insurers have taken a stright path up, while the reimbursement rates for Dr’s have declined in an equal and opposite fashion, this is a fact.
    One of the reasons why the salaries of specialists are so high is that they do not get paid a living wage to take a history and conduct a physical and render a diagnosis. However they get paid very well to conduct a diagnostic procedure, thank god for the widespread rapid decline of the individual Americans health profile, they can certainly provide the documentation to necesitate these procedures. For example there is nothing easier than diagnosing a radiculopathy, reimbursement for 20 minutes work for a Dr. that is $175,000 in debt, $40. Reimbursement for conducting a needle EMG/NCV test to confirm the obvious, $1,200-$2,200. The incentive to perform test to confirm the presence or the absence of the obvious is too great, and the art of diagnosis is degenerating among our young physicians.

  3. Doctors are making a lot less than they used to and working longer hours to get it. All available information cites serious upcoming shortages of primary care drs as well as a lot of oversued specialties like obstetrics, neurosurgery and orthopedics. Doctors incomes may sound big, but they have to pay a larger work force to manage managed care, and higher bills for utilities and taxes – add to that the possibility that they may have Medicare reduced by 40% over the next four years and kiss your doctor bye.

  4. I think I can provide some perspective since I have worked/trained as a doctor in Germany, France, and in the US.
    From the financial perspective, I don’t think that US physicians have a lot to complain (except maybe for some overworked PCPs in certain areas). I don’t think there is a country on earth with higher physician reimbursement. Student loans need to be factored in, but specialists with very long training tend to be interventionalists and make from 300 K (at the least) up to the 7 digits. PCPs may occasionally start with a 6 digit loan, but they also get a 130-250 K income when they start working in their early/mid thirties.
    With regards to work satisfaction, there is no doubt that in private practice, the pace is often fast and many patients unreasonably demanding (yes, I know that there also are patients whose reasonable demands are not met, that is not the point here) … but one can control at least the former (pace). I think that the threat of litigation is still a problem for most doctor.
    I think the core issue here is that a priviliged group is becoming overall slightly less priviliged. Working conditions are becoming more stressful, and I can understand when PCPs feel that they are overworked and underpaid, compared to their surgical/interventional colleagues. But overall, physicians in the US are well off and, due to the job market, have a lot of discretion where and how they work.

  5. I’m surprised you didn’t comment on this howler from the article, Matt:
    Stories of patients armed with medical knowledge gleaned from the Internet demanding antibiotics for viral illnesses or M.R.I. scans for routine symptoms are rife in doctors’ lounges.
    Uh huh, so it’s the Internet that’s responsible for people demanding antibiotics for colds….even though this misconception predates the Internet and I’m sure is hardly, if ever, promulgated through it.

  6. I was having a conversation last weekend on this very topic with a doctor (heart surgeon, actually). I couldn’t believe he was saying physician incomes were going down and he couldn’t believe I was saying that, with the exception of primary care, physician incomes were going up faster than inflation.
    After some discussion, we decided that some of our different perceptions could be explained by two facts:
    1. He was focused on payment rates for standard procedures that have been done for years. These indeed are pretty much flat, and some have even gone down.
    2. I, on the other hand, was focused on total income. For specialists in general this has indeed started high and just keeps going up at or above the rate of inflation.
    3. Three things could explain this discrepancy: volume, new procedures and uneven distribution of gains.
    Volume: Many physicians have been increasing their volume to compensate for flat rates. New procedures: When new treatments/procedures are introduced, often they are more technically advanced and get reimbursed at higher rates than the treatments they replaced, but this is not reflected in year-over-year analyses of procedure code reimbursement. Uneven distribution of gains: Some physicians are making a mint, whether through focusing on the most lucrative new procedures, starting their own outpatient surgery centers, etc. Thousands of physicians earn over $1M each year. It may be that the top 20% have seen a big rise in income while the remaining 80% have seen flat or declining incomes, much like for Americans generally.
    All that said, Peter is exactly right:
    Improve how? Less patients and more money? Isn’t that what what every body wants for their job, more time to do it better with more money. How abour social workers with case loads so large their clients (and society) are at risk, don’t they deserve less work and more pay? How about teachers with 30+ kids don’t they also want less kids and more pay? And just where will all these docs “flee” for a better life? Tell me what’s better, tell me that docs have it worse than anyone else in society.
    I’d only add that docs still have it better than almost everyone else in society from a monetary point of view, and I am completely unable to feel sympathy for them when they fail to reach their expectation of hyper-wealth and achieve only wealth.

  7. “If, for example, nationalized or socialized health care is enacted, there will be a new glut of patients…”
    New glut of patients?!! New because there will be perfectly healthy people seeing doctors just because, or new because those in need of care will now be able to afford it?
    “and at the same time, many health care professionals that will flee the profession unless conditions for them improve.”
    Improve how? Less patients and more money? Isn’t that what what every body wants for their job, more time to do it better with more money. How abour social workers with case loads so large their clients (and society) are at risk, don’t they deserve less work and more pay? How about teachers with 30+ kids don’t they also want less kids and more pay? And just where will all these docs “flee” for a better life? Tell me what’s better, tell me that docs have it worse than anyone else in society.

  8. I hope the writer will find a good doctor when he need one. Medical care is theoretical and abstract, until you’re sick or have an accident.
    In Los Angeles, doctors have been retiring and going bankrupt, as expenses outpace reimbursement. Doctors and hospitals are price-controlled, so fuel costs, and every other cost increase, can’t be passed through to the consumer.
    Medicare is cutting 10.6% on July 1, and another 5% January 1, 2009.
    Doctors have been forced out of business, or quit. Some salaried academic and large group doctors haven’t felt it yet, but the lower reimbursement will shortly trickle down to them, too. Hospitals and emergency rooms have closed, and 50% of those left out here are losing money.
    No one cares, and until you need a doctor, the loss isn’t felt by most folks.

  9. Is it just “primary care” that is in crisis? According to the Society of Thoracic Surgeons, a five-year shortfall in applicants for cardiothoracic surgery training positions threatens to create a shortage of physicians qualified to perform open-heart surgeries, lung resections, and other major procedures.
    Five consecutive years in which there were fewer applicants than open positions. With half of currently practicing cardiothoracic surgeons expected to retire in the next 10 years, the specialty society is warning of a “brain drain” of increasingly dangerous proportions and compromised patient care in the very near future.
    The situation with student loans makes it worse. I have a friend who has over $150k in student loan debt. It started with $116k, when he could afford to start paying, it was $236k. At 51 years of age, he’ll be in repayment until he’s 74. Sounds like an attractive job?
    As for backing off the extremes of medical micro-management by managed care, observation on various blogs and discussion boards about managed care’s denial of coverage on the backs of injured and diseased human beings, complaints seems incessant. Controls are given over to remote bureaucrats who determine who shall live and who just isn’t worth it.
    You’d think this was only a problem with Medicare reimbursement? It’s an interesting thing about outside Medicare, private insurers are still trying to practice medicine. I thought that’s what physicians were for?
    It strikes me that for the past seven and a half years, our federal government has been run by an administration that has little regard for running good government.

  10. Matt is right. Saying “doctors are [sad/frustrated/etc]” means nothing…it’s the kind of doctor that matters. I have no sympathy whatsoever for procedural specialists making piles of money. Their incomes are incredible, and any dissatisfaction is self-inflicted.
    Awww…poor cardiologist. Feel like you’re working too hard? I have a suggestion: cut your clinical volume. You’ll still make a very comfortable living, considerably more money than a full-time primary care physician. And patients will be better off…Dartmouth data show that areas with a higher share of primary care services (rather than specialty procedures) have lower costs, higher patient satisfaction, and higher quality of care.

  11. The NYT article expresses the opinion of many doctors very well.
    America needs to wake up about this. If, for example, nationalized or socialized health care is enacted, there will be a new glut of patients and at the same time, many health care professionals that will flee the profession unless conditions for them improve.
    But policy makers and insurance company execs either are blind to this or do not want the public to know the growing discontent among those who perform the hands on work in health care.
    This is a growing powder keg that is not likely to produce the outcome that the public currently believes.

  12. The money is better now for almost everyone, but student loans are a big issue. However, in primary care, I now see as many patients in two days as I was seeing in four days in the 1980s, and more things need to be done for each patient (there is no watch and wait any more….it’s an immediate MRI instead). There is also the mentality that everything can be fixed and also must be fixed right now. There is little tolerance for ambiguity or just old fashioned being sick for a couple of days. And just anecdotally, people seem to be sicker. I rarely hospitalized patients out of a primary care practice (maybe one a month) in the 1980s but in one day last week I did two.

  13. Yes, it really is worse and becoming more so. Perhaps you need to be operating from the inside in an effort to gain real and sane perspective.