Doctors Struggle to Make Ends Meet?

I’m already preparing for hate mail.

So I open up my email this morning to find a gem from the WSJ, entitled, “Doctors struggle to make ends meet.” Usually, when I hear that phrase used, it’s describing the plight of the poor, unable to figure out how to make a mortgage payment, pay off medical bills, and still find enough left over to put some food on the table for the family. That’s what “struggling to make ends meet” means. This? Not so much.

To be fair to the author, I’m sure she didn’t choose the title. In my experience, editors do that, and they sometimes choose catchy titles that are inflammatory and don’t, perhaps, truly capture the flavor of the piece. That is sort of the case here. It’s not really an article about a doctor struggling personally, it’s an article on how a doctor is struggling to keep his practice profitable. That practice sounds like a very nice place to be cared for:

His family practice uses electronic health records, calls up patients at home to check on their progress, and coordinates with other specialists and hospitals—all the things that policy makers and insurers say should be done to improve patient care.

Recently, the practice has been upgraded to attempt to qualify for anticipated future incentives for a “medical home”. In essence, we’re talking about more accountable care and paying for “quality”, not “quantity”. But there’s a problem. Getting ready for those new incentives ain’t cheap:

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?”

I’m sympathetic to this argument. I often offer the following thought experiment when I’m giving talks: Imagine you see 20 patients a day. Now the insurance companies comes along and tell you that if you improve “quality”, you can receive a 5% bonus in your salary. But it will be very hard, and very expensive, to set up a new system to do this. You’ll need to buy a better EHR, hire another nurse, pay for more office staff to do documentation, etc. Then, maybe, you’ll qualify for that 5% bonus. OR, you could just squeeze in one more patient towards the end of the day.  That will also increase your salary by 5%, and you won’t have to change anything about your office at all.

Which do you think a doctor would choose? And, when he squeezes in that patient, all other visits get shortened by a  minute, and everything gets worse. This, by the way, is one of the reasons I think sticks are as necessary as carrots.

But back to the article. It reports that some doctors are choosing to go work for hospitals or large groups, with the necessary infrastructure in place. That’s sad for those who like to be in private practice, but again – that’s not “struggling to make ends meet”. It’s a changing marketplace altering the way medicine is practiced. It happens in lots of fields. At least the doctors aren’t losing their jobs. But this misses the main point I want to make:

With the money from the nonprofit’s medical-home pilot project, Westminster roughly broke even last year, with a profit of $29,261. The practice distributes its profit as bonuses to staff; the result is adjusted to account for the effect of splitting off Westminster from another practice with which it was once merged.

Time to get real. The clinic still turned a profit last year, in one of the worst economies anyone currently alive has ever seen. That’s… pretty good. It’s certainly not something to go gripe about. It’s certainly not “struggling to make ends meet”.

But, again, we’re missing the larger picture. 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.

Unemployment is really high. Many have lost their jobs, or have not seen raises in years. People are hurting. While it’s a fact of life that this is a capitalistic society, and people are going to make more than others, it’s somewhat unseemly for those still doing pretty ok to complain so vocally. Moreover, it’s not something you’d want to do in public, in a high profile media outlet.

Doctors not only make more in this country than in any other country, they make far more than our wealth would predict. One in five physicians is in the to 1% of incomes, making doctors more likely than any other profession to make it there. It’s possible to explain how this incentive may be not only tolerable, but also desirable in attempting to achieve a high quality health care system. But it’s time for us to find a way to do so without crying poor and telling sob stories to others who literally are “struggling to make ends meet”.

Aaron E. Carroll, MD, MS is an associate professor of Pediatrics and the associate director of Children’s Health Services Research at Indiana University School of Medicine, as well as the director of the Center for Health Policy and Professionalism Research. Carroll’s work has been featured in The New York Times, USA Today, The Los Angeles Times, Newsweek, and many other national publications. He blogs at The Incidental Economist, where this post was originally published.

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