The crisis of primary care physicians

May 29, 2008
MRS. J. LOOKED baffled and hurt. I had just explained that I would no longer be her primary care doctor. I was leaving the field after just three years. "I have had three different primary care doctors over the past 10 years," she said. "You can't leave now. I was just starting to feel comfortable. I am getting older now. I can't keep changing doctors!"

Primary care is in crisis. Current primary care doctors are quitting, and medical students are pursuing other specialties. Primary care has lost its attractiveness as a profession because of poor compensation and plummeting job satisfaction. Primary care physicians are in short supply, and in Massachusetts, this problem has intensified in the wake of healthcare reform, as more than 300,000 previously uninsured individuals have joined in the search for available doctors.

As a former primary care physician, I am most troubled by the antagonistic state of the patient-doctor relationship. The system sets us against each other. Like many in the field, I chose primary care because I love people. I wanted to take care of the whole person, body and mind. I wanted the intimacy that comes with knowing your patients well and following them over many years. These goals are difficult to achieve in primary care today. After two years in my practice, I walked into an exam room one day and introduced myself to a patient. "We have met before," she replied, clearly aggravated. I was horrified and saddened.

Patients are angry, and rightly so. They feel frustrated by the inability to get timely appointments with their physicians, rushed by the 15-minute visits and the seemingly harried doctors, ignored when they do not receive letters with lab results or follow-up phone calls. They feel disrespected when they come to their medical appointments on time and then sit in the waiting room for 45 minutes. All of these feelings are justified. We are not offering high-quality care.

Doctors feel angry, too. We have too many patients. It is not uncommon for a full-time primary care doctor to have upwards of 3,000 patients. It is impossible to know all of these individuals well, to give adequate focus to each person's unique situation, to sift through the piles of paperwork and lab data daily. Our days are divided into 15-minute sessions, back to back. We move frantically from exam room to exam room, trying desperately not to fall behind in our schedule. We are given incentives to see patients as quickly as possible. We live in fear of litigation.

We are drowning, and in this overwhelmed state we lose our ability to take good care of people. Outwardly, we may feel resentful and burdened. Underneath, many of us feel loss, deep sadness, and personal failure.

This rift between patient and doctor is painful and destructive to the core of medicine: the therapeutic relationship. In an environment where patients and doctors don't know each other well and appointments are rushed, it is inevitable that more medical errors occur and that resources are wasted as expensive tests are substituted for communication. By contrast, research indicates that medicine practiced in the context of solid primary care relationships allows for earlier detection of chronic diseases, and, ultimately, better outcomes and monetary savings, to say nothing of patient and doctor satisfaction

In this election year, patients and doctors need to come together to support healthcare reform aimed at revitalizing primary care. To begin, our medical reimbursement system must be restructured. Our payment system values invasive treatments and procedures over time spent talking with your doctor. We need to reset these compensation levels to favor communication, care coordination, disease prevention, and chronic disease management. Doctors should be rewarded for keeping patients well. Incentives should be based on quality outcomes and efficient resource use, not on patient volume.

Most important, primary care physicians should be valued as team leaders and advocates, poised to help patients navigate the complex medical system. There is no reason why so many patients like Mrs. J. need to feel lost and abandoned in a country that spends far more on healthcare than any nation in the world.

Dr. Annie Brewster is an urgent care physician at Massachusetts General Hospital.
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Gotta love it -- the first thing we need to do to fix health care is raise the salary of family practitioners. Let's look at how underpaid they are.

http://www.allied-physicians.com/sa...an-salaries.htm

Seems that a FP (family practitioner) is hugely underpaid. Those who do not include obstetrics in their practice can expect to earn only $161K in years 1 and 2, and $135K in years 3 and above with a max of $239K. Those with an obstetrics practice can only expect to earn $182K in the first 2 years, $204K at years 3 and above with a max of $241K.

I can see where the primary problem is lack of pay for general practitioners. It is reminiscent of insurance companies complaining about drug prices because we know how unprofiatble insurance companies are.

I think nurse practitioners might be a good alternative for most of the stuff an FP does.

IMO salary is relative....given the level of education and years attaining the MD and then the number hours worked/required each week once in practice, I'd say it's a fair observation that compensation is poor for many GP's and family practitioners.

Personally, I never begrudge anyone the salary they make - not the CEO pulling in a million+ a year, the attorney pulling $500,000, the university professor pulling $250,000, or the doctor pulling $100,000-$300,000....why should I? Seriously, should doctors work for free? For minimum wage? What exactly is proper compensation? How is such determined? And, by whom?

I can understand why a doctor would want to specialize though. You probably see fewer patients and can spend more time with them and also make a lot more money. Maybe have fewer hassles with insurance?

How many doctors have actually sat down and did the math....
The hours, etc... it takes them to go through insurance forms and the things they must do to conform their practice to insurance requirements?

What is it going to take for a doctor to realize they no longer work for the patient and they are just slaves to the insurance industry?

Then, which doctors are going to have the guts to say ENOUGH and only work for THE PATIENT? Take payments only directly from the patient? Post their rates on the wall? Tell the insurance companies to take a flying leap?

Some doctors and specialists are doing just that.

I didn't suggest that $100,000 is miminum wage, however, the median salary across the US for all physicians & surgeons is $147,000.

The average doctor graduating today will have spent a minimum of 10 and upwards to 15 years just getting their education finished to practice medicine.....that is 10-15 years of not earning, which sets them behind peers who entered the workforce ahead of them by 4-8 years (those who are college educated). So right there, they're in a hole from a financial perspective for the number of years they can earn before retirement.

Now add to that, the average medical doctor graduating today will have an average 20 year payback on student loans, which now sit at around $300,000 for graduates entering family or internal medicine....some who specialize are graduating with upwards of $500,000 or more in student loans today. I still remember one of the residents from when I was in L&D having my son - he called himself the million dollar man since by the time he was going to make it into practice, his loans would total over $1,000,000!

But let's use the $300,000 in student loans - with a 20-year payback, the monthly payment on their student loan alone is $2500 a month.

So once they graduate and are in practice....how much do they work? The average family physician in the US clocks 72-hours a week with patient visits, paperwork, reporting, etc. - that's almost twice as many hours as the average person working in the US who clocks 40.25-hours a week (2006 figures).

What does a salary of $147,000 translate to now?

147,000/52 weeks = 2827 per week
147,000/12 months = 12,250

2827/72 = $39.26 an hour

12,250 - taxes (4290 for 35%) = 7960 per month take home

7960/312 (hours worked each month) = $25.51 per hour

7960 - 2500 (student loan) = 5460 per month after taxes and student loans

5460/312 (hours worked) = taking home $17.50 an hour

When you compare that to the average government employee, with an average salary (2006) of $58,992....who works 37.5-hours a week.....that's $1135 a week - $30.26 an hour (4918/mo), less taxes (28%) is $818 a week (3545/mo)....an average student loan debt of $30,000, so loan payment of $230 a month....leaving 3315 a month.....for 162.5 hours a month, or taking home $20.40 an hour.

So how attractive is that $147,000 average really?

Actually, it is very rare for an FP to practice obstetrics. The malpractice insurance is exorbinant (even getting out of reach of specialized OB/GYNs). It's not worth the risk anymore.

I practice in rural health in a community of about 9,000. We have recently lost 2 internal medicine docs--our community is struggling. We have been trying to recruit an OB/GYN for over a year, an ortho for 18 months plus. It's a shame.

Doctor's salaries seem exceptionally poor. They also have to pay for the overhead, the supplies, the rent, the insurance, the taxes, the gas bill... just like everyone else who operates a business. But then they have the whopping Malpractice insurance they are required to carry. The whole thing has become so skewed, that "the market" can no longer determine compensation. It is the insurance co that does it.



I remember when I was a kid, my Mom would write a check to the Doc. We had insurance, but back then it was really insurance, in other words it existed purely to offset the cost of MAJOR problems. It wasn't for shots, colds, scrapes, and hangnails.
Take insurance companies out of the picture, and watch how quickly the system heals.

Family doctors also have to rent office space, hire/buy the practice's furniture, equipment, and supplies, and pay secretaries, receptionists, etc. A lot of their income doesn't go into their pockets - it gets plowed back into the business. And let's not forget the various taxes they pay on their earnings.

Rachel

Physicians on staff at a private hospital or through a university hospital rarely have to deal with all the details of running a business as well as practicing medicine, unless they have a private practice in addition to their hospital position.

Those in private practice have some serious overhead to manage and get right if they're going to be able to pay themselves....overhead includes everything from personnel (receptionists, insurance, office manager, RN's, transciptionist, etc.) to specific medical equipment, office space and it's expenses, chasing collections, malpractice insurance, business insurance, salaries, benefits, matching social security, continuing education of self and staff, professional licenses, professional organization memberships, journal fees, employee "fringe", legal and accounting fees, medical supplies, office supplies, software licenses, capital equipment (computers, etc.), sometimes labs with equipment...this list goes on.

When people hear a private practice pulls in $1.2-million in a year, most don't realize the bottom-line "profit" on that sits around 8-15% (depending on actual overhead costs), in such a case leaving between $96,000 to $180,000 for the doc to pay himself and fund his retirement in a year (if he's a solo practitioner).

An article that talks about one of the proposals out there for healthcare reform includes this,

"Dr. Ezekiel Emanuel proposes a bold plan for health care reform that offers free, high quality health care to all Americans. No premiums. No deductibles. Low-co-pays. Under this plan, the government insists that all insurers offer the same comprehensive benefits to everyone, including: office and home visits, hospitalization, preventive screening tests, prescription drugs, some dental care, inpatient and outpatient mental health care and physical and occupational therapy."

And goes on to this,

"How do we fund it? Emanuel, who is the Director of the Clinical Bioethics Department at the U.S. National Institutes of Health, proposes a 10 percent Value-Added Tax (VAT) on consumption. For a median-income family earning $50,000 a year and spending virtually every penny, this means that they would pay $5,000 a year (10 percent of $50,000) in taxes on their purchases. But in return, they would receive health care benefits worth more than $12,500 (the current average price for comprehensive insurance that covers a family.) In addition, because The Guaranteed HealthCare Access Plan would replace employer-based coverage, many workers could expect a raise roughly equivalent to what their employer now pays toward their premiums."

Wow, now doesn't that sound like a bargain?

Here is what I've noticed no one really wants to talk about in the discussion about how to 'fix' the situation - the fact that, of those insured (either by private insurance, employer-benefit insurance or government programs), 80% utilize less than $1200 a year in medical services, 10% utilize between $1200-3000 a year, and 10% utilize greater than $3,000 a year in services.

Employer-based insurance, included as a benefit, averages $9,600 a year per employee (indiviual and/or family coverage with or without employee contributions toward the policy) on a group policy....the "range" for that average is $3,600 a year to $14,500 a year (depending entirely upon size of group, number of employees, policy benefits, individual versus family coverage, etc.)....Government programs spend an average $8900 per person covered and that includes administrative costs, reimbursements, etc.

Personally I think it's highly unlikely that employers are going to simply transfer to their employees the money they spend for health insurance into salary. And even if they did, insurance as a benefit is untaxed - even though an employee does not see it in real dollars in their pocket, it's there but they do not have a tax burden attached to it.

If an employer did take the average $9,600 and moved to the salary column, and the average salary in the US is $44,000....taxable income rises to $53,600 to pay taxes on.....and now shouldering an additional 10% for healthcare.

With $44,000, taxes will take about $12,300 and leave $31,700 take home.

With $53,600, taxes will take about $16,000, healthcare VAT at 10% will take $5,300, and leave $32,130

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But what if you're employed by a bigger company, with a much larger group, and lower cost-per-employee?

Say you earn $50,000 and your employer is paying $5,000 a year on your policy....your salary could potentially go to $55,000

With $50,000, taxes take about $14,000 and leave $36,000 take home

With $55,000, taxes take about $16,800 and the healthcare tax another $5,500....leaving $32,700....you make more, take home less.

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How about "big earners"...someone making $150,000 a year whose employer is paying toward the higher end, say $12,000 a year for health insurance per employee?

With $150,000, (higher tax bracket) taxes take about $48,000, leaving $102,000

With the money spent on health insurance transferred to salary that means you're up to $162,000, taxes take $52,000 and the healthcare VAT takes $16,200....leaving $93,800...make more, take home less.

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Now imagine you're in good health and are one of the 80% of those who utilize less than $1,200 in medical services a year.....is such a program like this really a bargain? Is it really a "makes sense" approach to changing how things are now?

A little personal experience...I run a medical transcription service company and currently one of my clients is a large orthopedic practice in a sparsely populated Western state. They have been looking for another orthopedist to join them for years. They have had to add a physiatrist and a PA. The area has a large number of practicing PAs. Two previous orthopedists in their practice have moved on to growing practices in more metropolitan areas. The money is better, the shared expenses are less. That is one reason you see orthopedic practices with 10, 20, even 30 orthopedists in central and satellite offices.

On another note, factor in the absolutely necessary insurance processing department of a practice and transcription costs. I have had clients, granted larger practices, whose transcription bills were $6,000 a month. These services are required for insurance purposes. A report has to be generated to get insurance approval. Letters and consultations have to be generated to keep business flowing. Nurses may make less than in a hospital setting, but they still are in demand (so many are coming from the Philippines these days, especially on the West Coast) so their salaries cannot be pittance either. Even the PAs make handsome salaries as do the nurse practitioners.

I know of three physicians who left what seemed to be lucrative practices because they no longer could justify the costs and how they were practicing medicine to keep that practice going. One internist went to Kaiser and this was a physician who was so popular and well respected she had closed her practice to new patients because the costs were less for her and she thought could practice more like she wanted to. One just quit, but her husband kept his specialty practice going. The third retired early. There did not seem to be any health-related problems. He just had had it.

After working for hospitals, offices, and clinics for these 37 years, the demands on these doctors (many of whom I do not like at all personally) is tremendous. What it takes to get into med school, complete med school, and run a practice leaves little time or energy for real life, family life. They do sacrifice for their dreams of being a doctor, and I for one do not resent what they make at all. I worked for the University of California San Francisco within the last 10 months and the expertise and devotion it takes to stay on top of the newest procedures for spine surgery and shoulder replacement, which is what I worked on, is life consuming. How they keep up is by sacrificing so much of their personal life. These docs were seeing 40 patients plus or 80 patients a week on two clinic days and operating three days all day long. Any time for keeping up with the field, very little. On call for the weekend? Residents may have handled it at the University, but not for the local doc.

I really believe there are not enough doctors to practice the kind of medicine they want to practice and the kind we as patients want them to practice.

That would be me, and no it is not a bargain. That would mean I'd have to shell out more money for services I'm not using.
I have heard horror stories from family & friends who live in socialized medicine countries (Denmark & Italy), and it's not the answer.