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| 2008/4/7-16 [Politics/Domestic/California, Politics/Domestic/President/Bush] UID:49680 Activity:moderate |
4/7 In Massachusetts, Universal Coverage Strains Care
http://www.nytimes.com/2008/04/05/us/05doctors.html
\_ If you add more people to the system and not more dollars this
will happen. Universal care will end up costing taxpayers more
money for a reduced (or the same) level of service - and don't
give me this BS about how preventative care will save money. If you
think that's true then make the Universal system include only
preventative care.
\_ Well, any solution that amounts to layering a bureaucracy on
top of the existing system is dubious.
\_ ...well, hell, if you don't believe preventative care will
save money, how about you go ahead and stop receiving any of it
and let us know how you're doing in about 10 years?
\_ I think you missed his point. -!pp
\_ Not if his point was that preventative care will save
\_ Not if his point was that preventative care won't save
money or cut costs in a Universal healthcare system.
\_ Do you mean 'will not save?'
\_ Er, yes. Will fix soon and erase both of these
comments.
\_ Preventative care won't save money if it then leads to
expensive procedures anyway. However, I'm all in favor
of free medical exams. Free clinics funded by the government
do this already. That's the extent of it, though.
\_ http://www.overcomingbias.com/2008/04/prevention-cost.html
-- ilyas
\_ Excellent: _some_ preventative medicine will save costs;
indiscriminate spending on unproven preventatives will
raise costs. That's important to know so's we can focus.
\_ Does early cancer screening save costs, improve
quality of life, or neither? I would argue that
overall it might improve quality of life, but it
doesn't lower costs. In fact, it adds to costs
because you have the cost of the screening plus the
costs of the treatment which is much the same either
way. On top of that, as the article points out,
you've extended a life so that you can have more
expensive screenings and ultimately (in many cases)
a recurrence anyway. Prevention works for conditions
which we have cures for like polio. It doesn't work
so well for cancer, heart disease, and such which
is probably where most of the medical $$$ go anyway.
\_ Have you included the value of saving the lives
of fully-productive adult members of society in
your calculation? [Hint: No.] -tom
\_ We are comparing prevention to no prevention +
treatment. Are you claiming that the former
actually saves more lives (aside from the
known beneficial cases, e.g., vaccinations)?
-- ilyas
\_ The data shows that the cases where preventative
care actually does save productive lives are
very rare, except for those few known things like
vaccines or a single colonoscopy at a certain
age.
\_ This depends entirely on what you consider
preventative: is abstinence education prevent-
ative? how about safe sex classes including
information on condoms? It makes sense, though,
that certain testable measures are much more
reliable than, say, handing out pamphlets.
\_ No, because over 1/3 of the current costs of the medical system
go to the "free market" beauracracy. All those countries that
go to the "free market" bureaucracy. All those countries that
have introduced universal health care have cut costs. I leave
it as an exercise for the reader to discover how this could
possibly have happened.
\_ US government != European governments. As history proves
over and over again, US government = inefficient beauracracy
that cannot be trusted, and hence we have no choice but
to rely on the free market.
\_ You mean inefficient like the US Army or Marine Corp?
\_ Our military branches are efficient at torture.
\_ They save costs because you die while waiting to get the
surgery you need because of rationing. The free market
can allocate resources much more effectively than some
bureaucrat can. If you really want to cut costs you should
eliminate insurance entirely. Right now people don't pay
attention to whether their doctor charges $1400 versus
$1200 for a procedure. If it's within the customary
averages insurance companies are going to pay it.
However, if that extra $200 comes out of their pocket you
can be sure people will pay more attention to costs. Our
current nightmare of employer-sponsored HMO plans is
basically already Universal Healthcare for the working
class. Sure, you can purchase individual coverage but how
many people eligible for an employer-sponsored plan do
that? (And if they do, not many employers refund their
portion of the premium!) For the elderly we already have
Medicare. Universal health care is a step in the wrong
direction. Eliminate virtual-mandatory participation in
these plans and watch both doctors and patients become
much happier as they split that 1/3 overhead that HMOs
currently enjoy. I pay $600/month for health insurance if
you count my portion and my employer's portion and I am
under 40 and healthy. That's your UHC tax right there.
Refund it back to me and let me decide how to obtain
medical care. Don't legislate away the only choice I have
(not to participate).
\_ Savings have to come from eliminating bureaucratic fat,
better experimental study design (so we actually know what
works), and more personalized medicine (relying on averages
works), and more RUSSIAN medicine (relying on averages
is expensive and kills people). People who just want
Universal Healthcare <tm> basically aren't thinking about
the problem, they are just shouting a political meme.
-- ilyas
\_ You mean how the free market so efficiently allocated
resources during the dot-com bubble and the housing
run-up and collapse? Simply repeating your ideological
position does make it any more persuasive. Yes, the free
market rations health care according to ability to pay and
state run systems allocate them according to need. Guess
which one gets more bang for your buck? People die in both
systems waiting for health care.
\_ What exactly was wrong with the <DEAD>dot.com<DEAD> bubble or
the housing run-up? It's how markets work. I'm sure
you far prefer the former Soviet Union which didn't
have those "problems". Bureaucrats cannot decide
"need" as well as dollars can. I argue that more
bang for the buck is the one that eliminates the
middle-man.
\_ The medicare and VA bureaucracy is much more
lightweight than the HMO/medical insurance one is.
I prefer what works, not what my ideology tells me
"must" work.
\_ I think you are the one with an ideological
problem here.
\_ Another issue is that people without insurance or ability
to pay still get care in emergency rooms. I don't know
what the $ numbers are for those cases. But most med
insurance is pretty obviously not very efficient. If med.
insurance should be mandatory it should have really
high deductibles. The biggest problem with insurance
is that it neuters market forces towards the medical
industry. With most insurance plans, all doctors and
all drugs cost similar amounts, barring some brand
name vs. generic category things. The consumer as you
say has little reason to look for medical "deals".
And insurance is expensive, and those who aren't insured
freeload.
\_ Exactly. There is no reason to shop around. When
shopping for a new doctor how many people inquire
as to his rates? How many times do you pay your
bill at the doctor *after* services are rendered?
High deductibles and large co-pays make sense, but
I do not think that's what the UHC people have in
mind. Anyone who has spent time at a free clinic
(or knows someone who works at one) realizes what a
disaster that is for all involved. We should be
looking for a more streamlined solution, not a
bigger and more difficult to administer solution
with mandatory participation that will screw
middle-class taxpayers even more than they already
are while doing nothing to improve medical care.
\_ I agree with everything except for your conclusion.
UHC works very well in the places it has been tried:
the US Army, VA hospitals, Canada, England, etc. In
this country, we will probably have to have a two
tier system, more like England, rather than a
mandatory participation system, like Canada, though.
\_ Do you know anyone in the military? My gf's
mom was an Air Force and then Army nurse
(active duty) for 30 years and when she
retired from nursing she continued to work
closely with Tricare, NIH, VA, and State Dept
(believe it or not they are involved for things l
like sharing patient data between branches of
military) as a consultant. She was also a
hospital administrator for a military hospital
and her daughter (my gf's sister) is Air
Force reserves, former Army, and works
full-time for the VA right now. In addition,
my gf's dad and stepdad were both military
officers and my gf's sister's ex-husband is
active duty Army who spent time in Iraq. I
can say from my experiences at military
hospitals (visiting) and from the stories
I've heard that I do not want military
medicine or the VA as a model for anything.
\_ I grew up on military bases all my life. My
father was a hospital administrator for the
Navy (35 years service). While I would not
suggest that OCHAMPUS is by any means perfect,
it provided adequate health and dental coverage
for us throughout my childhood. I would
consider it a fine model for basic services.
--erikred
\_ The key words you used were 'adequate'
and 'basic services'. I would say
'substandard'. I wouldn't go to a military
hospital unless I had to. Lots of military
people like it because it's free to them,
but if I had a serious illness I would
rather it be treated elsewhere. Also, ask
your dad about the waste that goes on. For
instance, military hospitals require the RNs
to be trained in almost every discipline.
Private hospitals only require nurses train
in the field they work. I think that part
of the reason that military healthcare
seems cheap is that many costs are
hidden. For instance, doctors' salaries
are very low (which scares me in itself)
but there are other benefits they receive
which many think makes it worth their while.
You will not be able to hire doctors
privately at those salaries because the
total package needs to be evaluated
(e.g. retirement benefits, travel benefits,
and so on). I am not sure if studies that
examine the costs of military medicine
account for these externalities. The
military hospitals receive many benefits
private hospitals do not just by virtue
of being part of the military machine
and yet the quality of care still sucks.
\_ I was a medic for three years, so yes
I am familiar with the military medical
system. I think it is fine. The VA
system is even better. We can easily
hire doctors at the pay level that the
military pays them: that is what MDs
make everywhere in the world, except
here. The AMA artificially keeps the
supply low, to inflate salaries. I am
surprised that such a purported free
market cheerleader would not be aware
of this fact.
\_ Many people would dispute your
assertion re: AMA. The AMA does
not have this power. Less than
20% of physicians are members and
the AMA has no direct regulatory
authority. Also, many countries keep
MD salaries artificially low. Spain,
for instance, recruits MDs from
Eastern Europe and Third World
nations at low salaries and
holds them hostage with visas.
It's not worthwile for Spaniards
to even bother with medical
school at those wages. The
salaries of US doctors are high
and it's one reason we have a
high standard of care. Plus, US
doctor salaries have actually eroded
over the past 40 years.
\_ The AMA controls licensing for
medical schools, which is how
they keep the number of doctors
low. Show me proof that MD salaries
have eroded over the last 40 years,
because I don't believe it. Maybe
for primary care docs, but almost
assuredly not for specialists.
Salaries are high due to monopoly
pricing power, not quality.
\_ The AMA does no such thing.
The government controls
this. Sure, the AMA is a lobby
but they can't mandate anything.
http://tinyurl.com/e33gk
http://tinyurl.com/4yn35s
\_ Your articles provide support
for my claim that an
artificial shortage of MDs
has been created. And a four
year snapshot of MD salaries
from 10 years ago doesn't
prove much. Lately MD salaries
are going up:
http://www.csua.org/u/l96
\_ An artificial shortage of
MDs has been created by
whom?
\_ AMA of course.
Why is it so hard to
get a medical edu.?
Actually learning the
stuff isn't that hard,
but getting into the
school is. -!pp
\_ The articles dispute
that the AMA has any
such power.
such power. It is
the gov't that you
trust to admin UHC
which is the problem.
-/
http://www.acgme.org/acWebsite/newsRoom/newsRm_acGlance.asp
"The ACGME's member organizations are the American Board of Medical
Specialties, American Hospital Association, American Medical
Association, Association of American Medical Colleges, and the
Council of Medical Specialty Societies. Member organizations each
appoint four members to the Board of Directors, which also includes
two resident members, three public directors, the chair of the Council
of Review Committee Chairs and a non-voting federal representative."
The AMA is one of the people on the board of the organization that
certifies medical schools, but is not the only member.
\- Might be of interest: WSJ article on non-profit hospital profits:
http://tinyurl.com/55v9th
\_ Nice to know, but in the end it is the government (through Medicare)
\_ Nice to know, but in the end is it the government (through Medicare)
that funds residents. In theory, we don't need any more accredited
programs to churn out more doctors. We just need more students in
the existing programs.
\_ In other words, the AMA (amongst others) controls licensing for
medical schools, which is what I said. The AMA also agressively
lobbies the government to underfund medical education, but that
is a bit more complicated as there are other players. But for
generations, the AMA has done everything in its power to keep
the number of doctors artificially low. Nice to see that some
people are waking up to the fact that this might not be a good
idea afterall.
\_ This is what you said:
"The AMA controls licensing for medical schools"
(This statement is not really true as the AMA does not
have sole, or even majority, control. They have input.)
"which is how they keep the number of doctors low."
(This statement is not really true either since, as I
pointed out, the number of residents is largely
determined by the government.)
The AMA is a lobby out to protect the interests of
doctors. Wow, what a shocker. Next you will tell me that
UAW is trying to protect American autoworker jobs. However,
the AMA always gets blame for artificially limiting the
number of doctors and the reality is that they don't have
that capability. They have the desire, but let's not
overstate their authority. The biggest party at fault is the
government - the same government that people want to run
Universal Health Care.
\_ You said "the government controls this" which is entirely
false. "The government" is you and me, put the blame
where it belongs.
\_ You can increase funding for medical residents? You
should get on that. |
| 5/23 |
|
| www.nytimes.com/2008/04/05/us/05doctors.html Kate, the supplicants line up to approach at dinner parties and ballet recitals. Katherine J Atkinson, a family physician here, she might find a way to move them up her lengthy waiting list for new patients. Enlarge This Image Christopher Capozziello for The New York Times Massachusetts primary care practices like this one in Shelburne Falls have been trying to manage an influx of new patients. Those fortunate enough to make it soon learn they face another long wait: Dr. Atkinson's next opening for a physical is not until early May -- of 2009. In pockets of the United States, rural and urban, a confluence of market and medical forces has been widening the gap between the supply of primary care physicians and the demand for their services. Modest pay, medical school debt, an aging population and the prevalence of chronic disease have each played a role. Since last year, when the landmark law took effect, about 340,000 of Massachusetts' estimated 600,000 uninsured have gained coverage. Many are now searching for doctors and scheduling appointments for long-deferred care. Just north of here in Athol, the doctors at North Quabbin Family Physicians are now seeing four to six new patients a day, up from one or two a year ago. Patricia A Sereno, state president of the American Academy of Family Physicians, said an influx of the newly insured to her practice in Malden, just north of Boston, had stretched her daily caseload to as many as 22 to 25 patients, from 18 to 20 a year ago. Sereno limits the number of 45-minute physicals she schedules each day, thereby doubling the wait for an exam to three months. "It's great that people have access to health care, but now we've got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care." Whether there is a national shortage of primary care providers is a matter of considerable debate. Some researchers contend the United States has too many doctors, driving overutilization of the system. But there is little dispute that the general practice of medicine is under strain at a time when there is bipartisan consensus that better prevention and chronic disease management would not only improve health but also help control costs. With its population aging, the country will need 40 percent more primary care doctors by 2020, according to the American College of Physicians, which represents 125,000 internists, and the 94,000-member American Academy of Family Physicians. Community health centers, bolstered by increases in federal financing during the Bush years, are having particular difficulty finding doctors. "Maybe we're at the front of the wave, but there are several factors making it harder for the average American, particularly older Americans, to have a good personal physician." Studies show that the number of medical school graduates in the United States entering family medicine training programs, or residencies, has dropped by 50 percent since 1997. A decadelong decline gave way this year to a slight increase in numbers, perhaps because demand is driving up salaries. There have been slight increases in the number of doctors training in internal medicine, which focuses on the nonsurgical treatment of adults. But the share of those residents who then establish a general practice has plummeted, to 24 percent in 2006 from 54 percent in 1998, according to the American College of Physicians. Government Accountability Office reported to Congress in February that the per capita supply of primary care physicians actually grew by 12 percent from 1995 to 2005, at more than double the rate for specialists. But the report also revealed deep shifts in the composition of primary care providers. While fewer American-trained doctors are pursuing primary care, they are being replaced in droves by foreign medical school graduates and osteopathic doctors. A Bruce Steinwald, the accountability office's director of health care, concluded there was not a current nationwide shortage. But Mr Steinwald urged the overhaul of a fee-for-service reimbursement system that he said undervalued primary care while rewarding expensive procedure-based medicine. Presidential candidates in both parties stress its importance. Here in Massachusetts, legislative leaders have proposed bills to forgive medical school debt for those willing to practice primary care in underserved areas; Massachusetts also recently authorized the opening of clinics in drug stores, hoping to relieve the pressure. Tips To find reference information about the words used in this article, double-click on any word, phrase or name. A new window will open with a dictionary definition or encyclopedia entry. |
| www.overcomingbias.com/2008/04/prevention-cost.html Tuesday's Post: Most of us naturally assume that preventing a disease is cheaper than waiting for the disease to appear and then treating it. That belief is especially dear to politicians, who often view prevention as an underused weapon in the battle against health-care costs. Since the book's appearance, her observation has been borne out by studies of hundreds of interventions -- everything from offering mammograms to all women and prescribing drugs to people with high cholesterol to requiring passenger-side air bags in cars and shortening the response time of ambulances. For example, Australian researchers tried out a program in which general practitioners watched a video and read a booklet about how to help their patients lower their heart attack risk. The patients were then given a series of videos and a self-help booklet on the same topic. Providing a single colonoscopy to men 60 to 64 years old also saves money. Similar to the finding that prevention rarely saves money is the calculation that people in good health probably rack up higher lifetime medical costs than their less-healthy brethren. Tracked on April 09, 2008 at 07:17 AM Comments Is the quality of life experienced by the subjects the same in both tests? I'd guess those in preventative tests would end up with a higher average quality of life, but that's just a guess... April 09, 2008 at 07:35 AM None of this seems surprising. If you'd asked me to sort preventative health care measures by cost effectiveness before reading this article, I would have put one time interventions at the top, continuing programs of education far at the bottom, and ongoing screenings somewhere in between (albeit closer to the bottom). I'd guess anytime you have a demographically-targeted one-time intervention it's likely to be a benefit (ie, vaccinations for childhood diseases, a single colonscopy for middle-aged men) and anytime you need an ongoing public education campaign (ie, healthy eating, exercise, etc) you're essentially throwing money away. April 09, 2008 at 12:06 PM alex, healthcare cost analyses generally use QALY as a metric, so differences in quality of life are already taken into account. In case it wasn't clear, the article mentions that the costliness of prevention is due to the fact that few people even in "very high risk" categories actually develop the targeted disease. IOW, prevention may still be highly cost-effective if combined with improved risk assessment. |
| tinyurl.com/e33gk -> www.usatoday.com/news/health/2005-03-02-doctor-shortage_x.htm Medical miscalculation creates doctor shortage By Dennis Cauchon, USA TODAY TALLAHASSEE, Fla. The doctor who found the cancer is the only urologist available in Taylor County, Fla. Michael A Schwarz, USA TODAY The doctor sent Bodiford from his hometown of Perry to Tallahassee 50 miles away for surgery. "You can't get the type of operation I needed in my town," says Bodiford, 68, who was hospitalized for six days in December and is feeling better. Bodiford experienced what many Americans may soon face: a shortage of physicians that makes it hard to find convenient, quality health care. The shortage will worsen as 79 million baby boomers reach retirement age and demand more medical care unless the nation starts producing more doctors, according to several new studies. The country needs to train 3,000 to 10,000 more physicians a year -- up from the current 25,000 -- to meet the growing medical needs of an aging, wealthy nation, the studies say. Because it takes 10 years to train a doctor, the nation will have a shortage of 85,000 to 200,000 doctors in 2020 unless action is taken soon. The predictions of a doctor shortage represent an abrupt about-face for the medical profession. For the past quarter-century, the American Medical Association and other industry groups have predicted a glut of doctors and worked to limit the number of new physicians. In 1994, the Journal of the American Medical Association predicted a surplus of 165,000 doctors by 2000. "It didn't happen," says Harvard University medical professor David Blumenthal, author of a New England Journal of Medicinearticle on the doctor supply. In fact, we're all gainfully employed, earning good incomes, and new physicians are getting two, three or four job offers." The nation now has about 800,000 active physicians, up from 500,000 20 years ago. They've been kept busy by a growing population and new procedures ranging from heart stents to liposuction. But unless more medical students begin training soon, the supply of physicians will begin to shrink in about 10 years when doctors from the baby boom generation retire in large numbers. "Almost everyone agrees we need more physicians," says Carl Getto, chairman of the Council on Graduate Medical Education, a panel Congress created to recommend how many doctors the nation needs. Getto's advocacy of more doctors is remarkable because his advisory committee and its predecessor have been instrumental since the 1980s in efforts to restrict the supply of new physicians. In a new study sent to Congress, the council reverses that policy and recommends training 3,000 more doctors a year in US medical schools. Even the American Medical Association (AMA), the influential lobbying group for physicians, has abandoned its long-standing position that an "oversupply exists or is immediately expected." "The truth is, we don't know if there's a shortage of physicians," says AMA President John Nelson, a Salt Lake City obstetrician. "It looks like there are enough physicians for the short term, but maybe we need more because of the aging population." The United States dramatically expanded the number of doctors being trained in the 1960s and 1970s, creating two new physicians for every one that retired, says Richard Cooper,director of the Health Policy Institute at the Medical College of Wisconsin. But the production of new doctors has changed little since 1985. Today, new physicians roughly equal the number of doctors retiring. Within a decade, baby boom doctors licensed in the 1960s, 1970s and 1980s will retire in large numbers that will outstrip the 25,000 new doctors produced every year, Cooper says. The effective number of physicians will fall even more, Cooper says, because doctors work shorter hours today. "The public expects good, innovative health care, but we're not producing enough physicians to provide it," Cooper says. Controlling the supply The marketplace doesn't determine how many doctors the nation has, as it does for engineers, pilots and other professions. The number of doctors is a political decision, heavily influenced by doctors themselves. Congress controls the supply of physicians by how much federal funding it provides for medical residencies -- the graduate training required of all doctors. To become a physician, students spend four years in medical school. Graduates then spend three to seven years training as residents, usually treating patients under supervision at a hospital. Residents work long hours for $35,000 to $50,000 a year. Even doctors trained in other countries must serve medical residencies in the USA to practice here. Medicare, which provides health care to the nation's seniors, also is the primary federal agency that controls the supply of doctors. It reimburses hospitals for the cost of training medical residents. The government spends about $11 billion annually on 100,000 medical residents, or roughly $110,000 per resident. The number of residents has hovered at this level for the past decade, according to the Accreditation Council for Graduate Medical Education. In 1997, to save money and prevent a doctor glut, Congress capped the number of residents that Medicare will pay for at about 80,000 a year. Another 20,000 residents are financed by the Veterans Administration and Medicaid, the state-federal health care program for the poor. Teaching hospitals pay for a small number of residents without government assistance. Medicare, which faces enormous financial pressure in coming decades, already spends 3% of its budget training physicians and may not have the resources to spend more. Cooper says the nation needs 200,000 more physicians because aging and wealthy countries demand more health care. That means more doctors are needed, whether it's for hip replacements or prescribing new drugs. Demographic changes in the medical profession also contribute to the need for more physicians. Nearly half of new physicians are women, and studies show they work an average of 25% fewer hours than male physicians, Cooper says. Physicians older than 55 work about 15% less than younger doctors. And medical residents have been limited to 80-hour weeks since 2003, ending decades of 100-plus-hour weeks. Most worrisome, the retirement of baby boom physicians means the number of doctors will start falling just as the first baby boomer turns 70 in 2016, says Ed Salsberg, a workforce specialist at the Association of American Medical Colleges. New medical school The United States stopped opening medical schools in the 1980s because of the predicted surplus of doctors. The Association of American Medical Colleges dropped this long-standing view in 2002 with the statement: "It now appears that those predictions may be in error." Last month, it recommended increasing the number of US medical students by 15%. Florida State University's College of Medicine, the first new medical school since 1982, will graduate its first class this year. Arizona, Nevada, California and Florida are considering opening additional medical schools. Florida State won approval from the state Legislature to become the nation's 126th medical school by emphasizing family practice and other specialties needed in rural areas and inner cities, where the doctor shortage is already acute. Florida State medical student Shannon Price, 34, plans to return to her hometown of Perry, when she becomes an obstetrician in 2010. She knows first-hand how having too few doctors hurts Perry. The only person in her family to attend college, Price worked in a munitions factory after high school. Laid off, she went to junior college, then became a nurse. "People go without health care in my hometown," she says. My family didn't go to the doctor, other than occasional visits to the health department." Doctors' Memorial Hospital in Perry is paying Price's medical school tuition to encourage her return. "She could go anywhere she wants in the country, yet she wants to come back here," hospital administrator Rick Brown says. Scramble for specialists Because physicians are affluent and in short supply, they tend to locate where they want to live -- not, as McDonald's or a Chinese restaurant... |
| tinyurl.com/4yn35s -> www.managedcaremag.com/archives/0304/0304.compmon.html Readers of P&T, Managed Care, and Biotechnology Healthcare will soon be able to enjoy the free digital version of these publications. Through this technology, readers will experience the full reading experience online. Biologic Therapy Management: The Need For Value-Based Health Benefits Models Free download MANAGED CARE April 2003. MediMedia USA COMPENSATION MONITOR Economic boom of '90s left many physicians behind While other skilled professionals enjoyed sharp increases in wages and salaries between 1995 and 1999, the average physician's net income from the practice of medicine dropped 5 percent, according to a survey released by the Center for Studying Health System Change. Primary care physicians' income fell 64 percent in constant dollars, notably further than the 4 percent drop reported for specialists. Still, medicine remains one of the highest paid professions in America. More than half of all physicians earned in excess of $150,000 in 1999, and the mean was about $187,000, the study found: $219,000 for specialists in 1999, compared with $138,000 for primary care physicians. Managed care's growth from 1995 to 1999 probably played a role in the physician income decline by holding down spending on physician services through discounted fees and restrictions on the use of care. However, the decline in physician income slowed between 1997 and 1999 as managed care restrictions eased and both the volume and price of physician services increased. "The real-dollar decline in physician income may help explain why physicians have objected so strongly to Medicare payment reductions and why a smaller proportion of physicians is providing charity care," says Paul Ginsburg, PhD, coauthor of the study and the Center's director. The study is based on results from HSC's Community Tracking Study Physician Survey, a nationally representative survey involving about 12,000 practicing physicians. The federal Bureau of Labor Statistics (BLS) Employment Cost Index of wages and salaries for private "professional, technical, and specialty" workers was used to calculate estimates for these workers. |
| www.csua.org/u/l96 -> www.nejmjobs.org/career-resources/physician-compensation-trends.aspx Advertisement Career Resources for Physicians Physician Employment and Compensation Outlook for '07 April 2007 By Bonnie Darves Editor's Note: "The basic economic model of supply and demand is working very much in favor of physicians. Whether entering the job market directly from training or looking for favorable opportunities with years of practice experience, both PCPs and specialists will find increased compensation and employed-model positions available. Expect generous signing bonuses and compensation packages, especially for PCPs recruited to underserved areas. For those in practice, higher income is also a function of increased patient volume. With ever-increasing medical education debt loads, robust remuneration for physicians is welcomed unequivocally." John A Fromson, MD, Chairman of the Department of Psychiatry at MetroWest Medical Center The job market -- and income picture -- for physicians is bright. Physicians heading into the job market for the first time or eyeing a career move in 2007 will find plentiful opportunities and attractive compensation packages regardless of their specialty or preferred setting. Demand for specialists and primary care physicians is high in many regions, especially in non-urban areas. That demand is translating into substantial signing bonuses, generous education loan repayment, and other competitive benefits -- especially among large groups and health systems. Also on the rise are compensation packages that feature creative mechanisms for rewarding physicians' hard work. Those structures include multifaceted annual bonus programs and elaborate productivity-based incentives, both intended to ensure star performers are recognized. Fully 90 percent of the medical specialties saw their incomes rise in 2005 and 2006, several large-scale national surveys found. Yet the most recent ones -- from 2005 and 2006 -- illustrate notable trends in compensation and employment. Following are highlights and key findings that may be of interest to young physicians heading into their first or a subsequent job search this year: * In 89 percent of specialties, incomes increased in 2005, and the average overall increase was 6 percent. The biggest jumps occurred in dermatology, gastroenterology, and cardiac/thoracic surgery; For the most part, however, those specialists also significantly increased their production. Five-figure bonuses exceeding $20,000 are not uncommon, Cejka Search reported. The Merritt Hawkins 2006 survey of physician incentives found that the average bonus increased to $20,000 in May 2005, up from $14,000 per year earlier. The most dramatic recent compensation increases occurred in the West, where incomes rose more than 8 percent in 2005. Even primary care, in which flat incomes and reimbursement produced a challenging practice environment in the recent past, is experiencing gains. Incomes for family practice physicians, internists, and pediatricians increased in 2005 and 2006, and the Centers for Medicare and Medicaid Services recently modified the Resource Based Relative Value Scale to attach a higher relative value unit (a measure of the physician work component) to most office-consultation services. The latter will increase Medicare reimbursement to most primary care physicians, industry experts concur. Primary Care Earnings Pull Out of Doldrums "This year and last year, we are finally seeing some compensation increases in primary care -- of about 58 percent -- after several years of flat incomes. That's a positive trend that some of us saw coming, because basically something had to give," said Brad Vaudrey, MBA, CPA, director of Minneapolis-based RSM National Health Care Consulting, which compiles the American Medical Group Association's annual compensation and financial survey. These increases, in concert with emerging innovations in employment and care delivery, make for a vibrant job market. "We're seeing supply and demand coming into play, and that is raising salaries and benefits for internists," said William Golden, MD, chair of the Board of Regents for the American College of Physicians. "And the Medicare fee schedule increase will likely translate into other insurance products down the road." Both developments -- underpinned by efforts to develop patient-centered, technology-enhanced care models in which PCPs assume a lead role in coordinating medical services -- augur exciting changes, added Dr. Golden, a professor of medicine at the University of Arkansas for Medical Sciences. Changes and innovations also are afoot in PCP compensation and employment structures. "We are seeing signing bonuses of $5,000 to $35,000 in primary care, as well as loan repayment. But the big change is that the demand for primary care has brought systems to re-engage in employing PCPs," he said, or to bolster community practices' financial viability. For example, some large groups and hospital systems are using "incubator" or transitional-employment models. In those arrangements, physicians are employed for two years and then allowed to buy out the practice for a sum that reflects the value of fixed assets and accounts receivable. "It's a bit different than a net-income guarantee," Mr McCartie said. Employment Structures, Financial Supports Help Physicians Get Started In other developments, multispecialty groups -- in vogue again after a long trend toward clustering of same-specialty physicians -- are actively recruiting PCPs and offering attractive financial support systems. Those systems include not only signing bonuses, but also sustainable "credits" structures that increase compensation and recognize the value PCPs bring to the group through services and care coordination. "In multispecialty practices, primary care physicians are certainly being supported to a higher degree than they were -- in hopes of increasing retention," Mr McCartie said. That support, whether achieved through credits, incentives, or salary ranges, is especially evident among large employed-model practices. Kaiser Permanente, for example, raises all physicians' salaries consistent with the large annual surveys' findings but "evens out" the disparity between specialists' and PCPs' incomes. "Like many large, high-performing medical groups, we pay a bit more than average for primary care and a bit less than average for the specialties," explained Robert Pearl, MD, executive director and CEO of The Permanente Medical Group - Northern California (TPMG), which employs more than 6,000 physicians. TPMG also offers a housing program in which physicians just starting their careers can obtain a 10-year, interest-free loan for a home down payment. Other large employers continue to modify and experiment with compensation-package arrangements -- especially in retirement benefits and CME allowances -- to recruit both PCPs and physicians in certain high-demand/low-supply specialties. Health Care System Changes Affect Incomes, Practice Models As the health care-delivery landscape changes, so do physician-compensation systems and practice models. For example, as costs increase and concerns about cost-effective care intensify, annual bonuses are undergoing modification. Community practice bonuses have typically been based on collections. Yet increasingly, they are being based on RVUs, the recruiting firms report. Quality-based bonuses -- particularly for improved management of chronic conditions -- are also on the rise. At Kaiser's TPMG, for example, physicians can earn up to 10 percent of their annual salary in an incentive payment that is based half on quality and half on service (measured by patient satisfaction). A recent study by the Center for Studying Health System Change (HSC) in Washington, DC, found that despite the movement toward quality-based incentives, productivity prevails in setting bonus or incentive compensation. In 2004-2005, approximately 20 percent of physicians reported that quality measures figured into their compensation, and roughly 24 percent cited patient satisfaction. Yet more than 70 percent cited productivity as the predominant financial incentive. Practice positions are changing to reflect certain marketplace devel... |
| www.acgme.org/acWebsite/newsRoom/newsRm_acGlance.asp PDF document * The Accreditation Council for Graduate Medical Education is a private, non-profit council that evaluates and accredits medical residency programs in the United States. Its forerunner was the Liaison Committee for Graduate Medical Education, established in 1972. The number of active full-time and part-time residents for academic year 2005-06 was 107,245. Each residency committee comprises about 6 to 15 volunteer physicians. Members of the residency review committees are appointed by the AMA Council on Medical Education and the appropriate medical specialty boards and organizations. Members of the Institutional Review Committee and Transitional Year Committee are appointed by the ACGME Executive Committee and confirmed by the Board of Directors. Member organizations each appoint four members to the Board of Directors, which also includes two resident members, three public directors, the chair of the Council of Review Committee Chairs and a non-voting federal representative. |
| tinyurl.com/55v9th -> online.wsj.com/article_email/SB120726201815287955-lMyQjAxMDI4MDA3NDIwNjQyWj.html Personalized Home Page Setup Put headlines on your homepage about the companies, industries and topics that interest you most. Nonprofit Hospitals, Once For the Poor, Strike It Rich With Tax Breaks, They Outperform For-Profit Rivals By JOHN CARREYROU and BARBARA MARTINEZ April 4, 2008; Page A1 Nonprofit hospitals, originally set up to serve the poor, have transformed themselves into profit machines. And as the money rolls in, the large tax breaks they receive are drawing fire. Riding gains from investment portfolios and enjoying the pricing power that came from a decade of mergers, many nonprofit hospitals have seen earnings soar in recent years. AHD, an information-service company, compiles data that hospitals report to the federal government. The Cleveland Clinic swung from a loss to net income of $229 million during that period. No fewer than 25 nonprofit hospitals or hospital systems now earn more than $250 million a year. Nonprofits, which account for a majority of US hospitals, are faring even better than their for-profit counterparts: 77% of the 2,033 US nonprofit hospitals are in the black, while just 61% of for-profit hospitals are profitable, according to the AHD data. At some nonprofits, the good times are reflected in new facilities and rich executive pay. Flush with cash, Northwestern Memorial Hospital in Chicago has rebuilt its entire campus since 1999 at a cost of more than $1 billion. In October, it opened a new women's hospital that features marble in the lobby, birthing rooms with flat-screen televisions, 1,000 works of art and a roof topped with 10,000 square feet of gardens. But Northwestern Memorial has been frugal in its spending on charity care, the free treatment for poor patients that nonprofit hospitals are expected to provide in return for the federal and state tax breaks they receive. By comparison, the hospitals run by Cook County, where Northwestern Memorial is located, spent 14% of revenues on charity care. Northwestern Memorial says that in addition to charity care, it provides other benefits to its community, such as pioneering research in obstetrics and other areas that improve standards of care nationally. To be sure, some nonprofit hospitals, particularly ones in inner cities that handle large numbers of uninsured patients, remain under financial strain and are struggling to keep their doors open. But the growing gap between many nonprofit hospitals' wealth and what they give back to their communities is raising questions about the billions of dollars in tax exemptions they receive. Read more about how nonprofit hospitals went from charity and tax breaks to healthy profits. "Some nonprofit hospitals seem to forget that their operations are subsidized with generous tax breaks. They allow their priorities to get out of whack," says Sen. The senior Republican on the Senate Finance Committee threatened last year to introduce legislation forcing nonprofit hospitals to provide a minimum amount of charity care. Nonprofit hospitals account for about 60% of the more than 3,400 hospitals in the US The rest are either for-profit or government-owned. Community Benefit In return for not paying taxes, nonprofit hospitals are supposed to provide a "community benefit," a loosely defined requirement whose most important component is charity care. But many hospitals include other expenses in their community-benefit accounting to the Internal Revenue Service, including unpaid patient bills. Often, hospitals also include the difference between the list prices of treatment they provide and what they are paid by Medicaid and Medicare, the government programs for the poor, disabled and elderly. Excluding those other expenses, many hospitals spend less on charity care than they get in tax breaks, studies by various counties and states show. Louis-based BJC HealthCare, counts the salaries of its employees as a community benefit. "The impact that any organization that's job-producing and buying goods has on a community is of benefit to that community," says BJC HealthCare spokeswoman June Fowler. However, she says BJC won't count its payroll as a community benefit in the future because of new standards adopted by the IRS. The new standards, due to take full effect in 2009, will require nonprofit hospitals to break out specifics of their community-benefit contributions. But they won't require the hospitals to provide any minimum amount of charity care. The size of nonprofit hospitals' tax exemptions is coming under scrutiny in part because their incomes have risen so sharply in recent years, and because they represent such a big chunk of America's health-care spending. Thirty-one cents of every dollar spent on medical care is spent on hospitals. One reason for hospitals' soaring profits is a gradual increase in Medicare reimbursements after federal budget cutbacks during the 1990s. By merging and gaining scale, many hospitals also gained leverage in price negotiations with health insurers. However, much of the industry's profit growth comes from strategies it honed to increase profits. hiking list prices for procedures and services to several times their actual cost; and issuing tax-exempt bonds and investing the proceeds in higher-yielding securities. Untaxed investment gains have greatly increased some hospitals' cash piles. Ascension says it needs to maintain a sufficient amount of cash to pay for charity care, to keep the interest rates it pays on its debt low, to provide retirement benefits to its 106,000 employees, and to make capital and technology investments at its hospitals. UPMC says the money goes toward producing "world-class health care, education and research," citing the $1 billion it spent over five years to create electronic medical records for patients and an additional $500 million to build a children's hospital and a network of cancer centers. But some of UPMC's expenses are only tenuously related to medicine. In its 2006 fiscal year, UPMC also spent $10 million on advertising, including $1 million on ads in the New York Times. Wendy Zellner, a spokeswoman for the hospital, says the ads enable UPMC "to better compete with other leading hospitals." Mr Romoff also received $36,995 from the hospital to cover a car allowance, spousal travel and legal and financial counseling. Ms Zellner says what UPMC pays Mr Romoff is in line with "nonprofit and for-profit organizations of comparable scope and complexity." A spokeswoman for Beaumont says it pays for the membership to provide the executive "a venue with access to potential donors." The Cleveland Clinic continued to pay its former CEO, Floyd Loop, more than $1 million a year for two years after he retired in April 2005. The Cleveland Clinic says part of that was deferred compensation and vacation pay and the rest was for consulting services. The University of California San Francisco Medical Center provided its CEO and chief operating officer low-interest mortgage loans of more than $1 million each, according to the University of California's executive compensation reports. A UCSF spokeswoman says such loans help recruit and retain executives, given the area's high cost of housing. Catholic Healthcare West, a hospital system based in San Francisco, forgave a $782,541 housing loan it made to its CEO, Lloyd Dean. Catholic Healthcare West says his compensation reflects his skill in turning the hospital system around financially. One nonprofit hospital executive who has benefited from the industry's good fortunes is Mr Mecklenburg, the former CEO of Chicago's Northwestern Memorial. Mr Mecklenburg, now a partner at Chicago private-equity firm Waud Capital Partners LLC, declined to comment, referring questions to the hospital and to the former chairman of its compensation committee, James Denny. Mr Denny, who chaired the hospital's compensation committee from 1995 to January 2008, says Mr Mecklenburg delivered stellar results, nearly quintupling the hospital's patient revenues. "Our view of it is: This is the best deal we've ever made," he says. Critics argue that Mr Mecklenburg's compensation is excessive for a charity organization that gets tens of millions of do... |