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It Comes Down to Dollars and Cents

If you could make a statement to the public and policy makers about the state of the medical profession today and how health care delivery can be improved, what would you say?

In Part Three of the Physicians Foundation’s 2020 Survey of America’s Physicians: COVID-19 and the Future of the Health Care System, many physicians shared the current payment model system is not working for smaller, independent practices and primary care physicians.

Why? For many physicians, it comes down to dollars and cents—the system is currently not financially attuned to these physicians’ needs to effectively care for their patients and local communities.  

Read the direct quotes from physicians about payment models:

“You have forgotten about the solo providers and small clinics who provide excellent care through fee for service.”

“The system is overly complex, expensive, unequal and inefficient…needs to be streamlined with complete price transparency aligned with costs and standardized services based on effectiveness.”

“I am concerned that the current burdens on physicians will drive more people out of medical school and primary care specialties, with an increase in primary care provided by physician extenders which I fear will lead to long term increases in cost due to increased referral to specialists, and subpar long-term care for chronic conditions.”

“We need a strong primary care base to support a healthy population and reduced spending on disease care. To have a strong primary care base, we must PAY primary care providers equally to less-needed specialists, or new graduates will not choose to practice primary care.”

“[Physicians] need to be paid for all the time we spend not just with patients, but working on patient issues and coordination of care, social services and counseling.”

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One thought on “It Comes Down to Dollars and Cents

  1. Being a primary care doctor is one the most miserable, thankless, and demoralizing professions out there. You spend your golden years in social isolation buried in books from dusk till dawn; you then work 80-100 hours/week at your residency program but only report 40 hours/week (so that your residency program avoids labor law issues and overtime pay…etc.); so when you consider the real number of hours worked during residency, you realize that you’re getting paid less than minimum wage (despite having a bachelors and an MD degree); residents are also placed in the smallest and dirtiest rooms of the hospital. While the rest of society gets to enjoy weekends, life, liberty, money, and the pursuit of self-interests, you are taught to be a selfless poor saint; you then finish residency with most of your soul sucked away from you with a half-million-dollar student debt chain wrapped around your neck. Just as you begin to recover from the mental and physical trauma of residency, they hit you with another dose of soul-sucking venom: it is called the ABIM.

    So, what is the ABIM? It is an “exam” that the newly minted physician must pay and prepare for. The emotionally exhausted and indebted physician must pay about $2000 to take it. But here is the first kicker: it requires a lengthy and arduous study time, which is worse than residency because in this case, you do not get paid a penny for all the time you spend preparing for this exam. At least in residency, you get paid minimum wage or less. But for the ABIM, it is the physician who pays for the exam and pays for the opportunity cost with the time spent preparing for it. And now the second kicker: the material tested on the exam and the correct answers to the questions on the exam have nothing to do with the daily real-life practice of any branch of medicine. The ABIM is not an exam. It is a scam that is disguised as an exam. So why do those doctors take it anyway? Great question! Answer: The ABIM is in the cahoots with commercial insurance companies and hospitals. Basically, hospitals will not allow you to work if you do not pass it. Commercial insurance companies will not pay you if you do not pass it. The purpose of the ABIM is not to improve the knowledge of the physician or the health of the patient; it is to pay the ABIM and its members.

    But wait…it gets better!

    You then enter the real world of medicine (either employed or open your practice) and finally see the million-dollar mistake you just made over the last 10-12 years of your life: Whoever hires you will work you like a slave; if you work for yourself, you will also work like a slave. Only 10-20% of your time is spent in real patient care. The rest of It is spent on documentation, which is mostly for billing and medicolegal. Also, about one third of your work is uncompensated; I will elaborate: on the books, you may be working 9 AM-5 PM Monday through Thursday seeing patients. The reality is that you sit at your computer every day from 5 PM-7 or 8 PM processing prescription refills, analyzing lab results, imaging results, reading emails, and going through specialist consult notes, and finishing your patient notes (which are nothing more than an insurance submission claim so you can get paid the measly fee that these insruance companies are paying). You also do this on your “off days” and “weekends”. Find me a profession in which this is acceptable! Find me employees who are willing to work overtime and weekends for free! What profession in what planet would accept these standards of living?

    Would a hair stylist, tattoo artist, janitor, lawyer, bus driver, waiter, or government worker accept not being compensated for one third of their work?

    What does it mean when your work is not compensated? It means that society is sending you a clear message: Your work has no value! Plain and simple. As a primary care physician, you are reminded of that every single day, especially when you realize that your patients themselves would not accept such standards and are substantially more financially solvent than you.
    Some of your patients—including the very wealthy ones–will argue over the $10 copay you charge them, or a $65 bill they got; some will ignore the medical bills you send them, or they will email you saying, “why am I getting bills from you?”. They will pay thousands of dollars for Art, skin care, tattoos, new German cars, and hundreds for a good bottle of liquor or in tips for their Botox nurse…. but nope! They will not pay their Doctor bill.

    And it even gets better!

    The little money you make, you do not even get to keep: They take that away from you in various forms; for instance, you pay malpractice insurance, which is about $10000 a year. Insurance companies send you recoupment notices to collect some of the money they had paid you. Every two years you pay the DEA hundreds of dollars just so that you can do your job. All that is happening to you while your student debt is piling at high interest rates.

    All the aforementioned factors lead to Doctors having to see many patients per day, which increases the workload on the Doctor while decreasing the quality of care, leading to patient dissatisfaction and resentment.

    So, do you now understand what Doctor burnout means?

    “Burn out” is therefore both, a physical and mental condition. The physical part involves the sheer number of hours worked per week, coupled with the strain on the cardiovascular system (due to decreased time for leisure or exercise and increased mental stress). The mental part involves the following:
    1-The demoralization and humiliation that the physician feels daily from performing a service that society deemed to be of no meaningful value.
    2- The hopelessness and sadness that the physician feels from being shackled to the profession by time and money invested over the years mustering skills that are generally non-transferrable to other professions.
    “Burn out” is not something that happens to doctors because they are weak; it happens to them because they are being abused by the entire healthcare system.

    My heart goes out for all the doctors who got fooled into hopping on this one-way train to lifelong hell and financial insolvency. For those who are in medical school or premed, please get out while you are young and relatively financially solvent. Know that If you are smart enough to get a B in organic chemistry, you can do something much better and more creative with your life; you will be able to have a family, own a home by a decent age, and respect yourself. Use your creative and intellectual faculties to do things that society values so you can get a sense of reward and fulfilment at the end of your workday.

    The hostile and ruthless takeover of this once beautiful and noble profession has been orchestrated by the profession’s leadership, businessmen and the government, all being ultimately at the expense of the American patient. Now if I can only find a good way out.

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