bdj, I seek u r opinion on this - hotobhaga

[ArchivalUser]

bdj, I value ur opinion on most issues. please read this article and tell me what you think of it
http://home.austin.rr.com/austintxmd/Pages/income.html

[ArchivalUser]

Hey hotobhaga!
The article is good and I could be talking for hours about it. And I know I will...but will try to be short!

For the most part it is true. Although somehow extremist about some issues (like the charges and the "bad" things) this is pretty much what you constantly hear private practice physicians complaining about. It is clear that after the HMO/pre-set charge era MDs stopped receiving exorbitant salaries based on what they wanted to charge to insurance companies. Back then, an MD charged between $100 and $150 per consult and the insurance co/patient with co-pay paid it without complaining. Imagine if the Ins. Co. hadn't jump into the arena of controlling this, anyone could be paying anything from $200-$400 per consult nowadays. And with the economy right now I truly believe that a lot of patients wouldn't be able to afford that payment! So in a sense the regulation was a good thing in the beginning. That joy lasted very little!

However I still see the positive things of the actual system, since I was a student and as such saw once a charge for $1800 for an endoscopy (more than my monthly stipend!) which is what the office "normally" charges and saw that slashed in half by the Ins.Co as they paid for it. If it would've been me paying....there goes my stipend! or I would be receiving constant calls and sometimes threats for not paying. Coming from a country with national healthcare system (and knowing the down side of it as it's far from being perfect!), I can't imagine a patient losing his/her house because they can't pay the medical bill (this is the first cause of bankrupcy in the US: inability to pay medical bills), or a patient deciding on his/her life because they don't have insurance or they can't cover the co-pay. It doesn't matter if the physician never asks if you have insurance, bottom line is you will get the charge, you will get the calls. So the system is by far perfect. And knowing how much a national healthcare system costs and knowing the "inability" of most americans to get into a "socialized" system -in which sometimes you pay and don't use it- (so that money can be used for those who don't pay), and knowing physicians even more upset having a specific pay regardless of the amount of time/work and knowing that they can be overload with work....I don't see that system as the solution to the US healthcare crisis. There are a lot of things that needed to be put in place and at this point I simply believe that it's way too late. You can't teach an old dog new tricks! (I hope I'm totally wrong on this, but may be not!). Bottom line is I really don't see any solutions, and that is what worries me. When I was at my US healthcare policy class they make things sound so simplistic that you think it's just a matter of putting it in place. I don't think it's that simple. I don't know the Brit nor the Canadian system well enough to decide or comment on how good things work for both pts and physicians/hospitals; but in my country there are a lot of flaws (endless waiting lists, unnecessary visits to the ED and admits through the ED as the only means to "move up of the list" and so on...) I think that even the US has left primary care way far behind and something needs to be done in that respect before you jump into the arena of a national healthcare system (NHS). It's amazing (and you'll see it) to see 50yo patients with ERSD due to HTN or DM...where is prevention, where is early detection? where is primary care? I don't know but not timely that is for sure (yes and usually these are medicaid patients so they never had the former as they didn't have money to pay for it). Thus, the advocates for a NHS say that if we had one here we will be preventing a lot of these patients from coming at so advance stages, my question is would these pts receive a prompt evaluation and attention in a country where nearly 25% are uninsured? I am afraid not....but it's just me!

The problem now? Well the Ins.Co. never transfered those "savings" to the patients and have drained the medical field to the point of controlling absolutely everything. In a way, this system is worse than a NHS because Ins.Co. hold a monopoly of what/how much you pay and what/when you can order certain things. So you have somebody who doesn't even hold an MD degree deciding what and how you run your practice (sickening at points, yes!) Example: where we are now it's almost a miracle to get an MRI approved in the office (and I mean a university based program in Neurology) amazing right? You have a pt with HA and positive neurologic findings, you want to find out if she has a tumor...and she has to wait for weeks (with office paperwork coming and going on and on to justify the MRI), and/or if she can't stand it she ends up going to the ED and as such (an emergency now) you can order the MRI right away. It's stupid, really stupid, because that visit to the ED is going to cost waay much more than the office consult and the MRI in that setting right? Wrong. They will still check and make sure that the PCP had approved the visit to the ED (after all he's the gatekeeper...) and that the urgent MRI was justifiable. So in order to do that the PCP ALSO sees the pt that day to charge (no free lunch here for the pt, PCP knows from the get-go that the pt will be going to the ED but needs to justify the time/counsel and cover for malpractice also!). If it's all in place pt will have to pay whatever co-pay she has (which is still a rate limiting factor for some patients) which is higher when she goes to the ED, and if something is not "up to the guidelines" then the Ins.Co will not pay. And there you are again doing paperwork, sending notes (now you can charge the "full fare", not only the fare that the Ins.Co pays as they are not paying), sending bills to the pt in order to recover the money....Good luck! And poor the pt!!!

Not only that, but they are even entitled to refuse paying for certain procedures in a medical group office or from certain physicians if they consider that there's been an "abuse" to the procedure. Example 3-D US. Specifically stated for certain things, but requested by many patients because they want to experience the joy of seeing their baby's face. I know of a few offices that were banned from doing them period. If they do it the pt has to pay the full fare....Imagine how many patients who really need it will be flying away from that office!

I do agree that a smaller firm has the most advantage. Mainly because a solo practice means not having anybody else to back up when you are sick, when your kid has an important event, when you want to go on vacation, when you don't want to be waken up every single night or going to the office every single weekend. The comparison with the big elephant on bigger firms is also true. And the rural issues are also important to note (why do you think that they send IMGs with J1 waivers to the rural settings, or to underserved areas where ppl don't have insurance and you have to deal with all this? well that is the answer: you have to pay for it!).

But of course in a world where ppl are used to have physicians answering questions all the time, they expect us to give things for free, welcome to America.... And there you have the wife of a friend asking you advice at a party, or the mom of a patient calling you on a saturday and expecting you to fill a prescription for otitis or a sore throat or for asthma or hives or poison ivy over the phone...and with no charge. Many PCPs simply don't do it anymore. I have a friend who was specifically told by her pediatrician "don't call on the weekends we don't answer calls" So guess who she calls now...LOL! And there you have people like I'd seen somebody in step2ck forum complaining b/c he/she was called to make a second appointment to evaluate the lab results (which I may not do if it was a colleague but it is still a valid "technique"). And you end up having people who are experts at dissecting any and every dime that you can get out of the Ins.Co by coding the right things and adding a few minor things that will add to that also (and paying for their expensive salaries) That is why we have become micro managers. That is why I got an MPH and I may be looking into administrative courses near the end of my residency if I find out that I will not be able to remain in an academic setting...And who pays for that extra knowledge? Nobody! But you need it anyways right?!

Hospital settings are not different than that. Filling up forms, stating constantly how much time you spent with the patient, charging ridiculous amounts and then ending up (even as residents) dictating your notes after hours (very time consuming), covering for the consults, having patients call over and over for you to fill orders, requests, paperworks, letters, etc, etc. So the system in a way (pardon for the word) really sucks but that is the down side of bringing home a "bigger" pay than what we would get in our own countries. The advantage that we have? we don't have loans to pay. Most AMGs have anything between 100K and you name-it in loans that they have to re-pay. No wonder why they are given priority in the match (I only think it's reasonable and fair!). I will not discuss the situation of whiny girly citizen IMGs or even GC holders who decided to "save" some money by not going to US med schools -and don't tell me that they could not get financing, or that they are part of a minority, if you are a good student you get the money from multiple places, I've been here long enough to see this happening over and over. In myhumble opinion the GC holders could go back to their home country right after all they are not citizens, and the citizens could become citizens of that country where they studied and practice there! (or get training in those countries) After all if they decided by choice to go there for their MD what makes them think that residency training is not good? And then they will say "and what about IMGs" well we're at the bottom of the food chain and don't complain right, we just work hard...very hard!!!

And you see I could go on, and on about it. Eight years being in the system (from the analytical point, from the patient's perspective, from the physician's perspective soon...) are not enough to make really deep comments, but at least to make enough ones and to have in hand enough knowledge to get an idea of what entails if I decide to stay in the US past my residency!

Thanks for bringing this in and for having the patience to read this very long post!
BDJ

[ArchivalUser]

an I didn't even mentioned the malpractice insurance monopoly and your constant fear of being sued for stupid things (in most states only one co. is willing to do this so they charge whatever they want)!...Just one example: Wife of John Ritter who just lost the lawsuit said in the news "All I wanted to get from this was to increase the awareness in the people and the physicians about John's disease...) And I kept telling myself "isn't this absolutely selfish, she put those physicians' names in doubt, in distress, they will be paying all the costs for this anyways, and the premiums will go up regardless, their medical expertise and qualifications have been put in doubt, they probably lost patients...and all this circus to create so called awareness!"
Check here:
http://www.efluxmedia.com/news_John_Ritt...13645.html

But it's late and this would require another humongous dissertation! Drop your email hoto if you want to continue this discussion I hate to force people to read long posts! LOL
BDJ

[ArchivalUser]

thank you BDG,
I am now doubting my decison to pursue residency in USA.
All said and done I still make 250K per month after taxes in local currency(INR)...and whatever the official conversion rate is vis a vis the dollar...buying power is about 10 to a dollar. And I work for 5 hours a day only!!!!!!!!!

[ArchivalUser]

LOL hoto!
Just put it this way: you are not forced to stay right? So you can be trained here, get your specialty and then go back and work there.
It's not as bad as it sounds (I already said that on my first line) but it's not perfect. Give it a try, get to know the system and decided by yourself. For me, since I am passionate about research and clinical work is hard for me to go back to my country as research funding is limited to pharm companies for the most part and scarce. However, I don't see myself doing private practice....if I'm staying here in the US it'll be in academia and that is why I'm thrilled that I landed a spot in an university program since I can still do research (translational) and I can build a name a respect during my residency to be an asset and to continue in this setting. If not, I will be looking to go back home and set some type of research collaboration....

Dont' quit now, again give it a try and if it doesn't work for you it's not like you are leaving empty handed right?

Best of lucks!
BDJ

[ArchivalUser]

Hotobhaga,
Don't worry cos you can relocate to a rural area after your FM training and make use of your surgical skills. It would even be better if u opt for 1 yr obstetrics training post FM residency so u can have greater latitude to do CS, hysterectomy etc. But if I were in your shoes I would have gone for Fellowship in CT or Plastic/Reconstuctive Surgery for example after which I will return home. There are a lot of these in NY and all u need is prior surgery residency in home country and usmle step 3. People on this forum keep saying it is impossible but most never tried contacting PDs directly to sell themselves and there skills. GL in your FM training.

[ArchivalUser]

This research tells that salary gap between IM/FM and subspecialities is decreasing and will ultimately be just nominal:

http://www.nejmjobs.org/career-resources...rends.aspx