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Tuesday, November 20th 2007

So What's The Big Complaint On Reimbursement?

There are a lot of upset physicians out there, rallying to the issues of physician reimbursement. Even amongst some of my favorite bloggers. I hear often about the death of primary care, about the SGR and Medicare reimbursement. There’s something to these and, at the least, you can hardly blame physicians for looking out for their self interests. But it is worth looking at some comparisons before we condemn the current reimbursement system.

Let’s start off with the pragmatic. The average primary care physician continues to earn more than any of his OECD nation counterparts. Not only more in absolute dollars, but also as a percentage of the average household income. In 2006 the average general practitioner in the United States earned 4.1-times the per capita GDP.

Even with the debt burden of the current medical student, such as myself, my lifetime earning potential is considerable and more than most of western country counterparts.

If, instead of going to medical school, one were given a million dollars to invest at 6 percent interest and pursued a career as a college graduate instead, the financial returns would be roughly the same as going to medical school.

As said above, harping for your own economic self interest isn’t a terrible thing. But where is this anger about physician reimbursement coming from? Where is this hyperbole about the death of medicine, the death of primary care coming from? Now granted, without such passion physicians may be in a much worse place than they currently find themselves. There are certainly situations where physicians are losing money – consider Medicaid in some states.

The growth of physician income has been…marginal in the past two decades. Without those who passionately advocate perhaps we would not be in a stale position but instead on a downward slope.

Physician Income
Physician Income In Adjusted Dollars

What peeves me is the hyperbole and the seeming ungratefulness. I truly believe that what physicians have that is most important in the fight over health care reform is physician trust. Doesn’t the current tone from organized medicine and individual physicians concerning physician income endanger that?

We know American physicians earn more than the rest of the world. The second question is if health care is inherently overvalued. Clearly, virtually no health care system represents a free market system. Even the American system is seemingly controlled by a cabal of payers.

The gut reaction is an obvious ‘no.’ But physicians have done marvelously well for themselves in lobbying Medicare and promoting their own reimbursement. The question is, outside of the current payer structure, in a truly free market system, could physicians further maximize their income?

In a world where the consumer=the payer, I’m sure for a large part they could not. Sure there are a set of unique services which could potentially further maximize their income. Acute care providers from emergency room docs to some types of surgeons. True the hyper-specialization of medicine is in and of itself partly a product of the current reimbursement structure. But that and other complexities aside, the vast majority of physicians and certainly the primary care physicians certainly could not earn more in a true free market system. Could they?

It seems to me that considering the health literacy of the populace and the seeming dis concern for future consequences, only both immediate and life or QoL threatening conditions would see increased reimbursement in a system where payment is more directly tied to the consumer.

If these things are the case, then don’t the cries of anguish over the SGR, over physician reimbursement, against those who favor single payer sometimes seem…histrionic and ungrateful? Or am I just not seeing the real picture here?