A Shortage of General Surgeons, Rural Hospitals Must Compete

The Washington Post ran a story today, "Shortage of General Surgeons Endangers Rural Americans," which, as the title suggests, reported on the shortage of general surgeons. The story describes the sort “jack of all (surgical) trades” existence of a general surgeon and reports that “In 1980, 945 newly trained general surgeons were certified in the United States. In 2008, the number was essentially the same -- 972 -- even though the population has increased by 79 million. In 1994, there were 7.1 general surgeons per 100,000 people. Today there are five per 100,000.”

WaPo reports

For the one-quarter of Americans who live outside metropolitan areas, general surgeons are the essential ingredient that keeps full-service medical care within reach. Without general surgeons as backup, family practitioners can't deliver babies, emergency rooms can't take trauma cases, and most internists won't do complicated procedures such as colonoscopies. But various forces -- educational, medical and sociological -- are making them an endangered species.

Many young physicians are opting for non-surgical specialties, such as radiology or cardiology, in which they can earn as much money as a surgeon with less grueling and unpredictable hours. Many young surgeons, in turn, choose to concentrate in fields such as transplant surgery or plastic surgery, in which they can make more money and don't have to face (usually alone) the wide range of problems a generalist faces.

Importantly, the article discusses efforts to recruit new general surgeons and relative compensation incentives; it recounts how 57 year old Bob Kuhl, who has spent his entire career as a general surgeon in Creston Iowa, threatened to quit 18 months ago because “When the hospital hired Kuhl's younger partner, it guaranteed him a salary greater than the $185,000 the older man had been making.” The hospital, however, is said to have made arrangements to assure Kuhl “a higher income, too.”

It is perhaps important to note that the recruitment of general surgeons is said to compete with such lucrative non-surgical specialties such as radiology. As posted recently, the median compensation for a not neural, non-interventionist radiologist is $420,858. As noted in another recent post, this level of radiologist compensation has been ably attributed on Ezra Klein's blog to advances in technology and antiquated fee for service structures:

Now because of the explosion of imaging, and practice efficiency, these guys are reading 3x the images they did 15 years, and making three times as much.

The post on Mr. Klein's blog assures us that “Eventually, payors and Medicare figures things out and start putting pressures on rates. But it takes a while.” Unfortunately, it seems that as hospitals and other medical providers must compete against such "not yet figured out" largesse for the services of newly minted physicians, the damage has been done-- and a benchmark has been set.

Model Wanted

The NY Times reports that according to Dr. Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and an associate professor at the Harvard School of Public Health, “there's a drastic decline in the number of geriatricians — and just 300 new ones are being trained each year — yet the number of people over 65 will double in the next 20 years. Those who work in geriatric care are among the worst paid in the health care system.”

That last statement, as shown in a recent post regarding physician compensation, is backed up by numbers. According to the American Group Medical Association (AMGA) the median compensation for a geriatrician is $179,344. The median compensation for a podiatrist is $180,080. These AMGA numbers have been approved by the Center for Medicare and Medicaid Services (CMS) for use in CMS related calculations.

Dr. Gawande “and others see a pressing need for new approaches to keep aging patients as healthy as possible and living independently as long as possible.” The Times reports that “Dr. Chad Boult, a geriatrician at Johns Hopkins School of Public Health in Baltimore, says the goal should be care that is well coordinated, and patients and families who are involved in and educated about the care plan.”

To that end, Dr. Boult is participating in the testing of a “team approach” which is somewhat reminiscent of the subject of a recent post, Alaska's Southcentral Foundation's “medical home” approach. Southcentral's “comprehensive” health care strategy has shown some promising results. The Times reports that

Dr. Boult is involved in testing a team approach, in which nurses trained in geriatrics are helping physicians in the Baltimore-Washington area provide coordinated care for 50 or 60 of their highest-risk older patients. The nurses go to patients’ homes, develop comprehensive care plans, help the patients in self-monitoring, help them overcome obstacles to self-care and connect patients and their families to community agencies.

According to geriatrics experts, social workers trained in the problems of the elderly can also participate by performing home assessments, for example, to prevent falls and costly, disabling fractures. They can help overcome barriers to good nutrition, and they can help make the community connections for assistance with the activities of daily living, like shopping.

Dr. Boult said that “The Baltimore team project has already demonstrated an improvement in the quality of care that ailing elderly patients receive, and by keeping patients out of the hospital, he expects it will save money for insurers like Medicare.

The NYTimes also reports, however, that the current fee for services compensation scheme has not yet been structured so as to provide monetary incentives for such prophylactic care. The Times states: “While current insurance systems pay many thousands of dollars for hospital-based care, they cover only a fraction of the far less expensive care delivered by doctors and nurses that can keep patients out of the hospital,” and that experts say “a new model of care is needed.”
Read full article here.

Physician Compensation II

Yesterday’s post displayed recent Bureau of Labor Statistic figures concerning physician compensation, and offered a link to recent median physician compensation data approved for use by Centers for Medicare and Medicaid Services (CMS) for calculations regarding direct graduate medical education under 42 CFR 413.78(f). The producer of this data, AMGA, also offers an interactive physician compensation survey which shows “average” and “starting” compensation for various specialties. A click on the arrow underneath “average” will sort from lowest to highest.

Here below is a list of a few of the CMS approved median physician compensation figures for a number of different specialties. The numbers are taken from the 2008 report.

The median compensation for a practitioner:

• Pediatric & Adolescent, Internal 161,444
• Pediatric & Adolescent, Infect. Disease 174,154
• Family Medicine, w/out Obstetrics 176,280
• Family Med., w/out Obst., Branch* 190,182
• Geriatrics 179,344
• Podiatry: 180,080
• Transplant Surgery, Kidney 368,750
• Dermatology, Branch* 301,111
• Dermatology, Mohs 423,848
• Not neural, Non-Interventionist, Radiology 420,858
• Mammography 540,028
• Orthopedic Surgery, Spine 611,670

*Branch is defined by AMGA as: These specialties have the same basic definition as the main specialty. These physicians located in small satellite or branch offices at least five miles from the main campus. The branch office practices primarily as its own separate entity, and often has different compensation and/or performance expectations than its main campus colleagues, there would be no teaching responsibilities at these locations.

With these numbers, over the course of ten career years, if calculated at a constant rate without regard to future increases in compensation, the median paid “Family Doctor, Branch” will have earned $1,900,182. During those same static ten years, a “Mammographer” will have earned $5,400,280. If the Family Doctor were to consult with the Mammographer at the end of those ten years, she would be doing so with someone who had made $3,500,098 more than she—nearly 3 times as much. If that same Family Doctor were to then consult with someone from the lowest paid of the three categories of Radiologist, Not neural, Non-Interventionist, she would be doing so with someone who had made $4,208,580 during that time—which would be $2,308,398 more than she--or more than twice as much.

Perhaps by way of consolation for the PCP, the Geriatrics specialist and the Pediatric Infectious Disease specialist would have fared worse, and even the Kidney transplant specialist who consults with the radiologist would be speaking with someone who had made a half of a million dollars more than he did.

But perhaps it is not consolation enough; the AMA has reported that the nation faces a shortage of 35,000 to 40,000 Primary Care Physicians.

Doctors and Debt

An article in the NY Times reports that The New England Journal of Medicine has said that “Almost one-quarter of U.S. medical students now graduate from medical school with $200,000 or more in debt, an expense that limits entry to the profession.”

A graph which tracks various educational costs and doctor compensation in relation to the CPI over the last 10 years accompanies the article.

Of particular note, Over the last 10 years:

The CPI has risen slightly more than 30%

The cost of:
Public 4-year undergraduate tuition has risen over 100%
Private 4-year undergraduate tuition has risen over 70%

Public “in state” med school tuition has risen over 100%
Public “out of state” med school tuition has risen 70%
Private “in state” med school tuition has risen 50%
Private “out of state” med school tuition has risen roughly 45%

The median compensation for:
All medical specialists has risen roughly 42.5%
Primary care physicians has risen roughly 30%

The median compensation for primary care physicians has risen slightly less than the CPI.

In a recent post, we noted that the AMA has predicted a future shortage of 35,000 to 40,000 primary care physicians. See full NY Times article and graph here.