When Doctors Earn Less Than The Burger Guy At Burger King

 I talked today with a local internist. A colleague of mine for whom I trained in residency with. A great doctor. I wanted to get a sense on how things are out there.  It ain't good folks.

They are hiring. But they aren't. Because they can't find any internists. They checked our University IM training residency. Not a one has any interest. All the stuff you are hearing about; the lack of medical students going into primary care. The rush into lucrative specialties and sub specialties. The kind that do procedures. The kind that do high volume relative to time requirements. That's where everyone is going.  It's all true.

Less than 15% of today's medical students are entering primary care.  When I was in training a few short years ago, the state had a program of loan forgiveness or low interest to bribe students into doing rural America primary care and work off their loans.

Well, guess what, rural doesn't mean Jack anymore. Because the cities are hurting too. Primary care everywhere is suffering.  It is a universal crisis.  Welcome Baby Boomers to your new health care system. We welcome you with open arms.  Now. Go find a doc.

This is a great group of docs I speak of. He is one that still follows his patients in the hospital. He works 12 hour days, 5 days a week and every 4th weekend. He works at other facilities in town to generate more income.  He shouldn't have to do that.  It is despicable that our 3rd parties create reimbursement structure that demands an unsustainable work environment.  That works out to at least 60-65 hours a week. 18 patients or more a day. 6 1/2 hours (of patient contact) clinics every day. 5 days a week. That's one patient from start to finish every 20 minutes.  That includes reviewing old records, evaluating the patient, documenting, dictating, ordering, discussing and referring.  In 20 minutes.  An absolute impossibility for patients with multiple chronic medical conditions.  If you want quality, safety, efficiency, you have to pay for it.

Right now it is the game that every primary care physicina  must play as established by the Medicare National Bank.  He used the same words I've been talking about. Volume. Volume. Volume.H  e is concerned about sustainability. Burnout. At the end of the week, the exhaustion. The lack of time with family. and talk of partners retiring down the road.

I don't blame them. The game is currently over. Retirement looms for a large generation of primary care doctors just as the Baby Boomers begin knocking down the doors wondering where all the doctors went.  It is an active implosion in the works. And the driver?  A lawfully mandated slave labor contract known as Medicare. You can blame them 100%.  By now I'm sure you all have heard that Congress passed a 6 month reprive on the 10% reimbursement cuts and replaced it with a 0.5% "raise"

Can you imagine the destruction on the office margins if that 10% cut goes through in six months? That 0.5% raise for the next six months is a joke and an insult to our intelligence. Medicare has docs by the balls (and ovaries) and they know it. When the doctors revolt you will be left with a massive Baby Boomer uprising that march on Congress and flush the whole system.  This is what will be necessary to overturn the monopolistic dictatorship known as Medicare. Their way or the highway. And the highway will leave doctors and patients in a state of unknown security.  But it gets worse. Much worse.

That 10% actually equates to a 20% cut and here's why.  Imagine for simplicity that an internist has an all Medicare practice that generates $360,000 a year in clinic revenue. Let's imagine the overhead is 50%.  Take home pay for that doc would be $180,000.  Now.  What happens when Medicare goes through with that 10% cut?  Well, that revenue of $360,000 just got a $36,000 haircut.  But you know what? You can't cut 10% off the overhead.  That overhead remains at $180,000. So take home pay?  $144,000.  That my friends is a 20% cut in take home pay.  So when you hear Congress talk about cutting 5% here or 10% there, take that number and double it for primary care and you get the true cut for primary care.

The SGR( sustainable growth rate) formula and RVU fiasco is slated by Congressional mandate to cut physician reimbursement to the tune of 40% over the next several years. (lets say 5-7 years).  Lets take a peek at the expectation here.  Lets be VERY generous and assume an internist is pulling in $200,000 a year in clinic take home pay. Lets assume that over head is 50%. So yearly gross revenue is $400,000.

To generate $400,000 on a 100% medicare practice seeing 18 patients a day 5 days a week, 52 weeks a year (no vacation), would require a payment in cash of $85 for every visit for an entire year. The most common office code (level 3) pays $60. The level 4 office visit (moderate complex) pays $90. So the office would have to average almost 95% level 4s to generate a take home pay of $200,000 a year.  This would  trigger a fraud investigation as an outlier in a community.

You can see much more here in my coding lectures 

But for the sake of argument, lets assume the doc plays the CPT medical coding  game correctly and is able to justify that and can pull in $400,000 in office revenue per year. What does a 40% cut look like?

well, 40% of $400,000 is $160,000 a year. Yearly gross revenue just became $240,000 in 5 short years.  Lets assume that practice expenses go up only at the cost of inflation over the next 5 years. Given the rapid rise in health insurance premiums, this is an unlikely event, but lets just assume they do. What does the overhead look like at the end of 5 years using 2.5% inflation?

Year 1: $200,000

Year 2: $205,000

Year 3: $210,125

Year 4: $215,378

Year 5: $220,762

Year 6: $226,281

At the end of the 5th year, over head, using only inflation of 2.5% on a very robust generation of $85/visit for 18 visits a day, 5 days a week, 52 weeks a year (no vacation) generate a total of $400,000 of revenue, with 50% overhead.  Overhead would be $226,281 in five years.  Total revenue based on the current flawed Congressional SGR/RVU? $240,000

What does that leave the primary care doc with boys and girls in 5 years?

$240,000- $226,281

That's $13,719 a year in take home pay.  And this is on revenue numbers I generated from a fantasy land clinic.  That works out to $6.60 an hour for a 40 hour work week.

That's less than Burger King Pays.

I believe that would allow your primary care doc to get Medicaid and food stamps.  That folks, is the reality of the current situation as set forth and established by the laws currently on the books by our beloved Congress.  Primary Care docs everywhere. Lining up for food stamps.  Just visualize that for a moment and ask yourself what's wrong with this picture?  All this talk about 6 months reprieve is just that. Talk.  They didn't save anything. It's political grace.

The entire system needs to be overhauled or primary care needs to exit the current system en mass.  Go to a cash only system.  Or balance billing must be allowed to even the field for survival.  Or Congress must establish a National Primary Care Initiative that will bring value back to the field.  The currenty reality is an unsustainable disaster creating all the skewed economics, inefficiencies, volume and waste in the current system.

Blame doctors?  Huh.  Blame Medicare.  Their policies are have created this disaster. And doctors are responding like any other capitalistic right of our citizens. Taking advantage in any way they can to retire early and get out of this disaster forever.  You won't find any doc anywhere, even in Canada, working for $13,000.  And the AARP screams that balanced billing will leave seniors without access.. Congress is so focused on preserving the vote of the massive baby boomers that by not allowing balance billing, they are killing the system off quickly.  But they won't blame themselves. They will blame the "greedy doctors"

When the cleaning lady and the burger flipper (no offense to cleaning ladies and burger flippers) make more than the doctor, it's time to pack up the bags and move on.

You can see much more here in my coding lectures