Tuesday, February 16, 2010

Cardiology Cuts Taking Their Toll

From San Antonio, Texas:
More than 10 employees for this group have lost their jobs. More layoffs loom. More than half of cardiology patients are on Medicare, but some specialists may stop accepting new Medicare patients.

“At some point, doctors are going to tell their Medicare patients ‘you know, I really can’t afford to keep taking care of you,’” Rabinowitz predicted.

His practice is handing out a letter about its concerns to patients, using them to contact their Washington representatives, calling for action to sop what they consider devastating cuts.

Rabinowitz predicts patient waits for visits will be longer and the visits themselves much shorter as doctors try to fit in more patients to make up for lost income. At the heart of the matter is an uncertain future for private cardiologists.

“It’s not really my choice,” Rabinowitz said. “It’s not my preference to start practicing like that. But I’m being forced to practice like that because otherwise, I’ll be out of business and I won’t be practicing at all.”
To think that cuts of this magnitude won't impact the quality of seniors' cardiovascular care in communities across the country is magical thinking.



Anonymous said...

Interesting Dr. Rabinowitz does not tell the patients that all his actions are in fact one of income preservation.
The debate should veer around how much is appropriate compensation for a cardiologist.
I would like readers of this post to comment

Anonymous said...

As a guy practicing geriatrics used to say, "When you lose money on every patient, you can't make it up in volume."

Anonymous said...

So cardiologists will now have to pay their overhead and make a living off what Medicare pays for E&M services? Join the club.

Pri Care Doc

Steve Parker, M.D. said...

Then maybe polititians will start listening to the voters instead of the lobbyists and special interest groups.

I like your quote, Anonymous. I couldn't make a decent living as a geriatrician, so I switched to being a hospitalist nine years ago. My former office patients switched to nurse practitioners and physician assistants, or just used the ER.


Anonymous said...

I thought physicians were flocking to Texas because it is the new physician Mecca? Guess all those claims about "reform" being the key to access were made up.

Anonymous said...

Reform or no reform, physicians are not going to get relief. When AMA and ACC screwed Primary care many years ago and bumped proceduralist income at the expense of internists/Primary care, it was unfair and no other specialist society complained. Now, for the first time cardiologist feel a pinch, it is news. WSJ had an article recently that USA is over stenting like crazy even for those that have no clear evidence, wonder what cardiologists would say.

Keith said...

C'mon Wes,

How severely is this affecting overall income? Who are they laying off? Is this maybe not such a bad thing since taking the profit motive out of non invasive cardiac testing will discourage some of the overtesting I see for the purposes of generating income?

We need more than gloom and doom and threats of lack of access to services with physicians deserting Medicare rather than anecdotes.

What the story might tell us is whether the cardiologists that are suffering so terribly cut their own salaries, or are they cutting personel, and asking more of their remaining employees so that they don't have to absorb any pain themselves. What is the current average take home of a cardiologist?

Anonymous said...

this is going to drastically affect practice valuations. any senior partners who counted on buyouts as part of their retirements may have to work a little longer.
people considering partnership may reconsider unless valuations take into consideration these new economics. you just cannot make business plans with all these changes and proposed changes looming.

StorytellERdoc said...

Well said...you have some excellent points made within your post.

Anonymous said...

As indicated above, the AMA, with the enthusiastic support of the cardiology associations, has for 20 years deliberately suppressed payment levels for E&M codes in favor of procedures. Remembering this, a lot of us can't share your indignation.

Pri Care Doc

DrWes said...

To the anonymous commenter who posted the data from the recently published Forbes article on doctor salaries:

For reasons that are unclear to me, your comment did not publish. I have provided a link to the article and regret the problem.

I do note, however, that the source for Forbes article's salary was Merritt Hawkins, a physician recruiting agency. While their survey data were not linked, they appear higher than other physician surveys conducted by other recruiters.

Finally, MGMA has a pretty good overview of current trends in physician compensation changes recently for specialists and primary care doctors that delves into the complexities of comparing these data.

While I grant you that cardiologists make significantly more than primary care doctors and certainly the FFS system we've inherited is partly to blame, it is not the sole reason differences in compensation exist.

Praveen said...

Most specialists' incomes would have to decline precipitously in order to reach a level that really impacted the desire of med students to sub-specialize.

I analyzed the career return on investment for a variety of careers, and based on official statistics (BLS data), medicine didn't rank in the top 5.

But if I were to use more accurate data like the Cejka research numbers, the data would indicate that Radiology, Cardiology, Orthopedics, and other high income specialties are far and away the highest ROI careers in the land!



This indicates that there's considerable room within the Medicare reimbursement structure to cut specialists' fees. To make the decision to be a specialist vs. primary care more-or-less income neutral, a specialist should be reimbursed about $30k more annually for every year of additional training. So a radiologist who spent three more years than a family practice doc should make 90k more, not 200k more (as they do today).

In a free market, doctors should be able to make whatever they are able, as with any other business. But when you're compensated by the government, you get what you get. In this case, specialists have used lobbyists to inflate their own incomes, and the trend is only now beginning to be reversed.

DrWes said...


Your logic is so flawed I don't know where to begin: ROI? Seriously? It would be nice if life, the marketplace, and salaries were just one big linear correlation, but that's not reality.

And where the heck do you come up with $30K/year salary for every year of education? Using your logic, profesional football and basketball players should make about $100 per year and employed by the government.

Praveen said...

Dr. Wes,

Take a look at the spreadsheets in my post to understand the ROI calculations.

In essence, rational young adults choose a career in part based on future projected income, and weigh this against the cost of education in terms of tuition and opportunity cost. Of course they look at many other factors, but money plays a part.

I don't dictate what anyone in particular should make - what I'm saying is, if there's a huge ROI differential between careers, then supply and demand will dictate that everyone goes to the high ROI career. In an open market, the oversupply of new, say, cardiologists, would drive down salaries to equilibrium. But you and I both know that medicine is far from an open market - it's one where the government already sets prices.

I'd rather the government not set prices, but they do. If the government is going to set prices, and blow a hole in taxpayer finances in the process, then I'd rather it pay a fair price for services rendered. In short, my ROI calculations imply that the government has been overpaying cardiologists, because the career ROI on being a cardiologist is so high that there's an oversupply of would-be cardiologists (and many other specialists).

Now, using my logic, I ask the question, how much more per year does a doc need to be paid to justify each extra year of training beyond a 3-year family practice residency? The answer comes to right around 30k extra per year of additional education. This is the amount of additional pay needed to keep the NPV and ROI of the career path roughly constant.

I am arguing that if a cardiologist who does, say three more years of training than family practice, is paid 90 or 100k more (so around 300k), that the field will attract a sufficient number of good candidates.

Finally, if I didn't make this clear enough, I'm not saying what anyone should make in a free market. If you don't like what Medicare or insurers are doing, stop taking insurance and practice in the free market. But if you *essentially* work for the government, don't be surprised when the game changes on you.

P.S. Regarding NFL/NBA players, the career ROI for these fields per my calculations wouldn't be that high. Why? The unemployment rate in such fields for would-be pros (let's say Div. I players) is 90%+. So the high salaries are more than offset by the low chance of actually making it. Compare this with 1% unemployment rates in medicine.