After the election, a lot of people are excited that they can now get healthcare. Or maybe not quite yet, but by 2014, when ObamaCare is fully implemented.
The only problem is that healthcare is not like an Obama phone. The phones are all made by a standard process in a factory, probably in China, and they usually work.
You can use them to call a healthcare provider. But you usually get the “if this is an emergency, hang up and dial 911,” followed by the phone menu.
How will this change with ObamaCare? Doesn’t that give you a right to care?
Whenever someone tells me about the “right” to healthcare, I ask, “From whom? From me?” This question exposes this “right” for the robbery and slavery that it is. Take it to the next step. Do you really want to exercise your “right” to healthcare on a physician who doesn’t want any part of this bargain? What kind of care do you think you’ll receive?
Years ago, I stopped doing cardiac anesthesia, because well over half of the patients were “covered” by Medicare and payment to me for my services was well below what I thought acceptable ($285 for my last 6-hour cardiac anesthetic). Soon thereafter I stopped my dealings with Medicare (and Medicaid) altogether as I increasingly saw myself as the recipient of money taken from my neighbors against their will. As an aside, the angriest patients I’ve ever encountered were the Medicare patients I subsequently treated with no charge whatsoever. My providing charitable care elicited patient rage like none I’ve encountered since.
About two weeks after I quit, an angry cardiac surgeon, inconvenienced by my departure from the group of available cardiac anesthesiologists and with his finger in my face, told me that he was going to see to it that I was forced to do these anesthetics, so as not to disrupt his schedule. I guess he thought he had a “right” to my services.
It didn’t help things that I laughed. I said, “Dr. X, I’ll be happy to visit with the family before their loved one’s elective surgery and inform them that I want no part of this and that I don’t really want to be here, but someone is making me do this. Maybe you all would like to wait for an anesthesiologist who wants to be part of this, because I certainly don’t.”
This cardiac surgeon suddenly understood. Now imagine this on a large scale. Angry mobs of folks waving their ObamaCare “insurance” cards in the street demanding their free healthcare outside a closed and vacant doctor’s office.
That is what Obamacare is: an insurance card. Come 2014, you’ll have to certify to the IRS that you have such a card, one that is acceptable to the government. Or else you’ll have to pay the government for the “choice” to not have insurance: a minimum of $95 at first, climbing to $695 in a few years.
So keep that ObamaCare card handy. Either you or the taxpayers will have paid maybe $15,000 a year for it. Or it is very likely to be a Medicaid card. You’ll need the card when you call the healthcare provider. If you make it through the phone menu, your insurance number will likely be the first question you will be asked. This will tell what type of care you are eligible to receive and from whom, and how much the provider will be paid.
It is likely that the provider will not be a physician. The physician you might eventually see will not be working for you. He’ll be working for an ObamaCare Accountable Care Organization, which is paid for not providing care.
If too many doctors quit, the government might try to make them work. But will your doctor still care if you point a gun at him? The fear of having to see such a doctor may be the great new incentive for “wellness.”
I never agreed with those who seem to imply that physicians and those in the medical field should basically work for FREE, YET expect them to pay an arm and a leg if things go wrong in the operating room. The medical field should work exactly like any other industry. Staff should be compensated and in the meantime, treatment costs should be transparent so patients can make informed decisions. I feel the way that things are going, the average person doesn't really understand costs let alone if they really need to receive certain treatments such as (ultrasounds, blood tests, urine tests, etc.). We undergo those things because our physicians recommends them but doesn't necessarily mean we need it done. Not only that but it would be nice if we could get those kind of things done at other places for a cheaper rate. I'm glad that I've had some very honest physicians. One made a recommendation for me to have a test done but after finding out the cost, I declined. He also said that it wasn't detrimental to my health if I didn't have it done. I can only imagine some other physician saying otherwise. I think because people don't really know the cost of treatment, some doctors just go ahead with services that may be unnecessary. As a mother of five, it became very costly for prenatal visits. I found many of the visits completely unnecessary and costly. When I was expecting my first baby I was really naive but thankfully at that time my health insurance was great. I didn't play anything for labor, only a$10 co-pay for prenatal visits. After my 3rd baby, we were under a different insurance and things had changed. We were paying for just about everything! By the time the 4th and 5th babies came along, I was a pro and cut down prenatal visits.
Ok, I commented on this years ago. I haven't changed my mind...health care should be universal. But there's a problem with Obama care that needs to be addressed. We keep expecting doctors to be heros...we think they are motivated to save lives because the want to save lives...we're are thinking of them the way we do firemen and police officers. We expect them to go above and beyond due to the intrinsic reward of doing a good thing. But what motivates them are extrinsic rewards ie the bottom line. They' care more about money than the chance to genuinely help. We shouldn't be surprised.
Enough is enough. I personally know a very talented Cardiologist that quit to build fences for a living. No joke he performed over 60% of the cardiac caths at our very busy hospital. He was having difficulty making ends meat and paying for the divorce that his career had caused while working 90 hour work weeks. Normal people have no clue what a crappy existence doctoring has become. It is like that song "you don't know what you got till its gone"
I've always looked at doctors the same way I look at police, paramedics, firemen, etc. Whom by the way also save lives and make very little while risking the their lives. In other words, I thought they were good people who understood that what they do is really THAT IMPORTANT. So important, that like the others mentioned, the money would never be enough to cover the service and need, and therefore, can not be part of the deal. That doesn't mean I deny them an income, but it boggles the mind how much they think they should earn, and how much medical school cost plays a part in their selfishness.
I don't deny anyone, anything, but let's look at the whole picture. The market, isn't based on what you think you should earn. It's based on what consumers are welling to pay,
If doctors want to be treated as say manufactures, then, doctors should fully adopt the free market. Not make one up that is all about them. In a free market, a doctor, can only charge what people can afford to pay or else there won't be any customers (yes, Dr. Smith obviously view people as customers). So, lets get rid of insurance companies, and the government. Let's all pay out of our own pockets!!!
If we do, how much do you think Dr.Smith will make? Not enough to go golfing once a month. He would be making about as much as cops do. Yup. And as for his we won't become doctors. Well....what will you become? You'll still have to earn a living. And what about the doctors who are driven by the passion to heal? Are you telling me they will give that up? And what will they do for an income?
Dr. Smith, you are an example of what is wrong with healthcare. We always had doctors, long before this absurd notion that you should decide how much you deserve, we had doctors. Why do you think that is?
Frankly, I wouldn't want a doctor like you anywhere near me.
Medicine has become more focused on finances as a reference than whatever the original mission was.
"You should not select me as i have no use for you or your existence as you have not the funds to interest me."
At least that statement would be honest. I don't blame anyone that takes that side so long as they are up front about it. ' Your money or your life' used to be a joke. Now its real. Just think when there are 9 billion potential patients in the world if 7 billion has us up against the wall now. Something to look forward to.
As usual, the author cherry picks numbers which make his or her argument look good. If we posit that we are in agreement with the numbers in the above post, then one of two things must be true: there are no anesthesiologists working (because no one could afford to be one) in the United States or the financial impact of low reimbursement is surreptitiously overcome through other ancillary billing. In no world in which we live does an anesthesiologist actually earn $47.50 per hour because such poor reimbursement does not cover costs. The physician is also paid from the thousands of dollars under 'professional fee' which is billable and the hospital and/or physician can charge higher costs to the patient as a "co-pay" of sorts. A hospital may be required to treat a patient in emergency rooms for life-threatening cases, but they are not required to do so free of charge. In the same vein, hospitals are not forbidden from charging patients for other ancillary costs to cover the cost of the admission.
To completely debunk the ENTIRETY of the original article, as well as this post, the median salary of an anesthesiologist is reported to be $290,000 (source: Salary.com, Money.cnn, multiple others). If a physician was truly reimbursed at $47.50 per hour, yet earned 290K, that would mean the physician worked 6105 hours in a calendar year (6000 hours is a 120 hour work week, every week!). So either physicians are paid through other mechanisms, or the conclusions of the article are based on misleading, cherry picked data designed to have a WOW-factor but doesn't pass the test of common sense. That's because there is a BIG difference between reimbursement rate and hourly wage.
Here's the numbers for a pharmacist: 1. 4 years of college
2. 4 years of graduate school @ 50k per year, also out-of-pocket
3. 1-2 years of optional residency (but increasingly popular) with 80 hour weeks and a pay rate of $9/hr, many of whom then go on for further fellowships, specialty certification (e.g. BCPS)
4. 250000 of debt after pharmacy school
Independent Pharmacy Expenses:
1. 8K in monthly rent
2. 200K in perpetual inventory
3. 100-500K franchise fee
4. 100K in computers, data storage, EHR, IT support, equipment, auditing, etc.
5. Salaries of several employees
The Deficit Reduction Act of 2005 (DRA) reduced the maximum amount of federal money that states would receive for generic drugs dispensed under the Medicaid program by lowering reimbursement amount to 250% of the lowest average manufacturer price (AMP) value of a generic. Studies by the General Accounting Office show that this reimbursement figure is between 17-36% lower than the true acquisition price of medications. This means that without even considering overhead, salaries, or any other costs, the reimbursement from government for Medicaid prescriptions is less than the cost of the medication representing a guaranteed loss for the pharmacy for every one of those Medicaid prescriptions. Worse still is the fact that while doctors are free to choose which patients to accept in their practices and can thus avoid accepting new patients which erode their profitability, in most if not all states, pharmacies are not permitted to discriminate based on insurance reimbursement - we must serve our patients regardless of how much money we lose on their prescriptions.
Even worse still is that in some states, such as the state of Maryland in which I practice pharmacy, the $1 co-pay required to be collected from the Medicaid patients for most of their medications is legally waived if the patient states he or she lacks the funds. The pharmacist is not permitted by law to deny the medication to the patient and must dispense.
Medicare is only somewhat better. While pharmacies lose money on nearly every Medicaid prescription, they only lose money on some medicare prescriptions. Without mentioning specifics, my pharmacy has seen prescription growth or nearly 10% over the past year but the margins and net profit have fallen by 3% due to lower reimbursement rates and an influx of more patients from Medicaid. And unlike doctors, I am not permitted to turn them away - by law.
And the cherry on top of the sundae which is our woe, some physicians have found it lucrative to dispense select medications from their office which skirts many laws and openly violates others - this excludes the normal practice of dispensing samples or starter doses which by law in many states is limited to 72 hours of therapy. Physicians who dispense are legally required to follow all the laws and regulations which govern the practice of pharmacy including procuring a dispensing permit and I know of exactly zero physicians who follow those regulations. Appeals to the board of medicine for pharmacy oversight over physician dispensing only are met with ridicule and derision - as if a doctor of pharmacy would know anything about the safe dispensing of medication! If the laws which govern dispensing of medication were indeed erected in the interest of public safety, what then could be the origin of physician opposition towards maintaining public safety? So not only are physicians breaking laws, threatening patient safety, they are doing so to make a quick buck while pushing off costly, low-margin prescriptions to pharmacies while keeping the high-margin, low-cost prescriptions for themselves.
So while the doctor has means for making up the costs of poor government reimbursement by charging other expenses to the patient - I am forbidden from doing the same meaning I am LEGALLY required to lose money while the doctor does just fine. And while I have comparable loans, the cost of running the business is comparable, my salary is 60% that of a family physician, and a mere 38% of the anesthesiologist making it several orders of magnitude more difficult to manage the finances.
Obviously, my initial argument applies to myself as well - the sheer existence of pharmacies, even in locations with high-density indigent, Medicaid paying patients, indicates that we are not losing money on everything - or else we would be out of business. We are fortunate that we have over 50% of Americans with private health insurance plans which offer higher reimbursement rates which make up for the deficit incurred by Medicare and Medicaid patients. We are profitable thanks to other revenue streams as a result of dispensing medications to patients with non-government assistance insurance.
I do find it funny that doctors and bankers (insert wealthy overpaid job here) complain about all this but still expect police, army, firefighters (insert underpaid service profession here) to support and provide a service to them through taxes but it doesn't work both ways. I'm always so happy to be British and living in England especially after living for 2 years in the states. I especially enjoyed paying over $100 for oral suspension fluid for my young one when she was ill, the same solution I can buy in generic form off the shelf in the UK for about $8. I think the problem is where the government is paying a private medical system rather than it being government health care with a separate private healthcare. Our doctors still live a very good lifestyle but probably alot more modest than the gentleman who wrote this article. Maybe we should privatise the police etc and they can charge him similar fees to protect him from these 'mobs' waiving insurance cards at him. Firefighters can check his credit before putting out the fire in his house (which was how I felt using the US health care). The military may then get a decent wage before offering their lives up to defend him both at home and on foreign soil. I find this guy a joke.
You pay a lot because you want a lot and generally you get a lot!
You have tthe biggest expenses because you have the best medicine (the best healthcare system does not exist!).
The author is completely right!!! Do belive him!!!
If you don't, make a visit to Romania to see what happens in our health system, still too comunist, even after 22 years of post-comunism! After that, be sure you will belive!
To those saying doctors are poor, there is something rotten in Denmark... and its a lot of your mathSo I ran the raw figures through an extensive excel spreadsheet designed to calculate net worth after figuring in median salaries (salary.com), average student loan debt with payments made on the standard 10 year plan (average of various web sources), taxes paid incorporating student loan interest deduction (tax estimator: H&R block), malpractice insurance. I did not incorporate inflation or changes to law/reimbursement rates as those can go up or down with time. I also used the average number of years of residency as well as data on earnings during residency with the assumption that no payments are made on student loans during residency with deferred interest accruing and capitalizing on the loan until the completion of residency. I also assuming that there was a zero dollar differential opportunity cost as all my projections start with an identical 22 year old graduate with a 4 year degree in a science field with no work experience and direct entry into his or her professional school in the healthcare disciplines and a work-life duration until the social security determined age of retirement of 68. Comparing dentistry, medicine, and pharmacy, the worst off financially is the clinical pharmacist with an average net lifetime earnings of $2.67 million. A primary care physician, by comparison, despite their additional years of schooling and higher loan payments after deferral earns approximately average net lifetime earnings of $4.73 million. Lifetime earnings for dentists was difficult to calculate given the annual income range is widely variable by over $100K in different parts of the country. With an averaging function, I figured dentists earnings per lifetime was $3.2 million.I compared my numbers to a study done at Georgetown (http://www9.georgetown.edu/grad/gppi/hpi/cew/pdfs/collegepayoff-complete.pdf). They did not incorporate loan payments,malpractice, or income tax and after subtracting those from my calculations, I arrived at numbers which were +/- 200K of theirs. Considering it took me 30 minutes to put together my raw calculations, I consider that to be valid and confirmed.So doctors, don't try and sell me on your hokey math. You are not "poor". You may be in school longer and have higher student loan debt, but your ability to pay that debt is unparalleled because your average salaries are far in excess of those of the other health professions. Everything you say about the difficulty in managing student loan debt may be true, but that makes it even more challenging for persons of other health professions who accrue similar levels of debt as physicians (on the order of 200-300K). So if you say you are struggling, others are living in a cardboard box.The hey day of all of our professions earning substantially higher incomes is gone. But this is the life we *CHOSE* to lead. No one held a gun to our heads and made us do what we do. We chose this life knowing that we would never be as wealthy as the physicians, pharmacists or dentists of yesterday. We just need to accept that reality and identify a path forward. That path forward means we need a system of reimbursement which rewards the professionals for creating the best health outcomes. This does one very important thing: redistributes income from poorly performing members of our professions (and we all know who they are!) and gives it to the high performers. Its no different than being in finance, construction, or concert piano. If you are the best at what you do, you should be paid accordingly.
Wow... so much comment and so much passion. US does not have to fix anything if it does not want to... but look at the facts OECD, WORLD BANK or wherever you want to get the stats... You pay more for your healthcare than anywhere else in the world! Unfortunately your outcomes are arguably average at best (when compared to similar economies). There is a problem, how you solve it, if you solve it , is up to you but think on this if you create an inequitous system it has a far greater impact on your overall economy than you think.... healthy people work harder and are happier... happier people work harder and spend more... Good luck with the posturing Dr Smith.
As a physician, I have $226,000 in debt at 6.8% from the government. That's nearly $2,000 a month over two decades for a total of $414K. Malpractice insurance in the state of NY runs about $97,000 a year, because tort reform is utterly inadequate. For those of you doing the math, that's almost $150K a year that goes down the tubes. For someone who goes through training until the age of 35, the math doesn't add up.
Most of you don't care about those numbers. You should. Because the reality is that any physician that has a choice will no longer serve the lowest reimbursing patient classes (i.e.: medicare and medicaid). Hospitals in inner cities that serve these populations will also close, and new hospitals will be built in more affluent areas. Just because you have Obamacare/medicare/medicaid does not mean that you will have access to healthcare, because there will be a shortage of providers who can afford to take care of you. Possibly younger providers without medical school debt and less training will be able to. For myself, I'll be manning an emergency department near you, where I will likely see all of the Obamacare/medicare/medicaid patients, because they'll have nowhere else to go.
Until the hospital closes my emergency department and moves it somewhere else.
I am a Canadian doc, practising in Canada. While we certainly have our gripes, I think that things are a bit easier here as well. There is ONE insurance provider here - the government. The medical association's negotiate the fee schedules with the government. Healthcare in Canada is considered a right, not a privilege. That being said, there is no doubt that a doctor in Canada is not going to starve to death. I also have the luxury of treating patients without wondering what insurance they have and if it will cover what ever health care they need.
We also have a lovely thing here called CMPA - Canadian Medical Protective Association - our malpractice insurance. Firstly, the courts in Canada do NOT tend to award huge malpractice settlements. Second, CMPA knows that the only thing a doctor has worth much value is their reputation. If we get sued, we call CMPA. They give us some advice, and get their medical experts to review the case (This is my understanding - haven't been sued - yet) If their experts determine that there was malpractice, they settle, immediately. If their experts determine that appropriate care was given, they will not settle. Period.And the law firms that represent CMPA are some of the best there are. Other lawyers think 2 or 3 times before taking a malpractice suit against a doctor.
So, in short, it is possible to make a living, a good living, practising as a doc in a climate of "government controlled" health care coverage. It all depends on how it is done.
If you think healthcare is over-priced then stop using it.Or as a Polish citizen/resident how they like their "free" healthcare (and super high taxes) in which they are "treated" in a half-assed manner. There is no RIGHT to healthcare by a physician. There, however, is the right to manage your lifestyle (eat right, exercise, don't smoke).
If you're bitter about a physician expecting to be paid a certain amount then please lead by example. Tell your employer that you'll go ahead and work for half of what you make now. The catch?? You don't get to complain that you have thousands of dollars in student loans or that you spent countless, sleepless hours studying to pass your college exams, or that you sacrificed family holidays because you were on call during residency or your fellowship. No, you don't get to complain that even on your off hours when you're not making any money (like at your kid's football game) that people seek your expertise and you don't get annoyed or tell them that it's intrusive to bother you on your personal time.
Since you're leading us by example, please don't complain when you go further and further into debt because you can't afford your licensure as required by the state and federal governments, you can't attract clientele because your practice is no longer in the green and can't afford the latest technology, and you're essentially living a martyr lifestyle. And thanks for doing that with a hearty smile!
I am a doctor in Taiwan, and after decade of health insurance policy, the situation of all healthcare stuff (doctors and nurses) are no better than hell. And the specialties in Internal medicine、Surgery、OBS/GYN、Pediatrics stop practicing increasingly, because of low pay and high risk of lawsuits. I can say, this will be the situation in US years later.
There is obviously no forethought in the political solutions to the problems faced in healthcare. First: the government is the problem. They allow themselves to regulate more than the cost of per patient care but also inducted severe penalties for unfunded mandates and restrictions to practice medicine (EMR, fines for time limits and usage of testing). Two: Government allows insurance companies to gouge their clients on policy costs yearly and restrict treatment options without logical or medical evidence as well. Three: the pharmaceutical companies have been allowed to gouge the cost of medications to extraordinary heights and pharmacies to increase their profits at the patient's expense. Four: the Medicare and Medicaid cuts and the low ball prices of the exchanges will lead to a marked reduction of payment rates by private insurance companies - all of these are essentially non-negotiable, it's an all in or all out proposition in which if chosen to be out, it is a cash only or concierge practice. Five: the false premise of bringing in as many foreign physicians, nurses and other para-medical individuals to fill the gap is just plain stupid - they come here to earn a better income and that is not achievable for very long on the current planned pay schedules. Six: healthcare is not a right - it is like buying any other thing (car, house) those with the money get the Rolls or Ferrari, the rest will have to do with "the peoples car", the more you spend of your own money the better you take care of t.hat car or house. The people's car individuals won't even change the oil or a flat tire. Best of luck finding a physician in the near future, yo will have to do with lesser experienced caretakers, many shortcuts fraught with misdiagnosis and less than optimal treatments dictated by some non-entity ill-educated government highschool GED' ed employtee - yes all of those medical treatment decisions will be determined by a central committee on real time phone calls at the time of visit per Obummercare decree. We should all start moving to Colorado, I never did any off that while growing up because I was too busy studying to become something much more important,what a big dummy, huh?
Most of the uninformed and hostiles responses to Dr. Smith can be summed up Milton Friedman's principles.
The people who derive their benefit when the cost is born by some one else they feel entitled and spend/utilize more leading to the spiraling costs.
"There are four ways in which you can spend money.
You can spend your own money on yourself. When you do that, why then you really watch out what you’re doing, and you try to get the most for your money.
Then you can spend your own money on somebody else. For example, I buy a birthday present for someone. Well, then I’m not so careful about the content of the present, but I’m very careful about the cost.
Then, I can spend somebody else’s money on myself. And if I spend somebody else’s money on myself, then I’m sure going to have a good lunch!
Finally, I can spend somebody else’s money on somebody else. And if I spend somebody else’s money on somebody else, I’m not concerned about how much it is, and I’m not concerned about what I get. And that’s government."
The entitlement mindset reflects the mismatch between who ( service/behavior ) is costing and who the (service/behavior ) is benefiting.
If benefits and costs are not both shared to some degree, we will have potentially troublesome motives!~outcomes
If it is my resource( Time, Effort, Money, property ) I am more likely to protect it. If it is some one else's resource, I am less likely to protect( value) it
Ownership of the Cost and Benefit ~ Powerful Motive.
If doctors want to become millionaires no one will enter the field anymore and will find ways to get out of the field. It's the compassion and satisfaction is what motivates.
Hourly wage of many physicians are less than Plumbers & over priced IT workers.
Can a physicians provide major health care services without a hospital? If the doctor depends on services provided by a hospital, then he/she should care a great deal about the price the hospital charges, because it ultimately affects his/her business. In other words, if the patient can't afford the hospital bill, it does not matter what the doctor's bill is.
Dr. Smith, I agree with most of what you had to say. But I have another concern. You said that if too many doctors quit, the government might try to make then work. One of your respondants said that many doctors will be replaced by less expensive persons such as MA's and nurses. In other industries American workers have been replaced by workers in other countries for a myriad of reasons. For at least 30 years foreign doctors have come to the U.S., gotten American training and worked here, replacing or supplementing the American workforce. What I think will happen as the demand increases and the pressure to reduce costs also increases is that the number of physician extenders (PA's, NP's, MA's, RN's, LPN's, CRNA's, and AA's) will greatly increase. We already see that happening. But here's where I make another even bolder prediction. I believe that many physician responsibilities (e.g. radiology, pathology, anesthesiology) will be performed by physicians electronically beyond our borders. In addition to that I believe we will see a large number of physicians and physician extenders from other countries allowed to practice medicine in this country with little or no American training. In other words the American residency requirement will be waived or terminated. What effects these changes will have on quality, cost, or litigation I am less certain. These changes might also occur so slowly that we won't feel the pain of their impact nor be fully able to recall "the way it used to be". I also believe the inevitability of these changes go way beyond the ability of either political party to avoid them.
Bottom line, no doctors no healthcare. You cannot force anyone to spend 12 years minimum training in premed, med school then residency, if he can make the grades and endure the schedule, to be competent to practice medicine. There are huge disincentives to go to medical school now. I have practiced medicine for 22 years and I love my patients and do not regret my decision to be a doctor. You do not get rich being a doctor ( should have been a college football coach or a movie star). Although my son has the intelligence, the temperament and the work ethic to be an excellent physician, I am not encouraging him to choose medicine in this litigious and political climate that treats physicians with disdain. So easy to criticize when you have not walked in the shoes of an exhausted intern. Most physicians I know now do not want their children to choose medicine now. Just the facts. Think about it before you get sick and need the expertise only an experienced physician provides.
Nobody is forcing you guys to become a physician but if you are not willing to carry out the job with dedication, get out of it. Society pays for your schooling too and most physicians do not earn badly in comparison to the average income in this country. When you are not willing to put in the hours and the dedication do something else. Medicine is more than a job and requires more than just the look at the bankbook. The problem are the for profit insurance companies that can in the case of Harvard Pilgrim pay more than 2 Million to an CEO. We do not need private healthcare companies, we need universal healthcare with a single payor system. Make the physician employed by the hospitals and work for a salary and if they are showing an attitude like the author, fire them.
@Fireinside That is an interesting generalization. Would you care to elaborate on your comparison of physicians, firemen and police officers? I do not think it is fair to compare these 3 professions. There are both altruistic and realistic components to why people choose each profession. However, to compare the pressures, time in training, cost of training, etc is simply not fair. But since you brought it up I would like to hear your more detailed explanation.
@Denise I am sure you have no problem paying actors and athletes 10's of millions of dollars though right?! SMH. The people of this country deserve the healthcare "they are willing to pay for". No more, and no less. Good luck with that......
To clarify a few of your misconceptions:
1. Doctors cannot change “co-pays” (or charge additional “professional fees“ to patients), as a patient’s co-pay is determined by his/her insurance plan. Doctors can be sanctioned under the Medicare False Claims act for filing false or inflated charges. Also this is considered a “breach of contract” in the eyes of the insurance company, who will then as a result no longer contract with that doctor.
2. A hospital is required to treat patients in the ER free of charge, if the case may be (all patients must be treated in the ER, regardless of the patient’s ability to pay, failure to do so would violate federal laws such as EMTALA).
3. Medical school are more competitive to get in to, in general as compared to pharmacy schools. Also the optional pharmacy residency is on average 3 years less than the average medical residency. Training is also more rigorous in general.
4. Pharmacists generally would not need to worry about paying the Independent Pharmacy Expenses mentioned in your post, unless they own the pharmacy. Similarly, doctors who own a practice would have to have sufficient reimbursement from insurance companies in order to pay their office overhead, whereas staff physicians would not (and so would have a lower salary or hourly wage, as they didn‘t have expenses).
5. It is true that doctors can decide not to accept Medicare and Medicaid patients. However in many areas this would eliminate 60-90% of all patients in the area, and so the doctor would have no patients (so many doctors don’t have the luxury to deny seeing patients with Medicare).
6. I cannot personally think of any doctors who push “costly, low-margin prescriptions to pharmacies while keeping the high-margin, low-cost prescriptions for themselves.” What evidence do you have to support this accusation? How many physicians are consistently breaking dispensing laws, and are they the rule or the exception? Please give data and statistics to support your statements.
7. I will again reiterate that your recap is incorrect in that private doctors have no means of making up the costs of poor government reimbursement by charging other expenses to patients. That is why many private doctors are closing up shop because Medicare/Medicaid reimbursement rates have been decreased to the point where it’s not enough to meet expenses. Also, you can only compare a private, independent pharmacy to a private doctor’s office, as chain pharmacies (e.g. Walgreens, CVS, Walmart, etc.) enjoy economies of scale.
8. There is not much point in comparing salaries or hourly rates, as that would be like having a pissing contest. I could complain about plumbers who charge $95/h. Or that my father, who is remodeling his home in San Francisco, is being charged $150/h by his interior designer.
@Healthcarerealist the arguement from you and from the article are both filled with some facts that are not debatable. Are doctors poor? No. Are pharmacists poor? No. Are ALL healthcare providers going to suffer significant pay cuts in the very near future? Absolutely. The arguements by you and the author are all relative to prior experiences. (And I am absolutely certain that all of the doctors in your state are NOT dispensing highly reimbursement medications and leaving you the low- margin medications to dispense. Let's "dispense" with the hyperbole, shall we?). Since when is competition a bad thing? And if there are doctors not following the law, report it to the authorities and quit whining. (Don't worry! The government is here to save everyone!) The issue at hand is that there is only so many dollars to go around and there will be no more spending like drunken sailors (no offense to the Navy). All will take cuts. Some practitioners will stay and some will go (me being one, if I can). Am I poor? NO. Am I underpaid for what I do (emergency medicine)? Depends who you ask. I am overpaid if you never need my services and your life does not depend on my healthcare team (including our ED pharmacist, who we LOVE having as part of our team). If you are dying and we save your life or your loved one's life, maybe we're not so underpaid. We can all cry poor and we can all have legitimate complaints about our lot in life. We all picked it. We are all paid pretty well for what we do. (I have yet to meet someone who thinks that they are overpaid for what they do, though I have seen a lot of people complain that others are overpaid for their job).
The joke is that people come from the UK to the US to get procedures done to save their lives rather than see if they can outlive the waiting list there.
@Healthcarerealist Using your figures....
A new college grad making $50k a year (with just undergrad loans) would bring in $2.2M over their 44 year work life...and a 'high demand' degree such as Petroleum Engineering ($98k starting) would bring in $4.3M. No, Doctors aren't in general 'poor', but they certainly don't make as much as a lot of people believe (especially factoring in student loans and the stresses of their jobs).
@mbtb Not really sure that would work in the states. Patients are looking to be rewarded millions of dollars and not settle for anything short of that. American mentality is very different from Canadians, I'm sure. For one thing, I doubt our government can support health insurance for all it's citizens and residents since we have so many other social programs to fund. There are way too many Americans who feel entitled to things for free and will use the "equality" card to get what they want at the expense of others.
@mandie21184 Complaining about all the hard work you put into becoming a doctor...not my issue you chose the profession. Perhaps if money is what you were really seeking you should have chosen a different profession...you know something like hedge fund analyst.
@mandie21184 I am sorry but your comment really doesnt make much sense. If you think healthcare is over priced then stop using it?? We hmmm then I would go to prison if one of my children die or I could die and then where does that leave my children? A change in lifestyle isnt going to stop all the things that kill you. Health care is not an option sometimes and some reform should be done yes but more so in the underlying costs. Doctors should be paid well we trust them with our lives and our loved ones lives. I would much rather pay a little more to know I have a qualified doctor over one that has the lowest level of training.
Interesting points, Pete(x3). One thing you can guarantee: If Obama brings in help from foreign countries to prop up his floundering healthcare system, he would exempt THEM from lawsuits. After all, they're just trying to help.
You didn't build that organic chemistry course pass society did...mkay got it...so clearly now.... it all makes sense. Only 252k last year as defense counsel, 70hr weeks and travel keeping doctors and other producers alive....I expect to hit 2000k in the next ten years as I bulid book. We are not average. What will you do when we and our bright children start taking civil service jobs at at 85k to 120k for a year for 30hrs. a week after breaks away from the average people who currently occupy those slots? Believe me, we will, because we aren't busting our humps for charity or working with gun to our heads, that's for sure.
@jkriegel8 While your altruistic notion of physicians solely being in it for "the greater good" is sweet, you are liberalizing the point. I am not a physician - I am a Registered Nurse. Physicians and healthcare employees are working at maximum capacity already. Our physicians deserve our respect for their value and ability. They earn what they are paid. By giving away healthcare like at a firesale, we will see the erosion of ability as our standards are forced to be lowered to accomodate the ballooning need. The system will become so clogged and strained to the point that it will resemble today's factories - people will eventually confuse volume for value. And I do agree with some that the only people profitting from the whole mess will be politicians, insurance companies (Wall Street) and lawyers. Bottom line: The government should not be FORCING the free people of the United States of America to buy something. Altruism, however noble, should NOT be forced upon us! Free people should have the ability to be charitable not the OBLIGATION to do so to help politicians pay for their votes. Doen't it anger you that the politicians do not have to submit to the same healthcare system they are imposing in the rest of us?!
@jkriegel8 When somebody works for a salary as opposed to a fee for each patient they see, the trend will be far less patients being seen. If the practice/physician is going to earn the same amount of money, regardless of the income they pull in, they will do less. It's human nature. Now, since you want salary and you understand human nature, I'm sure you won't mind having to wait 6 months for a specialist instead of the normal 2-4 months right now.
And good luck firing your staff since there won't be a high replacement availability. With a physician shortage already in this country (i.e. PCPs) it will be difficult to find competent physicians who want to work in this already bureaucratic field.
@jkriegel8 There is no excuse for being ill informed. Physicians choose the profession for a sense of challenge and demonstrate great dedication to the education, training and performance of medical practice - much more than any other profession. Society does not in any way pay for the majority of physicians to become educated, unlike the President Obama and his wife who did it all on public money. Talk about letting more foreigners into federal government. Any way, as with any human, there is a strong desire to be amply compensated for your above average talent and efforts (long hours, greatest risks of any business, past debts, etc). There is a very common misconception that physicians are of average, regular people - with an average intelligence and the low typical ambition of the rest of society. Well, they are not. They represent the top 2% of intellectuals, and mostly are the type A personality that drives them to accelerate to the top- which is also the reason patients despise the "bed side" manners of these type people, they cannot be that gummy personality of the public demand (not even asking anymore). For what has been paid over the past twenty years, the public has gotten more than they deserve for their dollar and when the dollars begin to decline, expect less for your currency (called devaluation) and lots of less time spent hearing the whinning.
@jkriegel8 "Make the physician an employed.....fire them....." Wow. Is there anyone else reading this crap think that mandating a physician to practice insurance medicine, take away independent and critical thinking and place it in the hands of insurance driven treatment protocols and factory-like patient care is the way to go then you are asking for a more diseased driven care system that rewards minimal thought process. Is that the care you are asking for? Would love to hear your answer. Think through what you said: In one sentence you stated logically that Medicine is more than just a job.....then in the last sentence you said...give all thedoctors a job.... As a physician I do not have a job, I have a simple calling and responsibility of improving an individual's health AND the overall society's health. You want to employ me and fire me if my attitude is not to your liking? Who judges that? An attorney? An insurance administrator? I certainly get calls from each of them telling me I do not practice medicine to their liking on a weekly basis. Well, the current trends in this country are doing just that: Firing me, the primary care physician.
@jkriegel8 Your ideas are basically communistic. If u want to take away all the incentives and let the government run everything go to a communist country and see how u will like their healthcare system.
@jkriegel8 Get used to lower quality care and less access to it.
@jkriegel8 No one has to do anything they do not want to do. If you did not read the article completely then you missed that he quit thus being his option to opt out of the field. Also society does not always pay for someone schooling. There are many people that pay for it themselves so don't assume that is the case for everyone. If you pay doctors a salary fine but they will take that salary on their terms or work somewhere else. Also when the incoming revenue is not as high as the cost of running a hospital due to the gov. decreasing what it will pay then you have no hospital or clinic. Everyone wants something for free but doesn't understand that someone somewhere is paying for it and when that person paying for it can't anymore you end up with a whole lot of nothing.
There are some legislative falsehoods in your reply... and some misconceptions about my reply. My point was not to compare pharmacy to medicine... but to demonstrate that using valid statistics assembled in a specified sequence can “prove” any point desired. Its basic math - no physician works an annually billable 6150 hour schedule thus the outrage over 47.50/hr is misplaced. There is a difference between billable service reimbursement and SALARY. The average salary is considerably higher than the federal reimbursement rate proving doctors must be receiving remuneration via alternate revenue streams. It is for that reason why I specifically stated that the existence of pharmacies in indigent neighborhoods demonstrates we can be profitable despite losing money on many if not most patients. Anyone can cherry pick statistics to 'prove a point'.
1) I put "co-pay" in quotes because there are charges which can be submitted to insurance companies which are non-reimburseable which then become a charge to the patient - a defacto “co-pay”. If the patient doesn't pay, the medical practice can boot the patient from the practice - this is different from pharmacy where we are required to take a financial loss and keep taking it. I cannot kick patients out of my pharmacy and tell them to find another pharmacist. Nothing in US federal or state law requires a physician to continue seeing patients regardless of unwillingness or inability to pay their bills.
2) You are incorrect about EMTALA which applies to hospitals - not doctors. It states that a patient must be given appropriate care regardless of ability to pay until the patient is stabilized or walks away AMA on their own cognizance. But it NEVER states that services must be provided at no cost. It also has provisions where hospitals may sue patients to recover payment for services provided.
3) We cannot compare difficulty of our professions. W made a conscious choice when we entered our professions. What about the man who picks up trash or the man who works in sewers? Labor laws state exempt employees aren’t entitled to a lunch break, but there is a difference between being entitled and being forbidden. The law states that pharmacists must be on duty to serve patients during posted pharmacy hours. If the pharmacy posts a closure at lunchtime (as many large retail stores do such as Walmart, Costco, Sam's Club, Target, etc), the pharmacist may take that break. If not, as in the case of CVS, Walgreens, Rite Aid, and most if not all independents, I must be available to serve patients – sometimes for 17 continuous hours. But again, these aren't things that are heaped on me at the last minute - I CHOSE to enter pharmacy. No forced me and no one is keeping me here. We all have different challenges in our professions and they are not comparable. Most if not all doctors do work hard to get where they are and to stay where they are. No one says a physician's job isn't stressful - but it is a stress and workload the physician chose to accept as part of their profession.
4) To the same degree, staff physicians need not care about the overhead of staff, rent, etc. 40-50% of prescriptions are processed by independent pharmacies. Contrary to common perception, it is not a small segment of the market.
5) There remains a fundamental difference in what is legislated because regulations drive everything (isnt that the point of the OP/article?). Physicians can make a choice about accepting/rejecting low-reimbursement patients. Hospitals cannot choose patients and cannot deny treatment, but can still charge a patient for services. Pharmacies cannot choose who they see, must give medication, and co-pays must be waived if requested. We are legislated into losing money. That is a fundamental legislative difference – physicians have a choice and pharmacies do not.
6) Many physicians dispense. In workman's comp cases (one of the first big studies on physician dispensing - http://www.flchamber.com/wp-content/uploads/Physician-Dispensing-in-WC_WCRI-7-12.pdf), some states had over 30, 40 and even 50% of prescriptions in workman's comp cases being dispensed by physicians. Average markup ranges from 60-300% greater than the pharmacy costs which have reimbursement rates pegged to AWP whereas physicians can create their own "AWP" because physicians purchase from repackagers for physician office sales which then creates a new, higher AWP with larger margins. Its also just common sense - for a physician who dispenses, s/he will not keep in stock expensive medications used with more rarity because the more expensive the medication (brand), the lower the margins. It is also known that the profitability changes what medications are prescribed (questionable ethic!). In states where physician dispensing is rare, H2RAs and PPIs are rarely prescribed in WC cases (<2%). In states where physician dispensing is common, H2RAs and PPIs make 8-11% of prescriptions in WC cases. In those states, pharmacies sell OTC H2RAs for about 70 cents per tablet but physicians are reimbursed between 3-7 dollars for the same tablet. Don't try and convince me that there is more GERD in those states! 7) Of course chains enjoy economies of scale - that is why my example covered an independent pharmacy only. Independents have overhead and costs just like physician offices. Physicians routinely bill for services which were not provided or overbill for services not needed. CMS estimates $50 billion dollars in fraudulent Medicare billing alone. More billing for the same work - pretty sweet deal! If overbilling was eliminated nationwide, it could cover healthcare for every citizen with some estimates ranging from 300-500 billion. Do all physicians behave unethically? Of course not! But it is not a rarity. 8) Agreed. My point wasn't to compare salaries, but you have to understand how the 97% feel when doctors say they are "poor". When you think of these professional athletes like hockey players making millions of dollars each year and then shutting down an entire season over a few thousand dollars this way or that, how does that make you feel about the players' and owners' greed? The country feels the same about physicians complaining about their pay.
In the American healthcare system, there is no direct relationship between healthcare cost/provider salaries and health outcomes. In the current world of healthcare, we are fundamentally financially advantaged by promoting a state of unhealth among our patients. Doesn't that bother you? It certainly bothers me. Restructuring healthcare to a a system where the primary care physician is a health case manager developing individualized strategies for patient care executed by other members of the healthcare team, especially in regard to chronic disease management, with nominal fees paid for services rendered but substantial financial rewards for preventing illness or disease progression would have a strong positive impact on trimming healthcare costs by preventing costly interventions, redevelop the patient-provider relationship so that we are no longer the healthcare equivalents of McDonalds, and create an overall healthier nation.
@clicky @Healthcarerealist Very well written and explained, except for 1 thing. The 60-90%. Where are you numbers and stats on this? That depends on the area. Small rural areas may have a larger per capita as do some inner cities. However, some of the retirement areas such as Lady Lakes or Clearwater, FL. Have some very well to do individuals who actually opt to pay their physicians cash for a private physician and contract them for a fee of anywhere from $5,000- up for basic care which includes house calls.The docs take on only 300-500 patients. Nice deal. Some doctors are opting to do just that, accept cash only. I do not blame them.Not a bad deal for all concerned.
This means no HCFA"S to fill out no hoops to jump through, no mailings, no waiting for reimbursement at a lower amount than billed.
There are going to be many individuals that will pay the fine imposed by Obama care and pay cash for their Dr.'s visit pure and simple.
Quite frankly I do not blame them.
@Erdrfl @Healthcarerealist Erdfl has hit on the point that the correct relativism here is not whether doctors are overpaid in comparison to bookkeepers but to compare what was legitimately expected as a result from a 'plan' and what is *now* the result. How many people would happily agree to a 50% cut in compensation from that objective that justified their entering their hard-won, life-long career path. And, yes, we are ALL facing that in some form and to various degrees.
I really wish we could stop prosecuting the 1% v 99% battle and recognize the THREE factions here that I call makers, takers and fakers. Makers are those who, with talent, hard work and whatever opportunities they encounter, *produce value* for themselves and society. Takers are those who, for *whatever* reason are net receivers of value. (Note: *Some* have no choice and *cannot* produce value; others *choose* not to produce value, and we don't need to delineate who fits into which group. To say that NO ONE chooses not to create value is absurd.) The real point I want to make is that the fakers are the real culprit. THOSE are the ones who build and work "the system" in which the makers and takers are polarized while they (the fakers) are getting rich off the process and the antagonism. This is EXACTLY like the bookie who gets rich no matter who wins and looses the endless stream of contests of one side against the other. Does ANYONE think the politicians, pundits, activists and operatives that are fulminating the %1 v 99% battle (also know as the "middle class", the "oppressed", "disfranchised", and "union workers") the most are POOR ? They work very hard to make it seem that they are just big-hearted, but they have figured out the means and context in which to ENRICH themselves from it. They aren't delivering value so that people and businesses *want* to give them money; they only create a contrivance and a control mechanism by which people and businesses are FORCED to give them money.
@WillGanz No, the joke is that people believe fairy tales like that.
@Healthcarerealist I should add: Rather than try and factor in taxes, etc...I just multiplied the starting salary of each (Petroleum engineers earn about $150k mid career) by your 'work lifespan' for them.
Well, if you you have ever visited a second (or third) rate doc and received poor care, then you would change your tune. There may be some physicians that go to med school thinking they are going to be a billionaire, but many physicians attend med school for the correct reasons. And they spend a lot of time and money to help you and your loved ones. You should not be so callous about people who try to do the right thing. And no, I am not a doctor.
Beth, I am a blue collar worker and pay for good coverage right now, but in the past couldnt afford coverage and i STILL agree with you. Innovation will also go outthe window..how many will put the time in for no extra pay to come up with new treatments and cures? This will kill the most innovative health care in the world!
Healthcarerealist, you still have a few misconceptions.
To summarize my points:
In your intro, you said: “The average salary is considerably higher than the federal reimbursement rate proving doctors must be receiving remuneration via alternate revenue streams.” This is not proof, just one possible explanation, which may not be correct. The usual explanations for your observation are: doctors have been forced to see more patients and/or work more hours, in response to declining reimbursement rates and rising practice expenses. Physicians decrease time spent with each patient so as to “squeeze in” more patients (4-5 patients/hr instead of 2-3 patients/hr), and/or work more than 40 hours/week (obviously not 6105 annual hours or 120 hours/week, but not uncommonly 50-80 hours/week or 2500-4000 annual hours). This is usually what happens Healthcarerealist, rather than doctors receiving remuneration via alternate revenue streams (be it legally or illegally), as you suggest.
1. If a medical claim is submitted to an insurance company and the claim is denied, it is illegal for the doctor to bill the insured patient directly for the denied claim. A patient’s co-pay for medical services is pre-determined by that person’s insurance. A doctor cannot charge a higher co-pay to that patient for those services covered under that patient’s insurance, and to do so would be an illegal “breach of contract” between the doctor and that patient’s insurance company.
2a. A physician can kick out a patient from his/her medical practice, at the loss of that patient from the doctor‘s practice (but thereby losing that patient and forfeiting any income generated from any future office visits).
b. A pharmacy cannot kick out a patient from the pharmacy (unless they violate pharmacy policies).
c. A hospital cannot kick out a patient in need of emergency medical services (unless they leave AMA, then they‘ve left AMA). I am correct about EMTALA, which applies to hospitals. Doctors who provide emergency medical services at the hospital are bound by EMTALA by extension. “In truth, then, the requirements of EMTALA are imposed on the people who work within and on behalf of the hospital, but the hospital is the entity which must bear the loss if it is found that they have violated the statute.” http://www.emtala.com/faq.htm (see #2, paragraph 2).
A hospital cannot deny emergency medical services to a patient who comes to the ER even if that patient cannot afford to pay for those services (to do so would be an EMTALA violation). If a patient has no insurance and no money to pay for the emergency medical care, then that patient must receive it for free. “A hospital may not permit a denial of payment or uncertainty about payment to interfere with its obligations under EMTALA.” (see #13, paragraph 4).
All too common example: an unconscious homeless man, detoxing from his alcohol binge, is brought by ambulance to the ER, and he is intubated and admitted to the ICU. This homeless man recovers and is discharged a couple days later. He doesn’t pay anything, as he has no medical insurance and no money to pay the hospital (and has no assets to sue for). That patient returns a week later for the same reason, and doesn’t pay a dime again.
I’ve not heard or seen of a case where a hospital has “sue[d] a patient to recover payment for services provided.” This seems like an extremely rare occurrence to me.
3. Yes, we made conscious decisions to enter our respective professions, with their respective challenges, and to keep working our jobs. I agree there’s no point in comparing professions.
4. OK, I see.
5. Already answered in 2. But to reiterate: physician have a choice to kick out low-reimbursing patients from their practices (but thereby losing that patient and forfeiting any income generated from any future office visits), but hospitals and pharmacies cannot. Hospitals can charge patients for their services, but patients can refuse to pay if they have no insurance and no money. So hospitals are also legislated into losing money on certain patients.
6. I was not talking specifically about Worker’s Comp cases (where I completely agree with you that there is a very high markup for dispensed meds), but I was talking about medical practices in general. You claimed that: “So not only are physicians breaking laws, threatening patient safety, they are doing so to make a quick buck while pushing off costly, low-margin prescriptions to pharmacies while keeping the high-margin, low-cost prescriptions for themselves.” Besides the specific Worker’s Comp situation (which I agree with you on), what evidence or statistics do you have to back up your bold statement? I’m still waiting for them.
I and some of my colleagues routinely prescribe off of the Walmart $4 formulary to patients who lack funds or have no insurance or request the cheapest meds for their medical conditions.
7. You state “physicians routinely bill for services which were not provided or overbill for services not needed.” If you are so hard at work in your pharmacy, how would you know the billing practices in the average doctor’s office, in order to make such a bold accusation? You state that “CMS estimates $50 billion dollars in fraudulent Medicare billing alone” but do you have data on estimates on underbilling of claims presented to Medicare? It is impossible to measure this, but in my personal experience, the majority of my physician colleagues traditionally underbill, so as to avoid a Medicare audit (and the time and money resulting from addressing an audit and denied Medicare claim). I suspect that it is the few unscrupulous individuals and organizations that intentionally and repeatedly submit fraudulent Medicare claims, resulting in the vast majority of false payouts (these lucrative payouts incentivizing them to continue billing fraudulently), whereas as the majority of physicians bill accurately or possibly even underbill. Medicare fraud and abuses hopefully will improve as EMRs will code and bill more accurately. Unfortunately those who engage in Medicare fraud will continue to bill fraudulently on EMR as well.
8. Yes, doctors shouldn’t complain about being poor, nor should anyone in America for that reason. Americans are in the top 1% in the world (I’ve seen and treated the “poor” in India, Mexico, and the Phillipines).
I too am bothered that “In the current world of healthcare, we are fundamentally financially advantaged by promoting a state of unhealth among our patients.” I am equally bothered that healthcare costs are amplified by a litigious environment that forces medical practitioners to order more tests to cover themselves.
Paying doctors less, even 40% less, isn’t enough to decrease Medicare spending substantially. The problem is that there are less in the workforce to support the growing number of Medicare beneficiaries as the Baby Boomers retire. The way Medicare is structured, the current workforce pays for the retired Medicare beneficiaries’ benefits.
the 60-90% is not based on any hard data, but solely my opinion on the percentage of Medicare/Medicaid patients that make up all the patients with insurance, in rural/low-income areas.
Yes, you are right that those who are able to afford "concierge" medicine will choose to do so, and the doctors in that area will be happy to provide them these services at a hefty fee. In general, I am not concerned with the wealthy who can afford this service (as they will be able to thrive and survive regardless of the President and the politics), but more concerned about the average person who is living day to day on Medicare, Medicaid, or no insurance.
@anonymous123456789 Of course I agree that physicians don't make as much as many people would believe. And there is no denying that physicians are stressed on the job. I also don't think Obamacare is good for the country. I think private markets can function perfectly well if certain regulations which promote monopolies and distort inefficiencies were eliminated. But I am VERY annoyed with physicians complaining about their 'destitute' lifestyle. While we all know of the anecdotes of some physicians movin' back home with the folks, its not the norm. In a financial sense, most doctors do perfectly fine. When I hear them talk about the magnitude of their student loans, I know that they will pay them off in HALF the time it will take me. And they complain *they* are struggling? Right... Tell that to the teacher who has 50K in debt with a 35K salary.