Home Blog 2010: the year it all changed

2010: the year it all changed

December 2010

Much has been written about the recent SHM/MGMA salary data that demonstrate a significant increase in our collective salaries. (As an aside, not all surveys indicated such gains: The Today’s Hospitalist 2010 Compensation & Career Survey showed us receiving a much more modest increase in 2010 over 2009.) If SHM/MGMA data are to be believed, it is no doubt good news for hospitalists and our bank accounts. But is this a blip or a sustained trend? I go with “blip,” but let me first step back a moment.

Many physicians will remember 2010 as the year that health care reform became law. But here’s what I believe is an even more significant milestone: This was the year when more of us started working for The Man (or The Woman) than for ourselves. While this employment transformation started before legislated reform, there’s no doubt that the passage of 2010’s Health Care and Education Reconciliation Act will accelerate the trend.

Primary care physicians have led the exodus from private practice into employment. While 17% of hospitalists in this year’s Today’s Hospitalist survey reported being a part of a local hospitalist group, some of these groups may eventually be bought out by large hospitalist management companies or merged into the hospital employment model. As for the rest of us–45% of the hospitalist population–we were of course born into the employed model. The idea of becoming our own boss is as foreign to many of us as taking responsibility for all stat C-sections.

Primary care docs and hospitalists have been the canary in the coal mine in terms of predicting future employment models. But cardiologists and certain other medical subspecialists have become the elephant in the room. Terrible analogy, but here’s my point: When invasive cardiologists start discovering that they are better off financially by being employed, wow! This is a huge departure from how medicine in this country has historically been practiced.

What happened? Reimbursement changes have resulted in a more level payment-playing field between those who traditionally lived very well off CPT codes (doing procedures) and those of us who’ve been feeding off the much more modest E&M codes with direct patient care.

When CPT code reimbursement initially went down, physicians did what they do best; they did more. It was a zero-sum game in terms of income, even though our patients may have found themselves more irradiated, poked and prodded than ever before.

Now, word on the street among many of my specialist colleagues is that reimbursement is reaching the proverbial tipping point. For the first time, doing more may actually mean making less.

Margins on procedures are so diminished that a doctor’s time might actually be better spent “E&Ming” a patient. Suddenly, the CPT specialists may find themselves stuck making a living off E&M codes. Not much fun, especially when you tell them that the only thing between us and a lowly five-figure salary is the hospital’s $100,000 per-doc subsidy.

Why do I think hospitalists aren’t really going to make much more than they do now? They are never going to pay us more than a cardiologist, nor should they.

And while some cardiologists are being employed at very nice salaries, I believe those may prove to be “teaser rates.” Once reform squeezes hospitals a bit more and everyone realizes that cardiologists aren’t going to earn $500,000 in private practice, well, welcome to what I earn as a hospitalist.

Then there’s the fact that we may not need as many proceduralists when the number of procedures dwindles in a bundled world. We all know that fee-for-service minus the fee part will result in a lot fewer services, especially those that have no clear, evidence-based benefit.

I certainly don’t see this as a nefarious plot by hospitals. Instead, I think the economic reality of the health care system will stress hospitals’ bottom line like it’s never been stressed before.

Money Magazine last month named its top 20 paying jobs, and physicians hold the first seven slots. Whack almost $50,000 off each specialty, and you’d see little change in the rank order of this list–so no one should feel sorry for us. After all, regardless of the vicissitudes of the economy, having an MD will always mean being gainfully employed.

As for hospitalists, if we thought we needed economic parity to truly feel respected, well, our day may be coming. But the bad news, at least in my humble opinion, is that the rest of the medical specialties may be coming down to us, not the other way around.