Finances and the Family Physician The Reality of Primary Care Compensation Emily Adams, BA, and John...
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Transcript of Finances and the Family Physician The Reality of Primary Care Compensation Emily Adams, BA, and John...
Finances and the Family PhysicianThe Reality of Primary Care Compensation
Emily Adams, BA, and John Wiecha, MD, MPHBoston University School of Medicine
Department of Family Medicine – Boston Medical Center
What is the scope ofFamily Medicine?
American Board of Family Medicine Official Definition of Family Medicine
“Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity.”
https://www.theabfm.org/about/policies.aspx
History of Family Medicine
1946 AMA established a section on General Practice to give voice to the mounting problems and decreasing numbers of generalists. Section develops into American Academy of General Practice.
1966 Three independent reports supporting the value of the practice of family medicine were published: the Millis Report, the Folsom Report, and the Willard Report
https://www.theabfm.org/about/history.aspx
They called for a “a physician who focuses not upon individual organs and systems but upon the whole man, who lives in a complex setting…”, and whose “relationship with the patient must be a continuity one”
History of Family Medicine
(continued)
1969 The American Board of Family Practice was officially recognized in February as the 20th primary medical specialty with 15 pilot programs
1971 The American Academy of General Practice became the American Academy of Family Physicians
1984 Family Practice became the third largest residency with 380 programs
https://www.theabfm.org/about/history.aspx
The specialty was formed because of the dwindling number of medical school graduates entering general practice and the difficulty of general practitioners without board certification acquiring hospital privileges
Training in Family Medicine
• Residency Training – 3 years• 497 accredited programs (2005)
• Broadest curriculum of all specialtiesRotate through internal medicine, obstetrics, gynecology, surgery, emergency medicine, critical care, and psychiatry as well as other medical and surgical subspecialties
• Includes training in both inpatient and outpatient care and a longitudinal patient load
Total level of debt of Family Medicine Residency Graduates
Median Level of Debt = $163,000
American Academy of Family Physicians, Annual Residency Completion Survey, 2005
Examples of Possible Fellowships after Family Medicine Residency
• Community Health• Faculty Development• FM/Psychiatry• Geriatrics• Hospitalist • Integrative Medicine • Minority Health • Obstetrics
• Palliative Care• Preventative Medicine• Research • Rural Medicine• Sports medicine• Substance Abuse• Urgent Care• Women’s Health
Certificate of Added Qualifications
• Adolescent Medicine • Geriatric Medicine • Hospice and Palliative Medicine • Sleep Medicine • Sports Medicine
Procedures Done by Family Physicians
Non-Cosmetic Procedures• Minor office surgery • Joint injection and aspiration • Surgical assisting • Intubation skills • Lumbar puncture • Chest tube placement • Thoracentesis • Anterior and posterior nasal packing • Tendon repair • Central line placement• Casting• EKG interpretation• Colposcopy• OB ultrasound• Cesarean sections• Vasectomies• Circumcisions• IUD insertion • Endometrial biopsy • Breast biopsy• Stress testing
Cosmetic Procedures• Chemical Peel• Laser Hair Removal• Botox• Sclerotherapy• Microdermabrasion• Cryotherapy
Geographic Distribution of ABFM Certified Doctors
(August 2006)
https://www.theabfm.org/about/stats_us.aspx
Practice Type of Family Doctors
https://www.theabfm.org/about/stats_practice.aspx
In What Contexts Do Family Physicians Practice?
Source: American Academy of Family Physicians
6.9%
3.3%
89.8%
Hospital
Other
Office
Most Family Medicine Residency Graduates are Office Based
Note: Based on a January 1, 2006 survey of 32,566 family medicine residency graduates.
In What Contexts Do Family Physicians Practice Versus Other Specialties?
33.0%
12.2%
54.8%
Solo
2 Physicians
3 or More
Internal Medicine
24.1%
6.9%
69.0%
Solo
2 Physicians
3 or More
Pediatrics
22.0%
9.9%
68.1%
Solo
2 Physicians
3 or More
Family Medicine
Source: 2006 Practice Survey - Merritt, Hawkins & Associateshttp://www.merritthawkins.com/pdf/MHA2006SurveyofPrimaryCarePhysicians.pdf
Average number of patient contact hours per week by family physicians
(October 2006)
Source: American Academy of Family Physicians, Practice Profile I Survey, October 2006http://www.aafp.org/online/en/home/aboutus/specialty/facts/14.html
34.641.8
52.6
29.335.3
44.1
0102030405060
Average numberof patient
contact hours inthe office settingper week by FPs
Average numberof hours spent in
direct patientcare or patient-related serviceduring the mostrecent completeweek of practice
by FPs
Average numberof hours
practiced duringmost recent
complete week ofpractice by FPs
Male (N=958)
Female (N=464)
84.4
8.3
2.8
0.4
5.7
9.4
2.3
7.3
0 10 20 30 40 50 60 70 80 90
Office Visits
Hospital Visits
Nursing Home Visits
House Calls
Patients Supervised UnderHome Health Care
Nursing Home PatientSupervised
Hospice Patients Supervised
Patients with Free orDiscounted Care
Average number of family physician visits per week and
average number of patients in various settings (October 2006)
Source: American Academy of Family Physicians, Practice Profile I Survey, October 2006http://www.aafp.org/online/en/home/aboutus/specialty/facts/5.html
Average Visits Per Week
How Are Family Physicians Paid?Six Models of Physician Compensation
Compensation Model
Pros Cons
Equal sharing ● simple to arrange administratively
● discourages overutilization
● no incentive for productivity● penalizes high producers; allows low
producers to “coast”
Productivity ● encourages extra professional effort
● complements capitalist economic system
● feed intragroup competition● requires substantial accounting
management● encourages overutilization● discourages activities (such as teaching) not
directly related to patient visits
Salary ● easy to administer ● can disincentivize entrepreneurship● can indebt corporation depending on
income
http://www.aafp.org/fpm/981000fm/cover.html
Compensation Model
Pros Cons
Salary plus bonus ● offers security● allows physicians to increase
income through performance
● may cause minimum work standards to become norms
● places large component of income at risk and depending on subjective measurements
Productivity plus capitation mix
● encourages efficiency● recognizes different revenue
streams of a practice and rewards doctors as such
● complicated to administer● can create differential treatment
levels based on patients’ payment stream
Capitation ● encourages physicians to have an interest in appropriate, efficient provision of care
● may encourage underutilization● requires complex data tracking
http://www.aafp.org/fpm/981000fm/cover.html
How Are Family Physicians Paid?Six Models of Physician Compensation
(continued)
How Are Family Physicians Paid?Six Models of Physician Compensation
(continued)
What Do Family Physicians Actually Make?
And Which Family Physicians Make More?
Salary in Residency
Average salaries offered (in dollars), 2002-2003
http://www.aafp.org/online/en/home/aboutus/specialty/facts/23.html
Median and Mean 2005 Income of Family Physicians
(Before Taxes)
• Data collected October 2006• Presented by Demographic Categories• Data includes Full-time and Part-time Physicians
http://www.aafp.org/online/en/home/aboutus/specialty/facts/15.html
Salary by Census Division (2005)
http://www.aafp.org/online/en/home/aboutus/specialty/facts/15.html
Salary by Practice Type (2005)
Salary by Gender (2005)
Salary by Practice Location (2005)
http://www.aafp.org/online/en/home/aboutus/specialty/facts/15.html
Salary by Age of Physician (2005)
http://www.aafp.org/online/en/home/aboutus/specialty/facts/15.html
Yearly Salary by Different Practice Traits (2005 Physician Salary Survey Report)
Low, median and high represent the 25th, 50th, and 75th percentiles.
Copyright 2005 - Hospital & Healthcare Compensation Service and John R. Zabka Associates
Distribution of Family Physician Incomes
(After Expenses)2002 AAFP demographic survey
Comparison of National Annual Incomes of Family Practice vs.
General Practice2005 Physician Salary Survey Report
Copyright 2005 - Hospital & Healthcare Compensation Service and John R. Zabka Associates
Low, median and high represent the 25th, 50th, and 75th percentiles.
Factors that Increase Earning in Family Medicine
• High-earners: Those with 2003 pre-tax individual incomes of more than $160,000 after expenses
• Low-earners: Those with 2003 pre-tax individual incomes of less than $160,000 after expenses
www.fotosearch.com
From a survey of 730 active AAFP members who had been out of residency five years or longer and worked at least 40 hours per week.
1) Providing more patient visits (high-earners saw a mean number of 122 patients per week; low-earners saw 84)
2) Practicing the full scope of family medicine in the hospital setting
3) Being in larger practices (which may be related to the next four factors)
4) Providing clinical lab, physical therapy, occupational therapy and imaging services in-house
5) Viewing negotiations with payers and evaluating contracts as very important
Factors that have a Large Association with High Earning
In order of significance
Factors that have a Large Association with High Earning
In order of significance (continued)
6) Participating in quality improvement, marketing, strategic planning and benchmarking
7) Having in-house billing and collections
8) Seeing more Medicare patients (nationally, may vary by state)
9) Working more hours
10) Being paid based on productivity
11) Planning to purchase an EHR
Factors that Do Not Have a Significant Impact on Earning
In no particular order
• Current use of an EHR
• Number of staff meetings
• Practice management courses for physicians or staff
• Educational level of in-house billing staff
• Fee-for-service versus capitated revenue
• Percentage of co-payments collected at the time of service
• Aging of accounts receivable
How does Compensation in Family Medicine compare to
other Primary Care Specialties?
What is the current demand for Primary Care Doctors?
Comparison between Different Specialties
All Physicians vs. Starting Physicians 2006 AMGA Compensation Survey
http://www.cejkasearch.com/compensation/amga_physician_compensation_survey.htm
Primary Care Internal Medicine
Comparison between Different Specialties (By Region)
2006 AMGA Compensation Survey
http://www.cejkasearch.com/compensation/amga_physician_compensation_survey.htm
Primary CareInternal Medicine
Income Trends by Specialty - 2005Presented by Percentage of Physicians in
Income Brackets
Primary CareInternal Medicine
Current Demand for Family Physicians
AMA NewsJune, 2006
“MOST WANTEDFor the first time in six years, general internists and family physicians are at the top of the ‘in demand’ list for hospitals and medicals groups, according to a review of 2,840 Merritt, Hawkins & Associates’ listings. Here by year are the number of physician searches by specialty starting in 2002-03 and continuing through 2005-06.”
Current Demand for Family Physicians
“According to Merritt, Hawkins & Associates’ 2005 Survey of
Hospital Physician Recruiting Trends, more hospitals are
actively engaged in recruiting family physicians than any other
type of physician.”
- Leslie Champlin – AAFP News Now (7/25/06)
Future EarningPotential
“It isn't unusual for students to hear that physicians working in family medicine don’t make enough to pay off their loans. However, the truth is that family physicians make enough money to pay off student loans and have the lifestyle they want.”
“In the future, incomes for family physicians are projected to increase as much as 25% in practices that use new technologies and new care models, such as chronic disease management.”
Debt Management – Publication of American Academy of Family Physicians, 2007
http://www.aafp.org/online/en/home/publications/otherpubs/debtmgmt.html