There was an article published recently addressing the shortage of pediatricians. Though the article focused on this specific shortage, it actually raised many additional questions regarding the physician workforce in general. It is difficult to disagree that continuing to decrease reimbursement, increasing maddening payment schemes, and increasing regulatory requirements to pediatricians and physicians in general will have predictable results. There will be physician shortages, and patient access will be compromised.
Hospitals do hire primary care physicians not because they are positive revenue streams but because these physicians use the profitable hospital services, including lab, imaging, physical therapy, and surgical specialists. Also, hospitals view this as a way to protect market share. Because hospital margins are tight, they must monitor (restrict perhaps a better word) their RVU reimbursements to their employed physicians in a way to protect their balance sheets. As the regulatory onslaught, increasing costs (overhead), and reimbursement contractions have made the private practice of medicine a near impossibility, in desperation, increasing numbers of physicians have sought refuge as hospital employees. New physicians, largely ignorant of health care insurance, business principles, health care law, and finance, are unprepared for the realities of the marketplace. To even contemplate an adventure into entrepreneurialism is foreign to their understanding. Of course, a critical examination of hospital efficiency and their rapidly obsolescent business model is another whole topic. If there are examples of hospitals increasing their RVUs to physicians, it is certainly a rare exception. I am unaware of this phenomenon.
Reinforcing and promoting dissension among physicians has been remarkably effective over many years. Those exercising this tired tactic continue to rotate reimbursement based on, for example, the idea that a pediatric surgeon, for some unknown reason, is deserving of higher compensation than a general surgeon, or that a family practitioner should make less than a general internist. This tactic does nothing but create and promote the classic internecine wars, which have defeated physicians’ effectiveness as a profession in representing their collective interests. Physicians are the base upon which health care exists at all. To ignore the well-being of this profession must have significantly negative consequences.
Pricing is the magic upon which value is built in a capitalist economy. I defy anybody to explain physician compensation. What is the value to be attached to a neurosurgeon, a geriatrician, or a rheumatologist? How are these values determined? Who is in charge of arriving at the value of these individuals? What about merit and exceptionalism? All athletes, CEOs, and other professions do consider differences in ability. All physicians and surgeons are not equal. Is there a mechanism to reward exceptionalism? Further, physicians differ regarding social circumstances, work ethic, and personality. They are not monolithic. Why should their compensation be? A physician who is the primary breadwinner with a number of children and still in private practice is certainly different from one with an employed spouse, is older, or unmarried.
This is further complicated by a government that has clearly over-promised its health care commitments. With a debt of $36 trillion and projected deficits into the distant future, shouldn’t there be some question as to future funding? Medicare and Medicaid insolvency are inevitable as now structured. Inflation in general has been 20 percent over the last four years and around 2 percent annually for the 20 preceding years. The calculation just to bring compensation back to where it was decades ago would necessitate a present increase in reimbursement somewhere in the range of 60 percent. There is no realistic government solution that can remotely solve this problem in the present environment of fiscal irresponsibility. When the rest of society has had wage increases to mostly keep up with inflation and physicians have experienced a significant reimbursement decrease, the demagogues have perverted the concepts of altruism and professionalism as a way to control physician behavior via their faux-declarations of moral superiority. This tactic is marinated in hypocrisy. Unfortunately, constant sacrifice to the demands of others cannot sustain any product or service. Such should be a choice, not an obligation; it is contrary to human nature. Depression, anger, and burnout are easily predictable and have now been realized. This is destructive to physicians, their families, and the profession. And, in the end, patient care must suffer.
Unless there are analyses and insights that I am missing, it can be concluded that the present system will implode and, tragically, take the profession of medicine with it. Only by honestly and realistically acknowledging the serious nature of a health care system in peril and a profession of medicine that is increasingly plagued with dissatisfaction by its members will solutions emerge. These solutions will not be found via politics, more regulations, more ridiculous schemes, more regulations, or more bureaucratic control.
I am afraid the shortage of pediatricians will not only persist but will worsen. And predictably, this will eventually affect all physicians in general. We have had a glorious profession. Passively witnessing its deterioration is something that should cause regret and perhaps even shame.
Can our physician peers finally begin to exercise their collective talents and power for their patients, their families, themselves, and their great profession? Sadly, a definitive answer to this question cannot be stated.
Allan Dobzyniak is an internal medicine physician.
