83% of u.s. Doctors consider quitting.

[Jeff Young]

You funny, and you don't know shit. I'll send you the NC State Bar salary survey I just received if you so desire. The average lawyer in North Carolina makes $70 or 80k and works harder than your lazy ass to get that. You can shove the survey up your ass so that it actually might have some impact on your brain.

 

[Mark]

Spoken like a truly intelligent man Jeff. Well done Sir, well done.

Again we see you and your ilk, stating they know things that clearly they do not, nor could not know!

I rest my case M'Lord!

(now where's the smiley for smug satisfied grin when you need it?)

 

[Doc Kaler]

Time to block Jeff too I guess. As a physician, I apologize for Jeff's behavior. Jeff, when the Pay-for -Performance is fully implemented under ACA you may want to improve your "people skills" lest the patient survey scores returned to you will be less than 8 out of 10.....

 

[Bob Fechter]

Once again the liberal youth brigade has decided there is only X amount of money available.

Can't you guys get over the "if he makes more money, I make less" syndrome?

Before Midicare, an immigrant family without a pot to piss in could afford doctor's visits out of pocket and still buy catastrophic insurance. That all disappeared with the government's medalling with the market.

 

[Jim Rosenthal]

Highly entertaining. Bob, as usual you don't know what you're talking about. But that hasn't stopped you in the past.

I think the American medical care system is PERFECT.

I just haven't figured out who it's perfect for. After over thirty years in the field, you'd think I'd know, but I ain't quite there yet.

 

[Bob Fechter]

Highly entertaining. Bob, as usual you don't know what you're talking about. But that hasn't stopped you in the past.

I think the American medical care system is PERFECT.

I just haven't figured out who it's perfect for. After over thirty years in the field, you'd think I'd know, but I ain't quite there yet.

My family immigrated to the US in the early Fifties, and that is exactly what we did. No Social Security, welfare, food stamps, nothin'. We lived in a tiny house in the back of a mansion, my Father gardened the grounds, and my Mother cleaned the mansion in lieu of rent, and they both worked jobs because America was the land of opportunity.

 

[Jeff Young]

Time to block Jeff too I guess. As a physician, I apologize for Jeff's behavior. Jeff, when the Pay-for -Performance is fully implemented under ACA you may want to improve your "people skills" lest the patient survey scores returned to you will be less than 8 out of 10.....

As a rational human being, I apologize to the rest of humanity for you kowtowing to silly posts on the internet.

Block away. It's the mark of folks of who can't handle opposing viewpoints. Weak and rather immature.

If you want to have a real discussion about health care costs and the incentives we provide for doctors to eschew PCP practices for specialities, by all means, go back to my previous posts before Pete, Mark and the gang started flinging pooh and let's have a rational discussion.

Or, turtle up (out of fear?) and don't participate in the debate.

 

[Jim Craik]

Jeff,

I think that's why Fox is so popular, it appeals to those who are not really looking to discuss or learn, that would entail hearing both sides of a issue or discussion. It seems like most here really only want to hear from people who see thing just as they do.

There are a few like our Florida friends Pat and Jack, who really do listen to both sides and they make well thought out statements and rebuttals. I greatly enjoy talking with them.

But too often what we get are thread after thread, started for no other reason than provoking not discusion or debate, but only as a means to belittle anyone who sees things differently.


22 of the last 40 threads in the Paddoc are one sided threads started by Consevatives, looking to stir up a response.

The number of one sided threads started by liberals...........0

Yet they see us as trouble makers that need to be shouted down. Then they come away thinking we are the ones who need to be blocked..................really?

Very strange.

 

[Larry L.]

Jeff,

...but only as a means to BELITTLE ANYONE WHO SEES THINGS DIFFERENTLY...THEY ONLY CALL US NAMES(!!!)!...Very strange.

Seriously?! You really ought to review your own posts in that regard, sir. :stunned:

 

[Steve]

No, it's a blatant truth. If we have X amount of dollars to spend on doctors in the US, and specialists get a disproportionately larger share than PCPs, then yes, you are earning more money at their expense.

In fact, the whole RVU system backs that up as you yourself state -- the rates for various procedures are stacked in favor of specialists. If this was market driven -- meaning that the patient and doctor agreed -- no problem. But it's not. It's a reimbursement scheme developed primarily by insurers, the doctors and government that heavily favors specialists (here in the US).

How much so? Last data I found showed PCPs making 170-180k average. Surgical specialists were mostly in the $500k range and up, meaning nearly 3 times as much or more.

Is this because an MRI an knee scope on a patient is more valuable than a 2-3 hour attempt to diagnose a condition like diabetes or fibromyalgia or so? Hard to say since the market isn't setting the prices.

Clearly doctors should be highly compensated, but what lacks intelligence is to say "give them whatever they want!" and then complain about healthcare costs in teh US. THAT is dumb.

And proof that curtailment and rationing of high end procedures will provide savings to staff and provide primary care for 30 mil newly insured?

It exists in every country in Western Europe, and Oceania. Health care costs per capita in those countries are generally 30% less than in the US with similar if not better results -- life expectancy, infant mortality, etc. How do they do it? Yeah, you wait for and may not get your knee scoped in all cases, and when you are in your 70s and 80s it may be impossible for you to get a heart transplant or a hip replacement. In return you get much better access to primary care at all times, and to specialist services when you are young and productive. Scream death panels all you want, but when you have a system where you spend something like 95% of all your lifetime health care costs in the last six months of life like we do in the US, primarily on specialists, you have a problem.

And that is why specialists want zero changes to the existing reimbursement system.

Whoa there big boy. Pretty much wrong on all accounts:

1. I just said specialists, in general, don't think the current reimbursement system is viable long term and don't favor it.

2. There isn't " x amount of dollars to spend". The rvu system is based on overhead expenses, malpractice expenses, and time spent treating the patient. There isn't a finite amount of money (which is why medicare is such a disaster because it's cost continues to rise faster than inflation). I make exactly the same for seeing a patient as does a primary care doc. The procedures I do that take 30 min on average pay the same as a 30 min office visit with a PCP.

3. Specialists didn't create the RVU system. The govt did and they used data from Harvard. There is an AMA committee that helps make recommendations for changes. Specialists are not favored via the AMA.

4. How do surgeons make more? We trained in programs that worked us 80-125 hours/week. PCP's trained in programs working 50-70 hours/week. In general, surgeons start earlier, work later. Does your PCP see patients at 6:30 in the morning? No. But I'm operating then and have frequently done 3 surgeries before my PCP colleagues show up to work.

5. I agree that letting the market decide would be better.

6. The complexities of why our life expectancy and "results" are not as good as much of Europe is beyond this discussion. Safe to say that it's multifactorial and much of it has to do with lifestyle issues (obesity, resulting diabetes etc.) not the quality of care. Ever wonder where wealthy people worldwide go for their healthcare? Mayo Clinic, Cleveland Clinic, Mass General, johns Hopkins, Duke, brigham and Woman's, Wash U, Univ of Iowa, Rush Presbyterian etc etc.

Agree with Doc

 

[Keith]

Hello Ian, I think perhaps that a limited explanation of our glorious PAYE system might go a long way towards explaining the apparent confusion over take home pay. The American employee tax method, as I recall, is essentially a self assessment system.

I do not believe that they deduct tax at source ever.

 

[Ian Anderson]

There are none so blind than those who will not see

 

[Jim Rosenthal]

Well, with respect to the RVU system, I will mention this: as an emergency physician, our group gets paid about eight RVUs for reducing a dislocated shoulder. I think we get four RVUs for managing an acute MI on the way to the cath lab. Granted, a dislocated shoulder is painful and the patient is quite appreciative when I put it back where it's supposed to be, but this takes me about thirty seconds with modern anesthetics. Getting an acute STEMI to the cath lab, though, is much more difficult; I have to manage their meds, watch their rhythm and vital signs, call the interventional cardiologist and the cath lab crew in, etc. And, at night, watch the rest of the ED as well. There's no question in my mind that managing an acute MI is far more risky and requires much more work. And yet the RVUs have been set at half that of a shoulder dislocation. Or something like that.

The only conclusion to draw from that is that orthopedics specialists had quite a lot of influence on the assigning of the relative values to the various procedures, and saw an opportunity to enrich themselves. If anyone has another explanation, I'd be glad to hear it. I'm not complaining about this situation, by the way; as an ER physician, I just see whoever comes in and eat what lands on my plate. But I do find it amusing and no more sensible than anything else I see these days.

Now that I've gotten to the age (61) where I am most likely to need medical care, I find our entire system of medical care, and how we deliver it and pay for it, completely ridiculous. I admit it has made me a comfortable living and been a rewarding way to spend my professional life, but given that God started us all out at least theoretically equal in our infancy, I find the inequities in our system, just in this country, absolutely breathtaking. An accurate way to describe our medical care system in this country might be this: a financial arrangement devised to channel money to those who complain the most and advertise the most, while meantime occasionally providing medical services in an arbitrary and uneven fashion, frequently to those who require it the least.

 

[Keith]

There are none so blind than those who will not see

Yus, innit.

And yet another breach of Rule No. 1 of the Forum Rules.

 

[Steve]

Well, with respect to the RVU system, I will mention this: as an emergency physician, our group gets paid about eight RVUs for reducing a dislocated shoulder. I think we get four RVUs for managing an acute MI on the way to the cath lab. Granted, a dislocated shoulder is painful and the patient is quite appreciative when I put it back where it's supposed to be, but this takes me about thirty seconds with modern anesthetics. Getting an acute STEMI to the cath lab, though, is much more difficult; I have to manage their meds, watch their rhythm and vital signs, call the interventional cardiologist and the cath lab crew in, etc. And, at night, watch the rest of the ED as well. There's no question in my mind that managing an acute MI is far more risky and requires much more work. And yet the RVUs have been set at half that of a shoulder dislocation. Or something like that.

The only conclusion to draw from that is that orthopedics specialists had quite a lot of influence on the assigning of the relative values to the various procedures, and saw an opportunity to enrich themselves. If anyone has another explanation, I'd be glad to hear it. I'm not complaining about this situation, by the way; as an ER physician, I just see whoever comes in and eat what lands on my plate. But I do find it amusing and no more sensible than anything else I see these days.

Now that I've gotten to the age (61) where I am most likely to need medical care, I find our entire system of medical care, and how we deliver it and pay for it, completely ridiculous. I admit it has made me a comfortable living and been a rewarding way to spend my professional life, but given that God started us all out at least theoretically equal in our infancy, I find the inequities in our system, just in this country, absolutely breathtaking. An accurate way to describe our medical care system in this country might be this: a financial arrangement devised to channel money to those who complain the most and advertise the most, while meantime occasionally providing medical services in an arbitrary and uneven fashion, frequently to those who require it the least.

Agreed, it's an arbitrary system that makes no sense.

BTW, reduction of a shoulder dislocation is 4.54 RVU.

There was some (weak) science behind the RVU system when initially imposed. There wasn't lobbying that benefitted one group.

Also, everyone knows that Orthopaedic surgeons make more on avg than PCP's. When in medical school anyone could choose to work extra hard and get better grades to get into a competitive specialty like ortho. Most choose not to.......and then complain years later when they don't make as much. Usually complain for govt intervention to correct the perceived injustice.

 

[Jeff Young]

Yus, innit.

And yet another breach of Rule No. 1 of the Forum Rules.

Then help us out Ian. How is the UK system different from the US?

Your assertion that gross revenue is essentially the same as take home pay in the US was flat out wrong. Now, I wasn't as precise with my post as I should have been. Correct terms are:

Gross revenue - deduction of business expenses = taxable income/revenue.

Again, I ASSURE YOU that in the US, no one treats the $130k in the example I posted as "take home pay". That's the gross number, and then you back out rent, etc.

Hardy's lost all ability to claim "violation" of forum rules withe last few posts about "wankers," "crass fools" and so one. So I have no idea what he is mumbling about now.

 

[Jeff Young]

Agreed, it's an arbitrary system that makes no sense.

BTW, reduction of a shoulder dislocation is 4.54 RVU.

There was some (weak) science behind the RVU system when initially imposed. There wasn't lobbying that benefitted one group.

Also, everyone knows that Orthopaedic surgeons make more on avg than PCP's. When in medical school anyone could choose to work extra hard and get better grades to get into a competitive specialty like ortho. Most choose not to.......and then complain years later when they don't make as much. Usually complain for govt intervention to correct the perceived injustice.

Your previous post contains some flat out inaccuracies about how surgeons make more than PCPs (as best I can tell from teh data I looked at, working more hours is not the reason for it) -- I'll post that up later.

But that last quote really sums up the problem. We've (well insurers, doctors, hospitals and the government have) created a system that rewards knee scopes and boob jobs and and lazik and heart/lung transplants over spending an hour with a patient to diagnose and GI problem for example. So naturally the best students are attracted to the specialities and more money (which the studies show, just as with attorneys, doesn't necessarily mean more happiness).

The real question is, why? It wasn't the market that decided to value these services more. For MOST people, a PCP corrently diagnosing a daily ailment if far more valuable than stuffing silicone in their wife's chest.

And that is part of the reason why in our system we pay 30% more per capita on average for poorer or equal overall results than in Oceania or Western Europe. And also why specialists tend to fear Obamacare, and a perceived shifting of the pie away from specialitists to PCPs.

 

[Keith]

Keith Hardy is mumbling about the two different systems of 'employee' tax between UK and USA.

In the UK income tax is deducted at source (employer) together with NI contributions (National Insurance), therefore a UK employee's pay is deemed net. It's called PAYE (Pay As You Earn)

If one was self employed, one could elect to be taxed on a self assessment system which is similar to the US model but far more complex.

Mr Anderson (a highly qualified Accountant) and yourself (?) were talking about different systems, which would have been clear to you if you had thought about it a little more and stopped playing to the jury.

You are still in breach of Rule 1.

 

[Jeff Young]

You've been in breach of Forum Rule No. 1 for quite a while so quite honestly, you've got zero ground to stand on about it. I'd stop talking about it, makes you look like a "wanker" or a "crass fool."

Here's the problem with our highly qualified accountant's assertion. I WAS TALKING ABOUT LAWYER TAKE HOME PAY IN THE UNITED STATES. His assertion that my numbers were wrong IN THE UNITED STATES was and is incorrect.

But once again, I contributed some to the problem by not being precise with my terminology. HOwever, despite that, from your post, it appears that the US and UK systems are actually more similar than it appears (which doesn't change the fact that I'm correct about "take home pay" in the US).

For a lawyer employed by a law firm, as I was for seven years, my gross salary was a number, from which my employer deducted federal income tax, state income tax and what we call FICA, which is our Medicare and Social Security contribution. The "net" on the check was take home pay.

So as a lawyer employed by a firm as an associate, I would work say 2000 hours a year, at (at the time) say $200/hour. That would generate roughly $400k in gross revenue for the law firm. My gross pay would be about 1/3 of that, with teh remaining $280k being kept by the law firm. The $120 would then be subject to the tax withholdings above, and I may actually see on a check 2/3 of that, or $80k or so.

When I became a partner, I was a part "owner" of the firm and (allegedly...lol) allowed to share in the profits. So the calculation was a bit different but no, my take home pay was never "gross revenue."

Example. In 2010, my best year in private practice, I think I billed 2300 hours and my rate was $350/hour. I collected something $750k in revenue for the firm (or the number Ian is incorrectly calling "take home pay"). From that, after paying the firm's expenses in generating that revenue, my gross share in the profits distributed to me was something like 1/2 of that.

That was my gross income received from the revenue the firm generated and that I contributed to.

From that number, in the US, I then get to deduct things like state income tax, mortgage interest, private retirement contributions, etc. to get to a number called taxable income. Let's say that number was in the $275k range. I then pay tax, including a special self-employment tax, on that, with my actual take home money being in the $150k range -- after generating $750k in revenue.

So you see know where Ian is off the rails in claiming in the US that a criminal defense lawyer doing mostly appointed work at $65/hour (which include a lot of excellent attorneys in NC, despite Pickford's rant above that also was in violation of Forum Rule No. 1) "takes home" 130k is gaming the system. That's just false and I suspect Ian knows that now as he has resorted to insults rather than discussing the issue.

Let's actually work it out based on the examples I gave above.

If this lawyer generates $130k in revenue as an employee of a law firm, his pre tax salary is going to be in the $60-70k range as I explained, with the firm keeping the rest to pay rent, etc. That lawyer actually takes home, after tax, probably something like $40-50k on $130k in gross revenue.

The situation may be better or worse if the lawyer is self employed, depending on how the lawyer manages overheads. If they can operate on $30k a year for rent, support staff, etc., then the lawyer gets $100k pre tax and probably takes home $70k or so. Again, on $130k revenue.

Ian's attempt to equate gross revenue with what a lawyer is paid was rather bizarre and again, I don't think the system is that different in the UK.

But I'll wait for him to actually respond rather than flinging insults and maybe we can discuss it.

 

[Keith]

But I'll wait for him to actually respond rather than flinging insults and maybe we can discuss it.

I don't think he's flung any insults at you at all, that is not his style. You are consistently the one denigrates your fellow posters and does all the insult flinging.

You are just one very nasty individual, and I am certainly not the only one that thinks that on either side of the pond - you have very little support here.