Exodus of male physicians from primary care drives shift to specialty practice

An exodus of male physicians from primary care is driving a marked shift in the U.S. physician workforce toward medical-specialty practice, according to a national study by the Center for Studying Health System Change (HSC). Two factors have helped mask the severity of the shift--a growing proportion of female physicians, who disproportionately choose primary care, and continued reliance on international medical graduates (IMGs), who now account for nearly a quarter of all U.S. primary care physicians. Since 1996-97, a 40 percent increase in the female primary care physician supply has helped to offset a 16 percent decline in the male primary care physician supply relative to the U.S. population. At the same time, primary care physicians' incomes have lost ground to both inflation and medical and surgical specialists' incomes. And women in primary care face a 22 percent income gap relative to men, even after accounting for differing characteristics. If real incomes for primary care physicians continue to decline, there is a risk that the migration of male physicians will intensify and that female physicians may begin avoiding primary care--trends that could aggravate a predicted shortage of primary care physicians.     

Pathbreaking Congressional Budget Office study shows dramatic increases in income disparities in the 1980s and 1990s: an analysis of the CBO data.

Researchers at the Center on Budget and Policy Priorities analyze the data presented in a Congressional Budget Office study that includes the best data any agency or institution has compiled on income and tax trends in recent decades. The CBO report shows that the average after-tax income of the richest 1 percent of Americans grew by $414,000 between 1979 and 1997 (after adjusting for inflation) while average after-tax income fell $100 for the poorest 20 percent of Americans and grew a modest $3,400 for those in the middle of the income spectrum. In percentage terms, after-tax income grew an average of 157 percent over this period for the top 1 percent, rose a modest 10 percent for the middle 20 percent, and was effectively unchanged for those in the bottom fifth. Income gaps between rich and poor and between the rich and the middle class widened in the 1980s and 1990s and reached their widest point on record in 1997. Even before enactment of the 2001 federal tax cuts, the percentage of income Americans pay in federal taxes has declined since 1979 for every income group. By one key measure, the percentage of income paid in federal taxes fell the most for those with the highest incomes.     

The impact of managed care on the physician marketplace.

OBJECTIVE: To examine the impact of managed care on the employment and compensation of primary care and specialty physicians, as measured by changes in income, physician-to-population ratios, and specialty choices. METHODS: The authors used data from the American Medical Association''s Socioeconomic Monitoring System survey, a nationally representative 1% random survey of post-residency patient-care physicians, and location data from the AMA Masterfile to evaluate the relationship between the growth in managed care from 1985 to 1993 and (a) inflation-adjusted physician incomes and (b) physician-to-population ratios for primary care physicians and specialists. They also used data from the National Residency Matching Program for 1989 through 1995 to look at trends in available positions and specialty choices. RESULTS: Primary care incomes grew 4.78% annually ($33,526 cumulatively) in states with the highest managed care growth, compared to 1.20% ($7448 cumulatively) in the lowest quartile of managed care growth. The difference in income growth for medical and surgical subspecialists between the highest and lowest quartiles was not statistically significant. The incomes of radiologists, anesthesiologists, and pathologists (RAPs) rose 0.14%, or $1700, in the highest quartile versus 4.14% ($58,558) in the lowest. Subspecialists per capita did not differ by quartile of managed care growth; but RAPs per capita increased fastest in states in the lowest quartile. Between 1989 and 1995, the number of family practice and pediatric residency positions that were filled rose 32%, while the number filled remained stable for medical and surgical subspecialists and the number of RAP positions filled fell 14%. CONCLUSIONS: The growth in managed care has been associated with significant changes in physician incomes and practice locations. Between 1985 and 1993, states with the fastest growth in managed care penetration saw the highest rate of growth in primary care physicians'' income and the slowest rate of growth in RAP physicians'' income. At the same time, the number of RAP physicians grew most rapidly in those states with the lowest rate of managed care growth. Finally, between 1989 and 1995, there was a dramatic increase in the number of primary care residency positions filled and a marked decrease in the number of RAP residency positions filled across the country.     

Rural-urban differences in primary care physicians' practice patterns, characteristics, and incomes

CONTEXT: Low salaries and difficult work conditions are perceived as a major barrier to the recruitment of primary care physicians to rural settings. PURPOSE: To examine rural-urban differences in physician work effort, physician characteristics, and practice characteristics, and to determine whether, after adjusting for any observed differences, rural primary care physicians' incomes were lower than those of urban primary care physicians. METHODS: Using survey data from actively practicing office-based general practitioners (1,157), family physicians (1,378), general internists (2,811), or pediatricians (1,752) who responded to the American Medical Association's annual survey of physicians between 1992 and 2002, we used linear regression modeling to determine the association between practicing in a rural (nonmetropolitan) or urban (standard metropolitan statistical area) setting and physicians' annual incomes after controlling for specialty, work effort, provider characteristics, and practice characteristics. FINDINGS: Rural primary care physicians' unadjusted annual incomes were similar to their urban counterparts, but they tended to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients. After adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practiced in rural settings made $9,585 (5%) less than their urban counterparts (95% confidence intervals: -$14,569, -$4,602, P < .001). In particular, rural practicing general internists and pediatricians experienced lower incomes than did their urban counterparts. CONCLUSIONS: Addressing rural physicians' lower incomes, longer work hours, and greater dependence on Medicaid reimbursement may improve the ability to ensure that an adequate supply of primary care physicians practice in rural settings.     

Relative incomes and rates of return for U.S. physicians

Since 1967 the supply of physicians in the U.S. has been growing by more than 3 percent per annum. This, coupled with public insurer fee discounts, might have been expected to depress both the relative and absolute incomes of physicians in spite of growing insurance coverage and new technologies. Real incomes of physicians did decline at a 0.2 percent annual rate between 1967 and 1980, but this was apparently due to economy-wide events since the income trends for lawyers, dentists, and college graduates were virtually identical. Internal rates of return to undergraduate medical training remained high--between 14 and 17 percent in 1980. Specialty training became more profitable for internists, general surgeons, and obstetricians/gynecologists (all with 10-15 percent rates of return), while pediatricians continued to suffer a financial loss. While Medicare and Medicaid fee discounts have been criticized as inequitable, the programs are also shown to provide a 'hidden subsidy' to physicians during residency training, materially adding to rates of returns.     

Medical Training Debt and Service Commitments: The Rural Consequences

This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.     

Affordable Care Act reforms could reduce the number of underinsured US adults by 70 percent

To provide a baseline and assess the potential of changes brought about under the Affordable Care Act, this study estimates the number of US adults who were underinsured or uninsured in 2010. Using indicators of medical cost exposure relative to income, we find that 44 percent (81 million) of adults ages 19-64 were either uninsured or underinsured in 2010-up from 75 million in 2007 and 61 million in 2003. Adults with incomes below 250 percent of the federal poverty level account for sizable majorities of those at risk of becoming uninsured or underinsured. If reforms succeed in increasing the affordability of care for people in this income range, we could expect a 70 percent drop in the number of underinsured people and a steep drop in the number of uninsured people.     

Differences in practice income between solo and group practice physicians

An examination of the distribution of physician incomes between different types of practices could help policymakers and researchers alike to gain an understanding of the effects of different organizational characteristics of practices on the practice of medicine as a whole. This study uses a national database to explore the relationships that exist between practice incomes and practice types vis-à-vis the overall size of practices. The primary data source for this study, which includes 7757 office-based physicians, was provided by the Taiwan Department of Health (DOH), with the dependent variable of interest to this study being the annual gross income of physician practices, while the independent variables are physician practice types and the number of physicians within a clinic. Multiple regression analyses were used to model the logarithm of annual physician practice incomes as a linear function of a set of independent variables. Kruskal-Wallis test results revealed the existence of significant relationships between practice incomes and practice types (p<0.001) and the number of physicians within a clinic (p<0.001). Multiple regression analysis also showed that after adjusting for socio-demographic and professional characteristics, the annual incomes of physicians in both single-specialty or multi-specialty group practices (p<0.001) were higher than those of their solo practice counterparts. This study concludes that after adjusting for other factors, higher practice incomes are enjoyed by physicians in single-specialty or multi-specialty group practices as compared to their solo practice counterparts. The finding of higher incomes for those physicians organized into groups supports the policy call from the DOH in Taiwan for the widespread formation of group practices.     

Rural–Urban Differences in Primary Care Physicians' Practice Patterns, Characteristics, and Incomes

ABSTRACT:  Context: Low salaries and difficult work conditions are perceived as a major barrier to the recruitment of primary care physicians to rural settings. Purpose: To examine rural–urban differences in physician work effort, physician characteristics, and practice characteristics, and to determine whether, after adjusting for any observed differences, rural primary care physicians' incomes were lower than those of urban primary care physicians. Methods: Using survey data from actively practicing office-based general practitioners (1,157), family physicians (1,378), general internists (2,811), or pediatricians (1,752) who responded to the American Medical Association's annual survey of physicians between 1992 and 2002, we used linear regression modeling to determine the association between practicing in a rural (nonmetropolitan) or urban (standard metropolitan statistical area) setting and physicians' annual incomes after controlling for specialty, work effort, provider characteristics, and practice characteristics. Findings: Rural primary care physicians' unadjusted annual incomes were similar to their urban counterparts, but they tended to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients. After adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practiced in rural settings made $9,585 (5%) less than their urban counterparts (95% confidence intervals: −$14,569, −$4,602, P < .001). In particular, rural practicing general internists and pediatricians experienced lower incomes than did their urban counterparts. Conclusions: Addressing rural physicians' lower incomes, longer work hours, and greater dependence on Medicaid reimbursement may improve the ability to ensure that an adequate supply of primary care physicians practice in rural settings.     

Using a population-based database to explore the inter-specialty differences in physician practice incomes in Taiwan

Gaining an understanding of the distribution of physician incomes between different medical specialties could assist policymakers to predict the future medical manpower supply. The purpose of this study is to examine the differences in medical specialty-specific gross practice incomes between office-based physicians in Taiwan. The primary data source for the study, which includes 7444 office-based physicians, was provided by the Taiwan Department of Health, with the dependent variable of interest to this study being the annual gross income of physician practices, whilst the independent variable is physician specialty. The study controlled for physicians' age, gender, specialty-board status, type of practice, location of clinic and urbanization level of the community in which the practice was located. Multivariate regression analyses were carried out to explore the relationship between physician specialty and gross practice income. This study finds a significant relationship between the annual gross income of physician practices and the physician's medical specialty (P < 0.001). Of all physicians, those specializing in rehabilitation and orthopedics had the highest gross practice incomes; conversely, obstetricians and gynecologists had the lowest gross practice incomes. The regression analyses demonstrated that after adjusting for socio-demographic and professional characteristics, gross practice incomes of physicians were significantly related to their medical specialty. This study concludes that differences in the gross practice incomes of physicians were significantly related to medical specialties. Those physicians specializing in procedure-based specialties, such as rehabilitation and orthopedics, had higher practice incomes than their counterparts in other more diagnosis-oriented specialties such as family practice and pediatrics.     

Medicaid for children: federal mandates, welfare reform, and policy backsliding

The 1996 federal welfare reform law delinked Medicaid enrollment from welfare participation. This paper estimates the impact of welfare reform on children's Medicaid enrollment using a methodology that both adjusts for income and other demographic differences over time and across states, and provides income-specific estimates of enrollment. The results indicate large enrollment declines: Between 1995 and 1998, enrollment probabilities for children in families with no income declined from 81 percent to 68 percent, while at half the poverty line, the decline was from 61 percent to 53 percent. This implies that 926,000 to 1.37 million fewer children were enrolled after welfare reform. At the state level, Medicaid declines and welfare reform were strongly associated, with only a few states succeeding in preserving children's Medicaid coverage.     

The future supply of family physicians: implications for rural America

Throughout the past century rural health care has been dependent upon general practitioners (GPs) and their successors, family physicians (FPs). Only FPs and GPs have practiced in rural areas in proportion to the population, then and now. As specialization occurred, numbers of GPs declined and physician shortages developed in rural areas. The creation of family practice residencies in the 1970s halted this decline, but rural shortages persist today. During the 1990s the number of allopathic and osteopathic FP residency graduates rose 54 percent. At the same time, the percentage of women enrolled in these residencies increased to 46 percent, and women have been less likely than men to select rural practice. We project that if current numbers of graduates continue, the nonmetropolitan FP/GP-to-population ratio will increase 17 percent by the year 2020. However, today, medical students' interest in primary care residencies (including family practice) is declining precipitously. If numbers of FP graduates return to 1993 levels, the density of FPs in rural America and in the nation as a whole will decline after 2010.     

Impact of statewide program to promote appropriate antimicrobial drug use

The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious antimicrobial drug use. Public education included radio and television advertisements, posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines, satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.     

Do new cohorts of family physicians work less compared to their older predecessors? The evidence from Canada

Although demographics, cohort, and contextual factors are expected to influence physician supply at the intensive margin, much of the literature has examined the demographics and very limited cohort analysis is undertaken. This paper employs a cross-classified fixed-effects methodology to examine the importance of age, period and cohort, and contextual factors in explaining the declining work hours of Canadian family physicians. We define cohorts with five-year intervals according to year of graduation from medical school. Contrary to the previous literature, we find no evidence of reduced hours of work provided by the new cohorts of physicians. Compared to the 1995-99 cohort, older male cohorts perform similar total hours of work per week except those who graduated in the 1960's while older female cohorts consistently perform fewer total work hours in the range of 3-10 h per week. Consistent with the literature, it is found that female and older physicians provide fewer hours of work compared to the male and younger counterparts, respectively. Although there has been a decline in total hours of work for all physicians in the range of 2-3 h per week in each period, we find a large decline in direct patient care hours (about 4-6 h) and a marginal increase in indirect patient care (about 2-4 h) over the period. Having children less than 6 years and children aged 6-15 years in the physician's family reduce the work hours of female family physicians by about 7 h and 3 h, respectively. A number of other contextual factors influence work hours of physicians in the expected direction.     

Reforming the primary care physician payment system: eliminating E & M codes and creating the financial incentives for an "advanced medical home"

The problem faced by primary care physicians is that they can only maintain or increase their (inflation adjusted) incomes by increasing the volume of visits and associated services. The fundamental flaw in a fee-for-service system is that only paying for individual services creates incentives for more services. This article offers a very different approach to paying primary care physicians that will result in both significantly higher incomes for these underpaid professionals together with incentives for creating a medical home.     

Going to scale with community-based primary care: an analysis of the family health program and infant mortality in Brazil, 1999-2004

This article assesses the effects of an integrated community-based primary care program (Brazil's Family Health Program, known as the PSF) on microregional variations in infant mortality (IMR), neonatal mortality, and post-neonatal mortality rates from 1999 to 2004. The study utilized a pooled cross-sectional ecological analysis using panel data from Brazilian microregions, and controlled for measures of physicians and hospital beds per 1000 population, Hepatitis B coverage, the proportion of women without prenatal care and with no formal education, low birth weight births, population size, and poverty rates. The data covered all the 557 Brazilian microregions over a 6-year period (1999-2004). Results show that IMR declined about 13 percent from 1999 to 2004, while Family Health Program coverage increased from an average of about 14 to nearly 60 percent. Controlling for other health determinants, a 10 percent increase in Family Health Program coverage was associated with a 0.45 percent decrease in IMR, a 0.6 percent decline in post-neonatal mortality, and a 1 percent decline in diarrhea mortality (p<0.05). PSF program coverage was not associated with neonatal mortality rates. Lessons learned from the Brazilian experience may be helpful as other countries consider adopting community-based primary care approaches.     

The decline in 'free' general practitioner care in Australia: reasons and repercussions

The Australian public insurer, Medicare, allows general practitioners (GPs) to bulk bill patients, or accept the government rebate as full payment for their services. The percentage of GP consultations bulk billed, however has declined from 78.6% in June 2000 to 65.7% in December 2003. The immediate impact of a declining level of bulk billing is a decrease in the availability of free GP health care for patients. This has implications for copayments and access to GPs for low income groups in particular. In this paper, we explore the reasons for and repercussions of the decline in bulk billing. We analyse two main reasons for the decline. The first is a failure of the rebate to maintain a level consistent with increases in medical practice costs. The second is a decline in GPs in some regional and rural areas resulting in a decrease in price competition. The government has recently made changes to deal with the decline in bulk billing and based on three quarters of data, there has been a modest improvement in bulk billing.     

A growing hole in the safety net: physician charity care declines again

Continuing a decade-long trend, the proportion of U.S. physicians providing charity care dropped to 68 percent in 2004-05 from 76 percent in 1996-97, according to a national study from the Center for Studying Health System Change (HSC). The ongoing decline in physician charity care is alarming given the increase in the number of uninsured people, particularly during the first half of the decade. Declines in charity care were observed across most major specialties, practice types, practice income levels and geographic regions. Increasing financial pressures and changes in practice arrangements may account in part for the continuing decrease in physician charity care.     

Pilot study comparing patients’ valuation of health‐care services with Medicare’s relative value units

Background and aims Physician reimbursement for services and thus income are largely determined by the Medicare Resource‐Based Relative Value Scale. Patients’ assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients’ valuation of health‐care services to Medicare’s relative value unit (RVU) assessments and to discover patients’ perceptions about the relative differences in incomes across physician specialties. Design Cross‐sectional survey. Participants and setting Individuals in select outpatient waiting areas at Johns Hopkins Bayview Medical Center. Methods Data collection included the use of a visual analog ‘value scale’ wherein participants assigned value to 10 specific physician‐dependent health‐care services. Informants were also asked to estimate the annualized incomes of physicians in specialties related to the abovementioned services. Comparisons of (i) the ‘patient valuation RVUs’ with actual Medicare RVUs, and (ii) patients’ estimations of physician income with actual income were explored using t‐tests. Outcomes Of the 206 eligible individuals, 186 (90%) agreed to participate. Participants assigned a significantly higher mean value to 7 of the 10 services compared with Medicare RVUs (P < 0.001) and the range in values assigned by participants was much smaller than Medicare’s (a factor of 2 vs. 22). With the exception of primary care, respondents estimated that physicians earn significantly less than their actual income (all P < 0.001) and the differential across specialties was thought to be much smaller (estimate: $88 225, actual: $146 769). Conclusion In this pilot study, patients’ estimations of the value health‐care services were markedly different from the Medicare RVU system. Mechanisms for incorporating patients’ valuation of services rendered by physicians may be warranted.     

Medicare payment changes and physicians' incomes

An effort to control the physician portion of Medicare expenditures and to narrow the income gap between primary care and procedure-based physicians was effected through t he enactment of the Medicare Fee Schedule (MFS). To determine whether academic and private sector physicians' incomes had demonstrated changes consistent with payment changes, we collected income information from surveys of private sector physicians and academic physicians in six specialties: (1) family practice; (2) general internal medicine; (3) psychiatry; (4) general surgery; (5) radiology; and (6) anesthesiology. With the exception of general internal medicine, the anticipated changes in Medicare revenue were not closely associated with income changes in either the academic or private sector group. Academic physicians were underpaid, relative to their private sector counterparts, but modestly less so at the end of the period examined. Our findings suggest that using changes in payment schedules to change incomes in order to influence the attractiveness of different specialties, even with a very large payer, may be ineffective. Should academic incomes remain uncompetitive with private sector incomes, it may be increasingly difficult to persuade physicians to enter academic careers.