By ALLAN DOBZYNIAK, MD
There was an article published recently (Healthcare Michigan August 2024) addressing the shortage of pediatricians. The article raises many additional questions regarding the physician workforce. Without question, 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 shortages.
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. Hospitals view this as a way to protect market share. Hospital margins are tight. They must spread their RVU reimbursements to their employed physicians in a way to protect their balance sheets. As the regulatory onslaught and reimbursement contractions have made the private practice of medicine an increasing impossibility, in desperation increasing numbers of physicians have sought refuge as hospital employees. New physicians, largely ignorant of healthcare insurance, business principles, healthcare law and finance are unprepared for the realities of the marketplace. To even contemplate an adventure into entrepreneurialism is foreign to their understanding. Examining hospital efficiency and their business model is another whole topic. If there are examples of hospitals increasing their RVU reimbursements to physicians, I am unaware of this phenomenon.
To suggest that a pediatric surgeon should receive higher compensation than a general pediatrician or that a dermatologist should make less than a general internist 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 healthcare 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 anyone 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 or other professions do consider differences in ability. All physicians and surgeons are not equal. Is there a mechanism to reward exceptionalism? Social circumstances are also important. A physician who is the primary breadwinner with a number of children is certainly different from one with an employed spouse or one unmarried.
This is further complicated by a government that has clearly overpromised its healthcare commitments. With a debt of $36 trillion and projected deficits into the distant future, shouldn’t there be some question as to the source of funding going forward. Medicare and Medicaid insolvency are inevitable. Inflation in general has been 20% over the last four years and around 2% annually for the 20 preceding years. The calculation just to keep compensation the same over this period would necessitate an increase in reimbursement somewhere in the range of 60%. There is no realistic government solution that can solve this problem in an environment of fiscal irresponsibility. When the rest of society has had wage increases to mostly keep up with inflation and physicians have taken a significant pay cut, the word altruism is invoked. Altruism, unfortunately, cannot sustain any product or service.
Unless there are points that I am missing, one must conclude that the present system will implode and take the profession of medicine with it. Only by honestly and realistically acknowledging the serious nature of a healthcare 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.