Primary Care Doctors, Education Debts, and Other Burdens

The negative impact of high tuition on physicians has not influenced medical school administration. In the last decade, the costs of a medical education increased at twice the rate of inflation without justified cause. This leaves graduates anxious to increase their salary and feeling justified to enforce co-pays in their practice, overbill and avoid low-paying insurances, including Medicaid patients. Moreover, they often are paying off this debt well into their 50’s at variable interest rates well above those paid by home owners.

Andrew Ibraham and John Brockman, “A Moral Imperative to Address the Cost of Training Our Doctors," KevinMd.com, April 26, 2011

Medical students are smart.

They know:

.Many of their classmates are over $200,000 in debt upon graduation, and the average debt is $130,000.

.Entering into a primary care career may commit them to paying off debts into their 50’s.

• specialists bring home roughly twice the income of primary care doctors and make $3.5 million more over the course of a lifetime.

• the cost of setting up a solo practice is prohibitive, and they may not be able to even give the practice away should they leave the practice;

. primary care physicians are much in demand by hospitals, who badly need referrals from these physicians to fill their beds;

• specialty-dominated medical school faculties disparage community primary care practitioners as LMDs, local medical doctors;

• current reform measures – federal grants, tuition-free rides to aspiring future primary care doctors, forgiveness to students choosing to practice in doctor-short areas - will take time to filter down to them;

• token increases in codes for primary care candidates – are unlikely to significantly close salary gaps with specialists.

• federally- promoted and incentivized medical homes and accountable care organizations are predicated on the premises of a broader primary care base.

• most medical school administrations are so far insensitive to the debt-inflicted plight of primary care doctors, because medical school tuitions are still climbing at twice the rate of inflation.

• the percentage of their classmates going into internal medicine remains about 25% but only 2% are choosing primary care as a subspecialty of internal medicine.

• the American public is specialist-oriented and is willing to pay more for specialist procedures than generalists opinions and prescriptions;

• where the rubber-hits-the-road, the specialty-dominated RUC (Relative Value Update Committee), which sets the fees for doctors, the committee generally rules in favor of higher specialty fees.

• creditors charge higher rates and remain unforgiving, charging higher rates than homeowners.

• Somehow the primary care slots will be filled by foreign medical graduates, who already provide more than 25% of all primary care positions in American health care.

• The public perceives that American doctors, all of them are doing well, thank you, and indeed, are paid much more than their foreign counterparts.

A note on the latter point. American doctors make more on paper on average than comparable foreign physicians ($230,000 vs. $113,000 for specialists and $161,000 vs. $83,000 for generalists) but these comparisons often ignore factors such as educational debt, which is much less abroad and is often paid by government; malpractice premiums, which are often inconsequential in other nations; costs of meeting third party expenses, which may comprise 50% of overhead; and cost-of-living expenses, which on average are 37% higher in the U.S. than abroad.

Tweet: The United States is singularly unique in the educational debts it imposes of on its physicians, who reap the consequences.