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Finances and the Family Physician The Reality of Primary Care Compensation Emily Adams, BA, and John Wiecha, MD, MPH Boston University School of Medicine.

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Presentation on theme: "Finances and the Family Physician The Reality of Primary Care Compensation Emily Adams, BA, and John Wiecha, MD, MPH Boston University School of Medicine."— Presentation transcript:

1 Finances and the Family Physician The Reality of Primary Care Compensation Emily Adams, BA, and John Wiecha, MD, MPH Boston University School of Medicine Department of Family Medicine – Boston Medical Center

2 What is the scope of Family Medicine? American Board of Family Medicine Official Definition of Family Medicine “Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity.” https://www.theabfm.org/about/policies.aspx

3 History of Family Medicine 1946 AMA established a section on General Practice to give voice to the mounting problems and decreasing numbers of generalists. Section develops into American Academy of General Practice Three independent reports supporting the value of the practice of family medicine were published: the Millis Report, the Folsom Report, and the Willard Report https://www.theabfm.org/about/history.aspx They called for a “a physician who focuses not upon individual organs and systems but upon the whole man, who lives in a complex setting…”, and whose “relationship with the patient must be a continuity one”

4 History of Family Medicine (continued) 1969 The American Board of Family Practice was officially recognized in February as the 20 th primary medical specialty with 15 pilot programs 1971 The American Academy of General Practice became the American Academy of Family Physicians 1984 Family Practice became the third largest residency with 380 programs https://www.theabfm.org/about/history.aspx The specialty was formed because of the dwindling number of medical school graduates entering general practice and the difficulty of general practitioners without board certification acquiring hospital privileges

5 Training in Family Medicine Residency Training – 3 years 497 accredited programs (2005) Broadest curriculum of all specialties Rotate through internal medicine, obstetrics, gynecology, surgery, emergency medicine, critical care, and psychiatry as well as other medical and surgical subspecialties Includes training in both inpatient and outpatient care and a longitudinal patient load

6 Total level of debt of Family Medicine Residency Graduates Median Level of Debt = $163,000 American Academy of Family Physicians, Annual Residency Completion Survey, 2005

7 Examples of Possible Fellowships after Family Medicine Residency Community Health Faculty Development FM/Psychiatry Geriatrics Hospitalist Integrative Medicine Minority Health Obstetrics Palliative Care Preventative Medicine Research Rural Medicine Sports medicine Substance Abuse Urgent Care Women’s Health

8 Certificate of Added Qualifications Adolescent Medicine Geriatric Medicine Hospice and Palliative Medicine Sleep Medicine Sports Medicine

9 Procedures Done by Family Physicians Non-Cosmetic Procedures Minor office surgery Joint injection and aspiration Surgical assisting Intubation skills Lumbar puncture Chest tube placement Thoracentesis Anterior and posterior nasal packing Tendon repair Central line placement Casting EKG interpretation Colposcopy OB ultrasound Cesarean sections Vasectomies Circumcisions IUD insertion Endometrial biopsy Breast biopsy Stress testing Cosmetic Procedures Chemical Peel Laser Hair Removal Botox Sclerotherapy Microdermabrasion Cryotherapy

10 Geographic Distribution of ABFM Certified Doctors (August 2006) https://www.theabfm.org/about/stats_us.aspx

11 Practice Type of Family Doctors https://www.theabfm.org/about/stats_practice.aspx

12 In What Contexts Do Family Physicians Practice? Source: American Academy of Family Physicians Most Family Medicine Residency Graduates are Office Based Note: Based on a January 1, 2006 survey of 32,566 family medicine residency graduates.

13 In What Contexts Do Family Physicians Practice Versus Other Specialties? Internal Medicine Pediatrics Family Medicine Source: 2006 Practice Survey - Merritt, Hawkins & Associates

14 Average number of patient contact hours per week by family physicians (October 2006) Source: American Academy of Family Physicians, Practice Profile I Survey, October 2006

15 Average number of family physician visits per week and average number of patients in various settings (October 2006) Source: American Academy of Family Physicians, Practice Profile I Survey, October Average Visits Per Week

16 How Are Family Physicians Paid? Six Models of Physician Compensation Compensation Model ProsCons Equal sharing ● simple to arrange administratively ● discourages overutilization ● no incentive for productivity ● penalizes high producers; allows low producers to “coast” Productivity ● encourages extra professional effort ● complements capitalist economic system ● feed intragroup competition ● requires substantial accounting management ● encourages overutilization ● discourages activities (such as teaching) not directly related to patient visits Salary ● easy to administer● can disincentivize entrepreneurship ● can indebt corporation depending on income

17 Compensation Model ProsCons Salary plus bonus ● offers security ● allows physicians to increase income through performance ● may cause minimum work standards to become norms ● places large component of income at risk and depending on subjective measurements Productivity plus capitation mix ● encourages efficiency ● recognizes different revenue streams of a practice and rewards doctors as such ● complicated to administer ● can create differential treatment levels based on patients’ payment stream Capitation ● encourages physicians to have an interest in appropriate, efficient provision of care ● may encourage underutilization ● requires complex data tracking How Are Family Physicians Paid? Six Models of Physician Compensation (continued)

18 What Do Family Physicians Actually Make? And Which Family Physicians Make More?

19 Salary in Residency Average salaries offered (in dollars),

20 Median and Mean 2005 Income of Family Physicians (Before Taxes) Data collected October 2006 Presented by Demographic Categories Data includes Full-time and Part-time Physicians

21 Salary by Census Division (2005)

22 Salary by Practice Type (2005)

23 Salary by Gender (2005)

24 Salary by Practice Location (2005)

25 Salary by Age of Physician (2005)

26 Yearly Salary by Different Practice Traits (2005 Physician Salary Survey Report) Low, median and high represent the 25 th, 50 th, and 75 th percentiles. Copyright Hospital & Healthcare Compensation Service and John R. Zabka Associates

27 Distribution of Family Physician Incomes (After Expenses) 2002 AAFP demographic survey

28 Comparison of National Annual Incomes of Family Practice vs. General Practice 2005 Physician Salary Survey Report Copyright Hospital & Healthcare Compensation Service and John R. Zabka Associates Low, median and high represent the 25 th, 50 th, and 75 th percentiles.

29 Factors that Increase Earning in Family Medicine High-earners: Those with 2003 pre-tax individual incomes of more than $160,000 after expenses Low-earners: Those with 2003 pre-tax individual incomes of less than $160,000 after expenses From a survey of 730 active AAFP members who had been out of residency five years or longer and worked at least 40 hours per week.

30 1) Providing more patient visits (high-earners saw a mean number of 122 patients per week; low-earners saw 84) 2) Practicing the full scope of family medicine in the hospital setting 3) Being in larger practices (which may be related to the next four factors) 4) Providing clinical lab, physical therapy, occupational therapy and imaging services in-house 5) Viewing negotiations with payers and evaluating contracts as very important Factors that have a Large Association with High Earning In order of significance

31 Factors that have a Large Association with High Earning In order of significance (continued) 6) Participating in quality improvement, marketing, strategic planning and benchmarking 7) Having in-house billing and collections 8) Seeing more Medicare patients (nationally, may vary by state) 9) Working more hours 10) Being paid based on productivity 11) Planning to purchase an EHR

32 Factors that Do Not Have a Significant Impact on Earning In no particular order Current use of an EHR Number of staff meetings Practice management courses for physicians or staff Educational level of in-house billing staff Fee-for-service versus capitated revenue Percentage of co-payments collected at the time of service Aging of accounts receivable

33 How does Compensation in Family Medicine compare to other Primary Care Specialties? What is the current demand for Primary Care Doctors?

34 Comparison between Different Specialties All Physicians vs. Starting Physicians 2006 AMGA Compensation Survey Primary Care Internal Medicine

35 Comparison between Different Specialties (By Region) 2006 AMGA Compensation Survey Primary Care Internal Medicine

36 Income Trends by Specialty Presented by Percentage of Physicians in Income Brackets Primary Care Internal Medicine

37 Current Demand for Family Physicians AMA News June, 2006 “ MOST WANTED For the first time in six years, general internists and family physicians are at the top of the ‘in demand’ list for hospitals and medicals groups, according to a review of 2,840 Merritt, Hawkins & Associates’ listings. Here by year are the number of physician searches by specialty starting in and continuing through ”

38 Current Demand for Family Physicians “According to Merritt, Hawkins & Associates’ 2005 Survey of Hospital Physician Recruiting Trends, more hospitals are actively engaged in recruiting family physicians than any other type of physician.” - Leslie Champlin – AAFP News Now (7/25/06)

39 Future Earning Potential “It isn't unusual for students to hear that physicians working in family medicine don’t make enough to pay off their loans. However, the truth is that family physicians make enough money to pay off student loans and have the lifestyle they want.” “In the future, incomes for family physicians are projected to increase as much as 25% in practices that use new technologies and new care models, such as chronic disease management.” Debt Management – Publication of American Academy of Family Physicians, 2007


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