Industry Payments to US Physicians by Specialty and Product Type.

This study examines the distribution of payments within and across specialties and the medical products associated with the largest total payments.

Microeconomic institutions and personnel economics for health care delivery: a formal exploration of what matters to health workers in Rwanda.

BACKGROUND: Most developing countries face important challenges regarding the quality of health care, and there is a growing consensus that health workers play a key role in this process. Our understanding as to what are the key institutional challenges in human resources, and their underlying driving forces, is more limited. A conceptual framework that structures existing insights and provides concrete directions for policymaking is also missing. METHODS: To gain a bottom-up perspective, we gather qualitative data through semi-structured interviews with different levels of health workers and users of health services in rural and urban Rwanda. We conducted discussions with 48 health workers and 25 users of health services in nine different groups in 2005. We maximized within-group heterogeneity by selecting participants using specific criteria that affect health worker performance and career choice. The discussion were analysed electronically, to identify key themes and insights, and are documented with a descriptive quantitative analysis relating to the associations between quotations. The findings from this research are then revisited 10 years later making use of detailed follow-up studies that have been carried out since then. RESULTS: The original discussions identified both key challenges in human resources for health and driving forces of these challenges, as well as possible solutions. Two sets of issues were highlighted: those related to the size and distribution of the workforce and those related to health workers' on-the-job performance. Among the latter, four categories were identified: health workers' poor attitudes towards patients, absenteeism, corruption and embezzlement and lack of medical skills among some categories of health workers. The discussion suggest that four components constitute the deeper causal factors, which are, ranked in order of ease of malleability, incentives, monitoring arrangements, professional and workplace norms and intrinsic motivation. Three institutional innovations are identified that aim at improving performance: performance pay, community health workers and increased attention to training of health workers. Revisiting the findings from this primary research making use of later in-depth studies, the analysis demonstrates their continued relevance and usefulness. We discuss how the different factors affect the quality of care by impacting on health worker performance and labour market choices, making use of insights from economics and development studies on the role of institutions. CONCLUSION: The study results indicate that health care quality to an important degree depends on four institutional factors at the microlevel that strongly impact on health workers' performance and career choice, and which deserve more attention in applied research and policy reform. The analysis also helps to identify ways forwards, which fit well with the Ministry's most recent strategic plan.

US Postgraduate Trainee Racial, Ethnic, and Gender Representation and Faculty Compensation By Specialty.

This study compares postgraduate trainee racial, ethnic, and gender representation and faculty compensation for 21 clinical specialties using 2015-2022 data.

Recommendations for Emerging Good Practice and Future Research in Relation to Family and Caregiver Health Spillovers in Health Economic Evaluations: A Report of the SHEER Task Force.

BACKGROUND: Omission of family and caregiver health spillovers from the economic evaluation of healthcare interventions remains common practice. When reported, a high degree of methodological inconsistency in incorporating spillovers has been observed. AIM: To promote emerging good practice, this paper from the Spillovers in Health Economic Evaluation and Research (SHEER) task force aims to provide guidance on the incorporation of family and caregiver health spillovers in cost-effectiveness and cost-utility analysis. SHEER also seeks to inform the basis for a spillover research agenda and future practice. METHODS: A modified nominal group technique was used to reach consensus on a set of recommendations, representative of the views of participating subject-matter experts. Through the structured discussions of the group, as well as on the basis of evidence identified during a review process, recommendations were proposed and voted upon, with voting being held over two rounds. RESULTS: This report describes 11 consensus recommendations for emerging good practice. SHEER advocates for the incorporation of health spillovers into analyses conducted from a healthcare/health payer perspective, and more generally inclusive perspectives such as a societal perspective. Where possible, spillovers related to displaced/foregone activities should be considered, as should the distributional consequences of inclusion. Time horizons ought to be sufficient to capture all relevant impacts. Currently, the collection of primary spillover data is preferred and clear justification should be provided when using secondary data. Transparency and consistency when reporting on the incorporation of health spillovers are crucial. In addition, given that the evidence base relating to health spillovers remains limited and requires much development, 12 avenues for future research are proposed. CONCLUSIONS: Consideration of health spillovers in economic evaluations has been called for by researchers and policymakers alike. Accordingly, it is hoped that the consensus recommendations of SHEER will motivate more widespread incorporation of health spillovers into analyses. The developing nature of spillover research necessitates that this guidance be viewed as an initial roadmap, rather than a strict checklist. Moreover, there is a need for balance between consistency in approach, where valuable in a decision making context, and variation in application, to reflect differing decision maker perspectives and to support innovation.

Medicine as business: are doctors entrepreneurs?

KIE: The emergence of health care in the United States as an industry, with a major role being played by for-profit providers, has stimulated debate over what happens to traditional medical values and relationships when medicine and money mix. In 1986, the Institute of Medicine contributed to the debate with the publication of its report, For-Profit Enterprise in Health Care. Two members of the committee preparing the document, physician and editor (The New England Journal of Medicine) Arnold Relman, and Princeton economist Uwe Reinhardt, corresponded concerning their differing views on the physician's role in a profit-oriented health system. Edited versions of some of their letters appear here, with Reinhardt arguing that doctors are and have always been businessmen, and Relman defending his profession as a calling entailing special obligations to patients.^ieng

Medical practice in the face of economic meltdown: peculiar challenges in Nigeria and other developing countries.

BACKGROUND: The impact of the global economic meltdown on every sector of economic activity has been enormous, especially in the developing countries. Medical practice in these nations has been particularly challenged and stretched under this milieu. This paper thus sets out to evaluate the phenomenon of economic meltdown with its effects on the developing countries, the challenges it poses to medical practice, with Nigeria as a case study, and makes suggestions to address this scenario. METHOD: A review of the literature on economic meltdown with particular emphasis on the effect on medical practice, was done, with focus on the developing countries, and specifically Nigeria. Literature search was conducted using the Medline, Google search engine, the media, as well as national and localjournals. RESULTS: The definition and historical perspectives of global economic meltdown, as well as the geographical location of the developing countries, are set out. The peculiar economic challenges and those in the medical practice, with the concomitant glaring effects in the developing nations, with particular reference to the Nigerian situation, are outlined. Specific measures to adopt in addressing these challenges are suggested in this paper. CONCLUSION: The peculiar challenges of the global economic meltdown on medical practice in the developing world, and in Nigeria particularly, must be addressed wholisticaly involving every sector of the economy, with fundamental policy and structural changes put in place.

Billing Codes Determine Lower Physician Income for Primary Care and Non-Procedural Specialties.

The income gap between specialists and primary care physicians and among specialists is well established, but the drivers of this difference are not well delineated. Using the Community Tracking Study (CTS) Physician Survey, we sought to isolate and compare premiums paid to physicians for specialization and the proportion of time spent on offices visit rather than procedures. We divided medical subspecialties according the proportion of Medicare billing for Evaluation and Management (E&M) codes for the specialty as a whole. We report substantial differences in income across physician specialty, and over 70 percent of the difference in income remained controlling for factors that may confound the relationship between income and specialty including gender, location and type of practice, and hours. We note a large variation in premiums for specialization: 11.3-46.8 percent above family medicine after controlling for confounders. Classifying medical subspecialties by E&M billing as procedural versus non-procedural specialties revealed clear income differences. Controlling for confounders, procedural medical specialties earned 37.5 percent more than family medicine, as compared with 15.3 percent for non-procedural medical specialties. This analysis suggests that differences in physician income and resulting incentives are a direct consequence of the payment structure itself, rather than compensation for additional years of training or a reflection of different underlying demographics.

Revenue of consultant physicians for private out-patient consultations.

Objective The aim of this study was to determine the revenue to consultant physicians for private out-patient consultations. Specifically, the study determined changing patterns in revenue from 2011 to 2015 after accounting for bulk-billing rates, changes in gap fees and inflation. Methods An analysis was performed of consultant physician Medicare claims data from 2011 to 2015 for initial (Item 110) and subsequent (Item 116) consultations and, for patients with multiple morbidities, initial management planning (Item 132) and review consultations (Item 133). The analysis included 12 medical specialties representative of common adult non-surgical medical care. Revenue to consultant physicians was calculated for initial consultations (Item 110: standard; Item 132: complex) and subsequent consultations (Item 116: standard; Item 133: complex) accounting for bulk-billing rates, changes in gap fees and inflation. Results From 2011 to 2015, there was a decrease in inflation-adjusted revenue from standard initial and subsequent consultations (mean -$2.69 and -$1.03 respectively). Accounting for an increase in the use of item codes for complex consultations over the same time period, overall revenue from initial consultations increased (mean +$2.30) and overall revenue from subsequent consultations decreased slightly (mean -$0.28). All values reported are in Australian dollars. Conclusions The effect of the multiyear Medicare freeze on consultant physician revenue has been partially offset by changes in billing practices. What is known about the topic? There was a 'freeze' on Medicare schedule fees for consultations from November 2012 to July 2018. Concerns were expressed that the schedule has not kept pace with inflation and does not represent appropriate payments to physicians. What does this paper add? Accounting for bulk-billing, changes in gap fees and inflation, revenue from standard initial and subsequent consultations decreased from 2011 to 2015. Use of item codes for complex consultations (which have associated higher schedule fees) increased from 2011 to 2015. When standard and complex consultation codes are analysed together (and accounting for bulk-billing, changes in gap fees and inflation), revenue from initial consultations increased and revenue from subsequent consultations decreased slightly. What are the implications for practitioners? Efforts to control government expenditure through Medicare rebate payment freezes may result in unintended consequences. Although there were no overall decreases in bulk-billing rates, the shift to higher-rebate consultations was noticeable.

Sources of U.S. physician income: the contribution of government payments to the specialist-generalist income gap.

BACKGROUND: Physician income varies threefold among specialties. Lower incomes have produced shortages in primary care fields. OBJECTIVE: To investigate the impact of government policy on generating income differentials among specialties. DESIGN AND PARTICIPANTS: Cross-sectional analysis of the 2004 MEPS. MEASUREMENTS: For outpatient care, total payments made to 27 different types of specialists from five types of payers: Medicare, Medicaid, other government (the Veterans Administration and other state and local programs), private insurance, and out-of-pocket payments. For inpatient care, aggregate (i.e., all-specialty) inpatient physician reimbursement from the five payers. RESULTS: In 2004, physicians derived 78.6% of their practice income ($149,684 million, 95% CI, $140,784 million-$158,584 million) from outpatient sources and 21.4% of their income ($40,782 million, 95% CI, $36,839 million-$44,724 million) from inpatient sources. Government payers accounted for 32.7% of total physician income. Four specialties derived > 50% of their outpatient income from public sources, including both the lowest and highest paid specialties (geriatrics and hematology/oncology, respectively). CONCLUSIONS: Inter-specialty income differences result, in part, from government decisions.

The primary care-specialty income gap: why it matters.

A large, widening gap exists between the incomes of primary care physicians and those of many specialists. This disparity is important because noncompetitive primary care incomes discourage medical school graduates from choosing primary care careers. The Resource-Based Relative Value Scale, designed to reduce the inequality between fees for office visits and payment for procedures, failed to prevent the widening primary care-specialty income gap for 4 reasons: 1) The volume of diagnostic and imaging procedures has increased far more rapidly than the volume of office visits, which benefits specialists who perform those procedures; 2) the process of updating fees every 5 years is heavily influenced by the Relative Value Scale Update Committee, which is composed mainly of specialists; 3) Medicare's formula for controlling physician payments penalizes primary care physicians; and 4) private insurers tend to pay for procedures, but not for office visits, at higher levels than those paid by Medicare. Payment reform is essential to guarantee a healthy primary care base to the U.S. health care system.

Analysis of consultants' NHS and private incomes in England in 2003/4.

OBJECTIVE: Consultants employed by the NHS in England are allowed to undertake private practice to supplement their NHS income. Until the introduction of a new contract from October 2003, those employed on full-time contracts were allowed to earn private incomes no greater than 10% of their NHS income. In this paper we investigate the magnitude and determinants of consultants' NHS and private incomes. DESIGN: Quantitative analysis of financial data. SETTING: A unique, anonymized, non-disclosive dataset derived from tax returns for a sample of 24,407 consultants (92.3% of the total) in England for the financial year 2003/4. MAIN OUTCOME METHODS: The conditional mean total, NHS and private incomes earned by age group, type of contract, specialty and region of place of work. RESULTS: The mean annual total, NHS and private incomes across all consultants in 2003/4 were pound 110,773, pound 76,628 and pound 34,144, respectively. Incomes varied by age, type of contract, specialty and region of place of work. The ratio of mean private to NHS income for consultants employed on a full-time contract was 0.26. The mean private income across specialties ranged from pound 5,144 (for paediatric neurology) to pound 142,723 (plastic surgery). There was a positive association between mean private income and NHS waiting lists across specialties. CONCLUSIONS: Consultants employed on full-time contracts on average exceeded the limits on private income stipulated by the 10% rule. Specialty is a more important determinant of income than the region in which the consultant works. Further work is required to explore the association between mean private income and waiting lists.

The surgical workforce: averting a patient access crisis.

This article examines the state of the medical and surgical workforce, and how business-based and economic principles such as supply and demand have continued to shape it. Specifically, this article focuses on the following topics: past and present efforts to determine physician supply; where workforce shortages are most apparent at this time; and the factors that are contributing to the current shortfalls and their broader implications. In addition, the author looks ahead to determine what changes we need to support, promote, and make to meet our patients' evolving needs and expectations.

[Health economics from the physician's point of view]. / Gesundheitsökonomie aus der Sicht des Arztes.

Physicians should be aware that overall resources in health care are limited. Thus, available funds should be allocated in a fair and efficient manner. Although the daily work at the bedside or in the physician's office create many direct and even more indirect costs to the health care system, many physicians believe that cost-benefit considerations should not be part of the daily work because they are viewed as a disturbing factor in the patient-physician relationship. However, due to the limited resources, strategic measures that reduce health care costs but maintain quality are unavoidable. Physicians must be involved in the design and implementation of these measures, and the administrative burden to document progress must be kept as small as possible. As an example we would like to discuss the pay for performance programme of the National Health Service in the United Kingdom, launched in 2004. Physicians could improve their income by about 25% if they were able to accomplish a number of well-defined quality indicators. As much as 97% of the primary care physicians reached the pre-defined goals, and there was no indication for manipulation. This example shows that through the implementation of quality improvement programmes, the position of primary care medicine can even be strengthened. Sponsors of the health care system should continue to look for measures that maintain a high quality standard in primary care medicine. However, before this system can be widely implemented, active research is needed to evaluate whether privileging some quality indicators over others has negative consequences on overall societal health. Only through an open-minded discussion among all participants of the health care system including the general population will a solution be found that is capable of winning a majority and that takes into account the limited availability of resources.

Tax saving ideas for physician practices.

As a top-earning physician, you spend 40 percent to 50 percent of your working hours laboring for the IRS and your state. That is a lot of time with patients, at the practice, in the hospital and on call. This article offers five ways to potentially save taxes on your income and will possibly motivate you to investigate these planning concepts throughout the year.

Fighting for their share. As Congress ponders how to fix the sustainable growth-rate formula for physicians, hospitals are wary they'll be a target.

As Congress tries to figure out how to fix Medicare's physician payment system, other sectors of the industry are poised to protect their share of reimbursement. Hospitals in particular are worried that they'll be targeted to fix the problem with doctors' reimbursement, which Bill Petasnick, left, blames for driving the growth of specialty hospitals, imaging centers and ambulatory surgical centers.

[Basic concepts of health economics for general practitioners]. / Conceptos básicos de economía de la salud para el médico general.

Economic development is one of the main contributors of the health status of the people. Health economics combines the economics perspective of production with the social objectives of health sciences. The concepts of this new discipline are common in the academic health field and in the professional literature, thus, health professionals adopt and use regularly these terms. However, previous research has shown that the average physician has poor knowledge and/or clarity about the meaning of health economics concepts. The objective of this article is to provide the basic concepts of health economics.

The Recent Losses in Medicare Imaging Revenues Experienced by Radiologists, Cardiologists, and Other Physicians.

PURPOSE: The aim of this study was to assess recent trends in Medicare reimbursements to radiologists, cardiologists, and other physicians for noninvasive diagnostic imaging (NDI). METHODS: The Medicare Part B databases for 2002 to 2015 were the data source. These files provide total allowed payments for all NDI Current Procedural Terminology codes under the Medicare Physician Fee Schedule. Medicare specialty codes were used to identify payments to radiologists, cardiologists, and all other specialists. In additional to total reimbursements, those made for global, technical component, and professional component claims were studied. RESULTS: Total reimbursements to physicians for NDI under the Medicare Physician Fee Schedule peaked at $11.936 billion in 2006. Over the ensuing years, the Deficit Reduction Act and other cuts reduced them by 33% to $8.005 billion in 2015. Reimbursements to radiologists peaked at $5.300 billion in 2006 but dropped to $4.269 billion by 2015 (-19.5%). NDI reimbursements to cardiologists dropped from $2.998 billion in 2006 to $1.653 billion by 2015 (-44.9%). Most other specialties also saw decreases over the study period. An important reason for the large decline for cardiologists was their dependence on global reimbursement, which saw a 50.5% drop from 2006 to 2015. Radiologists' global payments also dropped sharply (40.4%), but radiologists themselves were somewhat protected by receiving a much larger proportion of their reimbursement for the professional component, which was not nearly as affected by Medicare payment reductions. CONCLUSIONS: The Deficit Reduction Act and other NDI payment cuts that followed have created huge savings for the Medicare program but have led to sharp reductions in payments received by radiologists, cardiologists, and other physicians for those services.