Doximity Physician Pay Survey Raises More Questions Than It Answers

I recently got into it on Twitter with Leah Houston, M.D. regarding physician pay scales, and an alleged gender pay gap:

Serious question: what do you think of the looming physician-hours crisis? It seems to me this comes in (at least) two dimensions:

1) Insane levels of “paperwork”.
2) The feminization of the field. As of last year, a majority of incoming med school students were women. >

— Rob McMillin (@scareduck) April 11, 2019

Then, this:

Seriously? A “pay gap” that compares aggregate wages of male versus female doctors that fails to control for hours worked, continuity of employment, and specialization? For shame. This has been multiply debunked in the broad economy. No reason to think doctors are any different.

— Rob McMillin (@scareduck) April 11, 2019

(I was wrong about the control for hours, but see below.) The principal argument here comes from the 2019 Doximity physician pay report (PDF), but when you skip down to their methodology (p. 16), you see this:

Doximity’s study is drawn from self-reported compensation surveys completed by approximately 90,000 full-time, licensed U.S. physicians who practice at least 40 hours per week. Responses were mapped across metropolitan statistical areas, and the top 50 were ranked by the number of respondents in the data.

To control for differences in specialty, geography, and other provider-specific factors that might influence spending, we estimated a multivariate regression with fixed effects for provider specialty and MSA. We also controlled for how long each provider has practiced medicine and their self-reported average hours worked per week. This regression was estimated using a generalized linear model with a log link and gamma distribution. For the geographic and specialty rankings, we used the predicted values from this regression.

So, some questions:

1. Why does this not take into consideration interruptions in service years? Or, does "how long each provider has practiced medicine" refer to actual service time (opposite time since receiving certification)?
2. Was sex used for the multivariate analysis? If not, why not?
3. Why are self-reported hours not mentioned in the results? Considering the fracas of Relative Value Units, this would be valuable to know.
4. How many hours does an average male full-time physician work? How many for females?
5. When you say you queried "approximately 90,000 full-time, licensed U.S. physicians who practice at least 40 hours per week", is that physician-patient face time, or overall compensated time?

Overall, it does not seem to me that this looks closely enough at the data (and likely, does not ask the right questions) to arrive at any substantive conclusions as to whether there is a gender pay gap for physicians, even in the same specialty and market. 

Physicians Per Capita Continues Up In 2016 FSMB Survey

Good news on a subject I've harped on before: physicians per capita as a fundamental cause of the cost of medicine. Absent adequate supply, it almost doesn't matter what kind of payment system we have: medicine can't get cheaper without a bigger workforce. Accordingly, the Federation of State Medical Boards has published their 2016 survey results (PDF). The topline figure of 953,695 alleopathic and osteopathic physicians represents a 12% increase since 2010, and a 4.09% increase from 2014. This is a 2.01% annual growth rate, which is slightly off the pace of 2.14% rate I calculated in January, 2017 based on the 2014 survey (no longer available). Given the overall US population rate appears to be growing at about 0.7% annually, this is more than keeping pace with overall population growth, a good thing.

Physician immigration continues to be important, with Indian physicians, and physicians studying in the Caribbean countries, being the two most important sources:

India by itself provides about 23% of the immigrant physician population, and 5.1% of all US physicians. A majority of doctors studying in Caribbean countries are US citizens, and this has been true for years:

The largest single age group of physicians is those in their 60s, something that will have consequences as this group nears retirement — and as modern medicine becomes more bureaucratic:

Women physicians under 40 are now nearly double the number of men in the same age cohort, reducing available physician hours:

In all, mostly good news, but there's still an obvious iceberg ahead with pending retirements, Trumpian immigration restrictions, the crisis of part-time physicians, and Medicare internship throttling.

Shooting The Messenger On Part-Time Female Physicians

Tell the truth these days (or come close to it) and your assured destruction at the hands of the feminist lynch mob will soon ensue. Take Dr. Gary Tigges, M.D., P.A., who recently said of the alleged gender gap in pay among physicians,

Yes, there is a pay gap. Female physicians do not work as hard and do not see as many patients as male physicians. This is because they choose to, or they simply don’t want to be rushed, or they don’t want to work the long hours. Most of the time, their priority is something else … family, social, whatever.

Nothing needs to be “done” about this unless female physicians actually want to work harder and put in the hours. If not, they should be paid less. That is fair.

Of course, this yielded a pointless apology from him, a dumb parody piece (uncharacteristically) from Gomerblog — and the usual horrified objections disconnected from any actual rebuttal. Take this one from the American Council of Science and Health, by Jamie Wells, M.D. Mostly indignant offense-taking, she finally settles down to marshal something resembling an argument. And by "resembling", I mean just that, because it isn't much of one. For instance:

Dr. Tigges' misguided statements, out of step with more than a decade of data that disputes his biased assertions demonstrating that female physicians are not only as good as their male counterparts but in many instances provide higher quality care with better outcomes, are commonly held beliefs throughout the healthcare system, particularly by those in management and administrative roles (see here and here).

But wasn't the issue compensation due to time spent in patient care, not administrators and managers? Okay, let's keep going. Maybe she provides something of substance anon.

Another example that is standard fare for those subscribing to the Tigges way of thinking is that more women physicians work part-time. The reasons for this are often mischaracterized as "their choice." This is often not the case. Practices don't have to cover benefits or pay as much for part-time, so they offer it instead which uniformly results in full-time work for part-time pay. Changing jobs or accepting the reality of seeing more for less until something better comes is a mainstay dilemma for countless women.

This word salad rebuts not at all Tigges' assertion that women see fewer patients. Perhaps it is not their fault. But so what? Earlier, she complains of "the perverse payment incentives of the RVU (relative value unit) system here which values low quality, high volume patient mill type medical practice." All these things may be true. But, again, they do not form a counterargument.  At last, she drags out the big guns, from something called Equity Quotient. There, we learn

• Of 446 major U.S. occupations, physicians have largest median gender-based pay gaps; in some subspecialties, as much as $90k (Wall Street Journal 2016)
  
• Over $9,000 per physician/per year is spent by healthcare organizations due to gender inequality — cost accrued from attrition, burnout and litigation (discrimination/sexual harassment).
  
• Total cost of recruitment, on-boarding, lost revenue, about $400k (up to $600k) for a single hospitalist

At last, an on-point citation with numbers! Unfortunately for Equity Quotient and Dr. Wells, the underlying 2016 Wall Street Journal story buttresses Dr. Tigges' assertion, not hers. The devil is in the details (paywall, emboldening mine):

The biggest gaps in many white-collar professions don’t easily lend themselves to legislative remedies. In fact, the Journal’s findings belie policy makers’ hope that the most-educated women would lead the way in shrinking the gap. Currently, more women than men graduate from college.

Wage transparency—requiring employers to report salary data—is “just not going to move the needle much,” says Claudia Goldin, a Harvard University economics professor and one of the country’s foremost scholars on gender and pay. Prof. Goldin found in a 2010 paper that men and women earned almost the same salaries right after receiving University of Chicago M.B.A.s. At least a decade after graduating, the women earned 57% of their male classmates.

The main factor, she and her co-authors concluded: Women became mothers, interrupted their careers and eschewed lengthy hours that generated higher paychecks. “These particular occupations,” Prof. Goldin says, “are not very forgiving of taking time off and having kids.”

The Journal’s analysis of Census Bureau data for the five years through 2014 found male doctors working full time earned about $210,000 annually on average. Female physicians made 64% of that, about $135,000 a year. Among personal financial advisers, men took in about $100,000 while women made about $62,000.

Many white-collar jobs give substantially larger financial rewards to those logging the longest hours and who job-hop often, phenomena that limit white-collar women who pull back for child-rearing. Researchers on the topic say ingrained workplace cultures also impede women’s earnings.

What those "workplace cultures" are, the unnamed researchers don't say later in the article, but one suspects it has to do with the expectation of long hours, among other things. As with the overall and principally bogus "pay gap", hours, continuity, and specialization produce higher returns. A multivariate analysis based on specialty, time spent on the job, and continuity of employment would be useful. Too bad we don't appear to have it.

Previously: The Crisis of Part-Time Physicians

How Big Data Is Raising Costs And Killing Doctors

This week, I interviewed two doctors starting a new practice in Little Rock using the Direct Primary Care model. We talked a good bit about a number of issues, but particularly, those of Electronic Medical Records (EMR), their distribution, and security. It came up that their days as employees of the University of Arkansas for Medical Sciences went something like this:

• 8:00 AM to 12:00 PM: see patients (with fit-ins possibly pushing that back to 1:00 PM)
• Lunch
• 1:00-2:00 PM to 6:00 PM: paperwork (ICD-10 coding, mainly)

That is to say, they were expensive secretaries whose time was better spent doing other things. Doctors are scarce as it is, and this makes a bad situation worse. It also meant that these two young women were unable to pick up their children from daycare, even given a ten-hour window! It is all too sadly typical:

A recent study in the Annals of Family Medicine used the E.M.R. to examine the work of 142 family medicine physicians over three years. These doctors spent more than half of their time — six hours of their average 11-hour day — on the E.M.R., of which nearly an hour and a half took place after the clinic closed.

Another study, in Health Affairs, tracked the activities of 471 primary care doctors over a three-year period, and also found that E.M.R. time edged out face-to-face time with patients.

This study came on the heels of another analysis, in the Annals of Internal Medicine, in which 57 physicians were observed directly for 430 hours. The researchers found that doctors spent nearly twice as much time doing administrative work as actually seeing patients: 49 percent of their time, versus 27 percent.

The insanity of such paperwork loads is obvious, and contributes mightily to physician burnout. According to a study from the Mayo Clinic, 1 in 5 doctors plan to curtail their clinical hours over the next two years, and 1 in 50 plan on leaving the field altogether. Big Data comes with real-world consequences. Remember that the next time you see some self-interested company pitching its wares as a means to improve outcomes or costs,  or some dimwit politicians endorsing it using fatuous acronyms.

Burning Down The Medical Village To Save It: The Folly Of Big Data In Medicine

Rena Xu's recent piece in The Atlantic on physician burnout is mostly interesting for its between-the-lines reporting. Yes, Big Data (i.e. medical coding) is driving a lot of physician burnout:

Regulations governing the use of electronic medical records (EMRs), first introduced in the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, have gotten more and more demanding, while expanded insurance coverage from the Affordable Care Act may have contributed to an uptrend in patient volume at many health centers. These changes are taking a toll on physicians: There’s some evidence that the administrative burden of medicine—and with it, the proportion of burned-out doctors—is on the rise. A study published last year in Health Affairs reported that from 2011 to 2014, physicians spent progressively more time on “desktop medicine” and less on face-to-face patient care. Another study found that the percentage of physicians reporting burnout increased over the same period; by 2014, more than half said they were affected.

But won't we need ever-more new physicians to deal with the aging US population? Yes, we will, but —

A quarter of U.S. physicians are expected to retire over the next decade, while the number of older Americans, who tend to need more health care, is expected to double by 2040. While it might be tempting to point to the historically competitive rates of medical-school admissions as proof that the talent pipeline for physicians won’t run dry, there is no guarantee. Last year, for the first time in at least a decade, the volume of medical school applications dropped—by nearly 14,000, according to data from the Association of American Medical Colleges. By the association’s projections, we may be short 100,000 physicians or more by 2030.

And this despite modest, recent upticks in new physicians, even despite Medicare's meddling in internship slots. In addition, the article cites the "Resident Physician Shortage Reduction Act ... [which] would add 15,000 residency spots over a five-year period." That's a 1.6% increase vs. the 2014 physician population of 916,264, but nothing compared to the gaping hole implied by 100,000 missing doctors. Mandated medical coding — the raw material of Big Data in medicine — contributes to a physician burnout we can scarcely afford.

But this kind of insanity is to be expected. The people who imagine they are helping very frequently do not subject themselves to the consequences of their "help" (viz., Jonathan Gruber, who is not a doctor). The meretricious belief that big data will somehow "bend the cost curve" is deeply embedded, including, especially, in service providers with something to sell. There are costs to acquiring that data, and that cost is, more administrative overhead (emboldening mine):

...[D]octors are most valuable when doing what they were trained to do—treating patients. Likewise, non-physicians are better suited to accomplish many of the tasks that currently fall upon physicians. The use of medical scribes during clinic visits, for instance, not only frees doctors to talk with their patients but also potentially yields better documentation. A study published last month in the World Journal of Urology reported that the introduction of scribes in a urology practice significantly increased physician efficiency, work satisfaction, and revenue.

And who pays for that increased revenue? Ultimately, it's the patients, of course, or the government (taxpayers) if it's Medicare/Medicaid.

The Crisis of Part-Time Physicians

Something that came up elsewhere, but for which I was unaware of the magnitude of the problem: according to one unsourced estimate, around 30% of female physicians work part time. A better 2011 estimate in the Journal of the American Medical Association shows 21% of the physician workforce is part-time, with that figure plateauing as of 2015, of which 44% of female physicians worked part-time. Where this starts to get scary is in a recent Association of American Medical Colleges announcement that a slight majority of new med students are female, 50.7% of the overall total. Given that women exit internships into practice in prime reproductive years and are thus more likely to want time off for family, it suggests an upcoming crisis in terms of overall physician hours available: not all physicians are willing to work the same number of hours.

We're Doomed Dep't: Now Docs In Their 60's Outnumber Those In Their 30's (Updated With Some Good News)

I cannot make this stuff up (PDF, see the 2014 population statistics on p. 4). I have written about this before; the insane problems of new physician minting will not go away, and apparently are not being attended to, titular but comically small efforts notwithstanding. In two years, about thirty thousand doctors entered their sixties, i.e. near retirement age, while physicians in their 30's actually diminished, both in absolute population and as a percentage of the overall population. The problems of healthcare costs can not be properly addressed until we get the physician shortage addressed.

Update 2017-01-14: Last night, in a Facebook conversation Jerry Thornton made the point that the headline good news was a 4% increase in the overall physician population from 2012 to 2014. It's useful to do some quick checks to make sure this is of significant import relative to the larger problem, i.e. that of overall physician-to-population ratio. From my earlier work, the OECD average is 30.6 physicians per 10,000 population, or 3.06x10^-3, expressed in scientific notation. How long will it take to get the US from where it is to there?

• 2012 estimated US population: 314 million. (Population is only known precisely in census years, but is estimated between them. Source page here.)
• 2014 estimated US population: 319 million. (From the same source above.)
• OECD most recent year physician-to-population ratio: 3.29x10^-3 physicians/population. (It's actually gone up.)
• US most recent year physician-to-population ratio: 2.56x10^-3 (from the prior link)
• US physician population, 2012: 878,194
• US physician population, 2014: 916,264

 Let's find the annual physician growth rate first.

916 264 = 878 194(1+x)²

Solving for x, the annual physician population growth rate, gets us

x = sqrt(916 264/878 194)-1 = 2.14x10^-2

Now, the general population is growing at the same time. How much? Let's do the same math:

p = sqrt(319/314)-1 = 7.93x10^-3

So when will these converge at the OECD average of 3.29x10^-3 physicians/population? (I ignore the growth in the OECD average physician-to-population ratio.) Note that the Journal of Medical Regulation census physician population divided by the US Census general population figure gives us 2.87x10^-3, which is higher than the OECD physician-to-population figure; we'll use that as a basis anyway, as both numbers are presumably more up-to-date, and won't make much of a difference relatively.

916 264 physicians * (1+2.14x10^-2)ⁿ/3.19x10⁸ population * (1+7.93x10^-3)ⁿ = 3.29x10^-3 physicians/population

Solving for n, the number of years until the US meets the OECD average physician-to-population ratio, we get 10.5 years, which is pretty fast as these timelines go. However, given OECD physician-to-population ratios are rising (almost certainly in response to population aging), it's probably somewhat misleading.

Update 2017-01-15: Even more interesting: feet-on-the-ground physicians vs. state populations for the 50 states ratio is 385 physicians per 100,000 population, which puts the US in the upper half, at least, and maybe the upper third. This makes me wonder about the OECD methodology; do they count expats in the denominator?

Repost: Obamacare's Token Attempt To Adjust Physician Levels

Originally posted to Facebook 2014-04-29, reposted here for the usual reasons.

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Something that came out of a discussion elsewhere ... I have long said that Obamacare does nothing to actually reduce costs, because it does not attempt to increase the supply of providers, either through practice liberalization (as by allowing nurse practitioners to perform certain procedures now only permitted to physicians) or through licensing liberalization (increasing the number of physicians). Mary Cvetan sent me hither, a website (she, at least in part wrote) that makes mention of the following:

Training New Primary Care Providers: The Affordable Care Act invests in the training of new primary care providers, including providing nearly $230 million to increase the number of medical residents, as well as funding to increase the number of nurse practitioners and physician assistants trained in primary care.  With these investments, by 2015, more than 1,700 new primary care providers will have been trained and enter primary care practice. The Fiscal Year 2014 budget includes investments that will expand the capacity of institutions to train 2,800 additional primary care providers over five years.

Is this a significant number? Per the Henry J. Kaiser Family Foundation, the US has 24.2 physicians per 10,000 population, which means, rounding down to 300,000,000 population, that the physician population is 720,000 or so, of which 1,700 would amount to less than one percent (actually 0.2%). It's entirely possible that this actually represents a figure below retirement replacement. If Obamacare wishes to lay claim to fixing the supply side of things, it must needs do better. This, however, runs square against the AMA's interests, and so I have my doubts.

Update 4/30/2014: In a surprisingly candid blog post on Mother Jones, Kevin Drum late last year pointed out that the reason US physicians are paid so much is because there are so few of them relative to other nations; the US is in the bottom third of physicians to population. To get to the OECD mean of 30.6, you would have to increase the US physician population by a quarter. And that's just to arrive at average.

How Medicare Feeds The Physician Shortage

One of the big issues feeding medical cost growth is the current physician shortage, exacerbated by increasing numbers of retirees (and their attendant needs to see physicians), and a too-small pipeline of new physicians. I knew that the AMA had a great deal to say about that (and Federal funding as well), but I did not know the specifics until this great post at the Mercatus Center laid it all out:

Adding to the problem, and yet less noticed, is how the financing of graduate medical education is restricting the supply of doctors. This will be a surprise to many readers — Medicare funds GME [Graduate Medical Education] and residency programs. To be a licensed physician, a person must attend medical school and then pass board certification (both at great expense). What a lot of people outside the field of medicine don't realize is that to be a licensed physician, a doctor must also complete additional graduate medical education in a residency program. Finding a proper "match" for a residency relies in part on an algorithm that appears more complicated than astrophysics.

A Wall Street Journal article addressed the problem of a residency program shortage back in 2013, but the financing problem has only increased since. According to the Institute of Medicine, taxpayers provide $15 billion in GME support; Medicare provides $9.7 billion, Medicaid $3.9 billion, and the Veterans Health Administration an additional $1.4 billion. These funding levels have essentially been capped since 1997.

From a public policy perspective, it is questionable whether the federal government should finance GME, or whether hospitals that benefit from the cheap labor of residents should be picking up the cost of training doctors. Either way, without additional resources to fund residency programs, the nation may end up with a shortage of physicians and limit the availability of retirees to see and choose a doctor.

The state breaking the link between supply and demand, while putting in competitive moats for a politically powerful lobby? Say it ain't so...

Four Things That Almost Nobody Is Talking About That Need Fixing In Medicine

Obamacare is a farce, but its proponents frequently pull out the fact that it was, in large strokes, derived from a 1993 Heritage Foundation proposal. Significant in that Politifact piece is the following graf:

"The Chafee plan did not spell out how increased coverage would be financed," [Clinton adviser Paul] Starr said. "It was more of a symbolic bill than an actual piece of legislation."

This confirms a sense I've had of the Heritage plan: it always seemed like a half-baked idea that was intended more as a negotiating counter to Hillarycare, i.e. a delaying tactic, rather than a serious proposal. The Heritage plan was always a thing-on-a-thing, scaffolding erecting the next story on an already ungainly building. And of course, therein lay the trouble; its flaws were the flaws of ad hoc tax law manipulations that originated in World War II as a consequence of wartime pay restrictions.

All of which is to say, of course, that the solution for such problems has nothing to do with adding more mandates or subtracting restrictions on insurance, as Avik Roy sadly did, or more recently, John C. Goodman's proposal. Both retain the deep ties to the insurance industry that have done so much to degrade health care in this country, a reality limned by David Goldhill in The Atlantic, an article he later expanded into a book, Catastrophic Care. As I mentioned the other day, the most frequently mentioned repair for Obamacare from the Democratic side is single-payer, which for the reasons Megan McArdle recently outlined, is an economic non-starter (and with the Vermont failure, politically dead). Instead, I want to focus on four things that few people are currently discussing that need repair in medicine that could materially reduce costs. They all have in common the market, the one way we know best that works to reduce actual costs, not apparent costs.

1. End low-deductible insurance.  Goldhill outlines the problems with low-deductible insurance: by shielding prices from consumers, it saps power from and accountability to the patient, and eliminates meaningful cost comparison. This has all kinds of bad consequences, from steady cost inflation, deteriorating service, and adverse outcomes (even including death). The solution is to remove insurers from most transactions, and let people purchase directly their own medical care. The first step should be extending the medical income tax credit as a first-dollar deduction for individuals, rather than making the deduction so high that few ever qualify. The next would be to limit insurance to those things it truly does well: management of extraordinary expenses, i.e. risk.
2. Break the American Medical Association's cartel. It's a rare day when you'll see me agree with anything appearing on the pages of Mother Jones, but their analysis of why US physicians have such high compensation is both simple and spot on: because the US is in roughly the bottom third of OECD countries by physicians per 10,000 population. Their non-solution to this problem is to say, suck it, docs, which won't work; the real answer is that the AMA's ability to limit medical school slots and internships must end. Similarly, the AMA has succeeded in gaining a monopoly on the prescription pad and otherwise limiting practice options by registered nurses (who must attach themselves to a physician or practice for various legal reasons). California came very close to nurse practitioner liberalization just last year, only to have the AMA kill the idea.
3. Limit patents to 17 years, period. As it stands now, devices patented in the 1970's are still getting repatented for various uses that have the net effect of creating long-running monopolies counter to the interests of patients and consumers. An excellent example is the Epi-pen; created by the military for field use, it should have had no patent issued, ever. Instead, its 1977 patent continues to be renewed by various kinds of chicanery; this has the result of making the product in the US cost more than three times that in Canada, and that doesn't include the cost of getting the doctor's prescription.
4. Remove anticompetitive Certificate of Need state laws. Remember the Texas car dealers who bought a law in Austin to keep Tesla out of their state thanks to a business model that dispenses with independent car dealers? Something very like that is in play with Certificate of Need laws, which amount to a "government permission slip" for new competition. By creating a moat around existing hospitals and other medical facilities, governments retard actual competition and thus raise prices:

Studies of the COPN system around the country have confirmed what seems intuitively obvious. A joint examination by the Justice Department and the Federal Trade Commission found that COPN regulations hurt competition, fail to contain costs, and “can actually lead to price increases.” Restricting supply raises prices? Imagine that.

I do not claim this list is complete or even exhaustive. It does seem to me, however, that all are obvious flaws of the current system. Some will require cage-match fights to the death — patent reform particularly is unlikely without it — but all address actual, underlying costs, unlike Obamacare or even the Republican repair proposals.