The costs of making practice more cost-effective.
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Cost-Benefit Analysis↗
Biomedical subjects
Amy E Wallace
Publications and source records attributed to Amy E Wallace.
Financial returns on specialty training for surgeons.
BACKGROUND: Because of recent changes in physician reimbursement and managed care penetration, we wanted to examine the financial returns that medical students might anticipate when considering different careers. METHODS. We used standard financial techniques to calculate the return on educational investment for 5 surgical specialties (general surgery, otolaryngology, ophthalmology, orthopedic surgery, and urology) and primary care medicine between 1992 and 1998. RESULTS: The annual yield on specialty training fell for all specialties examined, from an average of 15% to 3% for primary care specialties, and from an average of 36% to 19% for surgical specialties. The difference in the average future hourly income between a given specialty and general practice decreased for all surgical specialties (for general surgery, from $12.03 in 1992 to $9.89 in 1998; otolaryngology, from $21.37 to $5.56; ophthalmology, from $14.12 to $7.15; orthopedic surgery, from $21.16 to $18.91), except urology (from $13.81 in 1992 to $14.84 in 1998). Returns became negative for primary care medicine, dropping from $1.72 to -$1.21. CONCLUSION: Efforts to create a "level playing field" within medicine have resulted in decreased returns on educational investment across all specialties. Financial returns and the incentives they create should be carefully considered as part of health care reform.
Income↗
The more things change: revisiting a comparison of educational costs and incomes of physicians and other professionals.
The authors previously compared the 1990 educational costs and incomes of physicians and other professional groups. Since then, there have been dramatic changes in the market for the groups examined. This article reports their update of the previous analysis, using 1997 data. For this update, the authors applied standard financial techniques to expected incomes and educational costs to determine the return on educational investment over the working lifetime for five professional groups: primary care physicians, procedure-based physicians, dentists, attorneys, and graduates of the top 20 business schools. The hours-adjusted net present values of the educational investments for attorneys ($10.73) and procedure-based physicians ($10.40) are considerably higher than those for dentists ($8.90) and businessmen ($8.27); the return for primary care physicians ($5.97) remains much lower than all others. Primary care physicians have an hours-adjusted internal rate of return on their educational investment equal to 16%, compared with 18% for procedure-based medicine, 22% for dentistry, 23% for law, and 26% for business. Although it remains the lowest of all professional groups examined, primary care medicine has made the largest percentage gain in net present value of all groups. Although anticipated changes in physician incomes have occurred, the standing of physicians relative to other professional groups has not changed. Students can still anticipate relatively poorer returns on their educational investment when they choose a career in primary care medicine as compared with careers in procedure-based medicine or surgical specialties, business, law, or dentistry.
Career Choice↗
Differences in income between male and female primary care physicians.
OBJECTIVES: to determine whether sex differences in income persist among primary care physicians in light of the increasing proportion of women entering the field. METHODS: We obtained sex- and age-specific self-reported data from the American Medical Association's annual survey of physicians to determine the annual income, annual income per hours worked, proportion of time in direct patient care, and outpatient productivity for family practice physicians, general internists, and pediatricians between 1989 and 1998. We compared female to male results for respondents in the 36- to 45-year-old age group as well as for the age-weighted gender aggregate. RESULTS: Female primary care physicians reported lower annual incomes (between 60% and 85% of those of their male counterparts) and lower incomes per hours worked (between 71% and 98% of those of their male counterparts). The income disparities decreased during the 10 years, at a rate of about 1% per year on average. Although the proportion of time female physicians spent in direct patient care activities was similar to that of their male counterparts, female physicians saw substantially more patients per office hour (about 17% more, on average, over time). CONCLUSIONS: Gender inequities persist in the incomes of primary care physicians. Although the disparities appear to be decreasing, female primary care physicians' increased productivity compared with men's suggests that these inequities are perpetuated in more subtle ways and warrant immediate examination and remediation.
Adult↗
Medicare payment changes and physicians' incomes.
An effort to control the physician portion of Medicare expenditures and to narrow the income gap between primary care and procedure-based physicians was effected through t he enactment of the Medicare Fee Schedule (MFS). To determine whether academic and private sector physicians' incomes had demonstrated changes consistent with payment changes, we collected income information from surveys of private sector physicians and academic physicians in six specialties: (1) family practice; (2) general internal medicine; (3) psychiatry; (4) general surgery; (5) radiology; and (6) anesthesiology. With the exception of general internal medicine, the anticipated changes in Medicare revenue were not closely associated with income changes in either the academic or private sector group. Academic physicians were underpaid, relative to their private sector counterparts, but modestly less so at the end of the period examined. Our findings suggest that using changes in payment schedules to change incomes in order to influence the attractiveness of different specialties, even with a very large payer, may be ineffective. Should academic incomes remain uncompetitive with private sector incomes, it may be increasingly difficult to persuade physicians to enter academic careers.
Academic Medical Centers↗
A cumulative meta-analysis of selective serotonin reuptake inhibitors in pediatric depression: did unpublished studies influence the efficacy/safety debate?
OBJECTIVE: The aim of this study was to assess whether unpublished trials of serotonin reuptake inhibitors in pediatric depression impacted efficacy or safety conclusions, and to examine the evolution of information contributing to the safety/efficacy debate. METHOD: From 939 potentially relevant studies extracted from Medline, Cinahl, Biosis, and Cochrane databases, and from the United Kingdom's Committee on Safety of Medicines website, we examined 38 studies: Ten published and five unpublished randomized, controlled trials, 22 observational studies, and one crossover trial. We performed cumulative and non-cumulative meta-analyses and generated pooled relative rates of response and serious adverse events for high-quality randomized, controlled trials. RESULTS: Unpublished studies did not substantially alter the risk-to-benefit determination. Cumulative meta-analyses of seven randomized, controlled trials for efficacy and 11 randomized, controlled trials for safety suggest an adverse safety/efficacy profile for selective serotonin reuptake inhibitors (SSRIs) overall. Fluoxetine and citalopram appear to offer favorable risk to benefit profiles, while shorter-acting agents pose greater risks and provide marginal benefit. CONCLUSIONS: While simple meta-analysis across all SSRIs for treatment of pediatric depression provided general efficacy and safety information, meta-analysis of individual drugs and use of cumulative meta-analytic techniques may have expedited our ability to formulate conclusions about safety and efficacy of SSRIs in pediatric depression.
Adolescent↗