House bill would end PSLF, current to be grandfathered

[Matt]

Zaphod wrote:

This is so vastly different than adult onc/nephro isnt it? What makes the discrepancy so huge?

Click to expand...

There's several issues.  The payor difference is probably the biggest one (I'm about 70% Medicaid).  There's also the inherent underpayment for all Peds services (thanks AAP!).  We also tend to be employed by hospital systems, and don't own/run our own infusion centers, which is where a lot of adult oncs make their money.  In fairness, the adult oncs do tend to see a lot more volume than we do (although ours tend to be higher acuity).

Kamban wrote:

Which does not even cover the cost of the high priced cancer drugs.

Click to expand...

There are no high priced cancer drugs in Peds.  We're still using the same old drugs from 30 years ago.  (Ok, not totally true, but the targeted therapy revolution is only slowly trickling down to Peds.  This may change once immunotherapy becomes widespread).

[RogueDadMD]

Some of the hospitals pay less because they can -- if they are fully staffed paying $100k/year, they are not motivated to pay $200k/year.  Some just do it as long as they can get away with it and market pressure slowly raises their salaries when needed.

Places like Boston Children's attracts so many qualified people that they aren't going to throw a bag of cash at (most) peds specialists when they have 10 more behind them willing to take the spot for the leftover change under the ER bench.

Also kids don't vote -- Medicaid often pays way less than Medicare for identical levels of care.  The children's hospitals have more money than they let on, but the ones that are seeing a ton of Medicaid patients (which is many) are not generating revenue the way a community hospital with a mostly private/Medicare population will.

https://www.forbes.com/sites/peterubel/2013/11/07/why-many-physicians-are-reluctant-to-see-medicaid-patients/#74cdd07e1045

 

[amphora]

It's worth adding that if the Republicans do manage to pass a reconciliation bill, it will likely be closer to the Senate version. There's less room for error in Senate negotiations. But since the Senate left the the business AMT tax, they could adopt some House provisions to raise revenue.

[ENT Doc]

Zaphod wrote:

Kamban wrote:

Zaphod wrote:

This is so vastly different than adult onc/nephro isnt it? What makes the discrepancy so huge? 

Click to expand…

Most kids who get cancer or ESRD end up on Medicaid. Which does not even cover the cost of the high priced cancer drugs.

So the net income to the academic institution is a small amount or a loss.

Click to expand…

Makes sense, from a payer mix standpoint. Would be interested to see the actual p/l of these centers specifically though.

Click to expand...

Looks like they've got more than enough to pay a few hematologists and nephrologists some more money.

https://khn.org/news/the-wealth-of-childrens-hospitals/

[ticker]

As of a 4 years ago, I know some peds subspecialists' initial offers at my training institution were not even quite 6 figures.  The crazy thing, to me, is that the pay in academic peds (and in academic medicine, as a whole) seems to be inversely proportional to the prestige of the institution.  The University of Midwest State pays exactly twice as much as the identical job at Big East Coast University.  The discrepancy is much more than just the geographical difference would dictate.  I don't understand how so many people are willing to "pay" for the affirmation of the 3x3 inch emblem on the right breast of their white coat.

 

And, yes, I know that often the motivation goes much, much deeper than that.

 

[Zaphod]

Kamban wrote:

Zaphod wrote:

This is so vastly different than adult onc/nephro isnt it? What makes the discrepancy so huge? 

Click to expand…

Most kids who get cancer or ESRD end up on Medicaid. Which does not even cover the cost of the high priced cancer drugs.

So the net income to the academic institution is a small amount or a loss.

Click to expand...

Makes sense, from a payer mix standpoint. Would be interested to see the actual p/l of these centers specifically though.

[Kamban]

Zaphod wrote:

This is so vastly different than adult onc/nephro isnt it? What makes the discrepancy so huge?

Click to expand...

Most kids who get cancer or ESRD end up on Medicaid. Which does not even cover the cost of the high priced cancer drugs.

So the net income to the academic institution is a small amount or a loss.

[ENT Doc]

Zaphod wrote:

MrsIMDoc wrote:

Rogue Dad, M.D. wrote:

Zaphod wrote:

Low 100s for ped heme onc? Can that be true? Couldnt do that emotionally, but to be paid so little for such a task… 

Click to expand…

Yes, it’s true.  I don’t know the # right now, but I know that was the range (at specific academic places) only 5 years ago.  I’m sure it’s increased, but I do not believe it’s increased to what you would expect.

Click to expand…

Yes had a friend who was peds nephrology.  Only making $100,000/year.  The thing is most Peds heme onc or peds nephrology are at academic centers so there is not a large private market.

Click to expand…

This is so vastly different than adult onc/nephro isnt it? What makes the discrepancy so huge? Organizations (insurers/hospitals) just know they can prey upon kids or that their providers are just such good people theyre willing to take a huge cut in pay? Similar issues/treatments should be similarly paid.

A look into this dynamic would be very interesting top to bottom, probably some weird things going on all around.

Click to expand...

Bet the difference is the payer mix and how much of a profit/loss center they are.  I'd bet more kids fall under Medicaid than adults do for the same specialist.  The money-makers get paid and have leverage.  The loss centers don't.  Ultimately you need cross subsidization to have a functioning system, but this limits the salaries for those not making money for the hospital.

[Zaphod]

MrsIMDoc wrote:

Rogue Dad, M.D. wrote:

Zaphod wrote:

Low 100s for ped heme onc? Can that be true? Couldnt do that emotionally, but to be paid so little for such a task… 

Click to expand…

Yes, it’s true.  I don’t know the # right now, but I know that was the range (at specific academic places) only 5 years ago.  I’m sure it’s increased, but I do not believe it’s increased to what you would expect.

Click to expand…

Yes had a friend who was peds nephrology.  Only making $100,000/year.  The thing is most Peds heme onc or peds nephrology are at academic centers so there is not a large private market.

Click to expand...

This is so vastly different than adult onc/nephro isnt it? What makes the discrepancy so huge? Organizations (insurers/hospitals) just know they can prey upon kids or that their providers are just such good people theyre willing to take a huge cut in pay? Similar issues/treatments should be similarly paid.

A look into this dynamic would be very interesting top to bottom, probably some weird things going on all around.

[Craigy]

tex wrote:

Re grandfathering… anyone read the actual bill? (I will not)

I’m imagining the MS4 who has been living high on the debt hog who is about to get burned…

 

Click to expand...

I was wondering this too.  The articles I've read suggest those grandfathered are just people who are enrolled and already making qualifying payments.  I don't feel too compelled to read through the text myself.

It seems the fairest way would be to include current students who may have been counting on this, to their detriment... but then obviously that could trickle all the way back to undergrad freshmen who might not graduate from their last degree program and enter the workforce for a decade or more.  The line has to be drawn somewhere.

I have to admit, I don't really feel all that sorry for that MS3 or MS4.

[Matt]

Zaphod wrote:

Low 100s for ped heme onc? Can that be true? Couldnt do that emotionally, but to be paid so little for such a task…

Click to expand...

Yup.  I'm Peds Hem/Onc (3 years out of fellowship).  My starting offer at the academic center where I trained was $140K.  I was able to negotiate it up to $160K.  I ended up taking a non-academic position at a private quasi-academic center in the same city for $235K.

[tex]

Re grandfathering... anyone read the actual bill? (I will not)

I’m imagining the MS4 who has been living high on the debt hog who is about to get burned...

 

[Craigy]

IMO this is a good thing, both ending PSLF and grandfathering in those currently enrolled.

Even though it's well-intentioned, PSLF creates a huge perverse incentive to go to the most expensive schools possible, get as many degrees as possible, take out as much debt as possible, and then once you finally graduate with doctorates in hand, go and be virtually as unproductive as you can be.  And there are tons of people doing just that as a result.

If they were forgiving debt up to a certain reasonable amount, it could possibly be an efficient, effective system.

But you have to grandfather.  You can't in good conscience pull the rug out from under people who are participating already.

[MrsIMDoc]

Rogue Dad, M.D. wrote:

Zaphod wrote:

Low 100s for ped heme onc? Can that be true? Couldnt do that emotionally, but to be paid so little for such a task… 

Click to expand…

Yes, it’s true.  I don’t know the # right now, but I know that was the range (at specific academic places) only 5 years ago.  I’m sure it’s increased, but I do not believe it’s increased to what you would expect.

Click to expand...

Yes had a friend who was peds nephrology.  Only making $100,000/year.  The thing is most Peds heme onc or peds nephrology are at academic centers so there is not a large private market.

[RogueDadMD]

Zaphod wrote:

Low 100s for ped heme onc? Can that be true? Couldnt do that emotionally, but to be paid so little for such a task…

Click to expand...

Yes, it's true.  I don't know the # right now, but I know that was the range (at specific academic places) only 5 years ago.  I'm sure it's increased, but I do not believe it's increased to what you would expect.