In 2022, outpatient doctors earned an average of 4,836 euros, with pediatricians, gynecologists, and general practitioners earning the most, and dermatologists and internists the least

Significant income disparities persist among outpatient medical specialties. In some cases, they are several times higher.

Following up on our analysis of the income of non-state outpatient doctors from 2019, where we assessed the period from 2014 to 2017 based on publicly available data from the Register of Financial Statements of Legal Entities and data provided by all three health insurance companies, this time we looked at the years 2018 to 2022 and the development of income in the outpatient (non-hospital) sector.

In the five-year period from 2018 to 2022, outpatient doctors saw their income increase by an average of 83%, a significantly higher rise than the 29% growth in the average wage in Slovakia's economy. This increase was also higher than the wage growth of hospital doctors, which reached nearly 33% during this period. Inflation (CPI) rose by 21% over these years. Due to this substantial growth and positive development for outpatient doctors, their average "gross salary" (expressed as the sum of the gross salary paid to the doctor and the clinic's profit recalculated to gross salary per one full-time medical position), which reached 4,836 euros in 2022, temporarily became comparable to the average gross salary of a certified hospital doctor (i.e., a doctor with specialization), which we approximately calculated for 2022 at around 4.5 thousand euros. The wage growth since 2018 is shown in Graph 1 below.

The significant income growth of the analyzed outpatient clinics during the observed period was driven by a 47% increase in payments from health insurance companies (ZP) and a 59% rise in the clinics' own revenues. This likely includes direct payments from patients, income from occupational health services, emergency services, fees from pharmaceutical companies (e.g., for participation in clinical studies or lectures), or other business income. Meanwhile, clinic expenses grew at a slower rate (+41%) compared to revenues from ZP and their own sources. This revenue and cost trend led to a doubling of outpatient clinic profits before taxes (+102%) from 2018 to 2022 (see Graph 2). The performance of individual outpatient specialties in terms of financial results is discussed below and in Table 3.

Graphs 1 and 2 also show that the impact of the coronavirus pandemic on outpatient clinics was reflected in only a moderate increase in doctors' "gross wages" and clinic profitability in 2020. This was likely due to a decline in services and patient visits, resulting in lower revenues from health insurance companies. However, in the following two years, there was a return to strong wage and profit growth in the outpatient sector. It appears that this segment of healthcare emerged financially stronger from the COVID-19 crisis. Further research should explore the extent to which direct payments from patients contributed to this, as outpatient clinics' own revenues have surpassed the growth of insurance payments, with their share of total revenues gradually increasing. A key question for future research is whether clinics have become accustomed to charging patients as a significant source of income.

In simple terms, "gross salary" = the sum of a doctor's gross salary and the clinic's profit converted into gross salary, expressed per one full-time doctor position.

The vast majority of doctors in outpatient clinics not operated by hospitals work in non-state (private) clinics, which are typically structured as business entities (e.g., limited liability companies or joint-stock companies), meaning they are legal entities and business enterprises aimed at generating profit. Most of these doctors own their clinics, and their total declared income consists of the "actual" gross salary paid, which, along with the nurse's gross salary, forms part of the personnel costs reported in the clinic's financial statements, as well as paid dividends or profit shares.

In 2022, outpatient doctors paid themselves and their employed doctors an average monthly gross salary of 1,778 euros. In many clinics with a single doctor, owners transferred only the minimum wage to their accounts each month. The remainder of their total annual income from healthcare services and clinic operations came from profits. After accounting for various tax factors, we convert these profits into an equivalent gross salary. Adding the actual gross salary gives us the final "gross salary" figure for outpatient doctors, which we use throughout our analysis. All data is adjusted to reflect one full-time doctor position.

The weighted average monthly "gross salary" of non-state outpatient doctors reached 4,836 euros in 2022, while the median for the top 19 most common medical specializations was 4,284 euros. In the pandemic year 2020, the average was 3,500 euros, and the median was 3,136 euros. As shown in Graph 3, the largest number of clinics in 2022 generated a "gross salary" for their doctors within the income range of 3,000 to 4,000 euros.

Graphs 3 to 10 (histograms) depict the distribution of outpatient clinics according to the income interval – the interval of monthly "gross salary" corresponding to their doctors' earnings.

Data Sources (including the following histograms): Register of Financial Statements, Ministry of Finance of the Slovak Republic (MF SR); health insurance companies; Statistical Office of the Slovak Republic (ŠÚ SR); National Health Information Center (NCZI)

Calculations and graph: INEKO

We found that significant differences in the incomes of doctors across various non-state outpatient practices continue to persist when comparing the 19 most common medical specialties. The difference between the highest-earning outpatient pediatricians and the lowest-earning outpatient dermatovenerologists (dermatologists) was identified as being as much as 2.7 times.

The following Table 1 shows the most common medical specialties in the outpatient sector, ranked by the amount of the average monthly "gross salary" of doctors, recalculated for one full-time position. The table also illustrates the development of this value over time – by comparing the years 2018 and 2022. The other columns present the distribution of doctors' "gross salary" in various specialties according to percentiles.

Table 1: "Gross Salary" of Doctors, Its Development, and Distribution by Income Percentiles in 19 Most Common Medical Specialties
(n=3,511 non-state outpatient providers – legal entities; data for the year 2022; monthly "gross salary" in euros recalculated for one full-time medical position; for multi-year comparison purposes, the "Development" column analyzes a sample of n=4,017 practices)

The winners in terms of the nominal amount of "gross salary" along with the dynamics of its growth in the observed period 2018-2022 were clearly general practitioners for children, as well as general practitioners for adults, whose gross incomes doubled during this period. Outpatient pediatricians rose to the top of the rankings of medical specialties with the highest "gross salary." In 2022, general practitioners for children and adolescents had an average monthly "gross salary" of 6,891 euros, and their median "gross salary" was 6,299 euros. General practitioners for adults reached the top 3 highest-earning medical specialties, with an average gross monthly income of 5,253 euros and a median income of exactly 5,000 euros.

We hope that this information resonates with young medical students who are choosing which specialty to study, as it is no longer true that general practice is not financially lucrative. Notably, outpatient pediatricians are lacking in many regions of Slovakia, including the Bratislava region. Financially, being a general practitioner pays off!

From Graph 4 below, we can see that for the given interval sizes (in thousand euros), the largest number of pediatric practices have doctors earning a gross monthly income in the range of 5,000 to 6,000 euros, followed by the second most common interval of 6,000 to 7,000 euros. It is also notable that a relatively high percentage (10%) of pediatric practices fall into the highest (open-ended) income interval of over 12,000 euros. As shown in Graph 5, for general practitioners for adults, in 142 monitored practices, doctors earn a gross monthly salary in the range of 3,000 to 4,000 euros.

Graph 4: General Practitioners for Children and Adolescents Practices ("gross salary"; 2022)

Graph 5: General Practitioners for Adults Practices ("gross salary"; 2022)

Above-average "gross salaries" in 2022 were also achieved by outpatient gynecologists (5,311 euros) and dentists (4,916 euros). Cardiologists, with a median "gross salary" of 4,324 euros, also ranked above the median "gross salary" of doctors across all specialties (4,284 euros). Gastroenterologists (4,284 euros) and ENT specialists (4,192 euros) had median gross salaries that were similar or close to the median value of all observed outpatient specialties.

Graph 6: Outpatient Clinics of Gynecologists ("gross salary"; 2022)

Graph 7: Dental Outpatient Clinics ("gross salary"; 2022)

On the contrary, at the bottom of the income ranking, below the 3,000-euros, are dermatologists, internists, urologists, and clinical speech therapists, while diabetologists and surgeons are very close to this threshold.

Graph 8: Dermatology Outpatient Clinics ("gross salary"; 2022)

Graph 9: Internal Medicine Outpatient Clinics ("gross salary"; 2022)

It should be noted that the analysis includes only those outpatient clinics that are legal entities and provide healthcare exclusively in one specialty. Therefore, it can be assumed that doctors working, for example, in joint cardiology and internal medicine outpatient clinics will earn on average less than "pure" cardiologists but more than "pure" internists.

Interestingly, in the analysis of the previous period (2014-2017), doctors in purely neurological outpatient clinics belonged to the specialty with the lowest "gross salary" in 2017 (1,418 euros). When comparing the previous observed period of 2014-2017 with the current period of 2018-2022, we find that neurologists saw the largest percentage increase in income from health insurance companies, second only to gastroenterologists. This resulted in a rise in the income rankings for outpatient neurologists, and between 2018 and 2022, they became the leaders in the growth of "gross salary" and pre-tax profit, which increased by 126% and 148%, respectively (see Tables 1 and 3).

Graph 10: Neurology Outpatient Clinics ("gross salary"; 2022)

Such high percentage increases could, of course, have been achieved more easily due to the relatively low initial base of neurologists' "gross salary." In the previous analysis, we raised the question of whether, in a time of increasing chronic diseases and the consequent growth in patient demand for neurological healthcare, combined with the shortage of outpatient neurologists in some areas of Slovakia and the resulting long waiting times for patients, it would be worth considering increasing payments for services by health insurance companies to make the profession of outpatient neurologists more attractive. We are pleased that the numbers are already indicating a gradual increase in resources and profitability for this specialty.

In the statistics of outpatient clinics' own revenues (i.e., revenues outside payments from health insurance companies) and the comparison of their share in total revenues across specialties, it is worth noting that the four highest-earning specialties also show the highest shares of own revenues (see Table 2). For dentistry, this is natural, as even in clinics contracted by insurance companies, direct payments from patients play a significant role. These outpatient specialties also share the fact that they are legislatively classified as part of primary healthcare, have mandatory health districts, and do not require referral slips (mandatory recommendations from a doctor). In three of them, capitation payments from insurance companies (a lump sum payment for patients registered in the clinic's records) dominate. And most importantly, unlike other outpatient specialists, they have a relatively stable base of patients whom they know and who regularly visit these specialties as their primary contact for almost any health problem or administrative need for a "stamp."

Table 2: Share of Own Revenues in Total Revenues of Outpatient Clinics in 2022
(n = 3,511 outpatient clinics)

The highest total annual revenues (turnover) recalculated for one full-time medical position (approximately 150,000 to 160,000 euros) in the analyzed sample of outpatient clinics were recorded by gynecologists, general practitioners for children and adolescents, dentists, and gastroenterologists. The average annual revenue for all specialties in 2022 was 137,648 euros, with payments from health insurance companies accounting for 73.5% and the clinics' own revenues making up the remaining 26.5%.

Regarding annual expences per full-time medical position, the specialties with the highest costs are logically those that require much more advanced equipment for their operations. These include dentistry, gynecology, and gastroenterology. To cover higher depreciation and other costs, they also require higher revenues.

On the other hand, speech therapists, who don't even need to employ a nurse, can manage with significantly lower revenues as their costs are also the lowest. Specialties with the lowest costs and revenues include internists and psychiatrists.

Generally, outpatient providers, who are private business entities, have been consistently profitable as their revenues exceed their costs. The analyzed clinics in 2022, on average, generated a positive financial result (before tax) of nearly 41,000 euros per full-time medical position, with the highest profits ranging from 43,000 to 63,500 euros reported by pediatric clinics, gynecologists, gastroenterologists, ENT specialists, and general practitioners for adults. The lowest profits were generated by dermatologists and clinical speech therapists. See Table 3.

The highest net profit margin, i.e., the profitability of revenues (profit after tax divided by revenues) exceeding 30.5%, was achieved by general pediatricians in 2022. After pediatricians came ENT doctors, general practitioners for adults, and gynecologists. The average net profit margin across all examined specialties was a high value of 21.5%. The least profitable were dermatologists in 2022 (though still with a respectable value of 12%).

The average operating marg, or EBITDA margin (profit before tax + depreciation / revenues), reached almost 34% in 2022 for the analyzed sample of private outpatient providers. The highest EBITDA was recorded by general pediatricians (43.6%). Data has shown that both net profit margin and operating margin have been steadily increasing in our non-state outpatient sector.

Table 3: Financial Results of Outpatient Clinics in 2022 Recalculated per Full-Time Medical Position and Its Development
(n=4,017 outpatient clinics)

If we look at Table 4 below, we will see the ranking of specialties based on the amount of payments from health insurance companies per full-time medical position. Naturally, when paying for outpatient medical care, health insurance companies also take into account the specific costs of each specialty, including the need for adequate equipment in the clinic. Therefore, it is logical that specialties requiring a large number and/or expensive equipment, or those with above-average consumption of medical supplies, are ranked higher. On the other end of the table are clinical speech therapists, who do not employ nurses, which logically results in lower payments from the insurance companies. Dentists undoubtedly need various instruments, tools, and medical supplies, but of all the specialties, they have the highest direct payments from patients and the highest share of their own revenue (as shown in Table 2), which may explain why they are not ranked higher in Table 4. Between 2018 and 2020, the average payment from insurance companies increased by 47% (see also Graf 2).

Table 4: Average annual payment from health insurance companies for outpatient clinics in different specialties in 2022, calculated per full-time medical position
(n=4,017 outpatient clinics)

The ambition of this analysis is not to assert whether outpatient doctors earn a lot, a reasonable amount, or too little, but rather to contribute to improving the public debate on healthcare financing and the remuneration of healthcare workers. The goal is to reduce the information asymmetry between the various participants in the public discussion, so that the debate is more grounded in data, arguments, and evidence, and less in unsupported claims, myths, and speculation. At the same time, we want to build on our previous two analyses: How Much Do Slovak Doctors Earn? from 2011, and There Are Significant Income Differences Among Outpatient Providers, published in 2019. While the first analysis was based "only" on various expert estimates, the second already utilized open data and drew on actual figures regarding the financial operations of outpatient clinics. The current analysis also draws on much more detailed data from all three health insurance companies on the amount of payments to outpatient clinics in various specialties and the number of contracted doctor positions.

How Much Do Slovak Doctors Earn? (INEKO, 2011)
There Are Significant Income Differences Among Outpatient Providers (INEKO, 2019)

The subject of the analysis by the non-governmental non-profit organization INEKO does not include hospital outpatient clinics or doctors employed in hospitals who serve in outpatient clinics operated by hospitals, nor outpatient clinics run by doctors as sole proprietors, as financial data for them are not publicly available. The analysis includes data from the financial statements of outpatient healthcare providers who are legal entities (e.g., limited liability companies, joint-stock companies) with complete data in the Register of Financial Statements for the observed period, who have contracts with all three health insurance companies, whose main economic activity is classified as general, specialized, or dental outpatient practice according to the SK NACE classification, and who provide healthcare in only one of the 19 most common specialties.

After statistical data cleaning and exclusion of extreme cases (outliers), we worked with data from 3,511 entities (for 2022) or 4,017 entities when comparing current data with 2018, representing 44% or 50% of all contracted outpatient providers – legal entities in the observed medical specialties, and 36% or 42% of all outpatient providers, including those operating as sole proprietors.

We sourced data on revenues, costs, and financial results from the income statements of individual providers listed in the Register of Financial Statements. To calculate the equivalent of gross salary ("gross salary") per full-time medical position, we used data from all three health insurance companies on the number of medical positions in outpatient clinics and in individual specialties. We also used information from health insurance companies on the amount of payments to individual outpatient clinics by specialty in our calculations.

Data on the average gross salaries of hospital doctors were sourced from the informational bulletins of the Slovak Trade Union of Health and Social Services (SOZ ZaSS), and the ratio of hospital doctors with and without specialization (certification) was obtained from the Ministry of Health of the Slovak Republic.

Additionally, in our calculations, we used data from the Slovak Health Yearbook from the National Health Information Center (NCZI) on the number of nurses working in outpatient clinics by specialty. For data on inflation trends (Consumer Price Index (CPI)), average nominal wages of employees in the Slovak economy, and the calculation of nurse labor costs, we referred to publications by the Statistical Office (ŠÚ) of the Slovak Republic.

There are no data on the salaries of nurses in the private outpatient sector; therefore, we used the figure from the Slovak Statistical Yearbook for all nurses (including hospital and "social" nurses). In 2022, according to the structure of earnings survey, the average gross monthly wage of a nurse in Slovakia was €1,239 (this value proved to be very similar to the average gross wage of nurses working in outpatient clinics (€1,349), which came from a survey (n=268 participating outpatient clinics) conducted for us by the Association of Outpatient Providers (ZAP) among its members, for which we are very grateful). We assumed that in specialties with relatively higher profits, nurse salaries would also be slightly higher than in less profitable ones, and we adjusted the average wage costs of nurses by specialty in our model based on this assumption.

The "gross salary" of an outpatient doctor, regardless of whether they own the clinic or are merely employed there, was calculated, simply put, as the sum of the doctor's gross salary (after deducting the nurse's salary from personnel costs) and the clinic's profit converted to gross salary (see more about the concept of "gross salary" in Box 1). The "gross salary," as well as other data on financial results, revenues, costs, etc., were calculated and are presented in the tables and graphs per full-time medical position.

This analysis does not take into account undeclared income (fees and gifts from patients without a receipt) or expenses (such as "topping up" a nurse's salary off the books) when calculating outpatient doctors' incomes. The analysis also does not filter out the effect of potential tax optimization through overstatement of costs (depreciation) or the use of company assets for personal consumption.

The subject of the analysis includes outpatient providers (only legal entities) contracted by all three health insurance companies, who provide healthcare in only one specialty, with their main economic activity classified as outpatient and dental medical practice (SK NACE 862**), have complete data for the observed years in the Register of Financial Statements, and have passed data validation and filtering criteria that remove statistically significant outliers related to various types of revenues.

It should be noted, however, that the calculation of the growth dynamics of average gross wages for hospital doctors does not account for the wage growth rate exclusively for certified hospital doctors, i.e., those with specialization, who are comparable in terms of education level to outpatient doctors (since such data are not available). Instead, it also includes the wage growth of less well-paid non-certified hospital doctors, for whom we assume a slightly lower wage growth rate than for certified hospital doctors. In 2022, the average gross wage for hospital doctors (both certified and non-certified combined) in state, regional, and semi-public institutional facilities reached €3,601. Based on knowledge of the base salaries of certified and non-certified hospital doctors, their percentage representation in hospitals, and simplified assumptions about the distribution of additional components of the total gross wage (those above the tariff level), we calculated that the average gross wage (with all bonuses) for a certified hospital doctor could have reached €4,480 in 2022.

A significant jump in hospital doctors' wages occurred at the beginning of 2023, when the more expensive wage formula ("struck deal") with higher coefficients and taking into account years of service began to be applied. Therefore, in the next period, the average wage of a certified hospital doctor will likely once again surpass the average income of a private outpatient doctor. In the third quarter of 2023, the combined average gross wage for hospital doctors (both certified and non-certified combined) reached €4,516.

We tracked four main cost components: personnel costs, service costs, material consumption, and depreciation, which together make up approximately 95% of the total costs of outpatient clinics.

The analysis did not cover outpatient clinics affiliated with hospitals, nor, for methodological reasons, outpatient clinics combining multiple specialties (such as cardiology-internal medicine clinics, etc.).

The specialty of physiatrics, balneology, and therapeutic rehabilitation, which is among the top 20 most common specialties, is not included in the analysis due to methodological reasons.

Interpretation of percentiles, e.g., in the case of general pediatricians: 10% of outpatient pediatricians earned less than €2,561 per month in 2022, 10% earned more than €11,959, and 80% of pediatricians had a monthly income ranging from €2,561 to €11,959. Exactly half of all pediatricians earned less than €6,299, and exactly half earned more than €6,299. 25% of pediatricians earned less than €4,303, and 75% of general pediatricians had a total gross income above this amount in 2022.