The problem with the Relative Value Scale Update Committee

80 percent of the committee are specialists: “Their bias is adding to the income gap between specialists and primary care physicians.”

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  • Anonymous

    Ummmm… instead of trying to lower the income gap by decreasing specialty salaries why not try to lower the income gap by raising primary care salaries? In many cases being a specialist requires double the amount of residency that being a primary care doc requires. Why shouldn’t they be paid better! Not all doctors have the same training so why should all doctors be paid the same! Why does money have to come from one pool. If it is so hard to find a primary care doctor why they don’t they pay them more like the free market would dictate.

  • Anonymous

    Well said, why shouldn’t more training equate to more earning potential. The primary care physicians that complain about specialist salaries didn’t go to a surgical residency so they have no idea what it takes to become one.

  • Anonymous

    I’m all for raising the income of PCP’s- provided that they train for a sufficiently long period of time to acquire the knowledge base to master routine care now being turfed to specialists.

  • Anonymous

    The whole RVS thing is a crock of cr*p. A committee cannot determine the relative value of anything–only an educated consumer purchasing a service. When prices are set by centralized planners, the value of price as the vehicle that transmit information about where supply is needed is completely lost. That is why we there are access problems with primary care and psychiatry, but not surgical specialty services. Without centralized price setting, maldistribution would be self-correcting.

  • Anonymous

    1) First, off specialists make a lot more than twice the primary care dudes. Try more like 3-6 times. Hell neurosurgeons earn 7 times what a primary care doc gets.

    2) In euro/canada, specialists make 1.5 to 2 times primary care MAX. They still make more than GPs, just not 10 times more like in the states.

    3) US system or any govt healthcare system will not allow net spending increases on doctors incomes year after year. We already spend much much more than other nations, yet you guys think that we should spend even MORE money? Not going to happen. New proposals will have to be cost-neutral at best, which means all docs have to compete for the same funding pie.

    4) Given the above, raising payments to doctors just will not happen and will never happen, even under the current system, much less a true socialized medical model.

    5) I think as docs it would be better if we convert to a single payer system and eliminate insurance companies and their 25% cut of the total healthcare costs they chew up. Make docs employees of the federal govt with a flat salary pay grade just like other federal employees. Have malpractice coverage thru the fed. Give them a G15 pay grade for primary care (about 120k per year) and a G20 pay grade for specialists (about 170k per year). Thats still a 50k per year difference, which is quite substantial.

  • Anonymous

    “Give them a G15 pay grade for primary care (about 120k per year) and a G20 pay grade for specialists (about 170k per year). Thats still a 50k per year difference, which is quite substantial.”

    Dream on. I would be willing to work about 10 hours a week for this salary. 50K is an inconsequential daily fluctuation of net worth for most other non-medical professionals of lesser training I know.

  • Anonymous

    So you think that lack of knowledge base is a small deal? Here’s an exercise:

    Patient with “Otitis Media” sees PCP for 3 visits. 3 antibiotics prescribed. No improvement. Sees otolaryngologist. Patient informed he does not HAVE an OM, but a referred otalgia secondary to TMJ. (Happens ever day)

    Specialist takes care of problem (and CORRECTLY to boot) in one visit vs. three. Do the math.

    Still thnk the PCP should be paid “just” $50K less than the sepcialist??

  • Happyman

    “Specialist takes care of problem (and CORRECTLY to boot) in one visit vs. three. Do the math.”

    Yeah, for like 5% of their income. The other 95% is a mix of a little useful care and mostly TONS of unnecessary procedures (true of cardiologists and GIs especially). This is where the cost concerns and solutions lie.

    And don’t expect any primary care doc to believe that “defensive medicine” is the reason for an ANNUAL nuclear stress test / echo /holter in every medicare patient referred to a cardiologist – we see the truth every day.

  • Anonymous

    You are full of sh*t. Why don’t you tell that cardiogist that you think 95 percent of what he does is ridiculous. That is the most ridiculous accusation I have seen on this board for a while. Yes, they have really pulled the wool over the eyes of everyone. Geez, why don’t we just pay them 5 percent of their average 275,000 dollar income. Oh what, you thought they were all millionaires? Oh, crap!!! So let’s see here primary care docs average around 175,000 and cardiogists average around 300,000. Yet, cardiogists train for three-four more years and can do everything a primary care doc does (Internal Medicine wise). Why shouldn’t they make more?

  • Happyman

    I didn’t say they shouldn’t make more, but can you really honestly say that the financial incentive isn’t a factor in the growth of nuclear stress and echo?

    A cardiologist friend of mine once told me that echo was “the best bang for the buck of any medical procedure reimbursed by medicare”. He echoes some patients 2-3 times a year!

    And if I send someone to a GI for abd pain, first question is “you want me to scope from above, below, or both?” If those tests don’t yield an answer, I’m back to square one, usually without an opinion, consult note, etc.

    And cardiologists DON’T do everything IM docs do, even though they completed an IM residency, nor do most want to. fellowship trains them to (appropriately) see everything through the lens of cardiovascular disease.

    By your logic, we shouldn’t have IM at all – maybe the system should be primary care provided by NPs and PAs, referring to specialists who saved the 3yrs of IM residency. But if you ask me, I want a DOCTOR seeing me for routine care and knowing me well, rather than an NP or PA.

  • Anonymous

    Happyman, you have some serious class envy clouding your judgement. I assume you’re a physician, so it’s hard to believe that a board certified practitioner would go on in such an illogical way.

    The top three diagnoses in at least one ER where this was studied were: otitis, sinusitis,pharyngitis. If you can’t get thes mundane things right on the first at-bat 90% of the time, it’s easy to see the magnitude of the problem, i.e. knowledge base. Again, please do the math.

    With respect to the accusation that another interlocuter is advocating a system of NP’s and PA’s, it’s already happening – much to the chagrin of both primary and specialty physicians. And it is intimately related to the problem wiht mundane disorders as outlined above.

  • Anonymous

    The above thread shows exactly the problem with the RVS and why the AMA should have never in any way, manner, or form cooperated with it. It pits doctor against doctor and specialty against specialty arguing with each other about the relative value of their services.

    The relative value of any service can only be determined by a customer seeking to purchase it.

    In my practice of psychiatry, I recognize the plain fact that no one places much value on my services except those in need of them. Most physicians discount the specialty entirely until they have a psychiatric problem disrupting their practice. I decided long ago that I will not allow anyone but the actual purchaser of my services to decide their value. I much prefer the free market to committees of non-customers. That mean no medicare and no insurance contracts but so be it.

    Many physicians are afraid of the free market, but I welcome it. There is not a single service that I provide that can not be obtained by people in other specialties or other professions. It keeps me on my toes giving good service, yet I thrive. Pride of craft is a great reward itself

  • Anonymous

    I would agree with the idea that if you have 3-4 years of extra training compared to a primary care doctor you should bill at a higher rate than one.It is very hard to get a fellowhip spot in any of the competitive specialties these days and usually the people getting them are at the top of their residency class, more published and more driven so if they make more in the end it is hard earned and well deserved.In the end it is about doing what you like and NOT money.The friends I had in residency who chose primary care did so knowing howmuch they would make but did it because it was what they wanted to do.if you are making 160-180 K with 3 years of training I think it is decent money.If a PCP thinks they can CATH,Scope or give chemo as well as a specialist they are clearly dellusional and to say people should be paid the same for these as a 30 minute PCP visit is ludicrous.Lets no forget people are refered to a specialist when a PCP doesnot know what to do or needs something done that they are not trained to do….if you are asking for help from someone sho is better trained in something don’t hold it against them if they get paid more than you…Don’t forget they are fixing something you couldn’t…

  • Anonymous

    RVS and CPT should be discarded, and physicians should charge by the hour in 5 min increments like other professionals. Payors, including Medicare would pay whatever their contracts with their enrollees required. Physicians could balance bill. Physicians whose extra skills and training justified it in the eyes of the public would charge higher rates. Excellence would again be rewarded and fostored. People would once again start taking histories instead of just scheduling procedures. Patients would get examined, managed and treated instead of just canulated and scoped.

  • Anonymous

    I agree that primary care docs should earn more than they do but it certainly should not come at the expense of surgical specialists. With differences such as 7 years of rigorous training requiring sacrifices of family and self (not to mention debt and lost income) versus 1 mildly challenging year for primary care (intern year) and career expectations of operating in the middle of the night versus few calls at night or weekends for pcp’s there is no other real correlation to the jobs so why should salary correlate?

  • Anonymous

    After reading most of these comments it becomes clear that most of the specislists commenting do not have a good understanding what primary care docs do. Additionally, why do all the specialists focus on their length of training as criteria for getting paid more? It is a valid point but what about radiology, neurology, anesthesiology,dermatology, occupational medicine, shall I go on? When we refer our patients to you, it is typically for a focused, one- organ- system problem. We are asked to manage the entire patient, keep tract of their medicine and medical problems all in one 15 minute visit. Do any of you have any idea how many of the patients we refer to you call us to make sure the treatment plan you have advised is ok before they proceed? Has it occurred to you that the reason we “turf” the patients to the specialist is not only because we do not have the expertese but in many cases we do not have the time or equipment to focus on one problem at our visits? Medicare and private insurers are requiring more and more forms and prevention outcome data to assure quality of care, yet no one wants to increase salaries to primary care. If our lifestyle, call schedule, etc. are so wonderful, why aren’t any med. students entering our field?