The gap does need to be narrowed, but paying more for treating an illness than for preventing it won’t solve the problem. It’s guaranteed to continue to perpetuate it by creating incentives to do more.

But be careful about decreasing payments to those of us who take of critically ill patients. If the pay goes down, so do the number of people doing it (witness primary care now).

So in 20 to 30 years, there will be a shortage of ICU qualified docs and people will start dying of things that used to be easily treated. Of course, futile care will result in death a lot earlier…

What’s the alternative? Pay the same (or less) for high risk, complex, procedures and decison making as you do for counseling someone to eat healthy and get regular exercise? (or giving them a statin or some blood pressure pills in clinic?)

Primary and preventive care is important, and we probably need to pay primary care docs more for managing complex patients over time. That doesn’t mean, however, that other doctors managing critical illness in equally complex patients shouldn’t be paid more for their work. The incentives that result are not perverse, they are appropriate, all things considered.

We need to narrow the specialty-primary care pay gap, but there still should be a gap. And a gap means “we pay more for treating illness than preventing it.”