How can you expect the ER doc or PCP to make a judgment call that it doesn’t warrant a cath when you, the specialist, don’t have the guts or aren’t able to make that call? What warrants higher fees is the extra responsibility and risk involved is making those decisions–not the manual skill which any neurologically intact person can master with practice.

It isn’t only proceduralists who are highly trained specialists with years of added residency. The subspecialist with years of extra residency asked to make high risk judgement calls with his hands in his pocket is also deserving of a higher fee which the RVS system doesn’t recognize. Nor does it recognize the value of years of experience vs green behind the ears new grads. In short the system is a frankly immoral holdover from communism–but it isn’t in Russia and it is supposedly “land of the free and brave” American physicians who are not only putting up with it but destroying the independence and solidarity of an ancient profession in greedily milking it for personal benefit instead of subverting it, shunning, and attacking it as they are morally bound to do.

I have seen this fracturing bear fruit in a severe decline in quality of care and professionalism in the last 15 years.

Kevin, you are part of the problem in this area.

Although my decision is probably premature and may change during my 3rd year, a small part of my decision will involve the consideration that I unfortunately forsee specialists losing in the reimbursement battle. The general public seems to adore their primary care physician, weather a FP, IM or a pediatrician. I not sure if the general public has the same adoration for their specialist that they may see less frequently.

I hope I will be wrong, but I think reimbursement will ultimately be left to politicians and the general public who will determine where the funding comes from and that will most likely favor their “doc”. So, for med students like myself, if financial considerations are a deciding factor, then I would be willing to wager that primary care will be a better decision in the next ten years as the tide shifts increasing reimbursement.

When all the baby boomers are eligible for medicare and can’t find a doctor who takes their insurance because it pays so little, then the public outcry will drive a policy change….and it won’t favor specialists.

That same specialist attacked on these pages is profusely thanked in the middle of the night when an acute MI arrives and has a door to balloon time of 45 minutes. So how much is a life worth…$~750 for the stent, half of the $240 for the cath, and the admission. Saving a life for around $1100, that’s not exorbitant pay for a specialist. All the while, the not-for-your-profit hospital collects $100,000. The hospital CEO laughs all the way to the bank while we fight on these pages.

Kevin, stop bashing specialists. You play right into the hands of the insurance companies and the administrators seeking to divide and conquer physicians.

1) This argument serves the purpose of those wishing to drive down reimbursement in general and to gain further control over the entire field. It will be used to take money from the specialists, but most of those savings will not be redistributed to PCPs. It is incredibly naive of you to believe that it will be sent to the generalists. It will be given to the insurance industry.

2) “Protecting their turf” is exactly what the surgeons should be doing. It is what you should have done, too. As you know, there are those who would happily insist that we provide our services for free if they could. We need more advocacy for our interests. Kevin’s weak sarcasm is misguided.

3) I am tired of hearing from the generalists that they are the thinkers who make important decisions, while all I do is perform rote procedures. I am a neurosurgeon. Every day I make dozens of decisions that carry enormous risk. I also do quite a bit of thinking and counseling. I respect my PCP colleagues, but they do not do all of the workup, evaluation, consideration, and teaching that goes into treating these patients. Sometimes you act as if you do all of that and then tell me what surgery to perform, and all I do is cut. Sorry, that is false.

4) The work that I do is difficult. I have more risk and more stress. I have more uncertainty. I have less control over my schedule and my time. Furthermore, I trained longer and harder to do this. I do deserve to be paid more for it. There does not have to be a “level playing field.” We are not playing the same game.

5) When I was in medical school in the mid 1980’s we were all aware that primary care was under attack. The current state of the field is not new or sudden or unanticipated. If you are under the age of 50 and a PCP (like Kevin), you cannot claim that you didn’t know this was happening. You made your choice to go into primary care with full knowledge of the pay disparity. Please stop playing the victim.

6) Kevin, again carrying water for the insurance industry, fosters the impression that specialist pay is outrageously high. I cannot speak for other specialties, but in neurosurgery the pay for the common CPT codes is surprisingly low. For a Medicare patient undergoing a lumbar laminectomy (63047) the reimbursement is about $900. A craniotomy for brain tumor is about $1500. A craniotomy for acute subdural hematoma, even in the middle of the night, pays about $1200 (if the patient actually has insurance). All of our codes carry a 90 day exclusion period. In other words, all of our in hospital and other postoperative care is included in that fee. And the PCP’s are not asked to help with any of that.
My overhead expenses are about $500,000. This includes insurance, rent, and three employees. I have to do a lot of surgery at those prices just to break even. I would be curious as to the reimbursements for other specialty procedures. Most people are surprised when they see how little we are actually paid. They are misled by their bill into believing that their $20,000 expense for their back surgery is going to the doctor. It is not. The hospital is getting more than 90% of that.

Kevin knows better than that, but it serves his purpose to play into the myth and feign ignorance.

As a specialist, I am aware of the crisis in primary care. I want to fight for you. Stop making me the villian. It won’t fix your problem, and you will end up losing one of the only allies you have in this battle.