who is going to make up the revenue lost from waived tuition? the other students?

raising the cognitive portion is fine if you don't want procedures done on your patients, which will result from such a drastic change. i fail to understand the attraction of constantly trying to divide up the medical specialties with these comments. ymmv

anon. The medical specialties have already been divided. Economically speaking. That's the result of SGR and failed Medicare policies. Any doctor who does cognitive care would benefit dramatically with an increase in payment for cognition. Patients would benefit as well by avoiding unnecessary invasive and non invasive evaluations. I see unnecessary procedures every day. Hell, I even saw a patient get an angiogram and attempted stenting of the dorsalis pedis artery for a small ulcer on the big toe. $15,000 later and I'm happy to tell you the big piggy survived. Which I'm sure would have happened had this expensive undertaking never been done. But with a few key words placed in the chart and this ridiculous procedure is considered "medically necessary" and paid for 100% by the Medicare National Bank. I am shocked everyday by the unnecessary things that get done to patients because we can. And I can assure you a big part of that is driven by money. Money from the incredibly skewed procedural payment model in this country. Almost every procedural specialty I work with has extenders that do their daily cognitive rounds while they spend all day in the procedure lab or the OR. That is not by chance. I can assure you of that. As I"m sure you are well aware. Seeing patients does not pay. That's why hospitals subsidize hospitalists to the tune of $100,000 per year per hospitalist. That's just sad. That our services save so much money (the $260/patient figure reported last year is laughable) for hospitals that they are willing to dish out big bucks to have a well run hospitalist program.

anon, the solution in the confines of the current fixed pot known as Medicare Part B/RVU/RUC/SGR must involve a redistribution of resources(money). If our goal as a nation is to produce more comprehensive care doctors, you must pay them more. A lot more. Not 10's of thousands of dollars . Add a zero to that at a minimum. Short of discarding the whole payment system,which got us in this mess, there is no viable alternative.

The medical home model, unless it raises comprehensive care docs salaries/take home pay 100,000 and more, will do nothing to encourage more medical students to enter this field. The back bone of any medical system in the industrialized world is comprehensive care. And ours is dead now. Not 10 years from now Now.

A drastic change is necessary to shift the out of control runaway spending on unnecessary procedures and interventions (that I see all the time) back to disciplined cognitive based evaluations. But thinking doesn't pay, and that's why it doesn't happen. Volume and procedures will trump thinking any day of the week. You know that.

Anon. You seem to want a solution without a change in the current payment model. How do you proceed under the premise that there is no additional money to throw at the system.? Unless of course you believe that the money will simply appear. Or unless you believe comprehensive care docs shouldn't be paid more.

I suppose one solution is to have all comprehensive care docs go into a cash only model and exit Medicare Part B. Those patients who can't afford it can go to a new system of federally funded comprehensive care clinics with federally salaried comprehensive care docs. Your VA style care. In my city, the current wait for an appointment at the federally subsidized comprehensive care clinic is 3 months. They are bursting at the seams with need from the poor and uninsured. AND the government denied their request for expansion. How's that for government run health care. Denying expansion of resources for a need based clinic bursting at the seams.

The only solution is to dramatically increase funding of comprehensive care. And that means paying comprehensive care doctors more. Much more. And in the confines of the current system, that means dramatically increasing the RVU value of cognitive care codes. And in the confines of the current system, that means a redistribution of the fixed pot of money. Unless you dramatically increase the fixed pot, there is no alternative.

And you know it.

Dervon,

Care to back that up? UK primary care physicians (government employed) can make 2x as much or more than their US counterparts.

Anonymous at 2:14 - It is WIDELY known that U.S. physicians are the highest paid in the world. In fact, I find it bizarre that you would even dispute that fact. You can find proof of that all over the place. Here's one of many:

http://www.worldsalaries.org/generalphysician.shtml

I would love for you to back up the 2X figure because it's garbage or possibly an anomaly at best. I also think it's cowardly to post something anonymously.

Kevin - Your points about malpractice premiums and med school costs are good ones, but the compensation gap is far too great to call it irrelevant.

anonymous (I hope you don't mind my calling you anonymous) - I hope you're a little more professional in your practice than you are as an anonymous poster on the www. Part of the reason you get paid more than double what I do (if you make an avg PCP salary) is the fact that you have to be available 24/7. That's part of your chosen profession.

Don't get me wrong, I have tremendous appreciation for what physicians do. I work with them on a daily basis and my number one job responsbility is making sure that my physicians make as much money as possible. I am 100% on board with the fact that there needs to be a compensation realignment between PCPs and specialists. With that being said, I don't see the average physician deserving a big raise because you are not significantly underpaid in comparison with other professions in this country.

Deron-

There are good reasons some of us post anonymously. That said, I think the most important flaw with international comparisons vis-a-vis the U.S. primary care practice is that they are largely irrelevant to the menu of choices actually faced by U.S. medical graduates.

Think about it. When a U.S. student graduates from medical school, his or her choices are not "should I practice in the U.S. or in some other country?" The choices are "should I make $150K a year working like a dog after a 3-year residency, or should I do, say, radiology and make $500K a year while enjoying a nice, predictable lifestyle with relatively low hours?"

Of course, now I suppose there's the option to leave the U.S. and practice primary care in the UK for big $$. I wonder if IMGs have shifted from taking rural PCP jobs in the US to taking similar jobs in the UK.

I sympathize with the general sentiment the U.S. doctors are well-paid. But some specialties are so ridiculously well-paid (GI, cardiology, dermatology, anesthesia, radiology, pathology, etc) that the _discrepancy_ in pay chokes off the pipeline of new PCPs. So there are 2 possible solutions: increase PCP pay, or decrease procedurist/imager pay while holding PCP pay constant.

If you think international models of physician compensation are better, then you would do the second option and maybe have free medical school. This might be politically tough...the U.S. electorate has repeatedly shown a real dislike for learning from other countries.

If our system gets the reform it needs, life for PCPs will get better. The RVUs need to be realigned, the complexity needs to be removed from the system, the extenders need to be better employed to take some pressure off physicians, etc.

Change is coming. I just hope the single payer folks don't beat the real reformers to the punch. Don't be surprised if I come back to all of you asking for your input in a reform effort I've just joined.