Underlying tensions between primary care doctors and specialists erupted into civil war this week as Senator Baucus’ white paper on health reform was unveiled.
Most health reform initiatives rely on a strong foundation of generalist physicians to see the influx of newly insured patients. Massachusetts was caught napping and did not adequately prepare for this, which is worsening their emergency department crowding and driving up costs.
Senator Baucus proposed a “budget-neutral” increase in primary care payments, which means that specialists are going to take a pay cut. Predictably, they aren’t happy, drawing the line in the sand, and decrying it as Robin Hood-like socialist tactics.
The question remains, is the disparity between generalist and specialist salaries justified? The bloggers over at Health Beat explain the situation:
Part of the anger no doubt stems from the fact that many specialists must undergo an extra two to three years of training to gain expertise in their chosen field. Given that they’ve studied longer, shouldn’t they make more money? Maybe. But how long can two extra years of school translate into three times the money? Isn’t there a point where the collective benefits of a doctors’ work also should influence how much she is paid, just as much””if not more””than years of schooling?
If your answer to this question is “yes,” then you’ll find the following numbers disturbing: between 1997 and 2006, annual compensation of dermatologists increased by 97 percent; for gastroenterologists, 78 percent; and for radiologists, 65 percent. Over this same period, however, pediatricians saw a jump of just 32 percent; internists 30 percent; and family medicine generalists a mere 21 percent. Specialists don’t just make more money than other doctors””over time, they also make more money faster than others. It’s hard to see how extra schooling can rationalize these numbers.
No one is happy when faced with a potential pay cut, so the specialists’ stance is understandable. Reconciling their opposition to budget-neutral increases in primary care payment will be a critical obstacle for any reform plan to overcome.
That being said, it is apparent that specialists’ interests are not congruent with those of primary care. As I mentioned last week, generalist physicians breaking rank may be a necessary strategic move to exert the influence needed on both politicians and the public.
Related posts:
- Will specialists sacrifice to pay primary care doctors? Are budget-neutral changes the only option?
- Where’s the money to better pay primary care doctors going to come from?
- Should primary care distance themselves from specialists?
- Should specialists be re-trained as primary care physicians?
- Males = specialists, females = primary care physicians
- "It’s a miracle primary care docs make any money at all"
- Encouraging news on the medical home
{ 16 comments }
Eventually specialists will make 90,000-120,000 and GPs will make 50,000-90,000 and you will still be complaining at how you’re under-compensated.
Maybe we can all run blogs to generate ad revenue.
As a patient, I want my specialist well compensated, and my family doc to get a raise.
If you decrease pay, you get Commie Care. In Commie Care, the surgeon goes home at 5 PM, come hell or high water. The British emergency surgery patient, the one exsanguinating, waits 6 days for surgery. During that time, he may catch all manner of diseases, from the 12 blood transfusions. The cost of these unnecessary diseases caused by delay will far exceed the raise the surgeon is demanding.
The other British surgery patients may wait years. The ones needing expensive operations, such as transplants, may die. It ain’t never gonna happen.
Their surgeons are as well trained as ours, if British. Because low surgeon salaries are still too high for Commie Care, they imported even cheaper terror docs. These are so incompetent, they failed to blow themselves up at Brit airports. They merely burned themselves, and endured expensive, agonizing burn care. They likely got other terror docs caring for them, and died.
I like it when my surgeon will get good pay if he stays late to see me, and will want to operate as soon as possible to make even more.
Perhaps the reason for the discrepancy is that a nurse practitioner and physician assistant can serve as a substitute for the GP. Our health care costs would drop dramatically if we just replace GPs with this model (5 minute clinics, etc… which have a very high satisfaction rate).
Also, arguing for a drop in reimbursement for any physician is kind of like shooting your own foot. In an environment where other professions see increases in salaries, perhaps we should unite as physicians.
Finally, getting into a GP residency is insanely easy. Foreign medical grads flock to them. These are not necessarily the cream of the crop. If we increase the reimbursement of GPs at the cost of the specialist, one could argue that the ‘C’ medical student will be operating on the glioblastoma, while the ‘A’ medical student will be tossing antibiotics at a pneumonia. Or perhaps the specialists will just get out of the US and head over the Canada where they are reimbursed quite well.
a budget neutral pay raise? how about we pay generalists more, and take that amount out of senator pay? how about we take some of that pork that gets thrown around (like for arrowheads made by children), and use that to compensate generalists? How about all of that money that goes to support giant agribusiness under the vise of “supporting the family farm” (I suggest first the subsidies to sugar cane growers, which keeps the corn sweeteners so cheap, so there is no longer an artificial market for high-fructose corn syrup). why does the government always suggest that someone else’s pay is lowered to pay for their pet projects? but then, hey, all congress has to do is vote itself a pay raise. wish docs could do that. Actually, I just wish docs could charge what they want to.
this is just the sort of “divide and conquer” tactics I would expect out of government.
It’s absurd to cherry pick the few specialties everyone agrees are overpaid (i.e. radiology) and compare their rates of increase with primary care while conveniently ignoring the far greater number of procedural physicians whose incomes have remained stagnant or declined.
Yes, many specialists deserve to make more money than PCPs. Not only is the training longer, but comparing the rigor of family practice residency with general surgery residency is laughable. It’s 3 years of a difficult job versus 5 years of having no existence outside the hospital. This isn’t even getting into the fact that surgery is just slightly higher stress; reams of paperwork can be depressing, perforating someone’s bowel and potentially killing them can be a bit more depressing. There is also that whole working 20% more and having to come in at 3am on Christmas thing.
There are a few specialist fields that are clearly overpaid. Other fields are probably about right and I would argue that general surgeons are actually clearly underpaid. And I’m not a general surgeon, but I do feel bad for them.
Note: I do not expect this to have any influence on Kevin’s daily “Pay Specialists Less” rants because he clearly has a large emotional investment in the idea of specialists as the enemy.
No such thing as ‘making too much money’, however the ‘too much’ may be defined. Just a good sign that free markets are at work, attracting new providers to increase competition. And, one person’s ‘too much’ may be another’s ‘the price is right’, based on the realized return.
Chuck Brooks
FutureWare SCG
Replacing family physicians and internists with mid level practioners will make things worse. The whole idea is to have the majority of well trained (7 years) physicians be operating at the primary care level, confidently handling most of the problems patients present with. NP/PA’s have less than 1/2 that training, and the training they have is much less intense. They, by definition, will not have the experience and confidence to handle things at the primary care level, instead referring anything potentially concerning to the specialists. Which is what we’re trying to get away from in the first place.
So start aligning the incentives to encourage a redistribution of MDs to primary care, or continue to watch our health care system move closer to bankruptcy.
So kevin once again the monolithic specialist rants. Infectious disease docs and endorcinologists make little if any more than PCP’s. Heck some of these docs do a component of general IM to make ends meet. Should we give them a pay cut too? How about oncologists who had their payment system eviserated in 2005. Another pay cut for them too? The problem is kevin you can’t see the whole picture. You have fallen into an us vs them mentality. General surgeons are not exactly “well paid” presently. Give them a cut too? As stated above there are some fields that do very well. But do you realize alot of rads big money comes from you and the rest of us ordering scans on the drop of a dime (as you pointed out last week). The issue is more complicated than us vs them. Most specialist’s agree that PCP’s underpayed. There may be some meoderate modifications to some procedural specialists pay, but if you think this while “budget-neutral” proposol is going to save primary care, may I suggest a bridge in Brooklyn I would like to sell you….
No one has any business deciding who makes too much money. The consumers should decide that via the free market–which is not what currently exists in medicine, but should.
I guess there is, deep down inside every person, a strong anti-freedom “inner communists”; and every person who asks the question “does ….. make too much money” is letting theirs show. The market doesn’t disburse money by how much the provider of the product “deserves” to make it by the ultimate value of their product or by how hard they worked to make it. If it did, Madonna would be living on 5$ a year and fishermen would make $500,000.
Radiologists make a lot of money because
A. They play a bigger part in the total diagnostic process than any other physician
B. They have permanent records of their mistakes, thus spiking the amount of money they need to combat litigious behavior.
By attacking other specialties, you take away the focus on the bigger issue. GPs should make more, but why at the expense of other specialties?
I’d be happy to have a GP make the same amount as a general surgeon …. the minute the GP takes the same amount of call, works the same hours, etc. You are really comparing apples and oranges here. And when you cite dermatologists, the majority of their increase in income has not come from traditional medical care; it has come from one variety of cosmetics or another. Generalists rightly have a beef with decreasing reimbursement, but so do most specialists.
No physician should make less than $200,000/year. That’s the minimum they deserve for all their hard work and sacrifice. If anyone thinks they work hard, try shadowing a doctor in the hospital for one day and you’ll know what hard work is all about. Or do an overnight call with a resident.
Good medicine is expensive. Deal with it or settle for substandard care delivered by nurses and mid-levels.
In the $2.3 trillion healthcare system, less than 10% is what physicians take home. We can easily afford to pay them more.
re:” They play a bigger part in the total diagnostic process than any other physician”
I thought the physical exam, cultures, and labs actually head something to do with diagnosis too. I guess we should just top to bottom CT everyone and let rads run the show. Please do let me know which antibiotics I need on my patient.
Actually, radiologists make a lot of money because:
C. Medicare’s system for calculating the practice expenses associated with imaging studies is unrealistic and results in ridiculous overpayments. Technological advances have allowed each CT scanner to produce more CTs per day, but Medicare still pays as if the scanner were slower (with a higher capital cost per scan). Because Medicare is such a big purchaser, it is impossible for private insurers to deviate too far from the CMS price schedule.
That is the reason. Period. And re: B, are you kidding me? The amount of money you radiologists make far exceeds any differences in malpractice premiums. As for reason A, it’s hard to know where to begin with such ignorance. I suppose you’ve never met a competent generalist. Believe me…you barely see the tip of the diagnoses we make on history and exam alone (a truly valuable skill not quite mastered by most midlevels, unfortunately).
If you need a little bedtime reading, treat yourself to a little Bob Berenson in Health Affairs. You’ll find it enlightening.
http://healthaffairs.org/blog/2008/02/13/interactions-between-the-sgr-and-rbrvs-making-sense-of-alphabet-soup/
“Stay with me here. The per unit resource costs of services that mostly represent physician work should not be affected much by the quantity of services provided — the physician’s work component is a variable expense; that is, it is associated fully with each additional service provided.(4) In contrast, the per unit resource costs of heavily practice expense concentrated codes do vary with quantity because much of these practice expense components are fixed costs and, therefore, do not vary with each additional service provided. For example, the unit cost of imaging equipment declines as it is used more.
Yet the Centers for Medicare and Medicaid Services (CMS) does not try to alter RBRVS values for quantity changes, even when the unit cost of fixed office expenses predictably drops as the volume of services increases. Thus, even though advanced imaging services double over five years, fees are not adjusted downward; instead, the per unit profit keeps increasing as the quantity of services delivered increases, raising expenditures and further promoting the incentive for physicians to purchase imaging equipment to self-refer imaging services.”
re: “I thought the physical exam, cultures, and labs actually head something to do with diagnosis too. I guess we should just top to bottom CT everyone and let rads run the show. Please do let me know which antibiotics I need on my patient.”
You act like thats not already happening, where I work it seems that everyone who steps foot in the ER gets a CT scan or some other imaging procedure. (Talk about not trusting your physical exam)The Radiologists are not to blame for that; we just read them, we don’t order them.
And if you want to know what antibiotic to use for your pneumonia patient look it up in your pharmicopia…it takes 2 seconds…and 2 neurons to do that.
You are all wrong. Radiologists make a lot because of supply and demand. There’s not a lot of us and you guys keep ordering more studies. With the aging population and the decline of the physical exam, thats not going to change anytime soon.
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