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.