Should specialists spread the wealth to primary care?

To no one’s surprise, specialists are already drawing the line at taking income cuts to help fund primary care:

Expanding and improving primary care physician payment will itself be controversial. I am writing this blog from the American Medical Association’s House of Delegates meeting, where primary care and medical homes are both major topics being discussed. Many of the physicians lining up at the microphones have expressed support for primary care – as long as it doesn’t involve redistribution of dollars among physicians.

It is not a good sign that some physician specialty societies already are drawing such lines in the sand.

It is highly unlikely that primary care will be able to be saved without some amount of income redistribution. The arguments that primary care physicians “don’t work as hard,” or “didn’t undergo as intense a training” will inevitably be entered into the physician payment reform dialogue.

Class warfare is going to hit the medical profession real soon, and it’s going to be ugly.

The civil war has already started in the medical blogosphere.

Internist Robert Centor: “I hope that we get earth shattering payment reform. I may not even mind hearing proceduralists whine.”

Cardiologist Dr. Wes: “Most of us already know what the Robin Hoods of bureaucracy are going to do: steal from the rich (specialists) and give to the poor (generalists). After all, that’s what ‘budget neutrality’ is all about.”

topics: primary care, specialists

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  • enrico

    Well that’s peachy, but where do these super-specialized people think the patients are going to go when there’s no PCP? Yes, that’s correct Dr. Left Thumb Surgeon–you’ll be managing your patient’s diabetes while their left thumb heals, and on and on. There aren’t enough ERs to absorb the disenfranchised patients, so don’t even bark up that tree.

    But don’t worry–these are the “hardest working” physicians, so it should be no sweat.

  • The Happy Hospitalist

    And hospitalists sit by and watch out their income explode in the last five years because they have left the fixed pot economies of Medicare Part B.
    Dinosaur over at Musings of a Dinosaur wants a reason why hospitals should be paying hospitalists more than they bring in under Medicare Part B.I tried to explain why. It has everything to do with the fixed pot and irrationally RVU system put together and protected by specialty societies. There is no rational reason why two or three extra years of specialty training should pay 2, 3, 4, 5, 10 times or more in physician work RVU components for procedural interventions when compared to an equivalent time based cognitive assessment. You’re article above, Kevin, is the exact reason why Hospitalist medicine is flourishing. By exiting that fixed and irrational pot known as Medicare Part B.

  • Roy M. Poses MD

    I posted this on the ACP blog:
    One question is the extent to which the specialty societies are influenced by their funding from pharmaceutical, biotechnology, and device companies, and the financial ties many of their leaders have to such companies.

    Such funding and relationships are not often fully disclosed. But we do know about the financial relationships among one sub-specialty society and its leaders and device manufacturers.

    For example, see this post on Health Care Renewal about AAOS funding from device makers:
    Also, see this post on the relationships among AAOS leaders and device makers:

    We know of these financial relationships only because of settlements of federal lawsuits against the device makers. It is likely, however, that other specialty societies have similar undisclosed relationships.

    It is obviously in the interest of device makers that orthopedic surgeons get inflated pay for doing procedures involving their devices, since these payments provide financial incentives to do more procedures. It is likely that it is in the interest of other health care corporations to support inflated pay to other kinds of sub-specialists to do procedures that use specific devices, or who are likely to use particular drugs.

    Such influences are not the only reason that sub-specialists may want to cling to their exaggerated compensation. But they may distort the discussion, and at least ought to be fully disclosed and acknowledged.

  • Anonymous

    OK, but watch the masses of surgical sub specialists go to cash only practices. I doubt your local ophthalmologist is going to do cataract surgery for $400.
    Disclosure: I have mixed breed dogs, not photogenic Italian Greyhounds.
    Eye MD

  • Robin

    My question is…”Who is going to send the patients to the specialists if there are no PCP’s?” As a patient, my next question is, “What the aitch-ee-double-hockey-sticks am I (the patient) going to do without a [good] PCP?”

    Now, let’s assume that I, the patient, have the sense to pick the right specialist and my insurance allows me to make my own referrals, who is going to take care of the other little things? Will I have to see a different specialist about each “problem” I have?

    SOmeone is going to have to manage the patient. Who is it going to be?

  • Anonymous

    Specialists should care.
    Once they succeed in replacing primary care doctors with cheaper, less trained “providers”, they are going to come for you next. Afterall, do you really need to be trained in GI to do a scope? Why can’t a PA or NP be trained to do colonoscopies? How about a cath? Or an appendectomy?

  • Anonymous

    This is excellent. It’s about time that PCPs finally strapped on a backbone and took it to the overpaid procedurists and imagers. It’s also about time that they realize the AMA represents the economic interests of specialists. Representing “doctors” means nothing when you have this degree of income disparity.

    The last thing that worries me is the hollow threat that specialists will be unwilling to work for significantly less. After all, oversubscription to their residency programs (2 US grads per spot in some specialties) guarantees that replacement of their laborforce will continue despite deep cuts.

  • Deron Schriver

    What is the AAFP role in all of this? I’m hearing that specialist societies are preventing the necessary RVU realignment. Are PCPs and the AAFP not speaking up?

  • Anonymous

    Deron, it’s the RUC (RVU Update Committee of the AMA). The AAFP has only 1 seat out of 29 (and there are only 4 primary care seats total). The rest are specialists…the vast majority of whom do cash-generating procedures or imaging. So it’s not surprising that trying to work within the system (i.e., organized medicine) has been futile. Time for a complete overhaul.

  • ERP

    Honestly I think a slight redistribution is necessary. Some specialties are paid WAY too much. I am sorry, but a neurosurgeon does not need to make over a million a year.

  • jb

    Will some PCP out there please explain why you don’t all go to cash practices? Instead of suffering for the crumbs that Medicare and Blue Cross drop on you, get out of their systems, and charge patients for your services like plumbers and grocers and lawyers, even. You could charge reasonable fees, greatly decrease your overhead, and spend more time in clinical matters and less on crap. I know that some have done this, and are derided as concierge practices, but isn’t that what practicing medicine really is? Specialists who see much lower volumes of patients at higher cost per patient are much at a disadvantage in this scheme, but surely most of your patients/customers could afford to pay $50-60 for a decent office visit, and you could afford to do that if you did not have $100K/year in overhead each in payroll and IT costs to deal with insurance companies. Really, why not?

  • Anonymous

    Agreed ERP: The first should be ER docs who were in residency the same time frame as PCP’s (three years), work 12-15, 12 hour shifts per month with no call, no follow up, and make $250,000-400,000 plus per year. What do you think?

  • Deron Schriver

    JB – I’m not sure it would make sense for a patient to pay their insurance premiums, which entitle them to a $20 copay, and then go out of network to a cash-only practice and pay the $50. I like they way you’re thinking, but it simply isn’t feasible with all other things equal.

  • Anonymous

    You are doing just what Washington wants you to do–fighting among yourselves so that they can better control you. It would just be your business if it wasn’t that they also want to take the health freedom of 300 million Americans away but need to bring you boys to heel first. to make you help them do it. That is what RUC is designed to do, and like Pavlov’s dogs you are salivating on cue.

    How about just throwing out RUC altogether. Set your own hourly rate and let third parties pay however little of it they think they can get away and bill your patients for the balance according to your own lights.

  • Anonymous

    I see Marxism is in vogue these days.

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