Are specialists preventing the government from spending more on primary care?

Dr. Laffel:
Your [comments] that specialists get paid more than primary care physicians is so old and actually destructive to the entire medical profession. Have you already forgotten what happened in the 1980′s when internists were whining that cognitive care was not being reimbursed as well as procedural care? The feds created the CPT coding system and everyone got screwed. Ten years later, you guys complained that primary care physicians should be gatekeepers, and guess what- the PPO/HMO scam was created and all physicians got screwed again. Currently, the whiners want “medical homes”-guess what will happen if this occurs? We are all physicians and should be in this together- the insurance industry, federal government, and the trial lawyer lobby is too strong for us to face unless there is unity. Remember, the old military tactic: divide and conquer.

It sounds like the politicians and insurance industries are making steady progress one of their goals: get one group of doctors envious of another group. When MDs fight amongst themselves, the big insurers and politicians can push through what best suits them (more money and more power), at the expense of the physicians and patients.

No it’s not “fair” that primary care doctors make less than (us) specialists. I think you should be paid more. Great. I don’t think I should be paid less, however. And frankly if that’s the choice I think you’re an idiot for being surprised that specialists don’t want their money redistributed.

The brutal answer is that pay is a crude (though the best practical) measure of how much your services are valued. At present, the market plays a(n incomplete) role in valuing services. Government and insurance reimbursement act to decrease the value of services over time. It should be noted that Medicare and Medicaid, in particular, play a distorting, downward pressure on primary care. This is less true in in specialists, because, well, when you need one, nothing else will do.

Understand that to decrease the downward pressure on primary care, it is necessary to first uncouple it from government and insurance reimbursement, so that it is easier to be paid the true market value of your services. The market does dictate the salary of concierge doctors, and most of them would say that the market values them more than government or insurance does. If you want to be paid what you’re worth, get paid from your patients.

Some specialists may get paid a lot more but not all. Rheum certainly doesn’t. Specialists also have trained a lot longer and provide a higher level of care. Of course they get paid more. Specialists are not the problem.

While I’m ranting, I’m sick of hearing the politicians blaming specialists for costing the system so much money. I see tens of thousands of dollars wasted daily on MRIs ordered by primary care docs who should have easily been able to manage simple musculoskelatal probelms without any scans but from lack of ?time/knowledge/basic exam skills they have no clue what is going on so rather than get the patient to an adequate physician, they first get the scan and when it doesn’t show anything or anything specific consult rheum or ortho. Order the consult first and at least save some money if you don’t have a clue about anything beyond controlling blood pressure. A consult is a lot cheaper than a useless MRI that you don’t know how to interpret in the first place.

As a primary care physician, I am concerned about the projected shortage of U.S. physicians almost as equally as I am concerned about the poor distribution of the present U.S. physician workforce. Look at MA; even if you expand insurance and give people a card that is supposed to give them access, that access is a phantom if there are not enough physicians, primary care and specialists, to see these folks (and as we are seeing with Medicare and Medicaid, many docs are opting out across specialties). Regards the present maldistribution of U.S. physicians, it distills down to payment. Now, I’m not here to write that specialists should get paid less in order to pay primary care physicians more…but I would, if push came to shove. Follow me here: after nearly 8 years of schooling and 3-6 years of post-graduate work ahead of them, medical student has accrued lots of debt and decides to enter higher paying specialty, usually procedurally-based (RUC effect); makes microeconomic sense, right? Here are a few proposed solutions that would not necessarily change payment for specialists (could you support these? see, not everything needs to be zero-sum): loan forgiveness for medical students choosing and staying primary care, expanding national health service corps, addl PMPM payments for primary care docs to compensate for care coordination. These would serve as incentives for medical students to enter primary care and for those of us in it to stay. Personally, I would like to see the U.S. physician workforce reach 50:50, i.e. even supply of primary care and specialist docs, with fair payments for everyone. We can get there…but not with the mentality of “not if I get shorted even one cent”. The reforms need to be uniquely American solutions to uniquely American issues. Are we Ameri-cans? Or Ameri-can’ts?

Regardless how onefeels about the “fairness” of specialty pay versus generalist pay, I bet there’s one thing where we can all agree.

Any pressure on government and insurers to even out specialist pay vs. generalist pay will definitely result in the pay evening out.

The specialists will get their pay cut, and the generalists will stay the same. There, now it’s even.

Any generalists out there, would you feel better?

Would you really?

Gee, the govt installs price controls via Medicare, Medicaid, CPT codes, etc heavily affecting PCPs. The PCPs try to increase efficiency (so as to not reduce revenue) by overbooking, spending 6 minutes/patient, etc. No place to go. The market place gets the message and fewer become PCPs.

The solution is simple. Allow markets to work, ie, cut the govt umbilical cord. Re-read Tom’s post above. When enough say no more Medicaid, no more Medicare, then this nonsense will stop.

No one ultimately can “win” when you negotiate with politicians – their objectives will never align with yours. Have the lessons of the past 45 years taught us nothing??

I hope that we as physicians we can come together and agree on evidence-based reasons to improve our patients’ access to primary care. That means finding ways to recruit and retain more medical students into family medicine and other primary care specialties. Leaving aside the issue of physician pay, for just a moment, let’s look at the evidence for solving the shortage. With our nation facing an epidemic of largely preventable chronic diseases – such as Type 2 diabetes and heart disease – both prevention and disease management become ever more critical for improving patients’ health and reducing health care costs. According to the literature:

• In communities where primary care physicians provide the majority of care, researchers found that patients are healthier and costs are lower.(1) Researchers from Johns Hopkins School of Public Health analyzed data from 3,000 counties and found that a higher ratio of primary care physicians to specialists in a population results in lower mortality rates and lower health care costs.(2)

• Research shows that adding just one primary care physician per 10,000 people contributes to a three to 10 percent decrease in deaths.(3) Studies also indicate that patients with access to primary care doctors suffer from fewer and less severe chronic diseases such as diabetes and heart disease.(4),(5)

• By providing primary care medical homes and emphasizing enhanced chronic care management for Medicaid beneficiaries, Community Care of North Carolina saved taxpayers between $231 million and $255 million in fiscal years 2005 and 2006 alone while improving care for more than 725,000 patients.(6)

• Since Geisinger Health System in Pennsylvania restructured care and began using the patient centered medical home model for 2.5 million patients, preliminary data reveal a 20 percent reduction in hospital admissions and a seven percent savings in total medical costs.(7)

Although our debates about how to solve the primary care physician shortage are difficult, the wellbeing of our patients demands that we find the answers. The California Academy of Family Physicians (www.familydocs.org) strongly supports the passage of meaningful health care reform legislation this year as a start.

David Emil Joseph Bazzo, MD
San Diego, CA

Citations:

(1) Starfield B. et al. “The effects of specialist supply on populations’ health: Assessing the evidence.” Health Affairs 24 (2005): w97-w107. Published online March 15, 2005: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.97

(2) Ibid.

(3) Barbara Starfield (Johns Hopkins University) research summary at:
http://pcpcc.net/content/evidence-quality

(4) Agency for Healthcare Research and Quality. National healthcare quality report 2007.

(5) Starfield, B. et al. “The effects of specialist supply on populations’ health: Assessing the evidence.” Health Affairs 24(2005):w97-w107. Published online March 15, 2005: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w.5.97

(6) Steiner, B.D. et al. “Community Care of North Carolina: Improving care through community health networks.” Annals of Family Medicine 6.4 (2008): 361-367.

(7) Paulus, R.A. et al. “Continuous innovation in health care: Implications of the Geisinger experience.” Health Affairs 27.5 (2008): 1235-1245.