Comments on: Specialists should staff the patient centered medical homes, not primary care doctors

By: Maggie Mahar

Maggie Mahar — Fri, 11 Dec 2009 07:18:36 +0000

Nuclear Fire–

I greatly admire how you view your own work, and why you do it.

You’re not looking into somone else’s pocket– not oomparing what someone else is making to what you earn.
You made your choice and like what you’re doing.

That said , I have to add that most physicans who pratcie cognitive medicine (listening to and talking to patients) are underpaid while those who pracice more agressive medicne( (cutting and burning) are overpaid for many services.

This doesn’t mean that PCPs should be angry–just that we should pay them more (and pay pediatricians, geriatricans, palliiative care specialists etc. more, , redistibuting the dollars on the physicians’ fee schedule .)

By: RM in STL

RM in STL — Thu, 10 Dec 2009 13:30:43 +0000

I work in healthcare, but not as a provider. I am also a patient. While this article may not have the full answer, I love the fact that the author is working to come up with a solution that limits the spending on specialty care that is making our healtlh insurance system impossible. I don’t hate specialists (several care for me) but as a patient and non-physician, I resent the extraordinary amount of money they make WHEN IT AFFECTS MY FAMILY’S ABILITY TO GET DECENT AND AFFORDABLE INSURANCE.

By: jsmith

jsmith — Sun, 06 Dec 2009 02:31:44 +0000

Jenga, I refer when I think consultation will provide significant benefit to the patient. Consultant salaries don’t directly influence my decision.
Indeed, the American people do value specialty care highly , even in those numerous cases when it is completely useless, or counterproductive, or lethal. Hence our current crisis.
Rezmed, I agree primary care will die unless something is done, and I’m not optimistic about something being done in the near term. A collapse would of course tighten the death spiral of American health care.

By: Rezmed09

Rezmed09 — Sat, 05 Dec 2009 18:15:21 +0000

Jenga,
You are absolutely right about the American people valuing specialty care. As I said above, this is where the money is going and this is where health care inflation is coming from. The question is how do we fix this explosion of cost and procedures. Shifting the solution back on primary care is not the answer – primary care is dying.

If Americans want to proceed with more fragmented, expensive, procedure oriented care with redundant testing which often enhance physician income so be it. And if the solution to this health care cost explosion is not more government, it will be more Walmart and more corporatization of medicine. That’s capitalism. And Americans do love Walmart.

By: Jenga

Jenga — Sat, 05 Dec 2009 05:47:41 +0000

If you feel they overpaid and don’t provide value to the patients you send to them, YOU are punishing your patients by referring to them. Neurosurgeons are one of the highest paid specialties, and I would never want to trade places with one of them. I bet you wouldn’t think they are overpaid when they are bailing you out of a jam.
Any physician should be able to easily workup a musculoskeletal complaint. It is not that hard. Anyone skilled in orthopedics, however, knows that’s not where the real decision making is made. For your difference in hourly wages you also do not take Emergency call such as rodding a femur at 3 am or make much more difficult operative decisions for musculoskeletal complaints such as selection, surgical planning and dealing with possible complications. When the American public has the chance to choose between a PCP and an Orthopod, I think we all know who they would choose. The American people value specialty care highly, that has been proven time and time again.

By: jsmith

jsmith — Sat, 05 Dec 2009 00:52:41 +0000

Jenga, Your analysis is puzzling. First, specialists sometimes provide a tremendous amount of value. I for one am not disputing that. And if some of them overpaid, we should not consult them? Huh? So we should punish pts just so we can punish specialists? Come one, get serious.
Look, we all know that the reimbursement scheme in this country is political to the core and has more to do with specialist domination of RBRVS than marginal benefit to the pts, let alone marginal benefit to population health. And don’t give us this nonsense about taking care of fractures. I do workups for orthopods and get paid a lot less per hour, not because my services are so much less important, but for the simple reason that orthopods are better at claiming economic rent from the government and the insurance companies that follow the government’s lead. That’s the reality.
Most PCPs think it is perfectly reasonable that they should earn less than the more difficult specialties. It’s the numerical value of the discrepancy that is a significant indirect driver of the poor value for money that the United States gets for its HC dollars. Of course we PCPs don’t expect to convince specialists on this issue. We would settle for convincing the American people.

By: Rezmed09

Rezmed09 — Fri, 04 Dec 2009 22:43:33 +0000

“Finally, why do all you angry PCPs (the PCPs who are angry, not all PCPS sare angry) refer to the specialists…”

I often don’t refer patients for many of these services; however, I and other PCP’s find that many patients don’t want reassurance, they want tests and, if they have insurance, they shop around until they get them. I am sure that as a rheumatologist you see many inappropriate referrals for positive titers etc., and can only imagine that this will increase with the ongoing decline of “angry” primary care physicians. But..

We have runaway health care inflation. If I understand correctly, the patient centered medical home is touted as a way to essentially reduce costs by coordinating care, improving access to primary care and reducing referrals. But 2/3 of physicians are now specialists. This is where the money is going. This is where the focus should be. This is the point of the editorial.

By: Jenga

Jenga — Fri, 04 Dec 2009 22:41:02 +0000

I agree nuclear. If some of these angry PCPs truly believe that specialists provide no value or are greater overpaid for their higher level of expertise, why do they send them any patients. Take care of these problems yourself and don’t support them financially and the problem will take care if itself. Do your own rheumatology workup, fracture care, manage all of your coronary patients medically to name just a few. Disparity will then solve itself.

By: Nuclear Fire

Nuclear Fire — Fri, 04 Dec 2009 18:30:03 +0000

This attitude is pathetic and unprofessional. I may be a specialist, but as I rheumatologist (no in-office imaging, infusion centers, botox etc or even lab) I make less than I can as a hospitalist. More training, more knowledge, less pay, but I’m doing what I like and that’s the point.

I have no ill feeling towards the Cards etc. who make more than I do. So what? This isn’t a capitalistic system, but even if it was, don’t I think that patients would pay more for the guy that saves their life from the heart attack at 2 in the morning than the guy who takes away their achey-aches (or even the guy who reassures them it’s not their heart than the guy who reassures them that it’s not “arthritis”)? And I’m certainly not interested in working the hectic pace of the hospitalist, even if my friends make more and only work 14 days a month. That’s life. We make choices and deal with it. Get over yourselves.

Finally, why do all you angry PCPs (the PCPs who are angry, not all PCPS sare angry) refer to the specialists and their “surgery centers, the off-site cath labs, the in office imaging centers and the endoscopy centers” only to be “reassured by yet another normal expensive workup” that you seem to hate? Is it because you don’t know the answer, you can’t provide reassurance, you need reassurance??? Then they’re getting a higher level of care, so why would they NOT get paid more?

By: Rezmed09

Rezmed09 — Fri, 04 Dec 2009 18:07:00 +0000

Let’s be honest here. For 2-3 years of extra training, many subspecialists earn double or more the income of primary care docs with comparable lifestyles. of course there are differences, but years after medical school and residency I had no idea that the income differences and lifestyles would be so disparate within my cohort. As everyone knows, much of the payment system is based on procedures. Who is building the surgery centers, the off-site cath labs, the in office imaging centers and the endoscopy centers? Cynicism is rising in the primary care world as we experience patient after patient reassured by yet another normal expensive workup, while managing the epidemic of multisystem chronic disease just isn’t paying well.
This is more and more about business, and this is clearly apparent to new med school grads and IM residents – primary care is now more (not always) a job for idealists or those who can’t obtain a fellowship. Follow the money.