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Primary care salaries need to be addressed to improve health care

| Policy | July 15, 2010

Physician salaries are always a sensitive topic.

A common view among health reforms is that doctors, in general, are paid too much. Various progressive pundits point to statistics showing that American doctors are the highest paid in the world.

For many specialists, that may be true. But not for primary care.

A recent Tweet by Ves Dimov pointed me to an article from the UK, stating that primary care doctors working in the National Health System are the highest paid in the world — an average of 106,000 pounds, or about $160,000.

It’s well known that the UK’s health system is based on a strong primary care foundation, leading the country to do well on a variety of health measures.

With an upcoming mandate in the UK that primary care doctors expand their hours, their pay is set to go even higher:

Family doctors in Britain are already the most highly-paid in the world, taking home an average of £106,000 a year – up more than 40 per cent since a lucrative contract signed in 2003.

But they pay looks set to rocket even further, because Health Secretary Andrew Lansley wants to hand them extra power to commission services for their patients, effectively putting them in control of Health Service spending.

Progressive commentators like to point how the American health system does poorly when compared to countries abroad. And yes, the numbers don’t lie.

But to improve our standing, it will take a fundamental transformation of primary care in the United States. And, as the UK has shown, that takes a strong financial commitment to primary care salaries that most reformers don’t advocate vocally enough.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.

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Tagged as: Health reform, Primary care

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  • pheski

    I think the proposition that paying more will get more/better primary care is too simplistic. (For every complex and challenging problem, there is a simple solution…that won’t work.)

    Primary care is not the sort of mindless algorithmic or mechanical process where financial rewards consistently result in a larger quantity of a higher quality product.

    I would agree that primary care should be paid better – but only in order to take the issue of compensation off the table. We shouldn’t be thinking about pay, we should be thinking about our patients.

    Based on my understanding of primary care and my knowledge over three decades of the best examples of primary care clinicians whose paths have crossed with mine, I would:
    1. Pay enough to take pay off the table.
    2. Largely eliminate volume driven pay incentives
    3. Maximize autonomy. Give providers the time and the tools to work 1:1 with patients to find the optimal plan for that given patient. (To do this, one has to already have done #1 and #2, of course.)
    4. Encourage and reward mastery. Both public recognition and pay incentives for quality care, rather than quantity of care. (Though experiment: which commercial pilot do you want to fly with? The one who flies the most hours monthly, or the one who flies with the fewest errors and problems? I thought so.)

    • twicker

      Very good points. A couple of thoughts on your #3 and #4:
      Maximize autonomy:
      As much as I value autonomy, my stance on this particular issue would depend on what kind of autonomy we’re talking about. For example, I’ve known PCPs who have done extremely well in various areas. From working in HIV medicine, I’ve also known of PCPs who prescribed efavirenz monotherapy, thinking that would be easiest (that’s about the surest route to killing an entire drug class through resistance — or at least it was at the time; etravirine hadn’t hit the market yet). So, a degree of autonomy is good, but not to the extent that they can ignore guidelines without good reason and appropriate training.

      #4: With your thought experiment: that depends: If the one pilot flew more hours monthly — and has for the past 5 years — and the other flew with fewer errors/problems — for the past week after starting the job last Friday, I’ll take the one that has more experience, thank you.

      It’s not just about the most recent month; it’s about the accumulated experience. If pilot A consistently has a better quality month than pilot B, and only flies a bit less, and has this over the span of a year or more — then, sure, take the pilot who flies a little less (ceteris paribus, of course). If one flies 10x as much as the other, and the quality difference is within 1 SD, and the “lower”-quality pilot is still in the upper 50% of pilots — then I’d go with the “lower”-quality pilot. Her index is more reflective of her true quality, she’s obviously survived 10x more landings, and she’s likely seen more anomalous events and, thus, is less likely to be surprised by them and more likely to know how to handle them.

      Like it or not, experience counts.

      • pheski

        I agree fully with your comment about autonomy.

        In terms of the thought experiment, perhaps I should have phrased it slightly differently to focus better on my point. Which data would you rather be given before selecting a pilot for your flight from San Francisco to Hawaii? A list of pilots and the hours they flew monthly for the last year, or a list of pilots and the hours they flew without adverse incidents in the last year. I agree that experience counts, but doing something frequently does not make up for doing it badly.

        • twicker

          pheski — with your thought experiment phrased that way, I concur completely. :)

  • stargirl65

    Over the last several years I have decreased my staff from 3 to one while increasing the numbers of patients that I see per day. This has been to simply maintain my salary at the level it was 10 years ago.

  • http://www.ohiosurgery.blogspot.com buckeye surgeon

    Being paid more means accepting more responsibility for patient care—no more shotgun consulting, no more referring every abdominal pain to a GI guy, no more sending every 1 cm pigmented lesion to a dermatologist, no more referring every diabetic to the endocrinologist, etc etc.

    • r watkins

      In medicine, as in most other situations, you get what you pay for. If you want well educated primary care docs who offer comprehensive care, you have to pay for them.

      Pheski makes many good points, but improving pay is the necessary (but not sufficient) starting point. It’s truly pathetic that none of the primary care professional organizations seem to realize this.

      • twicker

        I’ll agree with you that pay matters — up to the point that pheski indicated. To get good primary care doctors, and to get people to choose that field instead of other fields, you just need to shift the incentives so that there’s no or less monetary incentive to go to another, equally hands-on and caring field. You’re not going to poach many surgical types for primary care (nor would I suspect that you would want to), but people who want better lives for themselves and their families should have less incentive to choose, say, cardiology for lifestyle reasons. From BLS (2008 figures):
        Median annual compensation, general medicine: $186,044
        Median annual compensation, specialists:
        $339,738
        Source:
        http://www.bls.gov/oco/ocos074.htm

        Also, you don’t always get what you pay for. Prime examples would be folks like Ken Lay — really well-paid, really worthless when it came down to it. IMHO, you just want people who are already in med school to want to move into primary care without disincentive.

    • apurvab

      So when the “shotgun referral” that the GI doctor spends 45 – 60 minutes evaluating also mentions that he’s having back pain and has a skin lesion, he shouldn’t just dump it back to the PCP, but should actually address it? Greater pay for greater responsibility, and all that …

    • jsmith

      What apurvab wrote.
      And no, actually, being paid more, when you are egregiously underpaid for the responsibility you already have, means simply being paid more. High time. Not that it’s going to happen.
      And no guff about the hard road of gen surgery. You’d be preaching to the choir.
      Maybe the PCPs in your community refer the way you suggest. I can tell you they don’t in mine. My family doc does colonoscopies as well as pigmented lesions and DM. Does your local scope jockey do that?

  • Randall

    I found that salary is dependent on the society that represents you, Cardiology society is very vocal and fights for their speciality, they in fact overpower other specialities like radiology, they demanded that they can read stress nuclear studies which pays good for cardiology though technically it is radiology related. ACP, AAFP, which represent primary care don’t have the skills to lobby even when all studies point favorably toward primary care and so their fields suffer. AMA is filled with specialists on their boards, they skew results in favor of speciality with their RVU nonsense while primary care is on hamster wheel an withering the past couple decades.

  • M Osler MD

    When the English PCP signed their “world leading salaries” contract they promtly informed her majesty’s government that they would no longer be responsible for their patient’s healthcare; “before 8AM or after 5PM Monday thru Friday and not on weekends or a holiday. (go ahead search it). If paying PCPs more would solve the problem how do you exlplain the all time record resident matches of the mid 1990s (prior to the BBA), when the pay gap between specialist and PCPs was not much different from what it is now?

  • Fppa

    What is the current average that FP doctors are paid nationally?

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