Pay specialists less to save primary care

Since 1997 the number of US medical students choosing to go into primary care has decreased by more than 50%.

It seems that sources as diverse as the Obama Administration and the Wall Street Journal think that we should find a way to encourage medical students to choose primary care specialties in order to allow Americans to have the best and most cost effective care. This is very problematic when primary care specialists earn considerably less, often 50-70% less than physicians in specialties where most of the revenue is produced by doing procedures.

For years when asked about the disparity in physician salaries I’ve said, “I think primary care physicians are fairly compensated. I just think a lot of other physicians are overpaid.”

If you look at the 2009 AMGA survey of physician income it is clear that the pay you can expect as a physician has little to do with how hard you work, how long you train, or how stressful or difficult your work is, and everything to do with whether you perform procedures that are highly compensated. It is hard to think of specialties less demanding in terms of after-hours call, emergent life-threatening care, and overall lifestyle than dermatology ($350,627), diagnostic non-interventional radiology ($438,115) and radiation therapy ($413,518) (median salary in parentheses).

Compare these to what I’d consider some of the most difficult, intellectually challenging, and demanding specialties: pediatric oncology ($205,999), infectious disease ($222,094) and adult neurology ($236,500). Family medicine is one of the very few specialties where the first number in the median salary is a 1.

For the annual earnings of one orthopedic joint replacement surgeon ($580,711) we could have one general surgeon ($340,000) who operates on the sickest of patients often emergently at inconvenient times, plus a family physician ($197,655) and a first year school teacher thrown in for good measure. There are no emergent joint replacements. When a patient with a fractured hip is admitted to the hospital a primary care physician or hospitalist admits them, works for hours to days to get them well enough for surgery, then the joint surgeon operates for maybe 2 hours, spends maybe 1 hour on rounds the next several days, and sees the patient a couple of times in the office for follow up visits. If the patient has post-operative complications, the primary care physician or hospitalist, or maybe an intensive care specialist is asked to manage these problems. It’s a crazy system.

All efforts to change this have been met with intense lobbying efforts from physician specialty groups. The theme is always that we cannot make sudden changes in compensation; things must be done gradually so that it will be fair and thoughtful. Somehow the changes then just don’t happen.

As primary care physicians we are well paid. It’s just that by dangling the carrot of really high income in front of students, who see that the workload, lifestyle and difficulty of specialty care is not greater and is often less than that of primary care where they can expect to earn millions of dollars less over their career, they have trouble justifying a primary care career choice.

I’ve read lots of articles and posts recently saying changing pay alone will not fix the shortage of primary care physicians. Maybe not, but it is the easiest first step. Increasing primary care compensation a little, and decreasing specialist pay a lot, to bring them close to equal, would go a long ways towards making primary care training more popular. In his post on KevinMD.com, John Horstkamp, MD agrees that making pay more equitable is the key to providing incentive to medical students to go into primary care. He suggests we need to pay family physicians 50-70% more. This would suit me nicely. I could live with higher pay. I also know that any proposals that increase the amount spent on health care are likely to be poorly received by legislative decision makers. I suspect a more palatable solution to American society in this era of concern over medical spending may be to pay less for procedures done by specialists.

The rates for payment are set by the federal government. Each year the Center for Medicare and Medicaid Services (CMS) sets what are called Relative Value Units, or RVUs. These determine the compensation for every procedure physicians are paid to perform. Currently the weight on RVUs is heavily weighted towards procedures, and less weighted towards the evaluation and management of health concerns. CMS could choose to change this to make payment for procedures much less. This would functionally bring pay to primary care physicians and specialists closer to parity. Commercial insurers have always quickly followed the CMS determined RVU schedule.

Could this happen? Certainly if our legislators have the will to mandate this change by CMS, and the courage to stand up to the lobbyists of the specialty associations it could happen very quickly. The AMA will undoubtedly be opposed to “rapid” change. Primary care associations will take care not to be offensive to anyone. Legislators won’t pick a battle because it is always less than two years until the next election. This makes it unlikely to see this type of change anytime soon.

Legislators will whine that there is nothing they can do to get medical students to go into primary care, because they cannot afford to pay primary care doctors more. Don’t believe them. They just don’t have the courage to make obvious big changes that will be unpopular to some of their supporters.

Now, where can I find a place to hide from my specialist friends.