We must redesign our health care payment systems to value primary care

We must redesign our health care payment systems to value primary care

I share this post here to point out the discrepancy in physicians’ average salaries based on their specialties. In particular, I would like to highlight that the three lowest-paid specialties are the three primary care specialties: pediatrics, family medicine, and general internal medicine.

This post is not written to argue that physicians must be paid more. I would submit that if physicians cannot live on $150,000 then we might be doing something wrong … and we are unlikely to get much sympathy from the average person.

Rather, my intent is to note how undervalued primary care services are in our current system of healthcare delivery and payment. Primary care physicians — the physicians who provide comprehensive care, who provide preventive care, who coordinate care – are paid less than all other medical specialists. Radiology and anesthesiology make nearly twice what primary care doctors do; dermatology and anesthesiology make nearly 175% of the average primary care physician.

This is not to say that these medical specialists do not have important roles in providing medical care; however, should a physician who views x-rays and imaging studies be valued at twice the level of the physicians who keep our children well, who monitor their development and intervene if necessary, and who ensure children are fully vaccinated? Should a physician who deals with skin problems be paid at nearly twice the level of a physician who can deal with many of the same skin problems…while also addressing patients’ diabetes, blood pressure, heart disease, and mental illness?

The cost of any given service or item depends on its value. Precious metals are expensive because we value them greatly. Luxury cars are expensive because they are highly valued in our culture. Primary care physicians in the US are paid less than all other specialists, and cost less per physician than all other specialists…indicating that the primary care specialties are valued less than other medical specialties.

We have previously noted the importance of primary care to a high-functioning, efficient, and effective healthcare system. Despite the key role primary care should be playing, however, the chart above shows that primary care is not valued at a commensurate level.

Unless we value primary care, and redesign our healthcare delivery and payment systems to reflect this, then we will continue to have a healthcare system that under-performs even as healthcare costs continue to increase. The cost depends on the value: so long as we do not value primary care, then costs will rise even as outcomes do not improve.

This situation is untenable, and must change. We must demand a healthcare system that values those services and specialties that reduce costs. We must enhance primary care’s role in our system in order to improve our system’s performance. If we change what type of medical care our system values, then we can truly affect cost.

Mark Ryan is a family physician who blogs at Life in Underserved Medicine.

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  • http://pulse.yahoo.com/_3CY2U67646G7UIAHBQVTT2UP4Y Kristy S

    Excellent article, but what happens to the patients whose primary care physicians say that their cases are too complicated to take care of? The reason I ask is because I met someone like that once whose primary care physician told her this very thing.  I don’t know if she was able to find a Primary Care Physician to take care of her as far as coordinating the care of her specialists and treatment plans.

    • Brian L

      To say that primary care physicians are undervalued is only part of the story.  Primary care physicians are not only undervalued, but their most valuable and fundamental roles are undervalued the most!  Your question really highlights that.  As a third year medical student, I can tell you that if I were to medicine to the excellent standards to which I am being trained, I will be out of business within a year under the current predominant system.  Dr. Stephen Schimpff posted an excellent article today on how the costs of primary care have been artificially inflated.  http://www.kevinmd.com/blog/2012/06/primary-care-expensive.html

  • http://twitter.com/sjmo2 Stephen Motew

    I agree that the role of primary care providers is undervalued when it comes to compensation.  However, your argument confuses the concepts of value and assigned price (or reimbursement)  Economically, goods and services are priced differently due to the scarcity of the resources and demand.  This does not always equate to value as you describe. Precious metals are expensive due to the scarcity of the resource and the associated demand.  The demand might relate to how much we like/need/desire the object or what value it has to us.  My point?  The compensation for specialists follows a similar pattern. For those who practice many (not all) specialty services, a significant commitment of years of training, long hours, altered lifestyle, increased liability, call and weekend hours is balanced by higher compensation.  Does this always equate fairly?  Probably not, as the lifestyle, liability and call hour benefits of radiologists and dermatologists can be argued to match or exceed most primary providers.  The difference then becomes the demand for services as determined by the payers (or individuals) willingness to compensate for these services.  There is most certainly a disparate compensation system, and without doubt the impending primary provider shortage will require realigning compensation.  A fair system will take into account years of training, lifestyle, risk, hours worked etc. regardless of specialty and not disparately value to asset of a physician’s role in providing care for patients.

  • karen3

    i don’t know. Every primary I have ever had turns green at anything more complicated than a cold.  I do my care coordination. The primaries have not even understood what my tests were over the past five years. Why do I have a primary? One, to beg for diabetes meds when the endo is in a peevish mood and cuts me off with a 350 bg.  Two, because every specialist crabs when I don;t have one.  The primary is a waste, a pure waste. What needs to be compensated is value, not any one category of doctor.

  • sFord48

    RE:  Should a physician who deals with skin problems be paid at nearly twice the level of a physician who can deal with many of the same skin problems
    The last time I had a skin problem, I was sent to a specialist.  For office visits, my insurance pays the same rate to specialists and primary care for the same type of visit.   Primary physicians don’t do procedures anymore.

    My primary care physician prescribes medicine for conditions that were evaluated by a specialist.  He doesn’t have the background to make any changes to my medication regime.  He doesn’t have time to see me in a urgent situation or an emergency.  He won’t be involved in my care if I am hospitalized. If something is complicated…or requires something more than talking, I get referred out.  My PCP has never been there to be a familiar face in difficult moment.

    • http://twitter.com/#!/CloseCall_MD Close Call

      I’m sorry you’ve had such crappy luck with PCPs. 

      “Primary physicians don’t do procedures anymore.” Most national surveys say family physicians do.
      80% do both derm procedures and MSK injections.

      http://www.aafp.org/online/en/home/aboutus/specialty/facts/64.html

      It sounds like you haven’t found a good primary doctor.  You may feel you don’t need one, and you’re probably right., because you make it sound like the one you have is crap.

      • sFord48

        It’s easy to tell me that my lack of faith in primary care is my own fault, or perhaps I have a crappy PCP.  While you retort that I was unfortunate to have a physician that wouldn’t deal with a tick bite, that list you provided shows that primary care physicians miss out on income from procedures…and make their value to a patient decline.  It’s expensive, inconvenient, and delays treatment to go to a PCP and have him tell you to go somewhere else. 

        So what is it about my PCP that makes him crappy. Could it be that instead of seeing me for an urgent problem, he uses a physicians assistant?  Or is it his that he won’t admit me to the hospital, instead sending me to the emergency room to be admitted?  Is it he doesn’t have the time to look beyond a textbook case to make real suggestions for difficult problems?

        • http://twitter.com/#!/CloseCall_MD Close Call

          Nope.  Your lack of faith in primary care isn’t your own fault.  It’s likely because you don’t know any good PCPs.  If you only interact with crappy PCPs, of course you’ll lose faith in the specialty.  No one’s fault, just the hand you were dealt due to luck or location (certain locations have more choice in PCPs).  

          “Primary physicians don’t do procedures anymore” – have to say, as the list shows, most FM docs do LOTS of office based procedures.  It’s crappy that your doc doesn’t.  It’s crappy that your doc won’t see you in the hospital.  It’s crappy your doc won’t take care of a tick bite.  

          But most FM docs do lots of office based procedures.  I can assure you, most FM docs are trained to take care of a tick bite.  

          Seeing you in the hospital, that’s a different matter.  On the flip side, MANY studies show that being taken care of by a strong primary care team prevents hospital visits. 

          There are many good family medicine, internal medicine, peds docs out there.  There are many good NPs and PAs.  Sorry you haven’t met any.  

          Places like Kaiser, Qliance and Medlion illustrate how well-integrated primary care works… well. 

          • sFord48

            I have had 5 PCP’s in the last 10 years…one retired, one moved, I moved, I fired one…I am 0-5.  My husband and friends have had similar experiences.

            On the list you provided, only 4 procedures are done more than 50% of the time with only 2 more than 60% of the time.  

            I understand your need to defend your profession but the reality is that many patients don’t value primary care because there is no value.  Instead of listening to patients and providing needed care, your pretend these aren’t real issues.  I don’t want an appointment with a surrogate, I want my doctor to be involved in my care, especially when something is going terribly wrong.  I have experiences with 5 different doctors who failed to provide for these basic needs.  If I have to deal with strangers for these vulnerable situations, I need to be up to speed.  The step to coordinate my own care is an just an extension of that.

          • sFord48

            From 
            http://www.kevinmd.com/blog/2012/06/doctors-quietly-incrementally-bowing.html

            “The patient narrative is fracturing.  Primary care physicians are using hospitalists.  Patient centered medical homes and large medical groups are favoring speed of access over continuity of care.  A patient no longer has one physician but a team of doctors working on their behalf.  Unfortunately, as opposed to group think, what usually happens is that each provider knows strikingly little about the patient.  Tests are repeated, stories are retold  and modified, there is no longer a holder of knowledge. ”
            This is my experience…I am the holder of the knowledge because primary care refuses to do it.  Why would I pay them more?  

          • http://twitter.com/#!/CloseCall_MD Close Call

            “many patients don’t value primary care because there is no value.”  2 assertions, only 1 one of them is true.   Many studies have shown the benefits of good primary care on hospital readmissions, chronic disease management, costs, and many other criteria. 

            I’m sorry that not one of your 5 doctors listened to your problems.  It sounds like you weren’t getting good primary care.  

          • sFord48

             RE:  Many studies have shown the benefits of good primary care on hospital readmissions, chronic disease management, costs, and many other criteria.
            So really what you are saying is that I have to be old or chronically ill with a disease that puts me at risk of being hospitalized to reap the benefits of primary care.  Since I am athletic, somewhat of a “foodie” and middle aged, primary care is a waste of time.  Primary care has nothing to offer me that I can’t find cheaper and better somewhere else.

  • SidewaysShrink

    The Center for Medicare Services rejiggered their Relative Units to decrease payments to specialists “so they could increase payments to primary care”.  Private payers have used this excuse to cut my reimbursement by 15%.  I am in psychiatry. If you look back at that column bar chart, psychiatry is number 5 on the lowest paid specialties.  Psychiatrists who want to accept insurance from middle and working class people use CPT codes that are time based.  The principle of psychiatry is such that we do not have multiple exam rooms that patients wait in so that we can see 4 or more patients an hour.  And yet, we received the same percentage cuts that highly paid specialists did.  I think I am supposed to lump my student loans and accept being underpaid, but I can’t get used to it….

  • MarcGarfield_DPM

    Specialist make money on volume, Primary care increases reimbursements based upon the bullet points of there exam and coding.  Eliminate Stark Laws and primary care doctors will be paid for what they are worth.  Primaries rarely do procedures because if the outcome is not perfect, patients assume a specialist would have done it better and litigate. Primary care should be compensated for evaluating, treating and referring patients when appropriate.  How much do they get paid for properly guiding a patient to the most appropriate specialist for a particular condition. $0.  How much post graduate emphasis is placed on PCPs to avail themselves of new techniques performed by other specialists ..very little.  Society wants PCP’s to have a full understanding of everything everyone does and then send them off to the best specialist to do the work, but there are $0 to pay for this and everyone actually goes to jail or pays massive fines to government if such a system were to arise, in which PCP’s were paid referral fees either from the insurance company’s or physicians themselves.  Seems to me we need a system that rewards PCP’s for arranging for proper care.  A direct cut from the specialist would enrich PCP’s but would be viewed as a conflict of interest.  But a reward system for favorable patient care and cost containment by the third party payers might remove such a conflict of interest.  But the fee would have to be split from the specialist in exchange for volume to balance the overall healthcare expenditures.

    • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

       With the formation of ACO’s PCP’s should be getting a bigger cut of the pie of fees. 

  • Jim Jaffe

    It isn’t clear to me why this system is untenable, but if it is it will certainly change.  partners in law firms get paid more than judges, even those who serve on the supreme court.  hospital administrators and college presidents get higher pay than the President of the United States.  Nonetheless we see to have an ample supply of highly competent people who’d like to move into the White House or become a Supreme Court justice.  Elementary school teachers who help us learn to read routinely get paid less than professors at research universities.  the list goes on.  why this obsession with equity.  as you note, even primary care physicians make a lot of money by US standards.  why should we pay them even more?  is there any evidence that suggests we’d get better outcomes if we did?

    • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

       It is probable that if primary care physicians were paid more then there would be more entering this field.  There is a recognized shortage of PCP; paying more would help alleviate the shortage.

  • southerndoc1

    Primary care refuses to do it because no one will pay them to do it.

    Next whine, please.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      ^^ What southerndoc said ^^

    • sFord48

      So this is your argument for the value of primary care?   And whose whining?

  • http://twitter.com/knitsteel kskilesjewelry.biz

    Our family practitioner charges $150 per visit, which is charged to our insurance provider. That charge does not include any medical tests. I do not know how much of that money goes back to the physician through the clinic or on what basis the physician is paid. Visits average 15 to 30 minutes and are good quality primary, usually preventive, care, but not specialist care. I can’t imagine 15-30 minute visits costing more than $150. Would they need to cost more in order for the PCP to get more money?

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