Solving the physician income disparity

As an internist (yes, I am a specialist, just not a subspecialist), I do no procedures.  Patients pay me (albeit mostly indirectly) for my cognitive skills.  But we live in a culture that seemingly rewards procedures more that pure cognition.  Now I understand that procedures are not mindless.  Physicians doing procedures must think prior to the procedure, during the procedure and after the procedure.  But cognition without procedures seems undervalued.

The New York Times has an article that tells the story dramatically: “Patients’ Costs Skyrocket; Specialists’ Incomes Soar.” In glancing at the comments, many complain that physicians never discuss prices (note that I use price here rather than cost — cost has a specific economic meaning and price and cost are not equivalent).  Most physicians avoid this discussion, likely because an insurance company is usually paying, and because they are either ignorant of the price or embarrassed to discuss money.

Interestingly, patients probably value cognition more that the insurers (including CMS).  Many patients willingly pay extra for access, as the growing field of retainer medicine demonstrates.  Patients want adequate face to face time with physicians, access through phones, texts and/or emails and rapid access when necessary.

Our payment system is unfortunately gamed by too many subspecialists.  The decision to do a procedure is often made by the person who does and financially benefits from that procedure.  Thus, these subspecialists may have a financial conflict of interest.  Most physicians respond to such conflict in a healthy rational manner, but temptation can lead to abuses.

Dr. Wes, a cardiologist, takes offense at the Times article in his piece, The Importance of Demonizing Specialists. I do not read the article in the same way, but then I have a bias that the income disparity between those who financially benefit from procedures and those of us who “merely think” through patient problems is excessive.  I believe that we do need more generalists and that potential income drives our graduates (of both medical school and internal medicine residencies) away from generalism.  Money does matter.

I am happy for cardiologists to make more money than I do.  I have often advocated for an adjusted pay per unit time.  Those who have to come to the hospital at night for emergency care deserve a significant differential for that time.  The longer training for cardiology justifies higher pay, the only question is how do we determine the proper multiplier.

Price transparency might address these issues.  Perhaps this Times article will stimulate enough discussion to start a corrective process.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • DoubtfulGuest

    Nice post, Dr. Centor. I’ve been trying to get up to speed on this issue. My take as a patient, which has been better expressed by others on this blog, is that conflict between specialists and primary care doctors is unproductive. For me, it’s an artificial separation anyway since most of my health care is from cognitive specialists. I don’t know if this might add anything helpful to the discussion, since I’m pretty new to all this:

    https://www.aan.com/PressRoom/Home/PressRelease/964

    It seems that patients, the public, don’t realize how poorly “thinking” is reimbursed in general. We don’t understand much about diagnostic processes, we don’t know how to value them. But it’s a serious problem, I agree. We all want more time with our doctors, but are we willing to pay for it? I wonder if there are any cooperative efforts between primary care and the cognitive specialists? I don’t want to devalue procedural specialists, either, as some of them have helped me tremendously. I thought the Rosenthal NYT article was misleading.

  • Dr. Drake Ramoray

    I find it exceedingly interesting that the primary care crowd continues to vilify specialists as performing procedures that are supposedly unnecessary, all the while ignoring the fact that more and more primary care doctors find themselves under the employ of hospitals and as such will have the same conflict of interest in absolutely everything they do.

  • Dr. Drake Ramoray

    And will all the primary care doctors in the hospital owned PCMH refer these patients for evaluation to surgeons outside the hospital network?

    Either physicians will act in the role of self interest, interest of their employer, or they won’t. There will always be bad apples, the only change with the new systems is that now that conflict of interest will be thrust upon physicians by their employers.

    While not a PCMH issue, I remember working in a hospital system where I was told I wasn’t ordering enough labs and tests like one of my colleagues. They wanted me to order more A1cs like one of the other docs, you know order the test that represents an average blood sugar over three months every month like he did. He ordered a lot of cardiac stress tests too, against the recommendation of current guidelines for asymptomatic patients with diabetes. Yup don’t work there anymore.

  • Thomas D Guastavino

    Theres an old joke that goes something lile this:
    A homeowner notices that there is a leak in his basement so he calls a plumber. The plumber examines the area for about 10 minutes then takes out a wrench and tightens a valve, stopping the leak. He then hands a bill to the owner for $200. Incensed, the owner demands a breakdown of the work involved, demanding to know why he is being charged $200 for just tightening a valve. The plumber agrees and after adjusting the bill hands it back to the owner which now states:
    “Charge for tightening valve–$5.00″
    “Charge for knowing where to tighten–$195.00″
    Health care should be no different. Patients are best served if they can get to the provider who can not only has the skills to tighten the valve, but also knows where is the best place to tighten.

  • southerndoc1

    “The central conflict of interest in medicine has always been the specialist who decides a procedure is necessary, performs it – and pockets the fee for their services. This directly drives unethical over utilization in many different specialties.”

    Isn’t that the way every other profession and business works?

    The real, indisputable conflict of interest arises when the physician- patient relationship, based on direct sale of services, has to struggle against the employed physician-corporation relationship, in which the employee’s duties to the employer are primary.

  • buzzkillersmith

    No procedures Dr. C. ?

    One more procedure equals one fewer appt for depression. I think you know what I mean.

    Cryotherapy, easy lacerations, lumps and bumps, Nexplanon, Mirena if you practice below the waist,etc. etc. I’d go nuts without procedures. Check that, medicine has driven me nuts already, but I’d go even more nuts.

  • birchpoint5

    Perhaps the answer is for all insurance companies to require a PCP referral for specialist visits. That would also cut down on the wasted time of, say an ENT, seeing the patient who self refers for a cold because “I want the best treatment”.
    Also,if all procedures required preauthorization by the carrier, the number of unnecessary procedures would go down, and the number of unreimbursed episodes of care would go down too.
    I don’t believe most surgeons perform unnecessary procedures. Unfortunately, those that do seem to be quite prolific.

  • sparklingsoul

    I’m both a patient with multiple health issues and a pharmaceutical rep who has had the opportunity to get to know hundreds of doctors over the years.

    There is no question that primary-care physicians are underpaid. In Silicon Valley, engineers (with only a bachelor’s degree) who develop apps make as much money as primary-care physicians.

    My internist calls patients at night and on the weekends because he doesn’t have enough time to do this during the week. Shouldn’t he make at least double what a developer of useless apps makes?

    There are so many inequities in how physicians are paid. I had a three-hour surgery in which the surgeon was paid a total of $1,500 for his services, while my ENT got $500 for scoping me in the office (two-minute actual procedure time). That amounts to $250 an minute for the ENT but only $8.33 a minute for the surgeon. Can someone please explain this?

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