I have to make a confession.

I am bitter.

I know this may sound strange for those who know my usual laid-back demeanor, but I am really frustrated with how it seems my profession is under-valued. What I am talking about is the widening salary gap between primary care physicians and specialists.

The Problem

In a recent article in the Annals of Internal Medicine they discuss this gap (emphasis mine):

A large, widening gap exists between the incomes of primary care physicians and those of many specialists. This disparity is important because noncompetitive primary care incomes discourage medical school graduates from choosing primary care careers.

The obvious question is: what is the big deal with this?  The article goes on:

Does this income gap matter? Yes. Although incomes of primary care physicians are far higher than the earnings of most persons in the United States, and the public has little sympathy for physicians who cry poor, the lower income of primary care physicians is a major factor leading U.S. medical students to reject primary care careers (6, 7). The percentage of U.S. medical graduates choosing family medicine decreased from 14% in 2000 to 8% in 2005 (8). Seventy-five percent of internal medicine residents eventually become subspecialists or hospitalists rather than general internists (9). Because office visit fees are relatively low, primary care physicians schedule many short, rushed visits to keep afloat financially, which potentially compromises patient outcomes (10) and fosters the unsustainable physician work life that contributes to students' avoidance of primary care careers (11). With a median debt of $120 000 for public and $160 000 for private medical schools, medical students are further discouraged from choosing careers in primary care because of the noncompetitive income (12).

I understand that I am relatively well paid for my work. I am paid more than most of the people who come and see me in the office. My kids go to a private school, and I live in an OK neighborhood. Furthermore, I don't have any desire to own or drive a fancy car. I don't ever want to give appearance that I am flaunting my wealth.

Why this matters

So why would this bother me? First it is simply the fairness of the issue. I work as many, if not more hours as a specialist. I trained for four years in residency, where many of them trained nearly the same length of time. My knowledge base is far broader, and my direct effect on the lives of people is greater. It is part of a normal day that primary care physicians save the lives of their patients. We diagnose them with heart problems before they become serious, we diagnose appendicitis (or gallbladder problems, for that matter), and quickly decide regarding the seriousness of people's illnesses, referring to the cardiologist, gastroenterologist, or surgeon who does the final procedure to "save the patient."

If this is true, then why should the doctors who treat rashes, near-sightedness, or hemorrhoids get paid so much more than we do?

The second and more serious reason is the effect that a lack of well-trained primary care physicians has on the system as a whole:

Patients, specialists, and the entire health system need a healthy primary care base. In a 1997 patient survey, 94% valued having a primary care physician who knew their medical problems. Eighty-nine percent wanted their primary care physician to participate in the specialty referral process (35). Patients with a regular generalist physician have lower overall costs than those without a generalist physician (36–38). Increased ratios of primary care physicians to population are associated with reduced hospitalization rates for 6 ambulatory care–sensitive conditions (39). Health care costs are higher in regions with greater specialist-to-population ratios (40–43).

If I can diagnose high cholesterol and treat it, I can prevent heart disease or stroke. If I manage diabetics well, I can keep them out of the hospital (which is where the bulk of the cost of diabetes is in the US). The problem is, if you discourage doctors from going into primary care by not paying them as much, then you move more physicians into the areas that are more costly to US (specialists) and away from fields that would actually save money. It works doubly against the system to pay this way.

So what is the silver lining? The silver lining for me is that it is being increasingly discussed in public and there are rising sentiments among insurers and Medicare personnel that this issue needs to be addressed as well. In a recent post on the Health Care Blog, Walter Bradley states:

Over-utilization of health care services in the US has many causes. Defensive medicine is one of them, but another is the profit motive. The income of medical facilities and physicians increases when more tests are performed. As Allen (2003)17 pointed out, the US third-party payment system rewards technologically intense services. Surgical and other procedures are reimbursed at a higher level per unit of time expended by the practitioner than are cognitive services. This leads to the tendency for medical students who wish to make money to select higher paying procedural-based disciplines. 18

He adds later in the article:

It has long been recognized that the US does not have a  comprehensive primary care network and needs to train more primary care physicians.19 The United Kingdom has about 550 family practitioners per million of the population, 20 while Canada has about 740 primary care physicians per million. 21 In comparison, the American Academy of Family Practitioners has about 58,500 active members, 22 or 200 per million of the US population. In the US internal medicine specialists also provide primary care for many patients, perhaps without the breadth of training of family practitioners. The American College of Physicians has about 104,000 full members of whom perhaps a half (approximately 180 per million of the US population) provide some primary care. 23 Physician assistants and nurse practitioners, who number about 500 per million of the US population,24 provide primary care but are not as fully trained in diagnosis as are family practitioners.

First Steps

So what is the answer? The Annals article states:

In the short term, Medicare and private payers need to review and modify their reimbursement approaches to shift payments from procedural and imaging services to evaluation and management services. The 2006 increase in some evaluation and management codes recommended by the RUC is a small and inadequate step in that direction. The MedPAC has suggested that RUC membership include more primary care physicians, has recommended that CMS review overvalued services, and has discussed altering the SGR system to protect primary care physicians who are the victims of, but are not responsible for, most expenditure growth (21). Furthermore, MedPAC has recommended payments for care coordination services targeted to chronically ill Medicare patients, many of whom are managed by primary care physicians (44). The ACP recommends that Medicare substantially increase evaluation and management RVUs, pay for time spent on telephone and e-mail consultations, and reimburse care coordination for patients with chronic conditions (12). The ACP and AAFP call for a revision of the SGR process.

For the long term, it would be desirable to develop new payment models that blend the best of fee-for-service, capitation, and salary, while mitigating each approach's deficiencies (45, 46). For example, primary care physicians who are caring for patients with multiple chronic conditions could be paid on the basis of capitation-like principles, though avoiding the problems created by previous managed care capitation systems (47, 48). Surgeons and other specialists responsible for episodes of care over a delimited time period might be paid case rates on the basis of diagnoses, and specialists providing one-time professional services might continue to be paid fee-for-service.

While I don't agree with all of the steps (especially the E/M code suggestion), concrete steps can and should be carried out to close the gap. I don't think that primary care physicians need equal salaries with that of the specialist (especially those who have trained significantly beyond the PCP), but I think that a four-fold (or more) difference is not only unfair, it is harmful to the system.

My plan is to continue this series on American Medicine around a discussion of possible solutions.  It is one thing to gripe about the way things are; it is another thing to start putting up possible solutions.