It is axiomatic that one’s income is based on one’s value. If recent studies on physician income are any indicator, society still places a lot more value on doing procedures than on keeping people healthy.
According to physician recruiting firm Merritt, Hawkins & Associates, job offers for internists and family practice docs came with average salaries of $162,000 and $145,000 respectively. In contrast, cardiologists and radiologists were offered $$342k and $351k. The first group of docs provide primary care; diagnosing conditions, encouraging healthy behaviors, finding early indicators of life-threatening disease. They get paid for their time. Yes, they do procedures (excisions, tests, x-rays and the like) but their time is spent not doing things but figuring out what’s wrong with patients and making recommendations to fix the problems.
The second group of docs do procedures – yes, they diagnose, albeit on a patient that arrives with records in hand, preliminary work-up completed, and some indicators of a problem that falls into the specialist’s area of expertise – but they get paid to do things – analyze images, perform surgeries and invasive procedures, apply radiation to attack cancers and the like.
And primary care physicians are not (Lowes R. Earnings: Primary care tries to hang on. Medical Economics. September 17, 2004) seeing their incomes increase, while invasive cardiologists enjoyed an 11% jump in income from 2002 to 2003. Internists who are looking to generate more income are encouraged to sub-specialize in gastroenterology, cardiology, and other more lucrative areas.
The Lowes article provides an excellent perspective on the causes and results of the rise of “proceduralists”.
“The proceduralists have benefited from the waning of the gatekeeper model, since they’re now more accessible to patients. And they’re kept busy by graying baby-boomers anxious to preserve their hearts, knees, and various organs. Specialists also have managed to make up for meager third-party reimbursement by generating income from ancillary services such as diagnostic imaging, outpatient surgery centers, and even specialty hospitals.”
What does this mean for you?
The free market in healthcare is working. For specialists. It is most definitely not working for payers, taxpayers, and patients. And it is continuing to drag down our nation’s commercial and industrial competitiveness.
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So what is the alternative payment model and how could it work and be implemented in practice?
As one who developed heart disease, in part as a result of a genetic predisposition and despite normal weight and cholesterol readings over the years, I have been the recipient of a number of beneficial procedures including CABG and, more recently, a stent. I take five heart related prescription drugs and get periodic stress tests to monitor my condition. Is my doc being rewarded for doing procedures or just executing a textbook monitoring program and being paid appropriately for it? I think the latter is more accurate.
To the extent that it takes more years of training to become a cardiologist than a GP, especially if a fellowship is pursued, the specialist should make more money just because he or she has invested more time and money in securing the necessary education and training to do the job. In the case of surgeons (of all types), there is an additional set of physical / coordination skills required which deserves additional compensation as well.
To the extent that doctors may be performing procedures that are unnecessary or of minimal value at best, they should be called to account for it. However, there are perfectly legitimate reasons, in my view, why specialists make more money than GP’s and internists.
There are several distinct questions here. Here are two to start with: 1) Should specialists get paid more than primary care physicians? 2) Should PCPs earn $150K and specialists earn over $300K?
The answer to the first question, from a public interest standpoint, will depend on factors like the average contribution of specialists and PCPs to quality and length of life. BC’s personal experience doesn’t answer that question.
The answer to the second question depends on how much the average citizen is making and what value each type of physician provides. This one is much easier to answer: in developed countries that pay their physicians half as much as we do, their quality and length of life is actually higher than ours and they have roughly as many physicians per capita as we do (sometimes more). In short, there is no good reason why we pay physicians so much, only lots of bad ones.