Makes a lot of sense when looked at systemically. At the same time, at an individual practice level, an “efficiency cut” is a meaningful reduction in revenue. And expenses don’t go down. They are only going up. So, it makes practices less sustainable. Making it a zero sum game is the problem here.
Very thought-provoking post. The same issue is present in Canada. And the same incentive gradient btw “doing” and “thinking” exists here wrt remuneration scale. And all the same issues about inability of GDP to afford growing the pie, such that we need to redistribute the pie, yet bedeviled by subgroup self-interest which prevents the profession as a whole from doing so.
OTOH, that has to be balanced by recognition of all the extra years spent in training and developing deep expertise in a specific clinical area. As well as the reality that there has to be financial incentive for someone to be capable and available to respond to emergencies at 3am.
No easy answers here. But I thought this made a fair case for primary care.
Agree that PCPs are inadequately compensated in the US and that this fact has been eroding primary care for decades. The erosion negatively affects everyone, including specialists. The root cause of the problem is that all physician comp has been eroding relative to inflation - specialists have just had less erosion because of the nature of the CPT/RUC system, constant development of new procedures, and ability to increase efficiency and productivity in performing them. It is unfortunate that the USG has pitted specialties against each other with budget neutrality rules which apply to no other segment of the healthcare system. Hospitals, health systems, and pharma have all had healthy growth. Constraining physician comp has done nothing to control US healthcare spending and inflation in health insurance premiums. AMA is appropriately advocating to end budget neutrality for physician payment and to enact annual inflation adjustments to PFS similar to what every other dept and agency in the USG gets. Need to do even more to boost E+M payment, even if at the expense of procedures.
I started working in healthcare some 50 years ago. With this as context then, my reaction to this essay: Shrug - except for the acronyms, there's nothing new here. Perhaps we don't look for solutions but hope to rebalance the tradeoffs. In such a rebalancing I suspect no significant improvements will be found.
We say primary care is underpaid but we don't act like it. As a family med doc I endorse all the arguments for why we need primary care: patients need a point-person to navigate the medical system, symptoms do not fit neatly into one organ system, it's more convenient for a patient to see one doctor for five problems than to uproot their lives to schedule five appointments. At the same time, we vote with our dollars, and primary care providers continue to be paid less than specialists.
I think we need to explore the structural reasons why primary care providers can be underpaid.
As we become more specialist-centric, primary care's scope is shrinking. As a primary care provider surrounded by specialists in a large healthcare system, I feel like a referral turnstyle. It makes sense to refer a patient with afib to cardiology for management of their antiarrhythmics. But now there are preventive cardiology clinics. What do I even do? Referring a patient with statin questions to the preventive cardiology clinic does not take 3 years of residency.
Another thought is that primary care providers function as blind sheep offering a checklist of low-yield interventions because USPSTF said so. It may require 3 years of residency to offer nuanced evidence-based conversations about preventive care, but it is a pipedream to think this is what primary care providers are doing.
Any interest on a "devil's advocate" post expanding on why we can/should underpay primary care?
You’re just one of the dogs fighting for a bigger piece of the steak. Lots of allegations and a nice chart. You’re not going to prove that primary care deserves more and specialists deserve less, because there aren’t four “lenses” to assess the worth of medical care, there are four thousand! Central planners will always get it wrong from somebody’s point of view, in this case it’s yours. Who gets paid what can’t ever be anything but a tug-of-war. The best we can hope for is a handhold on the rope. Don’t make it more noble than it is.
Skin in the game is the only way. Whether you call it direct primary care or concierge. One way might be have Medicare (and all insurances) put aside $1,000 flex primary account so patients can do either directly.
I’m a low cost concierge for $1,500 a year. It’s working for me and for my patients. Doubled my hospital salary and halved my hours. No paperwork. I don’t bother to bill insurance.
With $1,000 flex accounts that would cost the patient $500 a year, about the same as a plumber visit.
Why aren’t there (already) 50 or more aggrieved, resentful or just plain angry comments on this post? Because it has nothing to do with vaccines or pharmaceuticals.
Instead, we are treated to an educated, very thoughtful, and well-written consideration of what may be the central issue underlying the future of primary care. Bravo.
Would the NY Times publish this piece as an op-ed? Couldn’t hurt to submit it and see what they say.
These are very important insights. I've lately been pondering if PCPs ought to start convincing their healthy below 50 patients to stop coming for annual visits. Maybe they establish care and then only come in for sick visits. No annual blood work, etc. Would that lighten the load? I don't know for sure because I don't practice primary care. But with PAP smears becoming home based in a year, perhaps it's time to end annual visits in general, make birth control renewable without in person visits, and allow those who are otherwise healthy to live their lives without the confirmation of "I'm healthy" that an annual visit may provide.
*I say age 50 but there's not really an age cutoff. There should be a screening for cvd risk factors at 45 for men and 55 for women, but if it's normal, then those folks can certainly continue on without annual visits.
100%. "Cognitive load is the most overlooked, underacknowledged, and undercompensated attribute of any of the physician’s talent stack. Primary care docs have it in spades."
While I agree that reimbursement for cognitive services should be more on par with procedural services, as a “seasoned” FP who sees opening salaries for graduating residents of FP programs reaching 250K + , it’s difficult to claim “poverty “ or expect the public/lawmakers to have a great deal of empathy. The “fix” is to make reimbursement more market driven by giving patients more skin in the game.
Makes a lot of sense when looked at systemically. At the same time, at an individual practice level, an “efficiency cut” is a meaningful reduction in revenue. And expenses don’t go down. They are only going up. So, it makes practices less sustainable. Making it a zero sum game is the problem here.
Very thought-provoking post. The same issue is present in Canada. And the same incentive gradient btw “doing” and “thinking” exists here wrt remuneration scale. And all the same issues about inability of GDP to afford growing the pie, such that we need to redistribute the pie, yet bedeviled by subgroup self-interest which prevents the profession as a whole from doing so.
OTOH, that has to be balanced by recognition of all the extra years spent in training and developing deep expertise in a specific clinical area. As well as the reality that there has to be financial incentive for someone to be capable and available to respond to emergencies at 3am.
No easy answers here. But I thought this made a fair case for primary care.
It seems that healthcare is too profitable for it to do a 180, but we should always be optimistic and advocate for the right balance.
While being hopeful, consider joining your local direct primary care doctor, whether you're a patient or a doctor.
I did a survey of my private practice docs on Whatsapp who have a cash-based practice. Less than 1/3rd were themselves part of a cash-based system.
Just like if you're a doctor you should be part of NBPAS because it's the only way to improve or supplant the ABMS.
Agree that PCPs are inadequately compensated in the US and that this fact has been eroding primary care for decades. The erosion negatively affects everyone, including specialists. The root cause of the problem is that all physician comp has been eroding relative to inflation - specialists have just had less erosion because of the nature of the CPT/RUC system, constant development of new procedures, and ability to increase efficiency and productivity in performing them. It is unfortunate that the USG has pitted specialties against each other with budget neutrality rules which apply to no other segment of the healthcare system. Hospitals, health systems, and pharma have all had healthy growth. Constraining physician comp has done nothing to control US healthcare spending and inflation in health insurance premiums. AMA is appropriately advocating to end budget neutrality for physician payment and to enact annual inflation adjustments to PFS similar to what every other dept and agency in the USG gets. Need to do even more to boost E+M payment, even if at the expense of procedures.
I started working in healthcare some 50 years ago. With this as context then, my reaction to this essay: Shrug - except for the acronyms, there's nothing new here. Perhaps we don't look for solutions but hope to rebalance the tradeoffs. In such a rebalancing I suspect no significant improvements will be found.
We say primary care is underpaid but we don't act like it. As a family med doc I endorse all the arguments for why we need primary care: patients need a point-person to navigate the medical system, symptoms do not fit neatly into one organ system, it's more convenient for a patient to see one doctor for five problems than to uproot their lives to schedule five appointments. At the same time, we vote with our dollars, and primary care providers continue to be paid less than specialists.
I think we need to explore the structural reasons why primary care providers can be underpaid.
As we become more specialist-centric, primary care's scope is shrinking. As a primary care provider surrounded by specialists in a large healthcare system, I feel like a referral turnstyle. It makes sense to refer a patient with afib to cardiology for management of their antiarrhythmics. But now there are preventive cardiology clinics. What do I even do? Referring a patient with statin questions to the preventive cardiology clinic does not take 3 years of residency.
Another thought is that primary care providers function as blind sheep offering a checklist of low-yield interventions because USPSTF said so. It may require 3 years of residency to offer nuanced evidence-based conversations about preventive care, but it is a pipedream to think this is what primary care providers are doing.
Any interest on a "devil's advocate" post expanding on why we can/should underpay primary care?
You’re just one of the dogs fighting for a bigger piece of the steak. Lots of allegations and a nice chart. You’re not going to prove that primary care deserves more and specialists deserve less, because there aren’t four “lenses” to assess the worth of medical care, there are four thousand! Central planners will always get it wrong from somebody’s point of view, in this case it’s yours. Who gets paid what can’t ever be anything but a tug-of-war. The best we can hope for is a handhold on the rope. Don’t make it more noble than it is.
Skin in the game is the only way. Whether you call it direct primary care or concierge. One way might be have Medicare (and all insurances) put aside $1,000 flex primary account so patients can do either directly.
I’m a low cost concierge for $1,500 a year. It’s working for me and for my patients. Doubled my hospital salary and halved my hours. No paperwork. I don’t bother to bill insurance.
With $1,000 flex accounts that would cost the patient $500 a year, about the same as a plumber visit.
What other ideas do our readers have?
Why aren’t there (already) 50 or more aggrieved, resentful or just plain angry comments on this post? Because it has nothing to do with vaccines or pharmaceuticals.
Instead, we are treated to an educated, very thoughtful, and well-written consideration of what may be the central issue underlying the future of primary care. Bravo.
Would the NY Times publish this piece as an op-ed? Couldn’t hurt to submit it and see what they say.
These are very important insights. I've lately been pondering if PCPs ought to start convincing their healthy below 50 patients to stop coming for annual visits. Maybe they establish care and then only come in for sick visits. No annual blood work, etc. Would that lighten the load? I don't know for sure because I don't practice primary care. But with PAP smears becoming home based in a year, perhaps it's time to end annual visits in general, make birth control renewable without in person visits, and allow those who are otherwise healthy to live their lives without the confirmation of "I'm healthy" that an annual visit may provide.
*I say age 50 but there's not really an age cutoff. There should be a screening for cvd risk factors at 45 for men and 55 for women, but if it's normal, then those folks can certainly continue on without annual visits.
100%. "Cognitive load is the most overlooked, underacknowledged, and undercompensated attribute of any of the physician’s talent stack. Primary care docs have it in spades."
While I agree that reimbursement for cognitive services should be more on par with procedural services, as a “seasoned” FP who sees opening salaries for graduating residents of FP programs reaching 250K + , it’s difficult to claim “poverty “ or expect the public/lawmakers to have a great deal of empathy. The “fix” is to make reimbursement more market driven by giving patients more skin in the game.
Interesting perspective. Thank you.
As a family physician, I think you hit the nail on the head regarding the problem of excess cognitive load.
While being paid more for that work would be nice, I would much rather fix that problem. There’s too simply much to do in too little time.
It’s stressful, and worse, it makes you feel as if you’re never able to be the doctor your patients need you to be.