In a blog entry post dated May 23, 2022 (The Medical Beat: medicalbeat.net), I documented the disparity between incomes of primary care physicians and procedure oriented specialists. On average, the net incomes of primary care physicians are 69% of specialists’ net incomes. How did our nation’s customs regarding such a skewed reimbursement policy come about? I don’t know, but I know how the gap is perpetuated.
The Relative Value Scale Update Committee (RUC), created by Congress in 1986, is a body of the AMA (American Medical Association) whose members are supposed to be representative of the various specialties of medicine. Medicare makes the final reimbursement recommendations for Medicare reimbursement rates for physicians, but the committee’s recommendations on reimbursement is virtually definitive.
Although Primary Care doctors constitute a little over 40% of the practicing physician population, they represent only 16% of the voting members of the RUC. “Rigged” would be an appropriate term for the composition of this committee that is supposedly representative of the medical community.
Training Choices That American Medical Graduate Make
Graduating medical students are aware of the income gap. Their choices for residency training programs correlate with the high incomes associated with the specialties.
Implications for the Quality of Healthcare in the United States
So the pipeline for training primary care doctors is in jeopardy. Does this matter?
A raft of research illustrates the problem with the de facto deemphasis on primary care. Doctors in primary care specialties do patient centered work, not organ centered work. They provide integrated healthcare for a large majority of healthcare needs and foster a sustained partnership with patients, all while managing multiple medical conditions. They consult specialists as necessary, coordinating care in what is often a labyrinth of care options. Studies show this results in a decreased annual number of visits to specialty providers, with less frequent hospitalizations, fewer diagnostic tests, and overall reduced total medical charges. A strong primary care presence helps prevent illness and death, and that it is associated with a more equitable distribution of healthcare in populations.
The current payment system favors high cost procedures over time spent on evaluation or management of care. Neurosurgeons are at the top of physician earners at an average yearly net income in 2021 of $471,000, while primary care doctors (Family Medicine, Pediatrics, Internal Medicine) average $233,000.
Remedies
First, let me acknowledge that specialists do good and important work. My brief is that the imbalance in reimbursement is unfair and bad for healthcare in general. But fixes to the scandalously imbalanced system are unlikely. I have shown that the influential body that basically determines parameters for physician reimbursement is heavily stacked against primary care. And the amount spent on federal lobbying for subspecialty care outnumbers primary care by an almost three to one ratio. Relying on a feckless Congress for significant reform is quixotic.
Nevertheless, the issue that finds primary doctors to be compensated at a rate one third less than that of proceduralists’ compensations, has an easy theoretical fix…close the gap. There are other issues besides money: the practice of primary care is more challenging–more paperwork and administrative burden, more off hour responsibilities, less perceived prestige. But a policy that closes the gap in net incomes is surely the first step.
Robert F Kennedy, Jr., the US Secretary for Health and Human Services, has acknowledged the problem by promulgating regulations for review that would narrow the gap between compensation for primary care doctors and subspecialists, most of whom perform expensive procedures. I don’t know where this initiative is going, but I predict that RFK will run into a buzzsaw operated by subspecialists.
A “Simple” Fix
Raising primary care reimbursement is conceptually easy. However, no one in this economy is looking to increase the nation’s healthcare bill. And how much to increase primary care physician services? Increase reimbursement to the point that primary doctors earn 80% of specialists’ incomes? 90%? Equal? Given the importance of primary care, maybe even more.
I don’t know what level of increased relative reimbursement for primary doctors would get the job done. I propose an organic process: freeze reimbursement for procedures that will close the gap until medical students start choosing primary care training in numbers that will populate primary care training programs to the point of what healthcare experts believe is an optimal ratio of primary care doctors to specialists. This could take awhile, but the beginning of the fix could start tomorrow.