Saturday, March 27, 2010

Why do primary care doctors deserve more money?

Today I had an interesting conversation with a few friends regarding the new health care reform that just passed. One future specialist asked me why primary care doctors should receive more money than they have in the past.

And this is an important question that I think sheds light on the whole mess of health care that we are in. It's important to specialists because there is only one pie - if primary care doctors start taking bigger cuts, specialists will have to take smaller pieces of income home. But more importantly, this question is compelling because really, what do primary care doctors do that make them deserve more money than what they are already earning (which is some of the lowest among the medical profession)?

I think the general notion is that primary care doctors manage various medical issues that are not complicated enough to be passed on to specialists. And so my specialist friend asked, why can't primary care doctors be replaced by less-trained health care professionals (nurse practitioners or physician assistants), if they are only managing basic medical issues? And if so, why do we need to pay primary care doctors more money if we can just hire non-doctors to do the same job?

I think that our job in primary care cannot be replaced any more than in other fields like surgery or anesthesiology. In every field of medicine, there are simple patients that can be taken care of by lower level health care workers, even in specialized fields, and then there are more complicated patients that need to be cared for by physicians with a deeper understanding of medicine. For example, in the field of anesthesiology, nurse anesthesiologists can do many things that MD anesthesiologists can do, but they serve as a simpler clone of that physician so that he/she can anesthetize a few patients at one time. In the field of OB/GYN, midwives play a very important role in non-complicated deliveries, while leaving trained obstetricians to care for complicated pregnancies.

I'd like to argue that in the field of primary care we specialize in coordinating care for the patient as a whole person - a manager for your health care - which I think is one of the hardest jobs in this complicated health care maze. Doctors in traditional medicine do not usually view this as a real or worthy specialization, but more and more people start to realize that this is a complex field of specialization that requires a smart physician with a thorough understanding of all other medical fields.

A good analogy I've heard is to think of primary care doctors as air traffic control . Specialists only see the problems within their field, just like a pilot in a single plane. They are important, but it's impossible to expect them to take in the big picture of the whole airport with hundreds other diseases in it, all interacting with one another. Primary care doctors step back and integrate all information to make sure that all treatments work together synergistically and that the airport as a whole functions optimally.

And this is why health care reform is focusing more and more on attracting talents to primary care. Since we're the managers, we make the decisions on when patients need tests or a trip to the specialists. If the managers suck, costs go up without increased outcomes, and specialists can't get good referrals without a good gatekeeper. Sure, for a young healthy person, their care can be coordinated by a nurse practitioner, but for a 70 year old patient with multiple comorbidities, that job gets complicated and it needs to be handled by a good primary care physician.

I have high hopes for primary care, and even though I obviously did not choose this field for the money (because there is none), I do hope that we get higher reimbursements in the future so that we can attract better talents (than me) that will turn our failing system around and keep our nation healthy.


  1. Another analogy is that of a football team. All members of the team are essential to a successful team. But what you have now is five open wide receivers while you have to search and wait for a quarterback.

    My cousin, who is a family doctor in a private practice group, is inundated with presents during the holiday time from specialists thanking them for their referrals or hoping to get more of their referrals. His practice, on the other hand, only accepts new patients when a new physician joins the practice.

    Gee, you think the fact that some specialists make three times his salary, with the same time of training and more appealing hours, has anything to do with it?

    But I'm careful not to paint all specialists with this brush. There are some specialties that are as relatively underpaid as primary care physicians. I even include general surgery in that category given their extra training and hours.

    By the way, thank you for being a primary care physician. Family doctors may be looked down upon by academics and specialists, but patients know that a good family doctor is worth his or her weight in gold.

  2. I agree that primary care medicine (PCP) isn't going to draw more talented students unless it pays more, but I think the current relative level of compensation is appropriate.

    You make an imperfect analogy of PCPs with managers in hierarchical corporations, where pay scales with increasing managerial responsibility. The justification is that managers in these companies manage processes that their employees/teams help move along, so the value add comes by making sure the process is completed smoothly and efficiently.

    I think a better comparison of medicine would be with a Wall Street financial services firm. There, talent is rewarded for increasing levels of specialization and knowledge. It is common, for example, for star traders and bankers to be paid much more than the CEOs of the banks they work for. Just as a trader brings special expertise in a market to bear for the bank, a specialist can identify a rare disease, or execute a tough procedure.

  3. Hi stocksandscalpels,

    Thank you very much for your comment.

    I think we have a disconnect on what medicine is and what medicine should be. In the way I perceive primary care, I think we *should be* managers in hierarchical corporations - our jobs of smoothing out the processes add a significant value in the current health care system that is extremely convoluted and prone to mistakes, causing 44,000 to 98,000 deaths from medical errors per year.

    Your analogy of Wall Street financial services firm describes the current state of our medical system, but I think it should be fixed. The fallacy of this analogy to health care is that in finance, more star traders = more money for the firm, while in health care, more use of specialists = people are getting sicker and the health care system is doing a horrible job.

    Specialists are definitely important, but currently the reimbursements are much too heavy on specialization that our system is encouraging patients (and doctors) to ignore prevention, focus on invasive treatments when the diseases have already progressed too far, use costly medical equipment/treatment when it does not provide better outcomes but exposes patients to worse side effects. The examples of these perverse incentives are abundant, and to be honest I am sometimes ashamed of agendas put forth by some specialist medical societies that focus first on profit instead of patient interests.

    In the end nothing is absolute - we need both primary care doctors and specialists. Currently, the balance is tipped towards specialists - the shortage of PCPs is no secret, and we need to find a way to attract talents to primary care most importantly for the sake of patients in our health care system.

  4. hello angienadia,

    thanks for your response. actually, the bank analogy wouldn't characterize our current system at all. in the current system PCPs have zero authority over specialists. Specialists aren't accountable to PCPs for their performance, their pay, etc. Some HMOs might require pts to see PCPs before seeing specialists, but the relationship b/w PCP and specialists there is still more like client-customer.

    i thought of the financial analogy because its analogous to your conception where PCPs are akin to managers and specialists are akin to traders, and would also explain why your idealization of such a system might not work. THe analogy is not perfect, as you hint at, because the benefits that specialists bring can be outweighed by their excessive performance of costly procedures. But this one flaw can be easily fixed - just change the third payer system to one where patients must bear costs proportionally. With that change, you could then institute the model you seem to want, where PCPs manage specialists, and the bank analogy is apt.

    But unfortunately, under Obama, third payer will grow even more, and we will see costs spiral as patients seek to maximize their care, while minimizing their own individual costs.

  5. Hi stocksandscalpels,

    Thank you for continuing to follow and make comments on my blog.

    I see your points and I have to admit I'm new to the game. As I start to pick up my own panel of patients in clinic and explore how decisions are made by both providers and patients, I have to say that your descriptions of how things work definitely happen in some scenarios, while what I describe happens in others.

    For my panel of patients, they are followed by specialists for various reasons - most because of my referrals, but others because they were hospitalized with a specific condition that required them to see specialists in house who continue to follow them as outpatients. Ironically, for other patients including me, my primary care doctor is my gynecologist, solely because none of the primary care doctors in my area will do a pap smear, and I refuse to pay copays twice. The bottom line is that the relationship between PCP and specialists are more complicated than we can characterize by a single rigid analogy, but I think the air traffic control analogy I mentioned in the original article well characterizes the way primary care doctors operate and think about patient care - at least for me in my personal practice.

    I'm also an economist, and I have to say that economic principles barely apply in real world, especially in the world of health care where underlying requirements for a free and efficient market economy rarely apply (as you may have read from my prior posts). I don't believe that pushing the costs on to patients will change their decision making substantially, because most patients do what their doctors tell them. I know for the population that I work with, no patients will question me if I tell them they need an MRI - most don't even know what an MRI is, not enough to question whether they absolutely need it based on price or ability to pay.

  6. hi angienadia,

    thanks for your response.

    I also studied economics (and worked as a derivatives trader) before med school, and would agree that economics doesn't apply in the "real world of health care" - but not because its the "real world" - in fact, its the complete opposite of a natural state with open competition for scarce resources. Medicine is a heavily regulated, government controlled industry, without a real free market.

    But my point against third party payer isn't to leave all or even most of the costs on consumers, poor or otherwise, (which is what I think Obama and his supporters fear) - it's to get patients thinking about the cost of their care.

    For example, I frequently see patients on my current neurology outpatient rotation getting EMGs, often with little justification. They allow it not because blindly "trust the doctor" but from a combo. of the neurologist's salesmanship ("this EMG will be good for you b/c it'll let me rule out x,y,z") and because the cost is limited to a copay and maybe a deductible if their insurance is crappy. This seems absurd. When the same patients go and buy a car, they don't just trust the car salesman's recommendation - they also do their own research. Forcing patients to share the burden of care, at least forces them to ask harder questions, and forces the neurologist, or the PCP ordering the MRI without having read the preliminary CT, to pony up some good answers.

    Anyways, to return to the original point - that PCPs deserve more money because they play an "important role". If we put this in economic terms, then 1) sure, they might be underpaid on an absolute basis, because few Americans wants to do it. of course, this assumes our society actually wants more American MDs to do PCP.

    But that's a big assumption. The reality, as I saw from my experience on Wall Street, is that pay comes down to one thing: replacement cost. And the replacement cost for a US MD PCP who isn't serving a select concierge population is honestly quite low. Advanced NPs, PAs, other physician extenders could probably replace most everything about outpatient MD PCPs, and they can just refer a few more patients than MDs might otherwise. Secondly, you may have seen the recent NYTimes article about foreign MDs vs US PCPs in managing chronic disease. Despite my reservations about the design of that study, the article shows we could a decent job even if we replaced all our US MD PCPs by scavenging the third world for cheap medical labor - because we've already done it in many parts of the US!

    Of course, this doesn't address the question of the replacement cost for a US MD specialist. Well, once medical tourism takes real hold, and the market for all medical labor and services globalizes, we'll find out...

  7. Hi Stocksandscalpels,

    Re: real world comment - thank you for reiterating my point, which is health care does not meet requirements for a free market so the free market hypothesis does not apply.

    Re: buying car vs EMG. Please read my prior posts. This again goes into why usual economic principles do not apply to medicine. Getting an EMG is not as simple as buying cereal. You can't try different brands a thousand times over until you decide which one you want - it wouldn't make sense to do so. And EMG isn't just processed corn - it's much more complicated, even more so than a car. For the marginalized population - illiterate, no access to internet - it will be difficult to expect them to simply "do research" and make informed decisions about the health care they're getting. I hope that in the future some of your patients are among the vulnerable population so you can see first hand how difficult it is to make informed decisions when you can't read and are pulling two jobs to make ends meet.

    Re: replacement - if you read my article, you will see I mentioned doctors in all fields, not just PCP, can be replaced by less-trained professionals (nurse Anesthesiologist, midwives in non-primary care fields).

    Re: foreign-trained MD - I'm actually from Thailand and I know foreign medical training inside out since I was actually going to train in Thailand before I came here. First of all, medical training outside the US can be phenomenal and place of training has no bearings on your quality as a physician or anything for that matter. Harvard Business School has trained multiple criminals and successful CEOs alike. But this is besides the point - replacing US PCPs with foreign-trained PCPs doesn't deviate from the notion that PCPs are important. Equally, foreign-trained surgeons, anesthesiologists, cardiologists are moving to the US to practice - this point is not relevant.

  8. Hi Angienadia,

    thanks for your response.

    If I understand you correctly then, it sounds as if you'd leave EMGs completely up to the discretion of the neurologist. This was the situation in the 80s - and the result was that doctors raped the system. If you want to provide "universal health care" with gov't as third party payer, staffed by bureaucrats who have no real incentive to control costs, you'll repeat the 80s.

    An EMG actually seems a pretty basic concept that I, as a 3rd yr med student, would feel comfortable outlining to a fifth grader with a normal IQ. A car is infinitely more complex, but most car buyers don't care about the thermodynamics of an internal combustion engine - they just want to know that it works, that it's safe, etc. A neurologist who can't explain the basic risks, benefits, and purpose of an EMG to an adult pt that comes in with muscle weakness probably doesn't deserve his license. Forcing the neurologist, or the PCP ordering a CT/MRI, or the CTS doing a CABG, to be responsible for their orders by explaining them to patients who demand them because they feel the cost of care is the only way to control costs.

    I have absolutely no qualms with CRNAs, midwives, supplanting MD anesthesios and obgyns, if the former are competent. Free Market in action, right?

    I want to reiterate my point about the value add of US PCPs versus foreign-trained PCPs. My point was that even if we do what you want and take the importance of primary care as a given, we don't need necessarily US trained PCPs to do it, if really, foreign PCPs are actually just as capable (despite the evidence that IMG grads score much lower on the USMLE than US grads, on avg). As an economics major who states "medical training outside the US can be phenomenal", surely you must see that we only need to pay US PCPs as much as their theoretically equivalent substitute (Third World medical labor).

    I do have to correct you on your last point. Foreign-trained MDs must go through US residency programs, before they can practice as Surgeons, anesthesios, or Cards. We both know the training to be a physician comes in residency, so their competence in practice is more a function of their US residency training than their foreign MD education.