Paul M. Fischer
Everyone in medicine knows that some physicians are overpaid for the services they provide and some are underpaid. The list of specialties in each category is no secret, though we don’t talk about it much. It’s part of the same ethic that teaches us not to criticize another doctor’s care.
But the sad fact is that in medicine, money is tied to prestige, power, public credibility, and medical student interest. If we don’t deal with this problem, medicine will continue to fall hopelessly into the “haves” and the “have nots,” that is, those who “own” lucrativeCPTcodes and those who don’t. So the question is how did this inequity come to be and how can it be remedied?
History shows that physician pay rarely follows value, but rather aligns with power. When I was a medical student, heart caths were new and were the domain of invasive radiologists. But it wasn’t long before the cardiology socialites took on the radiologists and successfully claimed heart imaging as their own. Power and wealth followed.
About the same time, neurologists were trying to win control of brain imaging, but they lost the political battle to radiologists. Think how different neurology’s image and influence would be today if neurologists owned all those CT and MRI scans! Instead, they are stuck in work that is time-consuming, patient-centered, cognitively complex, and are forced to make a living on payments from EEGs and EMGs.
No one would suggest that general surgeons, rheumatologists, psychiatrists, or geriatricians make more money than they deserve, but it’s a fact that many of the most highly paid physicians do the least stressful and most repetitive work in medicine. The radiologist sits in a dark room all day without the stress of patient interaction, looking at pictures that, in many cases, have already been read and interpreted by clinicians who needed the results yesterday. The anesthesiologist starts IVs, monitors drips, and measures vital signs. There is an occasional emergency but most of the day-to-day work isn’t very demanding. The gastroenterologist spends his day looking at the cleansed colons of patients who are asleep. The opthamologist spends most of his time doing a single procedure over and over again.
Cardiologists are the most striking example. They have perfected the “I saved your life” routine, when the truth is that most stents are placed in patients who could have been treated equally well with $4 medicines from Walmart. The greatest improvements in heart health are a result of statins, aspirin, and smoking advice – all the domain of primary care. And then there are the dermatologists. How stressful or cognitively demanding is it to freeze keratoses?
While it’s true that we need all of these specialties, it’s time for some of them to earn less. The reason is that many other specialties deserve to be paid more. The average primary care physician, for example, makes one third of the income of the specialists above, yet research clearly shows that, of all medical specialties, primary care provides the greatest value. The more primary care in a population, the better the healthcare outcomes and the lower the overall healthcare costs. No other specialty can make this claim.
Everyone gives lip service to better payment for primary care, but the AMA and many specialists say that this should not be at the expense of other physicians. In a societyalready overburdened by the cost of medicine, physician payment is a zero-sum game. Any increase in the income to underpaid specialists will come at the expense of those who are overpaid, and this should be publicly acknowledged by anyone who purports to support primary care.
The trick, then, is to figure out whose income should go up, whose should go down, and how to politically influence CPT and ICD coding – the language of physician payment – in a way that promotes better, more affordable medicine for America. The historical lesson from the past 20 years is this: the specialties that prosper are those that have positioned themselves to be defined by a few well-paid, narrowly defined, tightly held codes. The medical societies that fight for and defend their specialty’s codes will win. At the other extreme are the specialties that rely on vague, poorly paid, and widely used codes (think E/M). They have no chance. The medical societies that believe this engagement is “fair” are like boy scouts in the middle of a mob turf war.
It is hard to be a physician who spends all day caring for patients who are worried, angry, afraid, depressed, hurting, or dying. It is hard to spend all day cognitively sorting through limitless diagnoses based on the myriad complaints patients present to their doctor. It is often hard to know whether a patient is best treated with a few words of reassurance or if high-tech medical care is needed. And it is really hard to do all of this knowing that, in the payment game, the field is not level and the rules are rigged.
Paul Fischer, MD is a family physician in Augusta, GA. With 5 colleagues, he recently filed suit in federal court against CMS, claiming that agency’s longstanding relationship with the AMA’s RUC, the advisory group whose recommendations have resulted in the current physician payment structure, has broken the law by not requiring the RUC to adhere to the Federal Advisory Committee Act’s management and reporting rules.