From KevinMD, Dr. John Horstkamp has a piece detailing his ideas for fixing the primary care shortage in America. With universal coverage of all Americans seemingly on the horizon in some form or other, now would be a prudent time to address a very disturbing question: will we have enough doctors to take care of the influx of new patients?
Less than 5% of graduating medical students are entering primary care fields. The reason most cited for this phenomenon is the relatively low remuneration for primary care compared to subspecialist physicians. Dr. Horstkamp feels that substantially raising the reimbursement rates for cognitive medicine is the only viable solution. And by substantial, he isn't kidding. In the reform bill floating around DC now, there is a proposal to raise Medicare reimbursement rates by 8-10% for primary care docs. This isn't going to cut it, according to Dr Horstkamp. He wants fees raised by 30-70%. If you're thinking to yourself--- "wow that sounds really.....ridiculously, absurdly high"--- well, you're right. It is absurd. It's a juvenile, disingenuous entreaty for "equality". Let's delve into it.
His first error is the premise that all doctors are alike. Specialists can generally earn $100,000 more per year than most primary care providers. They also train longer, face higher malpractice premiums, and often endure higher levels of stress and personal strife. Over the course of a career, that difference can mean an additional $3 million dollars in earnings. One response to this actuality is to be morally appalled (the horror, the horror! The GI doc just made 400 bucks for a fifteen minute EGD!). Another is to say, so what? So there are discrepancies in how the market decides to remunerate certain kinds of doctors. Big deal. I just don't think you make any meaningful reform-minded progress going down this pathway. There will always be unfair differences in the way people are paid in a free and open market. Maybe our inner city schools wouldn't be such a collective cesspool if teachers made six figures. Or maybe indigents standing trial would get a better defense if their court appointed attorneys were paid the same as the Wall Street corporate lawyers (i.e. sharks). But you don't know for sure. And simply equalizing all salaries across the board is an overly simplistic solution to an incredibly complex reality. Demanding a 70% increase in pay just comes across as an unserious plea for fairness. It's like the fireman complaining to his boss about how Michael Vick just signed a million dollar contract. Yeah, it probably isn't right that a convicted felon/dog torturer makes ten times as much as the guy who pulls innocent grannies out of burning apartment buildings, but hey, that's the way it is. It's the dark side to free market capitalism.
No doubt, we can remunerate cognitive medicine far better than how it is now. And I think the 8-10% increases articulated by the bill are a great start. And student loans ought to be forgiven for ANYONE who goes into primary care, not just those who agree to take jobs in Cody, Wyoming. So now you're changing the terms of the argument. All of a sudden, primary care rebrands itself as a well-respected profession with earnings $150,000-250,000 and no student loan debt to worry about. You get to be a family doc. You work hard. You don't owe any money. You're going to be able to live the upper middle class suburban life. What's not to like?
But here's the thing with increasing pay for primary care docs. The practice of medicine must concommitantly change. I've written about this before. It can't be business as usual. No more shotgun consults. No more rushing through 45 patients during office hours and shunting off any complicated patients on subspecialists. No more referring all your asthmatics to pulmonologists. No more pawning off your stable type II diabetics on endocrinologists. No more dermatology referrals for obvious benign moles. There has to be a change in the practice of primary care medicine. So if we increase remuneration for cognitive medicine, it ought to allow docs to spend more time with their patients. And this may mean that average income won't change at all because they're seeing fewer patients.
It isn't about money. (Or at least it's not supposed to be). It's about job satisfaction and being able to do something noble and meaningful for a fair compensation. Worrying about what other professions are making is a fruitless, endless exercise in self abnegation....