As an informal part of my research for the book I’m presently working on, Your $100,000 Career Plan: Match Your Personality to a Six-Figure Job, I have chatted with physicians who are personal friends and have asked about their perceptions of their careers. Their comments have confirmed what you probably know already, that primary care does not pay as well as it used to, and that higher earnings are to be found in medical specializations.
Of course, this is entirely consistent with the information I gleaned from the Bureau of Labor Statistics: 75% of family and general practitioners earn $113,480 or more, but the same proportion of obstetricians and gynecologists earn some unspecified figure that is more than $145,600, as do anesthesiologists and surgeons.
But I found additional insights into this matter in a report for the United States Government Accountability Office that came out in February of this year: “Primary Care Professionals: Recent Supply Trends, Projections, and Valuation of Services.” The report, authored by A. Bruce Steinwald, Director of Health Care for GAO, observes that the dominant fee-for-service method of paying doctors encourages doctors to provide as many services as possible, especially specialized services, which are better compensated. The report notes that in Boston, a visit to the primary care physician for an established patient with a complex medical condition would last 25 to 30 minutes and would be reimbursed by Medicare at the rate of $103.42, whereas a colonoscopy, although it requires a similar amount of time, would be reimbursed at the rate of $449.44.
In addition, the use of assistants has enabled specialists to boost the volume of patients they serve and therefore their incomes. As an example, I think of my experiences in the office of the orthopedic surgeon who dealt with my tendonitis (“trigger finger”) problem last year. I saw ever so much more of the physician assistant than I did of the surgeon. By contrast, when I visit my primary care physician, my weight and blood pressure are measured by a nurse, but all other interactions are with the doctor.
The report notes that primary care visits tend to focus on disease prevention, and that states with a higher ratio of primary care physicians to the population have better health outcomes (disease-specific mortality rates and life expectancy) than other states, even after adjusting for other factors such as age and income. States with higher percentages of primary care physicians also have lower per-beneficiary Medicare expenditures. It would seem that we should be encouraging medical students to concentrate on primary care, but the financial incentives are pulling them in the opposite direction.
It is unclear whether we can expect the differences in potential incomes to result in a nationwide shortage of primary care physicians. Researchers differ on their predictions for the country as a whole, but it seems likely that inner-city and rural areas, which are already underserved, will not see an increase of access to primary care physicians.
What can be done to improve access to primary care? The GAO report notes that some organizations representing primary care physicians have proposed a “medical home” model, in which (to quote the report) “a single health professional serves as the coordinator for all of a patient’s needed services, including specialty care—and [the model] refines payment systems to ensure that the work involved in coordinating a patient’s care is appropriately rewarded.” Perhaps, after America has solved the problems of the financial system and has made health-care insurance available to everyone, we can reorganize the health-care delivery system along these lines.