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First-stop docs could get a pay raise

Monday, August 24th, 2009



Despite bitter disputes over the best ways to overhaul the health care system, there’s consistent agreement about the need to expand the role of primary care doctors. Those physicians are in short supply, and experts are predicting a pay raise for these doctors whose speciality is keeping patients healthy.

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Crimm: Everything looks really good. The diabetes control test is perfect at 6.3, it’s right where we want it to be, and the cholesterol test looks good as well.

Philadelphia physician Allan Crimm is a primary care doctor. That’s a catchall title for the internists, pediatricians and family physicians who are often the first-stop for patients.

Crimm says he and other primary care doctors try to devote extra time to patients. During this appointment with Anna Ciccone, Crimm’s listening for ways to nudge the 75-year-old toward healthier habits.

Ciccone: I just watched what I was eatin.’ And then of course the housework helps, and I’ve been gardening.
Crimm: Good for you, what have you been growing?
Ciccone: Tomatoes, green peppers ..

Crimm says the time he spends on counseling and education pays off in better patient health, but he’s not well paid for that work.

Crimm: An EKG which will take a physician approximately a minute to read and interpret, when a physician performs that in the office, they get paid almost as much for doing that as for actually seeing the patient and spending 15 or 20 minutes with the patient.

Primary care doctors, like Dr. Crimm, say they fall to the bottom of the pay scale because physician fees are heavily weighted toward tests and procedures.

Base Salary Offered to Recruited Physicians. Despite salaries that are significantly lower than other specialities, a review from the healthcare recruiting firm Merritt Hawkins suggests that the increased demand for primary care doctors has lead to higher salary offers in recent years.

Base Salary Offered to Recruited Physicians. Source: Merritt Hawkins & Associates’ 2009 Review of Physician and CRNA Recruiting. (Click to enlarge)

Crimm: That creates perverse incentives to do less of the face-to-face encounters with patients and more and more test ordering.

In a new survey from Modern Healthcare, salaries for primary care physicians range from about $150,000 to the low 200s.

University of Pennsylvania policy expert David Grande …

Grande: Certainly physicians are among the most well paid professionals, so it’s a big mistake to cry poverty if you are practicing physician in the United States. That said, there’s a big, big pay disparity.

Cardiologists, urologists and other specialists commonly earn two or three times more than primary care doctors. Physicians often leave medical school saddled with six-figure debt, and Grande says primary care salaries aren’t high enough to pay off those loans comfortably.

Grande: It’s harder and harder to convince people to go into these careers when in fact they’re desperately needed.

Average salary or income guarantees. Source: Merritt Hawkins & Associates’ 2009 Review of Physician and CRNA Recruiting.

Average salary or income guarantees. Despite salaries that are significantly lower than other specialities, a review from the healthcare recruiting firm Merritt Hawkins suggests that the increased demand for primary care doctors has lead to higher salary offers in recent years. Source: Merritt Hawkins & Associates’ 2009 Review of Physician and CRNA Recruiting. (Click to enlarge)

Some primary care doctors are so fed up they’re re-arranging their practices to give themselves a raise. In the practice model sometimes called “concierge” medicine, patients pay 15 to 25-hundred dollars each year to get extra attention from the doctor.

Wayne Lipton leads a company that helps doctors make the switch.

Lipton: The patient experience is something akin to old-fashion approach to medicine, where doctors did not feel compelled to cut you off and give you just a few minutes and only deal with the problem du jour.

Critics think concierge medicine leaves poor people with even less access to care. Curbing that trend is another reason policy makers want to boost primary-care salaries. But that could mean reduced pay for some specialists. Analyst David Grande expects a hard fight.

Grande: That process has unfortunately really developed into a lot of infighting among doctors between specialties who have more political leverage against specialties who have less political leverage.

Specialists argue they deserve higher pay because they have more training and more costly malpractice insurance.

Andrew Warshaw is an official with the American College of Surgeons. He says there’s a shortage of surgeons, too, so it makes little sense to cut their compensation.

Warshaw: If you need a surgeon, there’s no substitute. If you’re in a car accident you may well need a trauma surgeon. If you’ve got a cancer you need a surgeon.

Most of the health reform bills being debated in Congress seek to expand the role of preventive care. Policy analysts say, one way or another, that will likely lead to bigger paychecks for primary care doctors.


4 Comments

  • William Johns, MD says:

    I wanted to comment on two points that Dr. Smith mentioned.
    1. “primary care physicians are pretty commonly available”. This may be true in Pennsylvania, but is certainly not true in other parts of the country. Most primary care physicians are at capacity for their practice, and have difficulty recruiting new physicians. If healthcare reform passes and we have to serve as doctors for another 50 million people, there will be a severe shortage. This is what happened in MA when they passed reform.
    2. “[primary care physicians] don’t do much when they see you.” This is precisely the current pay problem with Medicare. My job is to counsel and guide patients toward healthy lifestyle habits, to screen for disease risk factors, and to treat risk factors appropriately…not to perform procedures. Unfortunately, Medicare pays perverse rewards to doctors who physically “do” things to patients. Monitoring and counselling are not among those tasks. I screen patients for cancers and cardiovascular risk factors, and while not dramatic, I save lives. I think that is a valuable service.

  • Perhaps Dr. Smith’s experience with primary care physicians has been less than favorable, because he is seeing them under a model that doesn’t allow them to do too much more than say hello. Perhaps he is having difficulty getting what he needs from his PCP, because the current paradigm punishes primary care physicians who delve too far into specialty areas if they are practicing in cities where specialists are available, even if their schedules make them inaccessible to the patients. All of these are reasons that the current system needs to be revised to better reward and empower primary care physicians to do well what we really are trained well to do. Concierge physicians are pushing the ball that is now rolling more rapidly toward massive healthcare reforms that will be better for all.

    Cheryl BryantBruce, M.D.
    http://www.elitepersonalphysician.com

  • I have to say that the experience of my wife and myself is that
    care physicians are pretty commonly available… but don’t do
    very much when they see you. About the only thing we wind up using a
    primary care physician for is routine lab work and a few prescriptions

    – but there are a lot of prescriptions they won’t write. I have wound
    up having to search out psychiatrists for some of my medication
    (despite that it’s been constant for years now), with massive problems

    getting in to see one (the more well-recommended ones have several
    months of wait time, which doesn’t work when one is on Schedule II
    meds that can’t be prescribed for more than a month…). Similarly, my

    spouse has had major problems getting in to see a decent GYN in any
    reasonable amount of time. (This may partially be due to
    Pennsylvania’s statute of limitations for lawsuits vs OBs – 18 years.
    This is ridiculous; any mistake the OB makes when doing a dellivery is

    almost always immediately apparent, or will be apparent within a month or so.)

    My father was a primary care physician – a pediatrician – for 25 years in private practice (and prior to that in the military and Indian Health Service); my uncle is practicing as a family practitioner right

    now. I don’t disparage primary care doctors. But for people who have
    some background in biology (I have a Ph.D. in it) and medicine, most
    of them aren’t knowledgeable enough to be that much use except for
    things that doctors have a monopoly on (prescriptions plus lab tests
    that insurance will pay for and aren’t overly regulated by states like

    California). I’ve been known to go in and simply tell a primary care
    physician what statins won’t interact with my other medicines. The
    good ones cooperate with knowledgeable patients.

    Incidentally, on concierge medicine – umm… we live in a capitalist
    society. That means that a basic incentive for people to work is to
    make money that they can use to buy things/services that are better
    than those without money can get. My family doesn’t currently have the money for concierge medicine, but we’d certainly be interested in it –

    provided that the primary care and other services provided were of
    distinctly better quality (not just time-wise, but competency-wise)
    than the average otherwise available.

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