AMNews: June 29, 2009. AMA meeting: Don't shortchange specialists to fund care model ... American Medical News

AMNews: June 29, 2009. AMA meeting: Don't shortchange specialists to fund care model ... American Medical News:

"Chicago -- In the discussion of how to pay for coordinated care under the patient-centered medical home model, the AMA House of Delegates agreed that primary care physicians should not be rewarded at the expense of specialists.

"At its June Annual Meeting, the house voted to advocate that additional pay to physicians for operating a medical home should not come from a reduction to the pay of specialists. Delegates approved language that medical home payments not be subject to requirements for budget neutrality in Medicare, where an extra dollar spent somewhere means a dollar has to be cut elsewhere.

"The house also approved recommendations that private plans and the Centers for Medicare & Medicaid Services develop one standard for a medical home, and that specialty practices as well as primary care practices should be able to serve as that home.

'Primary care needs more help. It just shouldn't come at the expense of specialists,' said Kim Williams, MD, a cardiologist from Chicago and a delegate for the American College of Cardiology."

I am aware that, in the House of Medicine, it is impolite to disagree with this notion that primary care physicians should get more money but there should be no adjustment of specialist reimbursement. It is not just impolite, it is also likely to start fights. I expect that the notion of knocking down the uber-specialists reimbursement lurks in the darkest places of the hearts of many a PCP and psychiatrist, the class-warfare-that-must-not-be-named.

But, consider the incomes of internists starting at $150K or so and neurosurgeons, radiologists (nuclear medicine), thoracic surgeons, invasive cardiologists and orthopedic surgeons starting at between $400K and $600K, it is hard not to wonder whether the economic disincentive of going into primary care can ever be overcome by raising PCP income by 20 or 30 or 40 per cent or more. Value is relative and simply increasing PCP income a bit and still having one's peers making vastly more explicitly marks the value we place on primary care.

Societies generally reward physicians with good incomes, but except for the incomes of specialists in the Netherlands, nowhere near as highly as we do. But, on the other hand, no country saddles their young doctors with the massive debt that we do. Heavily subsidized tuition is the norm, not the exception, and so young doctors around the world do not feel the economic imperative to enter the best paid fields as we do here. Nor do other countries have the massive overhead of physicians beyond debt: malpractice insurance, billing staff to fight with insurers and so on.

I expect that if we graduated medical school with debt similar to those of our non M.D. peers, incomes more comparable to our international peers would be more acceptable.

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