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Primary Care Docs: Pay Us More, But Don’t Pay Other Docs Less

    • Everyone wants more. While, there is a salary gap between the primary and specialists....the thing is that specialists are paid too high.

      Salaries are a function of skill and risk. Granted they take more risk than a primary care - but is it worth that much money.

      I know many will jump on me for saying this..but what is wrong with the idea of limiting salary so that no one gets more than the president. No one has such a difficult job than the president of the country. Then we can fit everyone in between these from doctors to engineers, from lawyers to teachers.....

      That is novel concept...but would be fair for all.


    • ok, what is the true salary of the president? living in a huge mansion, personal car service, personal protection, personal jet, etc etc, pension of over 200k/yr. fine, i'll take the president's actual pay for the rest of my career no problem. that is a novel concept= that is a bs concept that only a moron would ascribe to.

    • basically, the point i am making is that salary is paid salary + benefits. The president's benefits add up to over 1 million/yr. pay doctors that much and theyll be very happy. additionally, salaries are not a function of risk and skill. salaries are a function of what that person brings in additional revenue to a company/business. having a doctor such as a radiologist at a hospital is responsible for bringing millions of dollars in revenue to that hospital over time. doctors are paid a fraction of that, ie 300-400 thousand dollars. or they are paid from the money they bring directly from patients either through reimbursements or direct pay (such as plastic surgeons). unfortunately, the govt, the primary source of reimbursement for primary care feels their services are unworthy of large payment. primary care can either wine about it or they can create a new source of revenue, ie charge the patient directly for their care. doctors are not that bright and would rather cry and beg for additional payment rather than take matters into their own hands.

    • To med student
      President is also at risk for asassination and nighttime jokes, handling 30 issues at the same time, do you want to take that as well with your package? It is a shame that we are in this state where the pay gap is absolutely ridiculous by any standard.There is no doubt that health care will have a meltdown,the ironic thing is it'll be a predicted situation. Honestly do you think cardio interv and other speciality need 500k and over compensation? It will be a huge uphill battle to do the right thing, will be interesting to se how this plays out. All this talk has no value until congress can work together.

    • Point taken but every study showed that there are more stents placed than needed, because of incentives. There less incentatives to avoid these stents in the first place. I think that is the main issue here, not more care, better care.

    • Personally I don't care where they get the money from something needs to be done and fast!

    • Primary care is not complicated medicine, 99% of the time. That is why PAs, etc. are so popular. We are only a step or two away from the equivalent of a WebMD kiosk, where a brief questionaire gets one to an accurrate diagnosis more than 90% of the time and spits out a prescription or specialist referal. As a necessary cost-control, this is where universal health care will take us and as long as access to appropriate specialized care is maintained, it might be a pretty good deal.

    • Seems like lot of folks on this blog and apparently Mr. Goldstein too ("rich specialists") are very comfortable opining on other people's relative worth.
      The curious thing in health care is that the vast majority of people when asked don't want to have anthing to do with paying for their own health care?
      In a free market, which at one time time the US prided itself on being, market value is determined by a willing buyers and willing sellers doing business.
      As this blog argues back and forth about the relative value of primary care versus specialty care, and how to artificially set prices on the services others provide, let's remember that in health care the end user is almost completely insulated from the actual cost.
      So, unlike almost all other goods and services, the health care market hasn't been allowed to truely determine value in the traditional sense, and this is discussion is nothing more than a beauty contest!
      In the end, based on what people are willing to pay for out of pocket, the American public apparently values actors and professional atheletes more than doctors?

    • I think it is possible to increase compensation for primary care without lowering compensation for specialties. Primary care is an investment in health. If someone is screened and counseled they may be able to manage and/or improve chronic conditions like diabetes, or hypertension or hyperlipidemia. Perhaps if more people are healthier, there will not be as big of a need for specialists performing expensive procedures.
      The key to containing healthcare costs is better primary care and PREVENTION. We need to encourage our patients to exercise and eat better. We need to reach children in our schools and combat the childhood obesity epidemic. The long-term savings for health care is in preventing and/or managing chronic conditions- so that fewer people need to see specialists like expensive cardio surgeons.

    • about that patients need to see more out of pocket expenses in order to see the value of primary care: i totally agree but the problem is most patients do not see the value in this. What patient will voluntarily come in every 2-3 months to have their lipids, blood pressure, etc, checked on for the tune of 100 bucks out of pocket costs per visit? The problem is people have value for a doctor visist when they are sick, not when they are healthy. Therefore, things like prevention will not work if people see the doctor on their own dime. I cannot see any answer to this problem in the near future.

    • Ray,
      All said...we however do not have free market in healthcare. The number of seats are controlled by congress. The service is life critical so people can not postpone or avoid. Just like airline ticket - if you buy last minute, you pay so much more.

      Free market is fine if you open the number of seats and also let the global forces compete. But see, even there you have restrictions..from importing medicines to getting someone overseas writing you prescription and many more things.

      Over the years, we say number of doctos have gone down..but then the average hrs worked by doctors have gone down and salaries have gone up.

      I do not want to pick on is system issue. They are part of the system and have taken well advantage of.

      Then we hear that they pay so much money for education...well for that they get job security. I know lots of people with student loans from field other than medicine and they struggle to pay off too.

      Medicine is a noble profession. We can make it. Not by picking but by designing a system healthcare and social in such a way that we are focussed on care.

      As for as the salaies go...the original discussion. I still believe there should be a cap.

      We do consulting on healthcare quality, and operations...I can tell you that if you just utilize the money properly..there is more than enough to help all, cut the cost, and still have some money left.

      The key is smarter solution from all angle. I do not see that happening yet.


    • med student:
      Because the lion's share of traditional health care is paid for through insurance, many billions of dollars are spent by consumers on unproven vitamins, supplements and other naturopathic and homeopathic treatments.
      People clearly value good health, but have been trained to consider traditional health care a "free" entitlement that no one should have to pay for out of pocket.
      If insurance only kicked in for major medical illnesses or injury, I am certain a large amount of this largely ineffective health care spending would then have to compete with the traditional medicine you are working so hard to master.
      I believe primary care, working exclusively for the patient not the third party payer, can easily justify its worth to a public that has clearly demonstrated its interest in staying healthy!

    • You are an a hole and what you do (how many lives do u save? ) is not noble nor charitable.

    • Staying healthy from a car accident or appendicitis? Other than surgery or trauma care,there are no other legitimate uses for publicly financed health care in our system. Everything else in terms of sickness and disability is simply the result of very bad choices. POWER To

    • To Health Business Consultant: Seriously? The best idea you can think of is to limit pay? And you want to limit it to the tune of 400K, like the president? What about when the president leaves office and makes millions a year in speaking fees (Clinton)? Oh by the way, if you ask me 400K/year for interventional cardiology is not much at all. 7 yrs of residency and fellowship post-med school while some 25 yr old fresh out of law school with no job experience can go make 160K/year starting salary. Pay the docs enough to keep the future best and brightest coming to the profession.

    • Doctors just don't get it.
      As long as you depend upon Congress and politicians to figure out how much you're going to get paid, you'll be disappointed.
      Why: Because there is NO MONEY.
      Medicare and social security have tens of trillions in unfunded liabilities.
      Wake Up!
      No matter what you do, the government is NOT coming to your rescue.
      The cure: Move to a free market. Let the patient determine what you're worth. Prove your worth rather than just submitting a claim based on a crazy AMA CPT code.
      Prove your worth to the person in the exam room you're trying to help. Get away from 3rd party payers who distort both financial incentives and therapeutic treatments.

    • more $ for specialists is exactly whats killing the system - in the US, the specialist/PCP ratio is 70/30, in every other "comparable" nations, its 30/70...hopefully MedPAC gets something done soon -- all I see are a host of payment silos and Obama-laced rhetoric.......

    • Okay, so primary care physicians have faced reimbursement cuts for five years now, but at this point, the Sustainable Growth Rate (formula for depicting reimbursement) does not adjust for inflation or rising costs of care. So, the amount primary care docs are reimbursed for treating Medicare/Medicaid patients doesn't even cover their costs. Even for different specialties, docs view Medicare patients as only being able to cover their costs and they actually make money on private insured patients. So, the idea that some are arguing to *cut* reimbursement is absurd, at best. More at

    • People, let's start putting things into perspective. Doctors take home less than 10% of healthcare dollars. That's not the problem. There are thousands of people who are diverting billions their way behind the scenes.

    • The greatest fallout of the medical malpractice burdeon on physicians is the almost mandatory use of sub-specialists in order to prevent lawsuits. In the days prior to the scortched earth policy of the medical malpractice industry, primary care physicians and internists could tackle most medical problems. Now, the first question that is asked by a mal practice attorney at a deposition if there's a complication, increased morbidity (sickness) or increased mortality (death) of a patient is, "Why was this person not referred to a specialist". Until we see malpractice reform there will be no decrease in referrals from primary care doctors or internists to specialists. Only a decrease in referrals will change the market for specialists and increase the number of primary and internal medicine doctors.

    • The ACP has a good point. The specialists will fight any reform plan that takes away from them. So keep it a win- win proposition so we can agree to make some needed changes. The main change we need is the working people in this country who are in between Medicaid and Medicare need help getting affordable health insurance. Let's do a survey of patients. Survey Question: Which health insurance policy would you buy? (and you have to buy one of them) 1) $50 a month and the only doctors you can ever see is a primary care doctor, no more than 2 specialists a year, and no diagnostic test that costs more than $800 and you have to waive your right to sue any doctor or 2) $1,500 a month and you can see any specialist you want and get any diagnostic test you want but you cannot see a primary care doctor. Which policy would get the most sales?

    • Dr Rand is right. whats so hilarious about these discussions is that everyone has something to say on how doctors should be paid. there is only one person who should decide how a doctor is paid and thats the doctor himself. not the insurance company and certainly not the federal govt. the doctor is the one who provides the service, so the solution is simple: provide the physician with adequate compensation or lose the service. that can mean increasing reimbursements, or charging patients directly or a combination. health care is not a charity and until doctors realize their worth and exercise their rights, they will continue to suffer financially. consider...are cosmetic surgeons complaining about their insurance reimbursements declining?

    • Primary Care Physician:
      How about $50 per month but you pay everything unless you sustain a major illness or injury and spend $11,000 or more on health care in one year?
      Insurance is protection against perils that are otherwise beyond one's means, not pre-paid windsheld wipers replacements and free fill-ups.
      Why pay someone else to pay for stuff you can afford on your own but not provide protection against the unavoidable expense of a major illness or injury that will eventually strike everyone?

    • H. Green has the key point. Malpractice and the energy and effort that goes into protecting from it has become a core feature of most medicine, but Primary Care especially.

      These physicians have spent 7+ years training to be masters on the human body and illnesses and the prevention of illnesses yet because of our stupid law system and our parsimonous insurance system these doctors are relegated to using only a fifth of what they have learned. On top of that those that are willing to learn more and do more are not provided the training to become more.

      THERE IS NOT ONE, primary care physician that would not want to learn some specialist procedures in order to get paid more than the $40 they get for a visit and even for that they have to chase the patient for $20 and prove to the insurance company that they actually saw the patient to get the other $20.

      Malpractice limited the "primary care" physician and the insurance shark attacked when it smelled blood.

      For the last 5 years I have seen the cpas and lawyers shake their heads and tsk tsk at the state of primary care while they charge $250-$500 per hour.

      After I see 40 patients my feet are aching and my hand is numb from writing.

      There are a few patients that understand the value I give them and it gives me some satisfaction when they acknowledge I helped them.

      But most of my day is spent
      administrating, documenting, filling out the 5 page forms for patient's needs and there is no one else stupid enough to take on the task. My take home pay is lower than many of the accountants, lawyers, specialists, store owners that I know.

      I wasted most of my youth studying to provede the best healthcare and help people.

      I have been programmed to help people and so I can't turn down even this lowliest of tasks, since who else are they going to go to? A specialist? Ha.

      As for Ravi's comment on taking on risk, if you had paid attention to your statistic studies you would know like the actuaries know that me seeing 40 patients a day is a lot more riskier than a cardiologist seeing 20 or an allergist seeing 80 patients a day. If you look at the malpractice premiums you will see who bears what risks.

      I just say to anyone who will actually listen to:
      1) Get this huge fear that all the training and work I have put in for the last 25 years is at risk if even if I don't make a mistake. The legal system must differentiate between bad outcomes and real malpractice, that means the judges, jurors and the lawyers.

      2)Pay me enough so that I don't have to run around like crazy because I need to see a patient every 15 minutes in order to even have a hope of taking home a paycheck. (Remember the $40 only goes so far, I need to pay for a receptionist, a biller and a medical assistant as well as the landlord and the utilities).

      3) reduce the paperwork hassles we have to deal with. Just because all these beaurocrats need a physician's signature and specialists are to special to fill them out, even if they are the cause of the request, should not mean that I should have to spend 15 minutes of uncompensated time filling out paperwork so that the patient can go see the specialist.

      4) Have insurance companies and employers execute the prevention and wellness programs they have been saying is so important these last 20 years. That is actually what I do best and it would be nice if I did not have to remember which ones of the 50 or so insurance plans pay for what and how much they pay. Some insurance plans pay for preventive checkups, some don't. Some pay for vaccines, some don't. When they do pay for vaccines they use rates below what an individual doctor can buy the vaccine at. Maybe what I am saying here is that having a single payor may add risk of insurer abuse but it also takes out so much wasted time and effort to try to handle the different protocols setup by the different insurance plans.

      It has been a rough day, I will call it a night. I will look at the pile of rejected eobs tomorrow.

    • How can one expect payment to go up, time spend with patients to go up, quality of care to go up, and by the way keep it budget neutral? I think those doctors who do a better job will continue to do so at the same low pay and ultimately retire. They will be replaced by doctors and corporations that watch their bottomline more than their patients health. In the end, everyone will get exactly what they paid for. By the way, don't forget to to get your flu shot at the local gas station (afterall, why do we need to go to a doctor to get healthcare when we can get it at Wawa).

    • I read once that the President is billed for many White House amenities -- including meals. His family receives a bill each month which they must pay.

    • I believe specialist salaries are absurd! They dont even deserve the large salaries. I mean like common a anstheasologist or radiologist ($250K) yeah like okay...wat do u really do? Ditch mal practice claims all day? Is that even a real job? A nurse anthesa or radio tech can do some of the similar procedures. Okay so mabey the speciality docs went to med school longer--u still dont deserve to make that much to the point it's absurdity! People in this county are begining to pick up these crazy doc salaries that no one questioned since insurance companies picked up the tab but now because of increased co payment to these speciality theifs who are no different than car sales man. People are actually now looking at the sticker prices and refusing irrevelant procedures. We dont want you white coat elephants charging 10X much for somthing that is worth a dime. If all you docs care about money please leave the profession and you will not be missed:)

    • Doctors are underpaid relative to other professions. Also, if you ever have surgery, you probably want a good surgeon performing the procedure. Paying doctors less will only drive the good ones out.

      Also, why are you guys picking on doctors? What about actors, athletes, CEOs, and hedge fund managers? They get paid lots of money and what value do they contribute to society, relative to docs?

    • I'm no genius...but it doesn't take a brain surgeon to figure out that an idea on how to improve healthcare should not include pay cuts to the people who actually provide healthcare!

    • If the goal of health care is a fair payment system, quality, and good health, we will never get there as long as profit is the goal of insurance companies, physicians, hospital systems, and pharmaceutical companies. Our "system" is totally unsustainable and inefficient. Disincentives for good care (look at 31% c-sections in maternity care) will never allow is to rise above our 29th place in infant mortality globally.

    • If primary care doctors really want to draw attention to their plight they need to stop working so hard. Because of the low fees paid to them by health insurers many of them are working harder and longer and with less satisfaction than ever before, seeing a disproportionate number of patients that makes being a good primary care doctor almost impossible. Most of them have become medical drudges.
      But if these doctors were to just see a number of patients that is compatible with good practice, lawmakers would take the primary care problem more seriously. Of course, their incomes would suffer. But, the point is that as long as these doctors are willing to work harder and longer hours for less pay and less personal satisfaction, they will survive and insurers will not respond to their needs.

      Ed Volpintesta MD

    • Dr. Ray is right. Doctors, ditch Medicare, CPT codes, and you will find out your true worth.

    • I meant Dr. Rand

    • The greatest fallout of the medical malpractice burdeon on physicians is the almost mandatory use of sub-specialists in order to prevent lawsuits. In the days prior to the scortched earth policy of the medical malpractice industry, primary care physicians and internists could tackle most medical problems. Now, the first question that is asked by a mal practice attorney at a deposition if there’s a complication, increased morbidity (sickness) or increased mortality (death) of a patient is, “Why was this person not referred to a specialist”. Until we see malpractice reform there will be no decrease in referrals from primary care doctors or internists to specialists. Only a decrease in referrals will change the market for specialists and increase the number of primary and internal medicine doctors.

    • Shifting money from specialist to primary care will only reverse the problem. Instead of a primary care shortage, we will create a specialist shortage.

    • Solution to underpayment of primary care and internists....
      Put everyone on the nation on a single payer health insurance such as Medicare. Take the $750 Billion per year that the private insurance companies siphoned from doctors for their administrative overhead and executive pay and give it to the internists and primary care physicians.

    • At present CMS (Medicare + Medicaid) rates for cognitive care, present debts at medical school graduation, and present workloads, you will always have too few primary care doctors.

    • A large number of patients don't ever see a PCP, they go right to the specialist. I for one don't even need a referral. Is this a flaw in the system or designed for profits?

    • "At present CMS (Medicare + Medicaid) rates for cognitive care"

      Medicaid rates are too low. Little question about that and they vary widely from State to State. But the system for setting them is distinct from the system for Medicare which is essentially the same system used by private insurers with payments roughly the same as Medicare's. Throwing them together just confuses issues.

      I know Dr. Green is a broken record on the issue, but his message is in fact correct. Even with a single payer/insurer system, which is the only financing scheme that shows any rationality and would save USA residents minimally in the hundreds of billions if not the $750 billion Dr. Green cites, medical service delivery reform and provider payment revamping are needed just as much as financing reform.

      Whether the new Administration will get anywhere that improves the lot of tax-payers, patients and physicians alike is questionable given the irrelevant nonsense raised about Mr. Daschle's appointment. But one can at least hope...

    • Wendell,
      I'll turn off the broken record when all in the Nation receive quality affordable health insurance like every other civilized Country on this earth. Until that time someone needs to speak for the 55 million uninsured, 100 million under insured and the scores of physicians, nurses and therapists who must struggle and fight for their patients care daily.

    • Auto electric specialists charge more than general mechanics. Why shouldn't neurosurgeons be paid more than generalists? The issue shouldn't be competitive salaries or, more simply, divide and conquer (clearly their game.) What needs to be looked at are referral patterns, turf, etc. Treating with copious consultations, imaging, and lab tests to cover all bases place an unnecessary fiscal burden on the healthcare system. Focus attention on this area of practice and you'll find your savings.

    • Great posts everybody. The comments are more valuable than the article. I started as a CFO (a long time ago) making $40K per year. I deserved more in those years, given all that I had to do. I make much more than that today, but I don't feel I deserve's just that the market feels I do.

      Candidly, I think the specialists I work with deserve every penny, and I'm particularly pleased to see primary care doctors income going up (based on some initiatives we're undertaking).

      I have to pay accountants (CPA), with 10+ years experience, @ $120K in my market. I can't look a primary care doctor (with a lot of experience and many years of medical school/residency/fellowship) in the eye and say they don't deserve to make $200K. Further, I have to work with a lot of bankers/investment bankers to isse my tax-exempt bonds. If I'm willing to pay them a LOT of money (which I do, willingly), or my lawyers to do the same legal work each time I do a hospital financing, how can I begrudge an orthopod $500K for doing 400+ hip replacements a year and doing them almost perfectly? Did you ever see tears in the eye of an 85 year old Normandy veteran when he realizes that he (a.)can walk again without pain, (b.)still play his crappy golf with his buddies and (c.)still take his wife (my mother) out to dinner? Just how do you value that? I know how I do. Or a CV group who does a large number of CABGs and has the best outcomes in the State? Should they only make twice what a an accountant with 10 years experience makes?

      IMHO, I feel the answer is on the demand side of this equation, not the supply side. Focus on getting the patient engaged in this process, with real money and real consequences, and they'll help establish 'worth'. I'm already seeing it happen in my market.

      I still say the worst thing we ever did was value all medicine at being worth no more than a $50 copay.

    • Single payer of course means that the government will set the rates for everyone. I suspect that this will also lead to malpractice reform since, in effect, the government will foot this bill as well. Then Dr. Green will have to lobby Congress for his money for his entire patient set -- medicare, medicaid, and those currently in the private market. Lots of luck Dr. Green.

    • Remember too, that most doctors are working 60-80 hr work weeks, not 40 hrs with every weekend off.

    • while I understand the equity argument for paying primary docs more -- or at least shrinking the pay gap between them and specialists -- I'm at a loss about the health policy argument. Is there any evidence out there that paying primary care docs more will somehow enhance care or improve the system generally? would appreciate being put onto it.

    • If the best-paid specialists are neurosurgeons, and are estimated to make 2.5 million dollars per year for a relatively short period of time, and we have company CEO's making many multiples of this, including CEO's of health insurance companies, then the system is certainly out of touch with reality. If there develops a single-payor system, then doctors, both primary care doctors and specialists, should receive the benefit of the eradication of private health insurance companies. HOWEVER, that will never happen, because the insurance companies will lobby and convince Congress that they will be needed to administer the vast health empire. The low costs of the Medicare and Medicaid insurance will rise from a supposed 2-3 % to closer to the 20% administrative cost of private insurance. Either way, the reward for the physician will be limited. The only hope for the medical profession is a free-market system, but the true cost of that, paid on a true value for service rendered, would be prohibitive and would never be accepted by the American public. The closer the medical profession gets to a market-determined price, the fairer the reimbursement will be, relative to other professions and occupations. As a retired physician, I can look back to comfortable financial rewards for my labors, but not truly fair relative rewards. I didn't go into it for the money though, but I expect that more young men and women will examine this more closely in the future than I did. I know there is much more emphasis on "life style" by young physicians, and an unwillingness to accept the hours and the pay I accepted. Coupled with the "gate keeper" role, this is why primary care is having trouble attracting MD's. If the only way to make a wage commisuate with your education and sacrifice (long hours in professional training, extensive and costly education, and constrained social and family life) is to see more patients, then clearly such a career choice is less acceptable. It's fine to couch it in altruism but it doesn't work very well when there are other, more remunerative, occupations in computers, hedge funds or banking, yet fields that are viewed as just as challanging. It is the imposed regulation and restriction of remuneration by the Federal Government and the insurance companies that makes medical practice less enticing today. Everyone has whittled down the reimbursement, constrained the opportunities for entrepenurial advances within the practice, and prevented comparable ancillary opportunities. For whatever reason, physicians are even accused of being unduely influenced by trinkets from pharmaceutical companies, while the medical profession is expected to accept a politician like Mr. Daschle as head of HHS, who feathers his nest with consultant fees, lobbying and influence peddling. I don't see an easy answer except to vote with our feet, choosing what we want to do, and not what the general public perceives as what is best for it. Unionization is unacceptable, and the large professional societies are not unified enough to be effective. Just as no one wants to pay for medical care out of their own pocket, the Federal Government and the insurance companies do not want to pay a fair price. I suspect that veterinarians will make more than medical doctors in another several decades. Those who urge universal health insurance and want to "speak for the 55 million uninsured" have not fully examined the adverse effects of inadequate reimbursement for the delivery of medical services, just as Massachusetts is struggling with now. There is a great need to get rid of the "middlemen" in health care and adequately, and with relative comparable consistency, pay those who are delivering the service. Hospital systems, particularly non-profit hospital "systems" should be reigned in, and the monies paid them be used for primary care.

    • Mr. Hanna, let me think about this for a a recent nationwide poll published in the Annals of Internal Medicine, 60% of American Physicians said they would prefer a single payer health insurance based reimbursement such as Medicare adjusted for COLA any day over the 1500 different fee schedules associated with government subsidized private insurance companies. As you're aware, private insurance companies set their rates according to a secret actuarial population density and political analysis. The 40 year experiment with a high overhead government subsidized private insurance system operating parallel and within medicare has failed. Oh, by the way, physicians are the only workers in America forbidden by law to collectively bargain for reimbursment contracts. If two health insurance merge, they ring the bell on wall street. If two physicians discuss reimbursement rates they go to Federal prison.

    • "the government will set the rates for everyone."

      It already does.


      Any effective reform process is political, ergo need for politicians. Better to acknowledge that and make an effort to get as many relevant facts in front of the politician/legislators than to simply condemn them.

      I think Mr. Daschle should be questioned on his activities since leaving the Senate that have led to such high compensation. But he should be given an opportunity to discuss the issue.

      The tax issue for him is an irrelevant side issue that has nothing to do with his potential value in any healthcare reform effort.

      As anyone who reads a newspaper and reads any weblog on healthcare/politics knows that Daschle's tax reporting omissions are just "red meat" thrown to the right-wing rabble.

      Who knows whether the Senate committee will get its act together in concluding its hearings which have been more farcical than anything to this point.

      If HealthCFO pays an "accountant" a salary of $120,000 per year, I would say he is significantly overpaying. If that is reflective of his hospital's cost structure I would be interested in seeing the hospital's P&L statement to see where money is spent.

      Regarding compensation to physicians, a topic needless to say nearest and dearest to the heart of all physicians that recurs in postings here every month or so with the same response from commenters, current net compensation levels - although 2 or several times higher than compensation in similar OECD countries - simply is not a large enough number in healthcare spending to warrant consideration for reduction whether worthy of that consideration or not.

      Point is physicians should worry less about that than encouraging any reform that reduces the remaining 93% of costs in the system.

      It is the procedure-dominated nature of the RBRVS system that has to addressed. That is the ultimate source of the disparity between specialist and primary care pay.

      Administratively determined now and administratively changeable.

    • Physician pay comparators to other OECD countries are not relevant. The have different cost structures, subsidies, work regulations, liability climate and GDPs.

      Physicians represent about 0.2% of the general population. They spend a lot of time, effort and money getting to the level where they can provide an invaluable service to those who need it. To undercut and undermine them systematically as everyone from Gov't and Insurance companies and Hospitals and Frivolous lawsuits do, is to invite trouble.
      Why is it not appropriate to pay our Doctors in the top centile of income of this country? Are they not qualified enough? Do they not do a valuable job? Do they not work hard enough? Are they not by and large appropriate role models for our children? On any sensible measure we ought to be paying them well and asking them to uphold standards. That is what we did in yesteryear with our old fashioned values.
      For those of you that do not know what the Adjusted gross income of our top 1% of tax filers is, go to the IRS website and you can find it there. PCPs in many areas do not even make the top 5%.
      Somehow we have let special interests and expediency to mess up our values and now we have a situation where a career choice for the core of medicine which is Primary care medicine is in great peril. We must fix it. The ACP has some very good ideas, balanced ideas on how to go about doing this. Pres. Obama would do well to listen to their counsel.

    • To Wendell: "Accountant" is a managerial position, with 10+ years experience. Cost structure of my hospitals (particularly our large, teaching hospital) are in the lowest quartile of comparable hospitals in the U.S., according to the Solucient database.

    • HealthCFO: always enlightening commentary, but you have not indicated how your hospital's website is findable. Still how many $120,000/year salaried financial types does a hospital need?

      "Physician pay compar[isons] to other OECD countries are not relevant"

      Directly relevant in fact. Ancillary factors on work conditions, etc. are also relevant, but the relative multiples to USA compensation levels are accurate and indicative.

      Still system-to-system cost differentials are due marginally to net compensation differences. Gross compensation however is relevant at roughly 3 times net pay.

    • No, I disagree with Mr. Murray regarding the disparity between specialists and PCP's that is the focus of this entire blog. Physicians overall are underpaid, relative to other professions! And for too long they have accepted this underpayment, because the government has imposed it and the AMA has accepted this concept of a zero sum game. While other professions were continuously becoming better paid, because they don't have a nationalized, one-payor system, the Congress imposed this zero-sum approach-"give to one, take from another" game. As a result, the PCP, at the bottom of the food chain, got the worst fare, but everyone has suffered, while all the insurance companies, information technology outfits, commercial labs, and hospital monopolies, have grabbed the "healthcare dollar". At the same time, individuals like Pete Stark and "holier-than-thou's" have restricted any other source of physician income. Why can't doctors band together and have hospitals, or outpatient facilities? Why can't orthopedic specialists from different practices join together and form a physical therapy company? Why did ophthalmologists formerly have to do their cataract surgeries in the hospital? BECAUSE monied interests politicked to have CON laws or insurance companies and hospitals went into cahoots, as exampled by Partners and the Harvard hopitals with BCBS of Massachusetts. It's not the RBRVS system, it's the systematic attempt to cut out the doctors, who, because they were the persons who order the test or the treatment, and might over order or refer unnecessarily. So, at the cost of patient convenience, others were allowed into the opportunity space. And because the doctors were fragmented and not a viable force, the regulation could be imposed by Congress. In the end, the reimbursement for doctors has suffered, and the future implication will be a scarcity of doctors. This needs to be addressed, but it won't because doctors still cannot force the issue. And all the well-meaning attempts to do so will be defeated by lobbying and political influence. In the end, only by group-wide demographics will this be addressed. At present, that is seen by difficulties Seniors have finding a PCP who will accept Medicare, but later, it will simply be the scarcity of PCP's in general, such as Massachusetts is experiencing at present. Of course, we now get NP's at Walmart and Walgreen, but no move to improve physician reimbursement, which is at the root of the problem. World-wide, the caliber of American medicine is rated the best, but the delivery of it suffers as a result of the government intervention. The flip side is to have a universal government medical system, but the quality, the individual quality, will suffer. The aggregate may improve if some of the 55 million get health care, but waits will be longer and the results spottier, just as in the British NHS. Improving the pay for all physicians, particularly PCP's, and getting rid of the "middlemen" will improve the basis of any new approach to American health care

    • Greed. Greed. Greed. Dear Dr. Greed...You will get very little sympathy for your plight from the public. The average generalist makes about $175.00. The average specialist makes $400K. Greed. Greed. Greed.

    • Greed. Greed. Greed. Dear Dr. Greed…You will get very little sympathy for your plight from the public. The average generalist makes about $175K. The average specialist makes $400K. Greed. Greed. Greed.

    • Dr. Greed,

      What exactly are your credentials to tell a doctor what is a fair wage for his/her services?
      Until you walk in my shoes don't pretend to know what my services are worth.
      PCPs are under compensated for the value they bring to the table. Now that they are acting on their frustrations and the void is becoming apparent we have all the idiots coming out one by one trying to put a lesser value on their work. Go ahead, try fixing it that way.

    • Concerned citizens, doctors, and Wendell Murray:

      Dr. Rand has said it: as long as we depend upon Congress and politicians to dole out 'fair' reimbursements, we are going to be disappointed. It is time to vote with our feet, and make our own rules of the game. Ditch any link to Medicare reimbusement rates. Negotiate with your insurers for annual increase pegged to AT LEAST to inflation rate, and disregard what CPT codes dictate. If you are still taking Medicare patients, stop accepting new ones. Band together if you need to--internet provides excellent channels of communication and coordination. You have more power than you think.

    • Reading all of this I think everyone is out of touch with the simple reality that the middle class in the US is virtually dead. People cannot even afford groceries without using credit a significant portion of the time. Nothing is sustainable because the basic cost of living is more than most people are making. Health care is on the bottom of the list because there is no money. Speaking for myself I have insurance, but I cannot even afford the deductable, so I never go to the doctor unless it is a major problem, and I have not had a general physical in years. You may well say my priorities are screwed up, but when I have to borrow money to pay for basics because the wages just are not keeping up with the increase in living costs there is not much else to do. Very few people in a position of power realize where the middle class is really at now, least of the all the politicians, or the doctors. Who are all whining about themselves, but the the rest of us are just worrying how we can keep out of bankruptcy. We are more concerned about affording the rent and groceries than the damn doctors, they are not even on the list of priorities anymore.

    • Matthew,

      I see patients struggling financially and I feel for them. However I am in the same boat. If I can't pay staff or the landlord, I won't be around when you need me.

    • Dear Concerned Citizens,

      Doctors are banning together to VOTE with their feet by denying treatment because they are cruelly underpaid with average salaries ranging from $175,000 to $400,000.

      Well, we as patients should vote with our feet too!

      When you go to a specialist and they do nothing for you, not even have the intelligence to order a blood test but instead hand you a medical bill of $500.00 (no kidding) for services they THINK they are worth….why not WALK OUT AND DON’T PAY THEM?

      I think many doctors are overpaid for the quality of medicine that they deliver. Many other patients agree also.

      Let’s ban together as citizens and protest the high cost of specialists gouging the system for doing little more than NOTHING but indulging in greed and having heads bigger than their worth. Contact your insurance company and report inflated costs from doctors. Let’s start a website of doctors who deny patients treatment and start boycotting them. Let’s get rid of these doctors. Let’s replace them with a higher number of medical school graduates who understand that one does not become a doctor to become a millionaire. Let’s get kids in medical school who become doctors because they love medicine, they enjoy the challenge, they want to help mankind, they prioritize public health and safety and they understand that $175,000 is a decent salary to raise a family. They should know that being a doctor is a privilege, not a career stint on “Who wants to be a millionaire?”

      These discussions about low pay for physicians on this blog are disheartening. In light of our economic problems with many people unemployed and many Americans with no medical insurance, I find the whining and crying about low salaries of $175K-$400K pathetic.

    • I already gave my opinion earlier in the debate on where the money to fund primary care should come from (hint: from patients themselves). If patients paid for primary care out-of-pocket (or from FSAs, HRAs or HSAs), primary care physicians would be free to compete for patients by offering patient-pleasing amenities. These amenities might possibly include office hours during evenings and weekends; consultations by phone or email; maybe even house calls. Primary care physicians would also be free to set prices as high as the market would bear – who knows, patients might pay a premium for greater convenience or weekend office hours.
      However, the American College of Physicians (ACP) is mistaken in its claim that additional funding for primary care would pay for itself. This is a popular myth that’s been around for a long time – and it’s absolutely wrong! The conventional wisdom is that increasing primary care visits (or increased preventive screenings) would catch costly-to-treat illnesses earlier such that the savings would offset the marginal cost.

      However, with few exceptions, preventive medical screenings, annual physicals for health individuals, etc have a positive cost per life year saved. That’s not to suggest some additional primary care visits would not be beneficial – but they would come at a cost. Patients themselves are in the best position to decide if additional primary care visits are worth the marginal cost (or how much each office visit is worth to them).

      Louise Russell argued that preventive care does not save money in a recent Health Affairs. NCPA president John Goodman also blogged about it: “An Obituary: The Idea that Prevention Saves Money is Dead”

    • Dear Concerned Citizen, your comments are absurd. Doctors could also set up websites and blacklist patients that require too much time and talk too much. This does not accomplish anything. The market will eventually determine what physicians are paid. But I hope you agree that if physicians are paid too much then govt officials, athletes, movie stars, CEO's, dentists, vets, and a lot of other people are paid too much also. Maybe we should regulat their salaries too. But wait, we live in a capitalistic democracy. Why don't you move to a european country where there is equity in everything? I am sure there are people who make less than you who feel you are overpaid for what you do. Finally, medicine will become like teaching. why don't the best and brightest go into this noble profession. It is called the pay. You will only get the best if you compensate the best. Heck, many physicians would go into teaching for the same pay. You are idealistic but not realistic. you will get what you deserve. Imagine going to the DMV and dealing with govt employees. that is what your future medical visit will be like. a complaint? try complaining to the govt and see how far you get.

    • Concerned Citizen,

      You are correct that public is not sympathetic to doctors' grievances, and it's hardly surprising. The public is almost completely insulated from the REAL costs of medical care, and thinks that $175,000+ is 'too much' for a top-notch student with 10-12 years of arduous education and massive educational debt. Yet, no disagreement here.


      If you really want to find out how much our services are truly worth, how about ending government interference via Medicare price fixing and let the free market work it's magic? The doctors involved in cosmetics thrive in free market environment, and primary care physicians would, too. Our services and skills are in high demand. You think that the government has the right to take these hard-earned skills away from us, in the name of 'common good'. I disagree.

      Doctors are not 'denying' treatment. When you see a primary care physician who is not accepting new Medicare patients, he/she is reacting to market forces which has been distorted by the federal government. Remember, no doctor is obliged to treat anybody, and he/she has the right to fire patients at will. Those are his/her rights guaranteed by the US Constitution.

    • Concerned Citizen:
      Whatever your profession or job, I very much doubt you made a vow of poverty along the way.
      But apparently you believe that like some clergy, the decision to spend 10-11 years of greuling after college education, at subsistence pay, with many medical students buiding up mountains of educational debt also entails an obligate vow of poverty? NOT!
      Jealousy and envy are a terrible basis for policy; and the fact that someone else may be doing better than you doesn't mean it's at your expense!

    • Dear Anonymouse citizen…

      I don’t see where I stated that the government should regulate physician’s salaries. I am implied, however, that for the quality of healthcare that is delivered, it appears that many physicians are overpaid and many appear exceptionally greedy.

      You are the one being idealistic and not realistic if you think medicine can be work efficiently within a free-market. I cannot call up a doctor and compare prices. But I can do that with a plumber. A plumber cannot get away with gouging money for services not rendered, but physicians can. That’s not a free market.

      And if it were a free market, then all our taxes of billions of dollars that go to NIH for medical research would come to a halt, right? I don’t give my local plumber association money for the betterment of plumbing technology. The government mandates we pay for billions of dollars of taxes for NIH funded medical research but the majority of us never have access to those benefits because we don’t have the money or social contacts to receive them. The medical system is a CLOSED system, not an open one as should be in a free market. It is subject to whims of doctors referrals, etc.

      The public is getting the worst of it all, while the physicians cry about their low salaries of hundred’s of thousand dollars. Boo Hoo. You will get little sympathy from the public.

    • Everyone keeps getting hot under the collar, but to me I think again the real issues are being missed here. I personally do not begrudge a doctors salary. The problem is not that doctors are paid too much, a few CEO's on the other hand, but that is another issue. The problem is 90% of the American population is paid too little to even consider going to a doctor most of the time. It is a nice idea that health care is universally available, but it is not likely to happen until there is a much greater leveling of the economy. If someone is valuable enough to hire in the first place, they should be valuable enough to be paid enough to actually live on what they make. Then they may even be able to afford medical care without interfering with a free market. But, the free market has in fact run over most of the people in recent years. You want people to stop asking for the government to control the cost and availability of medicine then campaign for higher wages for the middle classes who have not seen a wage to match the cost of living in 25 years.

    • Dr Knight is right.
      Doctors to not take of vow of poverty. They deserve to make a good living. What we pay our PCP's is shameful, especially when some nurses are making more. One big problem with health care is that everyone is working off the backs of physicians!!

    • Matthew,

      While middle calss folks like you lump Doctors with the rest of te "out of touch" folks, the Insurance Execs, Hospitals Managements, The high paid Consultants, the Big Pharma administrators and countless other categories of people are laughing all the way to the bank.
      At the end of the day, when you get sick at 2am with Appendicitis, it will be you and I and a few other deserving professionals who will be addressing that problem. Politicians, CEOs, and the like will be nowhere in sight.
      All Doctors, were, are and will continue to understand the plight of the middle class in this country. We understand that int he past decade health care premiums have DOUBLED. Yet our payments have DECREASED. Do you see something wrong with that picture? Surely that money did not go into a black hole some where. Once we address that, we would have addressed much that ails the current system.

    • Who is coming up with this 175K number for an average? Are you averaging pcps with the specialists?

      It would be tough to get the average PCP compensation to that amount, even if you counted the malpractice premium as compensation.

    • I drive an 8 year old Honda with over 100,000 miles on it. My house is "average" in a cookie-cutter neighborhood. I don't even own it. People making less money than me have much nicer things. I don't know if it's because they don't have debt or are living off too much credit. I don't yet have a kid (I'm 35) because I don't feel I can afford to have one yet. I haven't had a vacation in a year.

      Having said all that I'm very happy with my life. Most of my paycheck goes toward debt, but such is the life of most of current Americans. My job is not secure, much like the jobs of many other people. I may be a surgical sub-specialist but I sure as heck don't see even $200k per year, let alone millions....

      It'll be interesting to see if my job is worth enough to today's society that I'll still be working at it in another decade.

      As for the middle class? I personally know of 1 or 2 physicians who I would consider "upper class". I also know hundreds who are mid-level "middle class".

    • There are some specialists who are not compensated fairly either. I drive a Mazda with 155,000 miles on it, rent, no vacation in 2 years. My health insurance is luckily through my relationship. There is no way I could afford health insurance on the meager fees I get from insurance companies. Technically, I meet the criteria for "specialist" working in behavioral health in a full time private practice. Though my practice is robust, I gross well under $100,000 and net far less due to costs. About 3/4 of my patients make more or much more money as well as live more lavishly than I with far less education or risk associated with their employment. I have retired lawyers on Medicare planning their next vacation to Aruba who pay no copay! I do not at all begrudge them this, but in comparison, I believe that I am not being paid fairly in accordance with costs of doing business, education, value of service etc. So, there are even some specialists who are not compensated fairly. I totally identify with the plight of PCPs and the need for more fair compensation.

    • According to the Medical Group Management Association (MGMA), the annual gross revenue per patient for family physicians is about $250. The vast majority of Americans can easily afford to pay this amount to their primary care providers out of their own pockets each year - especially considering the other things on which people decide to spend their money. Even the vast majority of Medicare beneficiaries are apt to do better paying their primary physician directly and keep the $1,000 currently withheld from their Social Security checks annually to pay for Part B which pays their doctor. Clearly, the vast majority of American don't need insurance to pay for primary care.

      Much would be saved if we didn't rely on third parties to pay for routine medical care. For the last 8 years my primary care medical practice has not taken any insurance. My overhead annually runs around $120,000 - about $200,000 less than that of family physicians who participate in the medical claims process. Given that most family practices have roughly 5000 patient visits per year, the cost of filing insurance runs $40 per visit or about what my patients pay for a typical visit at my practice. In other words, the transaction cost is as much as the service being provided – what a tremendous waste.

      Consider the national implications of this. If all 300,000 or so primary care physicians in this country settled accounts directly with their patients, there would be an annual savings of about $60 billion. That’s nearly 20% of the $350 billion paid to all physicians and their medical practices each year. Other deadweight administrative costs must be added in as well, including those incurred by insurers, employers, and government for making sure these small claims are paid. All of these expenses are a tremendous drag on the economy at a time when this country needs to cut costs everywhere we can.

      The best and fairest way to eliminate third party payment for routine medical care from a policy standpoint is to eliminate the tax advantage for employer based insurance as proposed by Senator Coburn or by President Bush in 2006.

      This would allow primary care doctors and their patients to agree on terms acceptable to each.

    • It its so cost effective for PCP's not to accept insurance, why do so many? What is the position of the AAFP and other medical organizations position on this practice?

    • My wife's OB-GYN just retired to his ranch in the country at the ripe old age of 43. Did not even bother to send a postcard to his patients - they learned of it when they called for an appointment. Looked up his tax records, and he only owns $6M of property in my county alone.
      I also remember my Dad's oncologist... everything stopped when his stockbrokers limo pulled up in front of the office.

      And then my internist struggles to get by. Something is really wrong here. The pay imbalances between primary care and specialist physicians is really out of wack, and something needs to be done.

    • Your right something is really wrong. It makes you wonder it this is another Wall Street?

    • No sympathy for MD's that whine and cry about not getting money from the government. Leave these debates to "experts" that have never seen patients, never had to go and see yet another druggie at 2AM on Saturday night that only wants to sue you if he/she can.

      Get rid of third-parties and sign contracts with a few patients that CARE about themselves instead of working like a dumb hamster racking out candydrugs to gluttons that don't give a crap.

      Doctors that whine for money from the government doesn't deserve a dime in my opinion. Stop whining, you guys are an embarrassment and a reminder why I dropped out of this slavery 4 years ago.

    • ConciergeMd represents what is wrong with the "business" attitude of certain primary care physicians. The physician's comment smacks of the frightening arrogance this type of physician has for patients, or anyone other than themselves, e.g. society at large.

      The market for so-called concierge medicine is quite small. What these physicians do is to skim those patients from the population of all patients who can afford to finance medical service charges from the physician.

      The patients pay at time of service, usually a premium amount. The patients can afford to carry this payment - and can further afford to pay any incremental cost for "premium service" not covered by insurance - until they can obtain reimbursement from their insurers.

      The physicians shift the administrative hassle and the financing cost to the patient. In addition the physicians ignore the needs of the larger community they are supposed to serve.

      There are very few patients who can afford to do that.

    • yeah wendell, the physicians are the ones to be burdened w/ administrative hassle and costs. also, why shouldn't patients pay at time of service? the patients can't afford it--baloney, they can afford everything else, groceries, car payments, insurance, etc, etc. Only the physicians $80 fee is "too much". get something for free, you'll treat it like its free. no wonder physicians are moving towards concierge md, also the market is not small, consider the advantages to the patient w/ a concierge practice (increased time of visit, less waiting).
      No other service in america is provided w/ no fee and a "pay it if you can" attitude. medicine is no different.

    • Go for it Wendell!!!

      Your condescending and elitist snobbishness is gold. Many of us need some good flogging from people like you to wake up further, but it is happening as we are speaking. Your harsh words really shows how much you guys DO care about solving the problem. You have no other solution, except putting a gun to my head, asking me to see 50 patients a day in return for my life, free food and "healthcare" I guess.

      Your insight into conscierge medicine is identical to the tone more and more insurance companies are taking. Certainly pays more to work for them herding "us cats" than it pays to take care of sick people, right?

      "Shift" adminstrative hassle, you're saying. Well, this "hassle" is one of the main reasons we got the problem to begin with.

      Another one of you liberal's unfunded mandates. Do you fix other people's computer and expect others to pay for it and then just sit around waiting for the government to pay you scraps?

      med student is speaking from passion, his heart and some common sense, while all you can do is rack up more hysterical stoneage rhetoric and the same old victimology.

      I see many people smoking two packs of cigarettes a day, so don't come here and give me that crap. There are rich, poor and people in the middle, but don't ask me to care for every poor in the nation, just because you have no clue what this is about.
      Likewise, I see patients for free that cannot afford doctor otherwise. I choose my own charity and don't need another EMR-parasite to tell me what to do.

      To all doctors here: Get out of this mess. It is easier than you think and you will never regeret so. Let the limousine elite keep ranting about things they clearly have no clue about.

      Wendell, can you fix my computer, it got a trojan in it. Sorry, it's in my wife's name and she has no computer insurance. Can you waive the fees??

      Sorry guys. I have seen calls to ignore WM and won't answer him again, but his replies were simply too classic to let stand alone. It's almost like hearing another "expert" with some phony "PhD" in "healthcare ethics" sitting cozy at his 9-3 job (half-Fridays) telling everybody how mean and selfish we docs are.
      You're a real class-act Wendell. I should invite you for a cruise one day, because people like you shed more light upon our hippocritical healthcare system than the worst politician.

    • No doctors should make more than 50000 a year. What do they need more moeny for?

    • ravi

      Fair only because you are a socialist.
      If you so hate it so much here where success is celebrated and rewarded,
      why not go to a socialist panacea.
      Inherent in that answer would be your hypocrisy.

    • Primary Care Physicians are NOT under-reimbursed. The problem with primary care practices in today's medical climate, is we are still practicing medicine as we have in the past... relying heavily on reimbursements for the "amount of patients seen" vs. the "quality of care delivered".

      The US Healthcare System has moved to "evidence based medicine". Reimbursements are going to continue to decrease for office visits and therapy, while reimbursements for "performance drivers" are increasing (clinical laboratory, diagnostics, billing & coding, and healthcare IT).

      We have a choice... we can continue to practice medicine as we have in the past and prolong our struggles with the reductions to reimbursements; or we can conform to the reforms that have taken place and significantly increase practice revenues.


      Most physicians feel pressured to see more patients, since reimbursements have been reduced for office visits, procedure complexities, and therapies. What is not taken into account is insurers have reduced incentives to see more patients… and put incentives in place to do more things with the patients they already have.

      The insurers want physicians to focus on prevention, wellness, and improving treatment of chronic disease... they want physicians to improve the quality of care.

      Financial incentives are in place to change the way primary care is delivered. The only reason primary care practices are financially distressed is they continue to deliver care as they have in the past, prolonging their struggle with reductions in reimbursements.


      YOU HAVE A CHOICE... continue to practice the way you've always practiced and make less money... or practice the way the insurers want you to practice and significantly increase net revenues.

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