We've been talking over the past few days about the primary care crisis, which is driven, in no small part, by the relative income and lifestyle benefits of medical specialties. Given the disparity, it makes little sense for aspiring doctors to choose the long hours and relatively lower pay of primary care. My commentary has focused on how to deal with this on the primary care side. But in comments, Wisewon takes on the other end of the problem: Cutting payments to specialists.
Specialist salaries aren't just determined-- they are based on volume of procedures and payments rates for their procedures. The "best" specialties are fluid, as are the best salaries (with exceptions, like Neurosurgery) primarily because physician payment reform is not keeping up with the changing practice of medicine. Specialties typically have a couple of bread-and-butter procedures that change based on changes in technology, diagnosis and clinical practice. Typically, these bread-and-butter procedures start small, are paid well per procedure, and physician groups figure out out they do a ton of those procedures to drive salary. Opthamologists used to make a lot more money than they do now. Why? Because cataract surgery used to get paid a lot more. 2-5x more per case than they do now. These docs figured out how to be more efficient so they could do more cases per day, and it takes a while for payors to say-- you're doing one every 20 minutes instead of every 90? Then we're cutting back fees accordingly. In the meantime, Ophthalmologists rake it in and are a "top" specialty for medical students. Eventually, payors and Medicare figures things out and start putting pressures on rates. But it takes a while. The same story is now true for Gastroenterologists, Radiologists and Derm. Radiology was one of the easiest fields to get into 15 years ago. You work in the dark, have little contact with patients, its frankly a weird field for people who went into medicine looking to help people. You used to have a couple of nerdy introvert types who liked being in the dark that chose the field. Now because of the explosion of imaging, and practice efficiency, these guys are reading 3x the images they did 15 years, and making three times as much. Payments will eventually come down for them too. But in the meantime, Radiology is now one of the hottest fields for medical students. Fixing this perverse dynamic is a key question.PS. General surgeons are the wrong specialty to pick on. What specialty has had vacant spot in the residency matching process the last few years? General surgery. Its a pretty tough life-- in terms of lifestyle impact, they deserve the $75-100K more than the PCP. Its the Radiologists and Dermatologists that have PCP hours but are making 300-400K that are the problem.
I agree with most all of that. I'd just add that we need ways to control volume as well as price. There's a lot of research showing that, in medicine, supply drives demand. if you live in an area with more specialists, you're going to end up getting a lot more care. And your health outcomes will be no better for it. Your health spending, however, will be much more expensive. This is where better evidence of treatment effectiveness and value comes in, to help us make these decisions. Paying rationally is part of the battle, but so too is prescribing rationally.
