Health in the Headlines: The primary care dilemma

by Lorien E. Menhennett

A few weeks ago, my mom went to see her doctor. While there, Mom decided to ask the physician if she had any advice for her daughter (me), a doctor-to-be.

“Yes, actually I do,” the M.D. replied. “Do NOT go into Internal Medicine, Family Practice, or Pediatrics!”

Why not? It comes down to one word: money. Or rather, the lack thereof. And this is at the heart of one of the biggest controversies and most serious issues facing the medical community, and perhaps our country, today. It was also the subject of Indiana University’s “Sound Medicine” podcast on June 13. But that story is coming up shortly.

What’s the big deal? Don’t doctors earn bank? Well … depends on who you are. The three specialties my mom’s doctor mentioned–Internal Medicine, Family Practice, and Pediatrics–have the lowest annual salaries of all specialties. Here are some average yearly salaries, according to Becker’s Hospital Review, an organization that surveys doctors every year about their income. (This data is from Becker’s 2010 study. You can find it on the Web at:

Average Physician Salaries (2010)
Specialty Salary (dollars)
Pediatrics $171,000
Family Practice $173,000
Internal Medicine $186,000
Neurology $258,000
OB/GYN $266,000
Pulmonology $293,000
General Surgery $321,000
Hematology/Oncology $335,000
Cardiology (invasive) $475,000
Neurosurgery $571,000

While I’m sure part of it is about lifetime earning potential, part of it is also solvency potential. When you finish medical school and residency–and perhaps a fellowship as well–with some $300,000 in debt, you need a decent income to pay that off in a reasonable time frame. Because the longer it takes, the more interest accrues. And you don’t want to be paying back that loan in your retirement.

Now refer back to the list of specialists and their salaries. Note that the difference between one of the lowest (Internal Medicine, at $173,000) and the very highest (Neurosurgery, at $571,000) is nearly $400,000. Put another way, the neurosurgeon makes 330 percent more than the family practitioner. Granted, brain surgeries are complex, and becoming a neurosurgeon requires more training than most specialties. But taking care of people of all ages, with all types of conditions, is pretty complex, too. So why such a disparity?

The answer is so simple … and yet, not. The short story is that the higher-paid specialties are the “procedure” specialties. Those doctors–such as surgeons and cardiologists–do a lot of “billable” work. In other words, they tend to get paid for most of what they spend their time doing. Primary care docs, on the other hand, don’t do as much billable work. In fact, they spend a lot of time doing things that earn them absolutely ZERO money: refilling prescriptions, answering e-mails and phone calls, and looking at lab results. This is still “doctor” work–it can’t be done by anyone without that $300,000 M.D. after their name–but neither HMOs nor Medicare will pay you to do it.

Basically, primary care docs are overworked and underpaid. Sounds like fun, right? So no wonder many medical students these days shy away from those specialties–a trend that is expected to leave us with a huge shortage of primary care physicians in the coming years, especially as the Baby Boomer generation ages and requires more and more care.

In reality, none of what I’ve just written is news. (HA! Gotcha there, didn’t I? You thought this was supposed to be a NEWS column? Well … I’m getting to that.)

What is news is that this spring, an internist from Philadelphia named Dr. Richard Baron did a quantitative study of this issues. (I heard Dr. Baron interviewed on “Sound Medicine,” a podcast produced by the Indiana University School of Medicine. Check it out on the Web here: Dr. Baron’s results, conclusions, and the actions his practice (Greenhouse Internists) has taken based on those results are pretty amazing.

Dr. Baron’s study was quite simple actually, and relied on data the practice had already gathered and stored in its electronic health record. This electronic health record, which the practice adopted in 2004, is used “exclusively to store, retrieve, and manage clinical information,” as Dr. Baron writes in his paper, which was published in The New England Journal of Medicine (April 29, 2010). Physicians and other clinicians can enter clinical information into different categories such as “office visit,” “phone note,” “lab report,” and “imaging.” Dr. Baron and his colleagues then studied the volume (and corresponding categories) of their 2008 records. For more detailed content analysis, they looked at one week’s worth of phone calls and e-mails.

Below, I have reproduced a chart from Dr. Baron’s study. Note that the only work the physicians are paid for is the patient visit. From this chart, you get an idea of how much work–and how much time–goes into doing things that insurance companies don’t consider to be billable.

Dr. Richard Baron’s Study Results
Type of Service Total Number (2008) No. Per Physician Per Day
Visit 16,640 18.1
Telephone call 21,796 23.7
Prescription refill 11,145 12.1
E-mail message 15,499 16.8
Laboratory report 17,974 19.5
Imaging report 10,229 11.1
Consultation report 12,822 13.9

Dr. Baron already knew that the physicians in his practice (as well as other primary care physicians) were doing “unpaid” work. This detailed look at his practice’s records shows just how much.

These results, while more reinforcement and quantification than new evidence on this topic, still do highlight the need for a redesign of the primary care payment system. This is Dr. Baron’s opinion; it is also mine. It is, as Spock would say, “only logical.”

But what might those changes be? That is the million dollar question. It is one that the politicians, lobbyists, insurance companies, physicians, and other interest groups must pound out. And sooner rather than later, preferably.

In the meantime, Dr. Baron has made some changes in his own practice as a result of his research. First, Dr. Baron and his colleagues took a hard look at the “administrative” work (the phone calls, e-mails, looking at lab reports, etc.) that the physicians were doing. While doing much of it required an M.D., some of it could be done by a registered nurse or other (less expensive) clinician. So hiring more nurses, in many situations, is one way to cut costs and therefore boost salaries.

Another change Dr. Baron and his colleagues made was to their “productivity formula.”Greenhouse Internists, like many other practices, uses a combination of base pay and productivity to determine their physicians’ total salaries. What Dr. Baron and the others quickly realized was that their formula–which calulcated productivity based on the number of patients seen–simply mimicked the same payment system they were claiming was so unjust and arcane. Their response? Include that administrative work–the calls, the e-mails, etc.–in their own productivity formula. So while insurance companies might not reimburse a doctor for refilling a prescription, Greenhouse Internists does, in fact, consider such a duty to be “work.” And so it pays its staff physicians accordingly.

These changes do not make up for the payscale differential or the disparity in billable procedures between primary care and the “procedure” specialties, but they are a step in the right direction. Policy makers would do well to read Dr. Baron’s paper and take a look at how his practice is handling these issues. They might learn something. (God forbid.)