Kaiser Health News reports that compensation is key to fixing the primary care shortage. The article goes on to say that there are many reasons for the shortage of primary care physicians, but one is inescapable: compensation. Here is a profound quote from the KHN article:
The areas of medicine that comprise primary care include family medicine, internal medicine, OB/GYN and pediatrics. Compensation for primary care providers averages from about $250,000 to $275,000 a year. I have read posts on Twitter by hospital employed physicians who faced starting salaries of just over $130,000. What sounds like good money to many people may not be to someone facing $200,000 in student loans. The website, Medscape, publishes an annual physician compensation report. The bottom line: many specialties earn nearly twice as much as primary care physicians, while some specialties make more than double. That’s a major difference.
Besides lower compensation KHN lists heavier workload for primary care that drives more medical students into specialties. Here is something the article alluded to but did not address directly: respect. Primary care providers just do not enjoy the amount of respect among their peers as specialists. It’s also the respect that comes from being among the elite physicians and surgeons who have the advanced skills to treat heart disease, oncology, orthopedics, even dermatology. Dermatology is among the most sought-after specialties because it pays well, and dermatologists enjoy work/life balance. Aspiring physicians are encouraged to specialize early in their medical education.
A specialist who performs surgery, implants hip replacements, and performs procedures gets paid by the procedure. By contrast, primary care physicians use a complex list of codes to bill for numerous tasks, but they perform a lot of tasks they don’t get paid for. There are numerus items that primary care physicians do that are minor things but add up.
The current fee-for-service system doesn’t fully accommodate the time and effort primary care physicians put into “small-ticket” activities like emails and phone calls, reviews of lab results, and consultation reports. A better arrangement, they say, would be to pay primary care physicians a set monthly amount per patient to provide all their care, a system called capitation.
Capitation is commonly used by managed care organizations, where primary care physicians are sometimes paid an amount for each patient under their care. Participating physicians often face the risk that some patients may need more care than is paid for, while other patients may need nothing. A direct primary care (DPC) provider is paid a monthly fee by members who want to be members of a practice that provides more individualized care. However, it’s not clear to me who would be willing to pay monthly fees to a managed care physician with a patient roster of 3,000 patients, compared to a DPC physician with a roster of only 300.
The article seemingly ignores the thousands of medical school graduates who fail to match to a residency each year. Many of the graduates rejected by residency programs would jump at the chance to practice primary care but are never given the opportunity. Residency slots were mostly frozen at 1996 levels in 1997. The supply of residency training positions is less than the demand. In addition, there are so-called midlevel medical professionals (nurse practitioners and physician assistants) whose professional associations petition state legislatures to expand their scope of practice, while physician medical societies lobby against them. If medical school graduates increasingly don’t want to practice primary care, there are plenty of medical professionals who would but are denied the opportunity.
Lower pay is just one reason for the shortage of primary care providers. There are other reasons as well. Congress and state legislators could do a lot to remedy the primary care shortage. Start by expanding primary care residency programs and expand scope of practice for midlevel medical professionals.
Read the article at KHN: Compensation Is Key to Fixing Primary Care Shortage