An answer to equilibrate incomes is to keep procedures and diagnostics in-house, that is the primary care house, as much as as reasonably would allow. I’m not saying that primary care docs need to do brain surgery, heart surgery, and read CT scans, but there is plenty of basic procedures and tests that have been traditionally in the hands of specialists that do not need to be referred out. For the most part, when a primary care consult a specialist, it should be for a COGNITIVE opinion and a knowledge base that is deeper, not for a procedure or test that be done just as easily in the primary care one-stop-office.

1. No more than 1.75 times what cognitive specialists make (ballpark). This will more than compensate for the extra years of training over a normal-length surgical career, even if you apply an aggressive discount rate.

2. If you go over, it will come out of the pockets of other procedurists and imagers. This is because procedures and imaging services should be under an SGR cap that is separated from the cognitive payment pool. Fine with me to let you good folks fight it out. You’re all rich, so I won’t lose any sleep over who gets the extra beemers. (hint: you may notice there’s no need for a personal cap, but I somehow doubt your procedural bretheren will let you take the whole pot)

3. There’s no need for number of residency slots to be unadjustable. But we do need a rational physician laborforce policy, and the number of slots reflects some notion of how many physicians we need in each specialty. Again, based on well-regarded Dartmouth/Starfield/international comparisons research, the number of primary care slots should probably increase relative to non-primary care in order to optimize health outcomes and lower overall costs. After all, we know procedurists and imagers drive their own volume.

4. The same place we do in primary care: international medical graduates.

Income caps were tried in Canada. Generally, what happened is that physicians hit their caps, then stopped working for the remainder of the year.

As for driving down incomes till residency slots are open, this assumes that the number of residency slots is just right, and will be forever. As for my “replacements,” if you’ve just eliminated them by driving them out of ortho residency slots, who are they going to be?

Until we see unfilled residency slots, access threats ring hollow. You’ll work for less, and if not, your replacements surely will. Even with a, say, 50% decrease in your net incomes, orthopedists will stilll make a positive ROI on their specialization decision (vs. general internal medicine). The magnitude of the disparity is just that great.

Since orthopaedic surgeons are an apparent target of your ire, let me inform you that hip and knee replacement, well documented as providing high value in terms of QALY, as well as risk/benefit, has seen reimbursement drop 40% since 1991. This is in real dollars, and does not take inflation or increased costs of practice into account. Since the number of joint replacements is projected to increase six-fold in the next 25 years, this is going to be a problem for access and care.

Rather than gratuitously insulting and alienating your colleagues, you may want to inform yourself first. If you persist in trying to carve a bigger slice of an ever smaller pie for yourself, as opposed to working together, you will be doomed to failure.

My solution? The government should subsidize comprehensive care docs. In much the same way that hospitals subsidize hospitalists. Outpatient comprehensive care doctors need a friend. If we want to value comprehensive care, we have to pay for it. It really is that simple. If you want a system based on a 70/30 mix of generalists/specialists, you must convince the mass of medical students to become generalist. That means getting the headaches out of the equation and making it a financially viable model. You do this by taking the business of insurance out of the business of comprehensive care. And you subsidize the whole thing as a matter of national security.

A market based approach to high quality low cost federally subsidized comprehensive care. I call it my Primary Care Initiative. An experiment that would pay for itself many times over in decreased front end and back end costs.

My 125 Billion Dollar Experiment

You take the generalists out of Medicare Part B that is responsible for their death. You give every single man woman and child a $360 tax credit to be used toward generalists physicians however they chose. I envision a monthly subsidized stipend to all comprehensive care docs, paid for by patients’ $360 tax credit. For less than the price of cable TV. Then, you you make everyone pay cash for their comprehensive care encounters. There is no reason that insurance should cover generalist encounters. It is a cost of living.

So how does it work?

No insurance. No claims. Just a doctors office and his nursing staff. And a cash register. Lets imagine a family doc in Kansas with a 1000 panel patient load(That would require 350,000 generalists in our country). That’s probably 1/4 the size of the current overloaded panel he is forced to see to keep up his revenue stream.

Under my plan, the patients would get $360 a year in a dollar for dollar tax credit to be used toward comprehensive care encounters. At 350 million people, that’s $125 billion dollars. But remember, since comprehensive care has left Medicare part B, the funding partially pays for itself. No more billing Medicare Part B by comprehensive care docs. What I foresee is a doctor in Kansas charging $30/month retainer fee. That’s $360 a year. It costs the patient nothing to retain a comprehensive care physician because their tax credit pays for it.

For an internist in Kansas, that’s $360,000 a year in revenue just for existing and having a 1000 patient panel. Now, how does the system benefit? Imagine for a moment that the internist works 46 weeks a year. 40 hours a week of direct patient care. That’s 1,840 hours of patient care, or 110,000 minutes a year in direct patient care. Now, that would allow every patient in the 1,000 patient panel to have four visits a year at 27.6 minutes per encounter.

Imagine for a moment what could be accomplished in a 27 minute encounter. Far more than the cursory exam and referral that happens in the current volume mills of comprehensive care.

Imagine if the internist charged just $25 per encounter. The total fee for a visit. That’s 4000 encounters a year * $25 or $100,000 a year in cash fees for his patients. That brings the grand total to $460,000 a year in revenue for a 1000 patient panel.

That’s a viable model of comprehensive care. Overhead would plummet by 20%, perhaps 30%, allowing a gnet gain of $100,000 or more from current payment models under Medicare Part B.
You wan’t a one hour visit? You pay $50. You want a 10 minute visit? Perhaps $15. It’s amazing what can happen if you allow the market to create competition amongst doctors, with the government subsidizing cheap affordable comprehensive care doctors for every man, woman and child.

The savings realized by Part A would pay for itself. I don’t have any doubt about that. I don’t need a study to convince me that allowing comprehensive care doctors to spend more time with their patients would save money from Medicare Part A. And with comprehensive care doctors out of the Part B insurance industry, their overhead plummets and they enjoy a markedly improved practice environment to the benefit of patient, doctor and government expense.

If you want to save money, you will have to spend money. And that means spending money on generalists, the docs who have the greatest ability to control costs. It is not a mystery. But it will take new ways of thinking about it.

Get the comprehensive care doctors out of the RVU mess that is controlled by specialy societies. Let them practice subsidized care for the masses, making their access cheap and affordable to most, while strengthening the reward for entering the field.

Let the specialists battle out their procedures with third party payors.

It really can be that simple

If an NP puts me out of business (and please tell me about all the NP’s you know that see 20-25 patients in the office, admit from the ER and round on ICU and floor patients 7 days per week) why would I care at all about you and how little you might be making?

I don’t believe that all specialist deserve a pay cut. I think general surgeons who come in in the middle of the night to do emergency surgery should get paid way more than they currently get. But radiologists working 9-5 Monday through Friday making $400 K could take a 50% pay cut (or have the work sent to India) and I won’t be shedding a tear. I could go on but you get the point.