The primary care pay system makes no sense. I get paid between $40-$70 from a dozen+ different insurance companies for a level three established office visit for the same work and care on various patients. Most fees are based on a percentage of Medicare, with the average fee around $53 for 2009, meaning Medicare is one of the better payers. I can see 4-6 patients established patients an hour. Each insurance company duplicates the same care to the patients for an average copay of $25, not including deductibles. Most of the care in the outpatient setting is lower risk than the inpatient setting. I can go to my local two hospitals and see 2-6 patients a day and get paid what averages $50 a day per patient for care the often involves life and death decsions, talking to family members and nurses after hours, and being available for inpaitent quesionts in the middle of the night for that $50. Shouldn’t inpatient care be paid higher for all the extra time spent caring for the patinet? On the other side, what about all the free time I spend preauthorizing prescriptions, MRIs/CTs, FMLA papers, patient phone calls, The primary care pay system makes no sense. I get paid between $40-$70 per visit from a dozen+ different insurance companies for a level three established office visit for the same work and care on various patients. Most fees are based on a percentage of Medicare, with the average fee around $53 for 2009, meaning Medicare is one of the better payers. I can see 4-5 patients established patients an hour. Each insurance company duplicates the same care to the patients for an average copay of $25, not including deductibles. Most of the care in the outpatient setting is lower risk than the inpatient setting.

I can go to my local two hospitals and see 2-6 patients a day and get paid what averages $50 a day per patient for care that often involves life and death decisions, talking to family members and nurses after hours, and being available for inpatient questions in the middle of the night for that $50. Shouldn’t inpatient care be paid higher for all the extra time spent caring for the patient?

On the outpatient side, what about all the free time I spend preauthorizing prescriptions, MRIs/CTs, FMLA papers, patient phone calls, refill requests, and other hours of daily paperwork?

At my local hospitals, specialists walk on water. They negotiate like professional athletes package deals for malpractice insurance discounts and guaranteed salaries support in exchange for keeping privileges at just one of my local two hospitals. Primary care salaries are between $140,000-$225,000 for FPs and internists in my area. Most local specialists are making between $350,000 and $700,000. The hospitals value the specialists, as the procedures and surgeries bring millions to the hospitals, yet most patients required a primary care for routine care, referrals, and admissions. The primary care doctors are getting the short end of the stick, while the specialty salaries keep increasing.
refill requests, and other hours of daily paperwork? The hospitals value the specialists, as the procedures and surgeries bring millions to the hospitals, yet most patients required a primary care for routine care, referrals, and admissions. The primary care doctors are getting the short end of the stick, while the specialty saleries keep increasing to 3-4 times what a typical primary care doctor makes for no additional time or effort.

Dear Ranter (I am one, also):

I am an internist trained in Canada. I was a WK Kellogg Fellow at the HSPH from 1981-83. I got interested in the issue of medical student debt, cognitive based vs. proceduralist medicine, work force policy, and universal health insurance over twenty seven years ago.

I have a win win proposal as a first step in payment reform that does not set proceduralist against cognitive physician. If you think these things through it is possible. It is even obvious and common sense to anyone who spent time abroad.

We have over the last three decades damaged our think tank structure so what is really obvious is not obvious to us. The most recent monograph on medical workforce policy in the USA was written by Professor Rashi Fein of Harvard over thirty years ago.

I am willing to discuss this offline or via telephone, etc. I would love to work with the ACP on this and I have tried to talk to their offices in DC. But they do not understand.

I have worked thirteen years in an inner city community health center for thirteen years. Now, may be the time for health care reform.

Bohdan A. Oryshkevich, MD, MPH
New York City
bao23@columbia.edu
bohdan_oryshkevich@post.harvard.edu
1-212-785-4170 (h)

You can also google me and find out that I do have some really practical experience in financing education. I have put 46 students from another country through college. Four years all expenses paid. We have a whole team of biomedical experts emerging also.

I am not writing of a bigger pie to improve the status or payment of primary care physicians.

One has to look at physician income over a lifetime. Professional income begins even before medical school with the decisions an individual makes to attend medical school. The medical school application process comes to several thousand dollars. Medical education like the rest of medicine has been monetarized. That is inflationary and impacts physicians negatively.

Second physician income is not the most inflationary aspect of health care. It is what the doctor orders that is so expensive. In order to implement change one has to look at all the expenses and not just demonize those done by proceduralists.

You have to factor in the negative income over the first eight or ten years of medical education from senior year in college to the end of residency. That hole is big for everyone – primary care doctors, secondary specialty physicians, and proceduralists. That hole is also extremely expensive to society.

The negative income of medical school and training impacts primary care and cognitive physicians much more drastically than future proceduralists. But it affects all physicians. The training of skilled surgeons is longer. So physician reimbursement of technically oriented physicians will always be higher. Maybe not as high.

Physician payment reform is clearly necessary but everyone must realize that it deals only with what takes place after medical school and residency after the big hole is dug and after doctors are in their professional roles. By that time, the divisions within medicine are set. Payment reform will only correct some of the distortions.

Physician payment reform is thus only partial reform. It does not reform the big hole in income in the early phase of the career. If one does the math, early income or early debt has a much greater influence on a career than later debt. If one does the math it is much less expensive to correct the distortions created by the huge hole in income that affects all physicians in the early phases of their career.

Physicians who are looking for payment reform must look at all the parties in the health care system and understand where all the distortions lie. It is not just in the area of high fees for technology procedures by physicians and low fees for cognitive services by physicians. So there are plenty of WAYS to move the money around and plenty of PLACES to move the money around from before one even gets to money transfers from proceduralists to primary care. Proceduralists are not the enemies of cognitive physicians.

Transfers of funds within medicine to reform it should be budget neutral wherever possible. We spend too much money on health care and health care reform must take into account budget control and even global budgeting. If we are forced to spend less we will have more disciplined and better care.

We have developed a whole range of sacred cows that we feel inviolable. When in fact, that is what we need to change. Who are our sacred cows?

More on that later.

Bohdan A. Oryshkevich, MD, MPH
New York City
bao23@columbia.edu
bohdan_oryshkevich@post.harvard.edu
1-212-785-4170 (h)