So, if primary care doctors earn more (encouraging more medical students go into primary care to fill the gap), and the specialists still get paid a lot to do procedures that may or may not be helpful to patients' health, then were does the savings come from?A recent editorial by AMA Board of Trustees Chair Joseph Heyman, M.D., has led AAFP President Ted Epperly, M.D., of Boise, Idaho, to emphasize the importance of the AMA working with primary care physicians to ensure they are fairly and adequately paid for the services they provide to patients with Medicare coverage.Heyman's editorial, which was posted Jan. 26 to American Medical News online and published in the Feb. 2 print version of the publication, urges payment increases for primary care physicians, but he emphasizes that the AMA would not support such increases if it means there would be corresponding reductions in subspecialists' payments.
"Payments to primary care physicians must increase," said Heyman, an OB-Gyn. However, he added, the AMA "absolutely opposes applying budget-neutrality rules that confine offsets to the physician payment pool."
"Congress should not rob Dr. Peter, the surgeon, to pay Dr. Paul, the primary care physician," said Heyman.
We know that a good primary care system saves money by decreasing complications of chronic disease, so there's an argument to be made there, but I think we should act less like children fighting over who gets more M&Ms (or BMWs), and frame the debate around questions that matter.
Doctors should get paid for delivering care that works. The payment system we have rewards procedures and discourages talking to patients. Not everyone needs a colonoscopy to look for colon cancer (very few people do, actually), but we put a lot of cameras into a lot of bottoms for a lot of money when a $10 screening study you can do at home is equally effective at preventing colon cancer mortality.
As the Dartmouth Atlas of Health Care points out, where there are specialists, there are is more specialty care. Live in a town with lots of gastroenterologists? Predict lots of colonoscopies. It has nothing to do with evidence or effectiveness. Doctors have to pay the bills like everyone else, so you do what you're trained to do and bill accordingly.
I agree that physicians should be paid fairly for the work they do, procedure or not. But we should only be paid for care that works (i.e. has a measurably positive effect in patients' lives). Elective colonoscopy for colon cancer screening? Medicare shouldn't pay for that (or should pay $10, which is what it costs to screen for colon cancer). Eventually the payments to specialists would be driven down using good outcomes-oriented science, fewer medical students choose lucrative lifestyle specialities.
Reframe the debate around what matters, what works, instead of bickering about cost neutrality. Health care costs too much. Some of us have to get less in order to make it work. And we'll all do just fine. Maybe our patients will, too.
