The economic divide between specialists and general practitioners is real, but physicians don't take out their financial angst on each other. Insurance plans and government payers get the blame for ratcheting down reimbursement. Still, salary considerations are changing who practices what, as medical students move away from primary care.

Despite the essential value of both specialists and generalists in healthcare delivery, specialist salaries are undeniably higher and probably always will be. But antagonism between the have-nots and the haves has waned lately, as changes in the economic structure of healthcare have hammered all doctors' incomes.

Indeed, the ill will these days is more unified--and more directly aimed at the insurance companies and government payers that use ratcheting down physician reimbursement as a key way to contain costs.

Kristin Santangelo, MD, is a urologist in Oxnard--and she's a good example of the sort of income detente that seems to exist between those near the top of the wage scale and those closer to the bottom. "Obviously, income depends a lot on overhead," she explains. "Being a specialist, I have a lot of equipment in my office and I do a lot of procedures there. But the general practitioners and primary care physicians spend a lot of time with patients, looking over a lot of stuff and managing a lot of medical problems. If you do things that are more specialized, like taking patients to the operating room, you need to be compensated for that. On the other hand, are PCPs making enough money? Probably not."

Lytton Smith, MD, a family practitioner in Yorba Linda, remembers when income-based hostility was much more of an issue than it is now. "In my community 10 years ago," he reports, "there was a cardiovascular surgeon making multiple millions a year, compared with PCPs, who were making in the $140,000-to-$150,000 range. Certainly, we respected the capability, tenacity and the work ethic of that particular surgeon, but we could never understand that degree of income difference. The extreme differential could never be justified in the minds of PCPs."

Day to day, however, interspecialty relations are pretty good, Dr. Smith says. "Most PCPs have good working relationships in their communities with surgeons and other doctors they refer to," he says. "In the aggregate, there may be some PCP angst about other doctors making too much money. But in our individual communities, we generally don't worry about the details."

That's right, Dr. Santangelo concurs. "I don't hear a lot of griping about the differences in pay," she reports. "I hear a generalized gripe about more work for less pay."

Physicians are somewhat resigned to the fiscal realities of modern medicine. "How we feel about reimbursement doesn't make a bit of difference," says Tim Pietro, MD, a urologist in Riverside. "We can argue until we're blue in the face. So most of us commiserate on the fact that it's not so much how big our piece of the pie is, it's the size of the pie--and it's shrinking. That's the problem.

"My income--not in inflation-adjusted dollars, just straight dollars--is less than it was in 1992," Dr. Pietro continues. "I know how the older doctors respond to that. We just work harder to keep our income up. Most of the younger doctors say, 'We don't want to do that.' Their whole philosophical approach is different. Maybe they go in with lower economic expectations."

Will Economic Expectations Drive the Future?
Economic expectations have begun to reshape medicine, as new entrants into the field are keenly aware of doctors' differing salaries and choosing their paths accordingly.

It certainly wasn't always that way. "Thinking back to when my fellow students and I were making specialty decisions, future income was not the major driving force behind them. Most people decided what they wanted to do based on what they liked doing," Dr. Santangelo says.

Dr. Pietro recalls that when he made his specialty decision some 20 years ago, he did it based on what would make him the happiest, what he was most interested in and what he felt he was best at. "I had no clue what paid the most," he says. "And at the time, I believe most folks were like me. We felt that medicine would provide a good living--and it didn't matter whether it was on the lower end of a good-paying job or the higher end."

Is that the case now? "I suspect not," Dr. Pietro says. "There is more knowledge by some of the younger doctors of the economics." Indeed, he adds, "if I were to advise someone younger trying to make a decision, I'd tell him or her to pay attention to that."

It seems medical students are already paying attention. "There is a trend of fewer and fewer medical students going into primary care," says Clayton Patchett, MD, an orthopedic surgeon in Pasadena and president of the Los Angeles County Medical Association.

Students are making the simple choice of enduring more schooling so they can make more in practice, Dr. Patchett says. "PCPs can make $150,000 or take a specialty course in gastroenterology for just two more years and make $250,000 to $300,000. Everyone's going to want to do that. In fact, studies show that the primary care programs are not getting filled and 60 percent of the people in them don't intend to practice it."

Dr. Smith says the prognosis for PCPs isn't good. "An emerging critical issue in medical training is young physicians' awareness of the economic disparity," he says. "And unless it's addressed, the sickest patients, those requiring the most analysis of medical therapies on an outpatient basis, will be treated by the least-qualified physicians. The high-profile, high-income specialties provide a small portion of the medical care given to patients, but economic factors are driving the top students into those fields. The fields where the medical care rubber meets the road--geriatric and internal medicine--will get only the lower-rated physicians. We'll have an upside-down medical care system."

Dr. Patchett puts the primary-care predicament another way. "I advise my colleagues to shake PCPs' hands and pat them on the back because they may not be around very much longer," he says. "The main reason is that the primary care model doesn't work economically. On top of that, the PCPs I know aren't having a good time." Part of the problem, he says, is all the extra work PCPs have to do--the cholesterol checks and the blood pressure tests and the phone calls--to get the lowest reimbursement.

Perhaps one solution would be to change the medical education system, Dr. Patchett suggests. He says there is an abundance of specialists. "We should cut back on the number of specialty care physicians," he says. "If somebody falls down on the sidewalk, there's an orthopedic surgeon there right away, presenting a business card."

Can the System Ever Be Fair?
The financial imbalance among the various practitioners raises tough questions without easy answers. No one is suggesting that pay be uniform across the specialties, just that pay reflect accurately what's involved.
 
Danielle Onstot, MD, is a pediatrician-a specialist, but one near the bottom of the pay scale. The Oxnard-based physician feels that what doctors do should drive what they're paid. "Some specialists respond to life-threatening situations at a moment's notice-draining blood in a patient with an intracranial hemorrhage or delivering a baby," she says. "They should be adequately compensated. Other specialists don't get called into the hospital very often. But when we do--for a trauma, say--we don't get paid any more for the inconvenience of getting up and driving to the hospital in the middle of the night."

Further, the pay differential between doing procedures and providing counseling irks Dr. Onstot. "I don't believe that quick procedures, such as reducing a subluxed radial head, should pay better than taking the time to counsel an adolescent at a well-child visit about sex, drugs, alcohol or date rape."

As chairman of the 105-provider, multispecialty Riverside Medical Group, Steven Larson, MD, sees the big picture and hears all sides. "For the most part, income is equitable for the training and risk involved in specialty work. And most doctors feel that way. I've been in management for 20 years and what I've learned is every doctor thinks he or she should make more money--and I agree. But we have realities we have to live with. The market sets income levels and we have to meet or exceed them to get the best people."

Changing financial realities may be impacting the very perception of medicine as a lucrative field, Dr. Santangelo concludes. "To be honest," she says, "most people looking at their lives these days and saying, 'I want to make a lot of money,' aren't going into medicine in the first place."
 

 

FEATURE STORY SIDEBARS

Economic Advocacy: CMA Takes Action
The California Medical Association feels primary care physicians' pain. And it has launched a variety of programs designed to secure better reimbursement for PCPs and, at the same time, improve the financial viability of their practices.

"We're very concerned that, generally, physicians are underpaid," says Nileen Verbeten, vice president of the CMA's Sacramento-based Center for Economic Services. "Many of the abusive behaviors and heavy-handed tactics that the health plans have been using have driven payment rates to extremely low levels for all physicians-and probably harmed more than any are the PCPs."

In addition to legislative efforts to stop reimbursement cuts, here are other ways the CMA provides economic advocacy:

1) "Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiation" is a free toolkit for members to coach them on how to think about and engage in contract negotiations, including when to walk away.

2) Ongoing advocacy in workers' compensation led to establishment of a reimbursement floor. "[It's the point] at which no codes can be reduced any further," Verbeten says. "That has protected some of the most inadequately paid from further harm."

The problem, she notes, is policymakers see physician income as a zero-sum game. If PCPs want more, they reason, specialists must make less. And the CMA, she emphasizes, "is not going to sacrifice one member for another." The payment floor "is not as big a solution as we'd have liked, but it was one we were able to achieve."

3) A comprehensive private practice cost survey is available for purchase. "It helps practices compare their costs with similar practices to get a better handle on their expenses," Verbeten says.

4) Revenue-improvement software company athenahealth has partnered with the CMA, Verbeten says. "We pushed the company very hard to make some price changes that will be attractive to the smallest physician practices."

The offering Verbeten is proudest of isn't quite off the ground yet. The CMA is developing an "Extreme Makeover"-style service for small-group and solo practices in primary care. "We've been funded by a grant from the Physicians Foundation for Health Systems Excellence, which was created by the RICO lawsuit settlement with Aetna," she says. "We'll bring a small number of volunteer practices together with organizational design and subject matter experts to look at the business drivers in a practice--and at how to redesign the way the practice works."

The experts won't address clinical operations. "We want to make the business side of the office much more efficient and much less of a distraction to the physician." When the project is completed, the CMA will make the results, toolkits and templates broadly available.

Call Verbeten for details on any of the above at 916/551-2068.


Salary Compromises: Making Less, Living More
A generation ago, many doctors may have focused on maximizing their incomes. Now, today's physicians weigh the size of their income against the lifestyle restrictions of earning it. More and more doctors are willing to make less to live more.

Chris Warner, of Panther Enterprises Physician Recruiting & Placement, sees the trend in his recruiting work. "Lifestyle is a very strong consideration, absolutely," he says. "It's an especially big factor with younger physicians with children. They're often willing to give up as much as 25 percent of expected income."

There are limits, of course, and the higher-paid doctors are better able to make salary concessions. A cardiologist can shave $100,000 off a salary offer of $400,000 and not feel too much of a pinch. An internist in the $150,000-a-year range obviously can't do the same.

Oxnard-based urologist Kristin Santangelo, MD, emphasizes that lifestyle factors don't just impact female physicians' decisions. "I definitely see it with my generation. Lifestyle is important. People will take less money to maintain their lifestyle these days."

Indeed, lifestyle considerations drive some physicians into less-stressful--and lower-paying--professions in the first place. Oxnard pediatrician Danielle Onstot, MD, made that call when she started her career. "Lifestyle is an important factor to consider in addition to pay," she says. "Working 120-plus hours a week is hard on family life and may not be worth the money for some physicians. It's also important to enjoy what you do. As a pediatrician, I'm on the bottom of the totem pole with regard to pay, but I love what I do."


Recruiting Trends: Supply and Demand Applies
Medicine is a business, which is why the law of supply and demand applies to physicians' incomes. Because of demand, orthopedic surgeons, radiologists and dermatologists are in the proverbial driver's seat when it comes to salary negotiations, according to recruiter Tracy Zweig of Tracy Zweig & Associates in Ventura.

Chris Warner, of Panther Enterprises Physician Recruiting & Placement, concurs. "The specialties in demand will see their incomes rise the fastest," he reports, "and they are orthopedic surgery, cardiology, dermatology and gastroenterology." Less in demand are pediatrics, anesthesiology, emergency medicine and pathology.

Reimbursement levels impact the supply of doctors in some fields, Warner says. "Diabetes is exploding, but endocrinologists are reimbursed so poorly that people aren't going into the field."

Hospitalists are one emerging group of specialists in increasing demand, Warner says. "The reimbursement is good compared with traditional general medicine," he reports, "and there's no call and the hours are predictable."