Disparity in pay divides doctors

Recently, a medical student confided in me a thought that few in our profession would dare say aloud: “We may have come to medical school to help people, but we choose our specialty careers based on potential salaries.”

This in part explains why the most-prized residencies are in fields such as dermatology and radiology, whose procedures generate high fees. According to a physician survey by the Medical Group Management Association, the median income of specialists is nearly twice that of primary-care physicians — $384,000 vs. $212,000. The highest-paid gastroenterologists make about $846,000 a year; the highest-paid internists make about $352,000.

As in most professions, it has long been true in medicine that specialists earn more than generalists. They train longer and in many cases pay higher insurance rates, but these factors don’t fully explain the chasm. We’ve now reached a critical point where the income disparity is harming the general population.
(Full disclosure: I am an infectious-disease doctor and make somewhere between the median income of a primary-care doctor and a specialist.)
It is, for example, a major cause of the dearth of primary-care doctors in the United States. The Association of American Medical Colleges estimates that by 2020 the shortage of primary-care doctors will reach more than 45,000 — that’s about 5 percent of the 851,300 physicians of all types that will be needed by then, or about 10 percent of the needed primary-care physicians.
The scarcity of primary-care doctors is leading many patients to forgo essential medical care or delay it to their detriment. I believe it’s time to intervene.
It’s not the market
Many of my colleagues may criticize efforts to level the playing field as “spreading the wealth” or “socialized medicine,” but I disagree. Physician payments are not determined by market forces or patient demand for a particular specialty. They’re driven by Medicare, Medicaid and private insurance. A 2008 study, for example, found that physicians in the highest- and the lowest-paid specialties (hematology/oncology and geriatrics, respectively), earned more than 50 percent of their outpatient income from government sources.
Moreover, in most cases, Medicare sets a payment amount, like a yardstick, for a procedure or a visit, and Medicaid and private insurers pay doctors a larger or smaller percentage of that fee. As a rule, Medicare pays physicians more for procedures — inserting scopes and cutting into the body — than for cognitive services such as diagnosing, coordinating and counseling. In fact, the widest income gap exists not between primary-care physicians and specialists but between proceduralists such as radiologists and opthalmologists and non-proceduralists such as endocrinologists and psychiatrists.
Medicare, for example, pays an ophthalmologist nearly $600 for cataract surgery and the insertion of an artificial lens. (As a medical school colleague once told me: The best job in medicine may be an ophthalmologist in Florida.) Medicare pays a gastroenterologist about $200 for a screening colonoscopy. These procedures take about 20 minutes or less.