Why Your Doctor Needs a Raise
Several months ago, I tried to get an appointment with a primary care doctor—any primary care doctor. I didn’t have a go-to M.D. already, but what I did have were the sorts of connections that I figured might make things easier: I’m a medical reporter for a national magazine, and my husband is training as a surgeon at a Boston hospital. I thought I’d find someone decent with a few quick phone calls. Instead, I spent a lot of time listening to hold music while waiting to be told that no one could see me, save for a handful of young residents—and if I wanted one of them, I’d have to wait four months.
It’s been just over a year since Massachusetts made health insurance mandatory. The goal was laudable: Improve healthcare by ensuring that everyone has access to it. Almost 350,000 newly insured patients entered the system, many of them seeking out primary care for the first time. And that’s great news, except for the fact that the flood of new patients has exacerbated a problem that those of us who’ve had insurance have been painfully aware of—there aren’t enough doctors. Though the state may have the nation’s highest doctor-to-patient ratio, the Massachusetts Medical Society (MMS) has for the past several years issued reports warning that patient demand is outstripping physician supply, especially in primary care, or so-called family medicine. Last year’s was the grimmest yet. According to the MMS, in 2007 just 42 percent of patients were able to get an appointment with their primary care doc in the space of a week (down from 53 percent a year earlier). Those patients who didn’t already have regular doctors had it much harder. The average wait time for them was 52 days, and that was assuming they could find doctors who were willing to take them on at all: Half the primary care doctors surveyed weren’t accepting new patients.
What’s ailing primary care—and consequently patients—is mostly a matter of money. Increasingly, medical school graduates choose hyperspecialized, high-paying fields such as invasive cardiology rather than become generalists, the more humble docs who do your annual checkup. The latter work has become labor non gratis, a thankless job, with too many responsibilities and not enough compensation. That’s especially true in Greater Boston, where the opportunities to work in flashier areas of medicine are plentiful. In a recent piece in the Journal of General Internal Medicine, Dr. Allan Goroll, who cofounded the primary care residency program at Massachusetts General Hospital, summed up the sorry state of the discipline. Primary care is “on the brink of crisis,” he wrote. “Practicing primary care physicians are demoralized, retiring early, and advising others not to go into the field.”
After years of systemic indifference, the plight of the beleaguered generalist is finally affecting patients. And that has some policy experts and doctors uniting around a radical yet simple fix: paying primary care M.D.s much more. That way, they reason, medical students lured by the prospect of higher salaries would seek out the field, easing the shortage of doctors while also lowering long-term healthcare costs by providing more patients with regular checkups. When more people stay healthier, we see fewer costly medical crises and fewer emergency room visits. The idea is a market-based solution—something all too rare in healthcare reform—and it would practically pay for itself (in theory), given its potential to slash costs by keeping people well.
Yet despite how much a primary-care salary boost sounds like a win-win proposal—creating happier doctors and happier patients—it’s already meeting resistance. Some specialists take umbrage at the idea, since it implies that they must be overpaid. Insurance companies say it’s difficult to get a handle on the work that primary care providers do, since much of it involves tough-to-measure old-school techniques like listening and talking. And everyone who dismisses the idea has another big objection: the potential cost. While the hope is that having more doctors could drive healthcare spending down, financial projections for this sort of thing are tough to pin down. For instance, the price tag for the Massachusetts insurance mandate is famously nearly $250 million more, and counting, than the state expected. Which raises a related question: How are we going to turn out our pockets to pay doctors what we should when they’re almost empty as it is?
The local primary care crisis runs counter to a national trend: Numbers of generalists per capita began rising in 1979, and grew by 26 percent between 1995 and 2005. The problem, for us, started when those new generalists decided where to build their practices. According to a 2004 study in the journal Health Affairs, a full 80 percent settled in places pretty well stocked with primary care docs.
Many newer generalists are foreign medical graduates recruited specifically to take the place of med students who are no longer interested in the field. (Across all disciplines, an astonishing one out of four doctors in the United States today did his or her training abroad.) Since 1997, the number of American med school graduates who pursue family medicine has dropped by half, meaning that what primary care doctors we have tend not to be educated here. Meanwhile, primary care residencies like the one at Beverly Hospital are shutting down, some for lack of interest among med students. Last year, Joseph Gravel, director of the Tufts University family medicine residency at Cambridge Health Alliance, watched three of his graduates drop out of the primary care track. Gravel was troubled, but he couldn’t blame them. “They told me, ‘Dr. Gravel, I hope you don’t feel like I’m a sellout,'” he says. “It’s an economically bad decision to stay in primary care.”
Across the country, the average salary for primary care providers has come up since 2004, but not much; it’s now somewhere between $160,000 and $175,000. That’s a decent wage for sure, but nothing compared to what young docs can make if they opt for specialized training, particularly in the fields that med students alternately refer to as “lifestyle specialties” and “the ROAD”— radiology, ophthalmology, anesthesiology, and dermatology—where salaries can top $400,000.
The disparity is felt even more keenly in urban areas like Boston, where the cost of living is high and salaries for primary care docs tend to be lower than the national average, at around $156,000. “If you have highly technical health problems, Boston is a wonderful place to get care,” says Gravel. “But primary care hasn’t been as valued in Boston as in other places. There’s been a pretty large lack of attention paid to things that aren’t glitzy—standard, basic stuff, like whether people are getting their Pap smears or hypertension treatments.”
Doctors’ salaries are determined largely by how much Medicare reimburses them for the work they do, a system that puts specialists at an advantage. A specialist’s job often consists of doing procedures, scans, and tests that are easily measured, and most of which can be done quickly these days, thanks to improvements in technology. But a generalist’s work is in some ways more complex. It requires extensively studying a patient’s history, calling nurses and family members, searching journals to figure out which ailment out of thousands could be in play, plus checking, updating, and managing a blizzard of paperwork. Medicare doesn’t pay doctors for any of that. The only reimbursement a primary care doc gets is for the time he or she spends sitting across from a patient, and even that time isn’t particularly well compensated: A half-hour visit in Boston brings in a little over $100 in Medicare payments, about a fourth of what some specialists get for the same amount of time. Private insurance doesn’t pay much better, and actually values specialists over generalists even more than Medicare policy does.
The process for setting these reimbursement rates is, not surprisingly, a bureaucratic nightmare, but the salient point is this: The doctors who sit on the committee that sets the rates are almost overwhelmingly specialists. Put it all together, and it’s a miracle primary care docs make any money at all.
Of course, none of this is the kind of thing that doctors, especially generalists, are supposed to gripe about, at least not in public. Compared with a lot of people, even the lowest-paid doctors don’t have very compelling financial complaints. After they’re done with their residencies, they make four times the salary of the average American worker. Besides, in the medical profession in general (to say nothing of Brahmin Boston in particular), it’s unseemly to be seen with your hand out. Instead, doctors are supposed to act in a noble spirit, as if they’re above monetary concerns. A doctor’s services are often treated as literally invaluable, as so important for the welfare of other human beings that they shouldn’t be associated with anything as tawdry as a price tag. But doctors are people. Like the rest of us, they do care about money, especially when they’re saddled with med school debt that can reach up to a quarter-million dollars.
Let’s assume state leaders come to agree that a pay increase is the only way to stock Boston with the primary care docs we need. How to put that into practice? The danger is that policymakers will do too little, too late. Though there are proposals on Beacon Hill to forgive med school debt if doctors become primary care providers in underserved areas, they are unlikely to make much of a dent. South Carolina, for instance, has tried a similar policy to increase its number of geriatricians. While commendable, this kind of effort has been “inadequate in both scope and consistency,” according to a report by the Institute of Medicine, a national think tank.
What if those specialist-dominated committees just raised reimbursement rates for primary care? Sounds like a simple solution. But it probably wouldn’t be an effective one. Two years ago, for example, the Centers for Medicare and Medicaid Services announced with great fanfare that it would seek to increase by 37 percent the reimbursement rate for the most common type of office visit that primary care docs handle. Alas, because of the labyrinthine way the policy was written, the increase actually worked out to about 5 percent by the time it hit doctors’ bottom lines.
Ultimately, what’s needed may be a wholesale makeover of how primary care is delivered and paid for. Goroll, the MGH doc, has helped design one such plan that’s garnering interest. Instead of reimbursing doctors per visit, it pays them a set amount per patient, shelling out more for those with serious health problems and less for the relatively healthy. Built into those payouts are the costs of running a practice: salaries for assistants, funding for efficient electronic record-keeping, and performance bonuses to ensure docs don’t get complacent. Meanwhile, the happier patients created by such a system would be more loyal (although they’d be free to change practices easily if they want to), getting all their care from a doctor with whom they have a steady relationship. It sounds like a dream—and for now, well, it still is. Goroll’s plan is in the testing phase; he’s raising money for a trial beginning in January to see if it will really work.
Goroll says he’s wary of the fact that his model will be “viewed as a giveaway to primary care physicians,” and admits that high costs will be a concern. But he’s got one thing working for him: the desperation of patients anxious for a solution to this mess. It’s a feeling I myself have become all too familiar with.