And not just residencies. Medicare and Medicaid systematically devalue the care provided by primary care providers by giving them lower reimbursement rates than specialists. This tends to lead to higher rates for provision of services for specialists in the general market. Improving compensation for primary care providers relative to that of specialists would improve the availability of good primary care physicians which would probably improve U.S. health outcomes more than churning out more dermatologists.
Yeah, and they are the gatekeepers to more specialized care, so they need to be good at diagnosing a vast range of conditions. I agree they seem to be currently underpaid as compared to many specialists.
Just curious - how much are they currently paid, and how much do folk believe they ought to be paid?
I have no real idea as to the first, and no firm opinion as to the latter.
The one young doctor I know has considerable med school debt, but as I understand it, if he works in certain settings for 10 years, his debt is forgiven. (He is a pathologist, about 6 years out of school, having worked at a teaching hospital and now at the VA.)
I think the point isn’t the exact dollar amount, but that the gap between primary care doctors and specialists should be reduced.
FTR, Weatherby’s annual physician survey indicates that the average US primary care doc makes $277,000 a year, while specialists average $394,000. But a few “specialties” like pediatrics and public health actually pay worse than primary care, while orthopedic and plastic surgeons make well over $500K.
A fundamental reason why the US will likely get health care cost efficiency to European levels is that the expectation in Europe is that medicine is considered a solid upper middle class occupation while in the US it has been considered upper class or even a 1%er occupation (particularly for specialists). Been that way for decades, not sure if it is reversible.
So, should the primaries be paid more, or the specialists less? There would be a lot of unpacking to make sense of those “averages,” but I’m not sure my PCP is underpaid if he earns $277k.
Also, what is involved in becoming a specialist? Can anyone who wants to become one? Or is there some winnowing out of the - for lack of a better term - more average doctors? I dunno - it doesn’t strike me as inherently wrong that the person I go to for an invasive procedure such as surgery gets paid somewhat more than the gatekeeper. What are the risks involved for a GP vs a specialist? The potential liability?
I recall a couple of decades back, playing golf at a private club w/ my kids’ orthodontist, who was a member. He observed how out-of-touch it was to think of club members as doctors and lawyers. Instead, the majority were “money” people. A sign of our twisted values.
No argument from me! I’ve always been of the opinion that most “routine” stuff can be managed by a primary care doctor, who is, after all, the one who is most likely to know all of your issues.
I’ve got a long list of doctors in my stable at the moment, which doesn’t thrill me. Some of them are “check in once or twice now then we’re done”. Others are “check in once a year and then see ya next year”. Some will be my friends for a long time, as they have skills a primary care doc wouldn’t (gastro, podiatry), or that a specialist could likely do better (dermatology), or I just prefer (gyn). But I’ve never tended to, say, rush to see a pulmonologist if I’ve got a bad cold.
I have a brief anecdote from my mother-in-law’s doctor, who “specializes” in geriatric medicine but is essentially an end-of-life equivalent to a pediatrician. He went to a “boutique” practice over a decade ago. He doesn’t take Medicare, charges patients a flat fee of almost $200/month to see him, and has one medical assistant and one office assistant.
In his previous practice, he felt pressured to take less time than he thought was necessary to get to the root of his different patients’ issues, many of which were quite profound given that they were generally quite old and often near the ends of their lives. In essence, doing the job he wanted to do for his patients at the given levels of Medicare reimbursement would have reduced him to penury (as he saw it). So he decided to increase his flexibility, lower his overhead, and become a provider who gets paid a fixed amount per patient rather than billing by the hour.
Given what I’m guessing the size of his practice is; the average amount of time he takes on MiL each month (adjusted for her age of 89 years); and the salaries of his assistants and rent, I’m guessing he is a bit less-well compensated than many of his peers but likely has a lot more job satisfaction.
The ACA was sold on “bending the cost curve” for healthcare in the U.S. - so not reversing compensation, strictly speaking, but certainly getting it down to the rate of general inflation rather than health-care inflation. I’d agree that forcing the current crop of doctors to take massive haircuts in their compensation is likely to be a nonstarter - consider how Anthem’s attempt to lower rates paid to anesthesiologists died along with UHC’s CEO last year - but one would think it would be possible to provide lower-compensation, higher-satisfaction career paths to people entering the medical field, and - combined with greater doctor availability and lower costs for pursuing a medical education - might over time contribute to that lower cost curve.
I’m a primary care provider that works in nursing homes. My base salary, and that of my colleagues, runs in the mid to high one hundred thousands. With bonuses, which myself and most of my colleagues earn, we end up bringing home somewhere in the low to mid two hundred thousands.
As the wife of a primary care sports med doc, fellowship trained and board certified but non-surgical, I can tell you that those numbers utterly do NOT reflect his income. The orthos he works with make pretty well twice what he does.
General Peds is primary care. Family Medicine and Peds are both on the lower end. Of course it varies by individual. Some are 90%ile producers and some are 10%ile and they usually don’t get paid the same. But yeah low 200s total package (includes benefits like healthcare and retirement contributions) seems like a fair average. With the debt load of medical school to service (hundreds of thousands commonly) which costs as much to get through for a primary care doc as it does for a specialist. Pediatric specialists (like heme/onc or infectious disease or neurology …) go through Peds general residency first, then fellowship training, usually not making much more than the general pediatrician does on the other side. Sometimes less.
The natural consequence?
Residencies in pediatrics are not filling in a worsening trend. Pediatric fellowships too. And not unique to Peds but there are lots of us over 65 out there working, and some are getting tired. Private practice positions do not qualify for the loan forgiveness deals that non profits get to attract with (although you need to gamble that the non profit will still exist for seven more years, often not a great bet.)
Compensation is only one factor. The current group of medical students exposure to the specialty was during Covid. Not a great time for Peds experience. I personally am dreading the increase in attacks on what we do, from promoting vaccines to advocating for pediatric trans care, that we know is to be.
There is a looming crisis for pediatric care. I love what I do, and I feel I am good at it, can’t imagine doing anything else, no plans to stop anytime soon, but I completely understand why few are opting for our path.
Thanks for all the info. One other thing - at what part of one’s career are we talking. I find myself comparing the salaries to mine - but I’m 40 years into a law career.
And this site lists pay scales for VA doctors. Looks to start at $123k. But, I guarantee that DOES NOT include health insurance, retirement contributions. And, after 10 years there is student loan forgiveness. I have no idea what is required to get to the tier 1 and 2 maxes of $300 and $400k.
I can’t say how it works everywhere but only know for us. New docs are attracted with a guaranteed salary as they ramp up their productivity (a function both of building a following and learning how to be efficient). They are being subsidized during that time and expected to reach a certain level of productivity by two years. At that point we are all on the same model and they can continue to make as much as they were making if they are working not quite as hard as I do but close. I don’t get more for being here 36 years. I usually make a bit more just because I take fewer vacation days. The patient demand is there such that any personable new doc willing to work can fill up. Comp also includes meeting various individual and department metrics, which have varied over the years. For the adult primary care side those metrics include quality measures associated with “value based care” bonuses. Things like if your panel of diabetics on the Medicare Advantage plan got their eye exams done, achieved lipid and blood pressure goals, etc. Fewer of those for Peds. I suspect our comp model is fairly typical.
Sounds like what my employer does. And I agree it doesn’t change much. To clarify for those not working in medicine, the reason it doesn’t change is because CMS hasn’t increased their rates. So in one sense, a doctor can earn more money by seeing more patients / becoming “more efficient”. But the amount that is paid per visit in primary care hasn’t changed, at least not since I finished residency back in 2006.* Those incentives for “value based care” help a little, but we’re talking about something like a 3% bonus for making the highest marks on all the quality measures, or at least that’s what my employer pays.
*. At least not for the code that I usually bill for a typical follow up.
My guess is that more likely they are including other compensation, like health insurance, malpractice insurance, employer 401K contributions, etc. as part of the reported annual salary. Unless someone is some sort of “doctor to the stars”, doctors will end up getting paid about the same since CMS sets the rates for Medicare and the private insurances follow suit. Most of the variation will be in how much the employers keep for overhead and how efficiently the business is set up for those few of us still with our own private practice.
ETA. Or unless they are including people who have a medical degree but whose day to day job is in administration rather than seeing patients.
Not too many years ago we had accounting that kept track of “local overhead” (a charge for our local staff rent etc), “general overhead” (a fraction that was considered our share of all the centralized expenses) and our revenue generated. Just FWIW.
The other aspect in a large multi specialty group is that some specialities revenues may underwrite the compensation for needed sorts of providers who do not generate big bucks themselves. For example Infectious Disease specialists are not generating much revenue with their codes but a group absolutely needs them, so they may be subsidized some. They are still paid crap though.
We pay an awful lot for healthcare.