As an internist (yes, I am a specialist, just not a subspecialist), I do no procedures. Patients pay me (albeit mostly indirectly) for my cognitive skills. But we live in a culture that seemingly rewards procedures more that pure cognition. Now I understand that procedures are not mindless. Physicians doing procedures must think prior to the procedure, during the procedure and after the procedure. But cognition without procedures seems undervalued.
The New York Times has an article that tells the story dramatically: “Patients’ Costs Skyrocket; Specialists’ Incomes Soar.” In glancing at the comments, many complain that physicians never discuss prices (note that I use price here rather than cost — cost has a specific economic meaning and price and cost are not equivalent). Most physicians avoid this discussion, likely because an insurance company is usually paying, and because they are either ignorant of the price or embarrassed to discuss money.
Interestingly, patients probably value cognition more that the insurers (including CMS). Many patients willingly pay extra for access, as the growing field of retainer medicine demonstrates. Patients want adequate face to face time with physicians, access through phones, texts and/or emails and rapid access when necessary.
Our payment system is unfortunately gamed by too many subspecialists. The decision to do a procedure is often made by the person who does and financially benefits from that procedure. Thus, these subspecialists may have a financial conflict of interest. Most physicians respond to such conflict in a healthy rational manner, but temptation can lead to abuses.
Dr. Wes, a cardiologist, takes offense at the Times article in his piece, The Importance of Demonizing Specialists. I do not read the article in the same way, but then I have a bias that the income disparity between those who financially benefit from procedures and those of us who “merely think” through patient problems is excessive. I believe that we do need more generalists and that potential income drives our graduates (of both medical school and internal medicine residencies) away from generalism. Money does matter.
I am happy for cardiologists to make more money than I do. I have often advocated for an adjusted pay per unit time. Those who have to come to the hospital at night for emergency care deserve a significant differential for that time. The longer training for cardiology justifies higher pay, the only question is how do we determine the proper multiplier.
Price transparency might address these issues. Perhaps this Times article will stimulate enough discussion to start a corrective process.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
