The cost depends on the value

Does the cost depend on the value? Today, Medscape released the results of their 2011 survey of physician compensation:

I share this post here to point out the discrepancy in physicians’ average salaries based on their specialties.  In particular, I would like to highlight that the three lowest-paid specialties are the three primary care specialties: pediatrics, family medicine, and general internal medicine.

This post is not written to argue that physicians must be paid more.  I would submit that if physicians cannot live on $150,000 then we might be doing something wrong…and we are unlikely to get much sympathy from the average person.

Rather, my intent is to note how undervalued primary care services are in our current system of healthcare delivery and payment.  Primary care physicians–the physicians who provide comprehensive care, who provide preventive care, who coordinate care–are paid less than all other medical specialists.  Radiology and anesthesiology make nearly twice what primary care doctors do; dermatology and anesthesiology make nearly 175% of the average primary care physician.

This is not to say that these medical specialists do not have important roles in providing medical care; however, should a physician who views x-rays and imaging studies be valued at twice the level of the physicians who keep our children well, who monitor their development and intervene if necessary, and who ensure children are fully vaccinated? Should a physician who deals with skin problems be paid at nearly twice the level of a physician who can deal with many of the same skin problems…while also addressing patients’ diabetes, blood pressure, heart disease, and mental illness?

The cost of any given service or item depends on its value.  Precious metals are expensive because we value them greatly.  Luxury cars are expensive because they are highly valued in our culture.  Primary care physicians in the US are paid less than all other specialists, and cost less per physician than all other specialists…indicating that the primary care specialties are valued less than other medical specialties.

We have previously noted the importance of primary care to a high-functioning, efficient, and effective healthcare system.  Despite the key role primary care should be playing, however, the chart above shows that primary care is not valued at a commensurate level.

Unless we value primary care, and redesign our healthcare delivery and payment systems to reflect this, then we will continue to have a healthcare system that under-performs even as healthcare costs continue to increase.  The cost depends on the value: so long as we do not value primary care, then costs will rise even as outcomes do not improve.

This situation is untenable, and must change.  We must demand a healthcare system that values those services and specialties that reduce costs.  We must enhance primary care’s role in our system in order to improve our system’s performance.  If we change what type of medical care our system values, then we can truly affect cost.

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Posted in healthcare, Innovation
  • JoelHigh

    Great post! And I completely agree. In a way we have taken the primary care specialties for granted for far too long. If we are to transform our healthcare system and create a new focus that moves us from the problem/disease model to a health and well-being model than we must put more emphasis on primary care and downplay other specialties. This is really important stuff here.

    • RichmondDoc

      Thanks, Joel. I was afraid this would be a bit hard to argue, and I’m glad it came through well.

      We need a robust primary care system…too bad that the changes required for this are mired in politics.

  • Carmen

    I agree with your argument about the need to value primary care physicians more generally. For me, there’s a larger issue about compensation in this society hanging in the air. I think all professions where vital services are rendered and where actual services/products are created should be valued higher than speculative professions like brokers, traders, and investors. Just this week, the L.A. Times posted a story on how just 50 Lehman Brothers employees received $700 million dollars in compensation prior to the economic debacle. There is nothing those employees could perform in their roles that could justify those sums. In contrast, if we actually paid our doctors and teachers such sums, I wouldn’t bat an eye—their contributions are priceless.

    • RichmondDoc

      It is a striking that we value important services so poorly…

  • pursuitofPH

    I could not agree more with this post or Joel’s and Carmen’s comments! Also, given that the Prevention and Public Health Fund is currently on the chopping block, I’d love to see Medscape’s graph expanded to add public health, education, and other such salaries to the list – prevention is just as under-valued as primary care, and it infuriates me. What could be more critical to our well-being than promoting health and preventing disease?

    • RichmondDoc

      If we added public health and educators, then we would be even more despondent.

      The killer fact is: we have known these issues have been present for decades, yet we still do not address them meaningfully.

  • Mark

    I am coming late to this and agree 100% with your thoughts Mark and the comments. Part of this issue in addition to Carmen’s key point is that the institution that owns the CT, MRI, xray etc or other equipment MUST creat an ROI for those investments. They will not pay for themselves and they do pay huge dividends but not without physians. Carmen, like the brokers who earned $700 million for what they earn for the corporatation. These physicians on the left of the chart make money for the institution. And I would present like the brokers who churn client accounts to earn fees some of institutions churn their capital investments to improve ROI. The subtle reality is a good PCP with a well managed and engaged patient population reduces the need for advanced dx procedures and bingo the MRI is used only 70% each day.