The primary care-specialty income gap: Why it matters

University of California, San Francisco, San Francisco, California, USA.
Annals of internal medicine (Impact Factor: 17.81). 03/2007; 146(4):301-6. DOI: 10.7326/0003-4819-146-4-200702200-00011
Source: PubMed


A large, widening gap exists between the incomes of primary care physicians and those of many specialists. This disparity is important because noncompetitive primary care incomes discourage medical school graduates from choosing primary care careers. The Resource-Based Relative Value Scale, designed to reduce the inequality between fees for office visits and payment for procedures, failed to prevent the widening primary care-specialty income gap for 4 reasons: 1) The volume of diagnostic and imaging procedures has increased far more rapidly than the volume of office visits, which benefits specialists who perform those procedures; 2) the process of updating fees every 5 years is heavily influenced by the Relative Value Scale Update Committee, which is composed mainly of specialists; 3) Medicare's formula for controlling physician payments penalizes primary care physicians; and 4) private insurers tend to pay for procedures, but not for office visits, at higher levels than those paid by Medicare. Payment reform is essential to guarantee a healthy primary care base to the U.S. health care system.

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    • "Most interventions shown to be effective in improving correct dosage adjustment of medications in CKD patients involved inpatient settings, such as concurrent feedback by pharmacists [20,21], or the integration of a decision support system (CDSS) into a computerized physician order entry (CPOE) system [22,23]. However, these interventions appear less feasible in small, isolated primary care settings where personnel and financial resources are limited [24]. "
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    ABSTRACT: Patients with chronic kidney disease (CKD) are at increased risk for inappropriate or potentially harmful prescribing. The aim of this study was to examine whether a multifaceted intervention including the use of a software programme for the estimation of creatinine clearance and recommendation of individual dosage requirements may improve correct dosage adjustment of relevant medications for patients with CKD in primary care. A cluster-randomized controlled trial was conducted between January and December 2007 in small primary care practices in Germany. Practices were randomly allocated to intervention or control groups. In each practice, we included patients with known CKD and elderly patients (≥70 years) suffering from hypertension. The practices in the intervention group received interactive training and were provided a software programme to assist with individual dose adjustment. The control group performed usual care. Data were collected at baseline and at 6 months. The outcome measures, analyzed across individual patients, included prescriptions exceeding recommended maximum daily doses, with the primary outcome being prescriptions exceeding recommended standard daily doses by more than 30%. Data from 44 general practitioners and 404 patients are included. The intervention was effective in reducing prescriptions exceeding the maximum daily dose per patients, with a trend in reducing prescriptions exceeding the standard daily dose by more than 30%. A multifaceted intervention including the use of a software program effectively reduced inappropriately high doses of renally excreted medications in patients with CKD in the setting of small primary care practices. Trial registration Current Controlled Trials ISRCTN02900734
    BMC Family Practice 09/2012; 13(1):91. DOI:10.1186/1471-2296-13-91 · 1.67 Impact Factor
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    • "A given specialty's residency fill rates linearly correlate with that specialty's expected income [48,49]. Although medical student debt is often cited as a deterrent from primary care specialty choice, gross income and lifetime earning potential may be more influential than educational debt [50]. Indeed, most studies do not show a linear association between debt and primary care specialty choice. "
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    ABSTRACT: The United States pediatric population with chronic health conditions is expanding. Currently, this demographic comprises 12-18% of the American child and youth population. Affected children often receive fragmented, uncoordinated care. Overall, the American health care delivery system produces modest outcomes for this population. Poor, uninsured and minority children may be at increased risk for inferior coordination of services. Further, the United States health care delivery system is primarily organized for the diagnosis and treatment of acute conditions. For pediatric patients with chronic health conditions, the typical acute problem-oriented visit actually serves as a barrier to care. The biomedical model of patient education prevails, characterized by unilateral transfer of medical information. However, the evidence basis for improvement in disease outcomes supports the use of the chronic care model, initially proposed by Dr. Edward Wagner. Six inter-related elements distinguish the success of the chronic care model, which include self-management support and care coordination by a prepared, proactive team. United States health care lacks a coherent policy direction for the management of high cost chronic conditions, including rheumatic diseases. A fundamental restructure of United States health care delivery must urgently occur which places the patient at the center of care. For the pediatric rheumatology workforce, reimbursement policies and the actions of health plans and insurers are consistent barriers to chronic disease improvement. United States reimbursement policy and overall fragmentation of health care services pose specific challenges for widespread implementation of the chronic care model. Team-based multidisciplinary care, care coordination and self-management are integral to improve outcomes. Pediatric rheumatology demand in the United States far exceeds available workforce supply. This article reviews the career choice decision-making process at each medical trainee level to determine best recruitment strategies. Educational debt is an unexpectedly minor determinant for pediatric residents and subspecialty fellows. A two-year fellowship training option may retain the mandatory scholarship component and attract an increasing number of candidate trainees. Diversity, work-life balance, scheduling flexibility to accommodate part-time employment, and reform of conditions for academic promotion all need to be addressed to ensure future growth of the pediatric rheumatology workforce.
    Pediatric Rheumatology 08/2011; 9(1):23. DOI:10.1186/1546-0096-9-23 · 1.61 Impact Factor
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    • "Most private practices are paid fee-for-service by commercial or public (Medicare and Medicaid) payers, with a small amount of capitation payment surviving in a few states. The fee schedule used by most payers causes PCPs to have incomes averaging 55% of procedural and imaging specialist incomes [18]. US adult primary care is in crisis. "
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    ABSTRACT: All modern healthcare systems need to respond to the common challenges posed by an aging population combined with a growing number of patients with (complex) chronic conditions and rising patient expectations. Countries with 'stronger' primary care systems (e.g. the Netherlands and England) seem to be better prepared to address these challenges than countries with 'weaker' primary care (e.g. USA). The role of primary care in a health care system is strongly related to its organisation and funding, thus determining the starting point and the possibilities for change. We selected the Netherlands, England, and USA as examples for the diversity of approaches to organise and finance health care. We analysed the main problems for primary care and reviewed strategies and practice models used to meet the challenges described above. The Netherlands aim to strengthen prevention for chronic diseases, while England strives to improve the management of patients with multimorbidity, prevent hospital admissions to contain costs, and to satisfy the increased demand of patients for access to primary care. Both countries seek to reorganise care around the patient and place their needs at the centre. The USA has to provide sufficient workforce, organisation, and funding for primary care to ensure better access, prevention, and provision of chronic care for its population. Strategies to improve (trans-sectoral) cooperation and care coordination, a main issue in all three countries, include the implementation of standards of care and bundled payments for chronic diseases in the Netherlands, GP commissioning, federated and group practice models in England, and the introduction of the Patient-Centred Medical Home and accountable care organisations in the USA. Organisation and financing of health care differ widely in the three countries. However, the necessity to improve coordination and integration of chronic disease care remains a common and core challenge.
    Zeitschrift für Evidenz Fortbildung und Qualität im Gesundheitswesen 01/2011; 105(8):571-80. DOI:10.1016/j.zefq.2011.09.029
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