OP-ED

Another Modest Proposal* – Paying for Physician Training

One of the main considerations in physician pay under CMS’ relative value system is the training required to complete a task. This is generally thought to be well understood but is, in fact, a quagmire of controversy.

Take for example the specialty of family medicine compared with dermatology, anesthesiology, or ophthalmology. Family physicians make between 1/2 and 1/3 of what these other specialties make, so one would think that there is a huge training difference. The truth is that each of the four require 16 years before medical school, 4 years of medical school, and 3 years of residency.  The 3 highly paid fields require 1 additional year in a transitional internship.  So the family physician education represents 23/24 or 96% of the length of education required for the others.  Since when is a 4% investment worth a 200% to 300% return?

There are, of course, longer training programs.  Internal medicine fellowships are 2 to 3 years on top of a 3-year residency.  There was a time when this made sense, since the idea was to educate competent general clinicians and then for them to specialize in a narrower field.  Given the limited general physician work of, let’s say, cardiology, one could easily argue that the 3 years of internal medicine training are wasted. Should cardiologists, therefore, be credited with 23 or 26 years of training? It would obviously be more efficient to move these physicians directly from medical school into the cath lab.

There are some physicians who keep going on and on in their training, completing one residency and then another. One fellowship and then another.  CMS must come up with a numerical way to appropriately compensate these individuals for their time, yet discount it for any lack of relevance that their training might have for performing a particular procedure.  Take, for example, the resident who completes his general surgery training then goes on to do a fellowship in vascular surgery, then goes into practice and limits his practice to the laser closure of veins, a technique he learned in a weekend CME meeting.  Should this physician’s income reflect 7 years of training or 3 days?

I have always argued that the year you learn the most is the year you first go into practice.  It would certainly seem appropriate, then, to give everyone credit for this 1 year of training.  But what do you do with compensation for training after that, given that almost all physicians are engaged in work that requires lifelong learning?  It would seem a reasonable solution to give credit at .5 of a YOT (year of training) for that first year and for up to 20 consecutive years. After that, you would subtract .25 YOT for each subsequent year, acknowledging that some of what you had learned by that time would be out of date. Passing a mini–mental status exam on an annual basis after age 60 would also be required to know whether any financial advantage at all should be given for previous training.

It would obviously be essential to add training income for CME.  I would personally be opposed to awarding such training time for drinking coffee in the doctor’s lounge while watching FOX news.

So, be very careful when you emphatically state that all of your long education merits more pay.  Someone may want to actually count.

Paul Fischer MD is a family physician at the Center for Primary Care in Augusta, GA. He is lead plaintiff, with five of his primary care colleagues, in a law suit against CMS and HHS, claiming that those agencies’ reliance on the AMA’s RUC has been out of compliance with the Federal Advisory Committee Act, because they have failed to require that committee to adhere to the Act’s management and reporting rules. SeeReplace the RUC for more information.

Take for example the specialty of family medicine compared with dermatology, anesthesiology, or ophthalmology. Family physicians make between 1/2 and 1/3 of what these other specialties make, so one would think that there is a huge training difference. The truth is that each of the four require 16 years before medical school, 4 years of medical school, and 3 years of residency.  The 3 highly paid fields require 1 additional year in a transitional internship.  So the family physician education represents 23/24 or 96% of the length of education required for the others.  Since when is a 4% investment worth a 200% to 300% return?

There are, of course, longer training programs.  Internal medicine fellowships are 2 to 3 years on top of a 3-year residency.  There was a time when this made sense, since the idea was to educate competent general clinicians and then for them to specialize in a narrower field.  Given the limited general physician work of, let’s say, cardiology, one could easily argue that the 3 years of internal medicine training are wasted. Should cardiologists, therefore, be credited with 23 or 26 years of training? It would obviously be more efficient to move these physicians directly from medical school into the cath lab.

There are some physicians who keep going on and on in their training, completing one residency and then another. One fellowship and then another.  CMS must come up with a numerical way to appropriately compensate these individuals for their time, yet discount it for any lack of relevance that their training might have for performing a particular procedure.  Take, for example, the resident who completes his general surgery training then goes on to do a fellowship in vascular surgery, then goes into practice and limits his practice to the laser closure of veins, a technique he learned in a weekend CME meeting.  Should this physician’s income reflect 7 years of training or 3 days?

I have always argued that the year you learn the most is the year you first go into practice.  It would certainly seem appropriate, then, to give everyone credit for this 1 year of training.  But what do you do with compensation for training after that, given that almost all physicians are engaged in work that requires lifelong learning?  It would seem a reasonable solution to give credit at .5 of a YOT (year of training) for that first year and for up to 20 consecutive years. After that, you would subtract .25 YOT for each subsequent year, acknowledging that some of what you had learned by that time would be out of date. Passing a mini–mental status exam on an annual basis after age 60 would also be required to know whether any financial advantage at all should be given for previous training.

It would obviously be essential to add training income for CME.  I would personally be opposed to awarding such training time for drinking coffee in the doctor’s lounge while watching FOX news.

So, be very careful when you emphatically state that all of your long education merits more pay.  Someone may want to actually count.

*In an earlier essay, the author proposed collapsing all specialty procedures into 4 CPT codes.

 

Paul Fischer MD is a family physician at the Center for Primary Care in Augusta, GA. He is lead plaintiff, with five of his primary care colleagues, in a law suit against CMS and HHS, claiming that those agencies’ reliance on the AMA’s RUC has been out of compliance with the Federal Advisory Committee Act, because they have failed to require that committee to adhere to the Act’s management and reporting rules. SeeReplace the RUC for more information.

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Categories: OP-ED, THCB

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rbaerPeter1steveDeterminedMDMargalit Gur-Arie Recent comment authors
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rbaer
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rbaer

Dr. Fischer is mostly right, the current codes are unfair and arbitrary. I think a fair reimbursement system could be developed within weeks, based on a formula “usual physician time for service x(x meaning adjusted by) risk x minimal educational level to perform the service x elective vs. emergency”. (I would add that the current problem is mostly not underpayment of nonproceduralists but rather absurd overpayment of certain specialists/procedures.) But I don’t hold my breath that any easy and fair change is going to happen in the US. @fakepeter: going to the specialist for the organ system in question sounds… Read more »

steve
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steve

This would be a much better basis for starting a conversation than what Paul is doing, He seems intent upon throwing bombs then disappearing. I suggest we stop responding to his posts as I do not think he writes in good faith.

Steve

Peter1
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Peter1

“In addition, I believe that anesthesiology and opthalmology have a much greater responsibility than primary care with much more risk involved. Keeping me alive on the OR table and being able to keep my vision are a bit more important.” Then how would you rate and pay nurse anesthetists? A PCP can’t compete with dramatic heroics for effect, but they can keep you alive and out of the OR and protect your vision from needing an ophthalmologist – there is value in that. They can also save the system countless millions by preventing the need for specialists. “Probably not, but… Read more »

Peter1
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Peter1

The continued use of my name in comments that may or may not reflect my viewpoint and the fact that requests to Matthew to fix the use of duplicate names has gone unanswered, I am changing my name from Peter to Peter1, which denotes me as the longtime poster here and the original “Peter”.

DeterminedMD
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DeterminedMD

My comment earlier was directed to the Peter who made the comments I rebut. Besides, your comments seem to echo my sentiments.
Maybe be Peter1st?

steve
Guest
steve

If you want to look at years in training, you also need to look at degree of difficulty. After internship, internal medicine is easy compared with many of the specialties. Junior residents did about half of the year on ward rotations. Senior residents did about four months. The rest of the time, they did electives. That meant lots of reading time, no call and most of them made a bundle working as house docs elsewhere. One of my fellow residents finished internal medicine, then started with me in my year. He informed me that he made about double his residency… Read more »

DeterminedMD
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DeterminedMD

Hey Peter, good luck getting that appointment with the specialist in a timely manner if you have an insurance plan, and if you do and they do not ask for a referral from a PCP or other initial point of contact person, then what do you do if you have another problem that the specialist you first saw cannot handle in the office? Specialists are a bit wary to refer to another specialist because of, here it comes, accepting some accountability if you show up trying to get service for the problem from your initial specialist. Plus, I would hope… Read more »

Margalit Gur-Arie
Guest

Education attainment impacts compensation up to a point. A full Physics professor, which takes as long as a medical doctor to educate, has a median compensation of less than $100K.
I guess those über “best and brightest” who go into Physics have different drivers in life.

Peter
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Peter

In addition, I believe that anesthesiology and opthalmology have a much greater responsibility than primary care with much more risk involved. Keeping me alive on the OR table and being able to keep my vision are a bit more important.

Samuel Stenes, MD
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Samuel Stenes, MD

You have it all wrong.

Become a PA in two years, prance around in a white coat, do not clearly disclose you are a PA, patients call you doctor, do all of same procedures that a Derm does, debride wounds for the Plastics, suture lacs in the ER, inject knees for the Ortho…get paid what a fam doctor gets paid, and enable the DERM, PLASTICS, ORTHO,and ER docs to waltz in, and bill as if they did it!

Peter
Guest
Peter

It appears that you will do anything to raise your salary. Look–a nurse can easily do your job. You should be grateful that you still have a job and accept what you have since it may be taken away in the near future. People pay for what is valued–you fall into an area that isn’t that highly valued. Look at sports—are players really worth millions of dollars? Probably not, but more people value them than not, so………………they get paid millions of dollars. Why don’t you expand your practice to areas that are valued by others? I personally never go to… Read more »