Income Gaps Between Primary Care and Specialists Threaten Health Care

February 19, 2007
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The number of medical students in the United States choosing careers in primary care has drastically fallen, threatening the foundation of the U.S. health care system overall. This impending crisis is caused in large part by the sizeable and widening income gap between primary care physicians and specialists, according to a University of California, San Francisco health policy expert.

Dr. Thomas Bodenheimer, professor of family and community medicine at UCSF, discusses this crisis in the Feb. 20 issue of the Annals of Internal Medicine. He is lead author of a "perspective" piece on the topic.

"This disparity is important because we are seeing a resulting decrease in the population of primary care physicians," Bodenheimer says. "Payment reform to narrow the income gap is essential if the United States is to maintain a good primary care base and a cost-effective health care system." Past studies have shown patients with a regular primary care physician have lower health care costs than those without, and health care costs are lower and quality is higher in geographic areas with more primary care physicians, explains Bodenheimer.

Specialists earn almost twice as much as primary care physicians, working the same amount of hours. A 30-minute routine procedure performed by a specialist is often reimbursed two-and-a-half to three times the amount paid to a primary care physician who spends the same amount of time with a complicated patient.

Bodenheimer's perspective bolsters the warning of an "impending collapse" of adult primary care made by the American College of Physicians in 2006. In 1998, 54 percent of internal medicine trainees planned careers in primary care rather than specialty medicine. By 2004, only 25 percent chose primary care.

The percentage of medical school graduates choosing family medicine decreased from 14 percent in 2000 to 8 percent in 2005. Consequently, patients are having an increasingly difficult time finding a primary care physician, waiting times for appointments are growing, and patients may have compromised outcomes due to the short, rushed office visits that physicians must maintain in order to stay afloat financially, says Bodenheimer.

In the article, Bodenheimer challenges the usefulness of the "resource based relative value scale," a system designed to lessen the fee disparity between office visits and specialty procedures. Since its implementation in 1992, the system has failed to decrease the income gap. Part of the problem, according to Bodenheimer, is that the process for reviewing and updating physician fees is heavily influenced by a specialist-dominated committee of the American Medical Association named the Relative Value Scale Update Committee, or RUC.

"More than 80 percent of the members of this committee are specialists," Bodenheimer says. "RUC recommendations tend to favor specialist over primary care reimbursement. Their bias is adding to the income gap between specialists and primary care physicians."

In addition, the volume of specialty services such as diagnostic and imaging procedures is increasing more rapidly than office visits, contributing to a faster income growth of specialists over primary care physicians. Private insurers likewise add to the problem by reimbursing specialists at higher percentages than reimbursement for primary care physicians, he notes.

"Patients, specialists and the entire health care system need a healthy primary care base," says Bodenheimer. "Unfortunately, primary care practice is not viable without a substantial increase in resources for primary care physicians."

UCSF is a leading university that advances health worldwide by conducting advanced biomedical research, educating graduate students in the life sciences and health professions, and providing complex patient care.

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