Should Doctors Spread the Wealth Around?

Elyas Bakhtiari, for HealthLeaders Media, November 13, 2008

I'll bet you thought you wouldn't hear that phrase again so soon after the election.

But now that we know which party will be setting the healthcare agenda for the next four years and the discussion about reform has shifted from abstract goals to a more concrete framework for change, a debate over income redistribution has ignited within the physician community.

The spark came at the AMA's interim House of Delegates meeting this week, where members voted to make permanent Medicare physician payment reform a top priority for its 2009 legislative agenda. While physicians across the board agree on most of the proposals discussed—expanding the medical home model, providing quality incentives, adjusting the Medicare sustainable growth rate—the controversy stems once again from the question of how to fix primary care.

According to Bob Doherty of the ACP, specialists were lining up at the microphones during the discussions to express support for primary care "as long as it doesn't involve redistribution of dollars among physicians."

This is a sentiment expressed before, and it has nothing to do with which party is controlling the government. Because of Medicare's budget neutrality requirements, high-earning specialists are worried that much-needed increases in primary care reimbursement will lead to a corresponding decrease in their pay.

Cardiologist Westby G. Fisher, MD, explains it more bluntly from a specialist's perspective: "Most of us already know what the Robin Hoods of bureaucracy are going to do: steal from the rich (specialists) and give to the poor (generalists)."

Primary care physicians don't see it that way. Judging by some of the hostility expressed on other physician blogs recently, they feel their work is undervalued, and in some cases that specialists are overpaid.

Kevin Pho, MD, warns that this division will escalate and "class warfare is going to hit the medical profession real soon, and it's going to be ugly."

That's the last thing we need right now.

The healthcare industry has a unique window of opportunity to address some of its problems, and there's a danger of that being squandered by factions working toward different self-interests.

There are without a doubt some difficult questions to answer. Can some primary care services be provided by non-physicians? Are specialty procedures overvalued and overpriced? How will patients receive primary care if the shortage isn't addressed?

But the key is to look at these questions based on what's best for the overall healthcare system, not individual physician factions. Whether you agree with his policies and politics or not, it's worth taking a lesson from President-elect Obama's notion in last week's acceptance speech that "we rise and fall as one."

If inter-specialty bickering stalls reform, the overall system suffers. If primary care fails, patients won't get the care they need. Ensuring that doesn't happen should be something all physicians, regardless of specialty, can agree on.

Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at
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