Specialty Interests

Collectively, physicians can sometimes be their own worst enemies. Just when primary care physicians caught a break and the Medicare Payment Advisory Committee advised Congress to find a way to increase their payments, their surgeon colleagues fired off a letter in an attempt to prevent a possible payment change.

A consortium of 14 associations representing surgical specialists wrote to MedPac and members of Congress expressing "strong opposition" to the recommendation. The problem, from the surgeons' perspective, is that the advisory group suggested a "budget neutral" payment adjustment, which would require cuts from other specialties to fund the increase for primary care.

This budget neutrality requirement is at the heart of the subspecialty payment disparities that I touched on last week. The physician payment system is often likened to a pie—there are only so many ways it can be divided, so to offer one specialty a bigger piece, CMS must give other specialties a smaller one. Years of competing with each other for a bigger piece of pie has created some pretty significant rifts between primary care and specialists.

William C. Thornbury, Jr., MD, medical director of Medical Associates of Southern Kentucky made the case for primary care in an e-mail I received this week, and he didn't mince words in placing the blame on specialty physicians. "The irony of it all is that though they are paid the least, primary care physicians and general surgeons are the most gifted and most intelligent physicians in the system. However, specialists, which have markedly easier, finely defined roles, are banded together to support their own efforts at the expense of the system that cares for us all."

He directed his criticism in part at specialist overrepresentation on Medicare committees, like the Relative Value Scale Update Committee—an argument that has some merit and has been made before.

On the flip side, a physician blogger using the moniker "Buckeye Surgeon" defended surgical specialists against criticism over the letter, arguing that higher malpractice premiums and additional training warrant higher reimbursement rates. "Surgeons aren't opposed to primary care docs getting more money," he wrote. "We're all for that. But don't obtain that funding from the already dwindling surgeon's piece of the pie."

It's understandable that physicians would identify with their specialty first and defend their turf against reimbursement encroachments, but these divisions can be counterproductive to efforts to enact widespread payment reform. Physicians are competing against very large industries (pharmaceutical, managed care) for the federal government's attention, and lately the physician community has been too disjointed to develop a clear message about what a reformed system would look like. If physicians are sending Congress mixed messages about how physician reimbursement needs to change, they'll probably continue to get more of the same.