Get Beyond Salaries To Understand Failed Design

Data is often collected, processed, and promoted for dramatic impact. Dialing for dollars is very lucrative when it comes to health care. The controversies dominate our attention  as health care eats its way through our budgets, our employer budgets, our state budgets, and the federal budget. Physician salary data is a popular attraction. This data is often used to claim that physicians seek careers associated with higher salaries. The payment design shapes much more than physician salaries and in turn shapes those in our nation that win and those that lose - by national design.

Data from Medscape

The payment design has long favored procedural-technical services over office-based/cognitive/basic services. The highest paid physicians perform procedures that are paid at highest rates. Other highest paid physicians are those that perform higher volumes of higher paid procedures. These highest rates have been determined by academic, hospital, and physician association representatives that have dominated payment panels. The favor is returned as highest payments work well for academic institutions, largest systems, and associations.

Not surprisingly, the highest paid and highest volume services are the easiest to overutilize. Knee surgeries, cosmetic procedures, cardiac stents, prostate surgeries, tonsillectomies, and skin procedures are big business. Dr. Otis Brawley first came to my attention in his talks about too much done. He learned from hospital CEOs how various screening tests were reliable for harvesting a set amount of dollars in areas such as prostate surgery.

In a cruel irony, the tide has turned against unnecessary procedures and higher volume. This has also been applied to those lowest on the scale. As noted by various experts, higher volume of lowest paid office services has not broken the bank. But higher volume is castigated. Sadly, those paid least and limited to office services have had little choice other than to try to increase the volume. As costs of delivery have been forced higher, there are no good choices. In office based practice, the decisions can lead to fewer team members and lesser paid team members - a short term fix with cascades of consequences.

Brave New World for the Procedurally Focused

At the top of the scale can be seen those who have been able to separate from hospitals and systems, thus providing some competition for higher salaries. Surgical centers involving orthopedic and other procedures have done well for orthopedists and others establishing such centers. Orthopedic surgeons fresh out of fellowships get paid the same as the orthopedists nearing retirement.

The fact of the matter is that the national design for payment shapes winners and losers. Winners are indicated previously. Those most procedural, technical, subspecialized, and centralized are most organized for best payment and profit. Those less organized, not the biggest, not centralized, not academic, office-based, cognitive, and basic have had lesser payments. The consequences of lesser payment are many:

• Lower salaries for those lower on the scale is just one consequence. Salaries are higher for those generating more under the payment design.
• Team members working for those generating lesser payment are fewer and have more different tasks. They often follow the pay gradient to better support. The most specialized physicians can hire and support the most specialized team members who do much of the work. Public health and Community Health Centers are lowest on the scale. Academic and private primary care can pay better. More specialized practices and hospitals raise the ante. The most specialized can pay best. Stable team members, continuity, more team members, and more experienced team members follow the dollar gradient.
• Nurse practitioners and physician assistants have followed this pay gradient following the physician example and adding more different specialties and subspecialties with more added to each new career type. This results in fewer and fewer remaining in primary care, especially in family practice.
• Care where needed is compromised by design. About 90% of the services where needed (rural, underserved, 2621 lowest concentration counties) are generalist and general specialty services.  Primary care, mental health, and general specialty services are stagnant to declining where 40% of Americans are found. The workforce is aging - another indicator of lack of replacement and other consequences.
• Paying the least for these basic services means sending the least dollars to these lower concentration settings where 40 -  50% of Americans are found. The designs for payment actually create the shortages that are seen. Team members in these areas face the most complex populations and have the least support - by design. 
• With fewer dollars shipped to settings that already have lowest health, education, and economic outcomes - outcomes worsen as disparities widen.
• The academic centers that train MD DO NP and PA graduates benefit by having shortages such that they can generate more interest for funding more graduates - who still cannot go where needed because of payment design. 

There really is no reason for the designers to change the design. It serves them very well. Those who do the studies and the reports shape the design. They also give the press releases and engage the media.

Most Americans lose in the design in a number of ways. They are the least likely to become physicians at 3 to 1 against. Even those that become physicians are least likely to become the physicians that shape the design. The designs are shaped by those far away, most exclusive, and most different than most Americans. 

Medscape and other information brokers do very well at capturing and selling our attention. Often the way the information is presented paints a certain impression. Not surprisingly the picture that is painted hides more than is shown.