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High earning in the practice of family medicine

"What Makes a High-Earning Family Physician?" [July/August 2005] makes a particularly sharp contrast with the issue's second-most interesting article, "Chronic Care Guidelines Prove Impossible to Follow" [Monitor, July/August 2005]. For higher income, you have to see more patients in less time. That means shorter visits. For high-quality care, you have to do more with each patient. That means longer, more comprehensive visits. Too bad those aren't compatible.

99212s, 99213s and procedures pay more per hour than 99214s, and Gresham's law holds that "bad money drives good money out of circulation." So primary care physicians doing 99212s and 99213s will replace those doing longer, more complex visits, and specialists will drive out generalists. It's already happening.

For the good of the country, we should be doing chronic disease management and prevention, but for that to happen, we have to get paid as much for providing it as we do for treating sore throats and coughs, and as much as other specialists. If our goal is to improve America's health, the payment model for primary care has to change drastically. Tinkering around the edges won't do it.

Peter Liepmann, MD
Highland, N.Y.

I was surprised that the number of procedures performed (beyond lab, X-ray, etc.) was not mentioned in the article. Was it not included in the survey? In some cases, it only takes a couple of procedures each day to double income.

Barry White, MD
Chinook, Mont.

Author's response:

The relationship of procedures to family physicians' incomes hasn't been included in our studies to date. Your question is valid and could provide a good start to the next round of research.

Jan Carter
Prairie Village, Kan.

After reading Jan Carter's article on high-earning family physicians and the final chapter of Dr. Sanford Brown's Practice Diary, I find myself wondering if we are in fact "turning out cadres of physician employees - homogenized lemmings," as Dr. Brown states, instead of vibrant, independent, efficient physicians. The characteristics of high earners seem to focus on doing more and seeing more and moving ever faster on the assembly line of medicine. As a solo physician who works part-time, I earn as much as I did when I was an employed physician working full time - not because I do more but because I control my overhead. What good is a high salary if it undermines a balanced life and one's original aspirations?

Pamela Wible, MD
Eugene, Ore.

The analysis in "What Makes a High-Earning Family Physician?" punctures a few balloons and gets close to the truth. However, most of the suggestions at the end are inconsistent, naive and probably wrong. The two that bothered me most were as follows:

1. "See more patients." Right. Also "buy low, sell high." And "plant your corn early." Pick up a good divorce lawyer with some of the extra money, because you'll be in the office two extra hours each day.

2. "Look for ways to increase the number of patients you see who are insured by the best-paying health plans." In other words, act like an insurer and cherry-pick. That's OK because there are always a few saps who will see the patients who really need care and can't afford it. Let those dedicated, ethical boobs see the rest of the patients while you go home at 5 p.m. with the best reimbursement.

Gerald P. Corcoran, MD
Needham, Mass.

Author's response:

Evaluating the contracts you sign isn't cherry-picking. It's good business sense. And while there certainly is a difference in socioeconomic status between individuals with insurance coverage and those without, there doesn't appear to be any connection between socioeconomic status and the insurance plan a patient has, at least where private insurers are concerned. Therefore, favoring the better-paying insurance plans doesn't mean excluding a class of patients. You could close your practice to new patients from the less desirable plans, or you could drop those plans, and these patients could still see you as an out-of-network provider.

Jan Carter
Prairie Village, Kan.

Homogenized lemmings

I have always looked forward to Dr. Sanford Brown's "Practice Diary," but the final chapter was disappointing. As a physician who is employed by a hospital-owned group, I was irritated by his description of "physician employees" as "homogenized lemmings." My position allows me to focus my energies on patient care rather than spending time balancing the books. This vision of family medicine is no less valuable than Dr. Brown's.

Many medical students see overworked physicians in primary care and choose specialties that seem to be more conducive to a balanced life. In family medicine, we should support a diversity of choices and provide training that helps residents decide on the type of practice that suits their lifestyle. But just as some doctors choose not to deliver babies, some of us choose not to run a business. Please respect our choices.

Marissa Muscat, MD
South Lake Tahoe, Calif.

Author's response:

I meant no disrespect. I just do not feel that your model is the direction that family medicine needs to go. I am disturbed by the large numbers of family physicians who claim they are unhappy practicing family medicine and would not do it again if they could choose over. I'm also disturbed by the paucity of physicians choosing independent practice as a model. I feel that, in general, the economics of being employed dictate against optimal patient care and physician satisfaction. You might feel differently if you were overworked and underpaid in a hospital-owned group that wasn't being managed efficiently. But a medical practice is a business, and if you're not running it, then someone else has to be, for better or for worse.

I feel more physicians would opt for independence if they had the requisite training. I can hardly blame new family physicians for choosing a salaried position when they don't know anything about running a practice. Independent practice, incidentally, doesn't mean having to be a solo physician. Belonging to a small group in which all the physicians participate in practice management decisions qualifies.

Sanford J. Brown, MD
Mendocino, Calif.