Medical Device Daily Contributing Writer

I belong to an HMO that, among other things, lets me visit a primary care provider (PCP) for a reasonable co-pay. However, the provider is usually a nurse practitioner or a physicians' assistant, and it's a different one each time (despite claims that I can chose my own personal physician).

Now, I'm healthy and a pretty good amateur diagnostician, so this isn't a problem. But everyone isn't as fortunate. Lack of access to primary care may be the one reform-related issue on which all parties agree. And most also agree about the reason: money.

According to the Medical Group Management Association (Englewood, Colorado), the 2007 median compensation for primary care is $182,322. For all specialties combined, it's $332,450.The difference in compensation ties directly to medical technology.

Technology and disparity

Med-tech companies are developing amazing products that provide a healthy ancillary income stream for many specialists (the proceduralists). That's a revenue stream pretty much unavailable to PCPs.

So yes, it's primarily a reimbursement issue, but one that should be of interest to the med-tech industry – and everyone with a stake in healthcare. The disparity is embarrassing and damaging and it cannot be attributed simply to a few extra years of specialty training.

Talk to primary care docs and you will hear this repeatedly: Time spent managing chronic conditions and the general well-being of patients doesn't generate the same income that performing procedures does.

Compounding the problem is debt: According to the 2008 American Association of Medical Colleges (Washington)Graduate Questionnaire, the average debt for medical graduates in 2008 was $141,751; that's $10,000 more than in 2007. It's going take a newly minted PCP a lot longer to pay that off than it will a new orthopedic surgeon.

Reform and shortages

As I talk to physician leaders, consultants and the occasional politician, it becomes clear: Something's going to give. It may be as simple as helping primary care residents with education debt. Or maybe we'll see reimbursement changes. (Medicare has already made some such adjustments.)

There aren't enough primary care docs to meet current needs. And it's growing worse. Primary care had the lowest percentage of filled residency positions among U.S. graduates (42%), according to a study in the Sept. 10, 2008 Journal of the American Medical Association. The highest? Radiologists and orthopedic surgeons.

And what will happen if we do approach universal access? The goal is to provide adequate access to primary care. The way to accomplish that is to close the compensation gap.

Yes, that may mean limiting the use of med tech's miracle devices. (And it certainly means curbing unnecessary uses and over utilization;on that, there seems to be some consensus according to an article in HealthcareIT News.)

It's becoming increasinglyclear, according to the Dartmouth Atlas of Health Care, that high healthcare costs don't necessarily correspond to better outcomes. I'm certainly not the first to bring this up. For those so inclined, I recommend Dr. Atul Gawande's recent New Yorker article. Evidently, it's alsorequired reading at the White House, according to a New York Times article.)But the solution may not come out of the current health reform package. Specialists won't want to lose income, and Congress probably won't want to take them on. And there is a battle shaping up between specialists (or, at least, proceduralists) and generalists. Blogger Kevin Pho, aka Kevin MD,shows just how sharply the lines are drawn.

Just another tool in the toolbox?

It's a battle that also could pit device makers against primary care docs. But it shouldn't. Costly procedures and tests often are not the best tools for promoting good health or reducing healthcare costs.

As I wrote a few weeks ago, medical technology is astonishing. And policy makers need to understand that. But we all need to understand that the devices med-tech companies create are tools to be deployed strategically, not as a matter of routine.

Specialists should not profit from ordering unnecessary tests and procedures, and med tech companies should discourage such behavior. It's not just the right thing: Judiciousness is enlightened self interest – especially in this era of heightened scrutiny. ("Scrutiny of device industry unlikely to ebb anytime soon." MDD, June 5, 2009.)

Beyond sound bites

Here's what I believe: Generalists shouldn't be penalized because they practice cognitive medicine. We give lip service to prevention, but the disparity in compensation suggests we aren't true believers. But while we must focus more strongly on prevention and cognitive care, patients should not be denied access to essential – albeit costly – medical technology. Sounds fair, right? But how do we make such determinations.

People much smarter than I are working on the answers. Complex compensation and reimbursement issues are not adequately addressed in political sound bites or 750-word essays. What it comes down is this: Unwittingly, med-tech has contributed to the primary care crisis. But by encouraging wise use of its often-amazing technology – and discouraging overutilization – it can be part of the solution.