V.A. Physicians Are Not the Problem

article-1371907-0B6BD62D00000578-139_468x317What has been seen as a serious problem with the care given at our Veterans Administration hospitals is not really a V.A. problem, although the Veterans Administration is being battered by the media and politicians seeking publicity. The vast majority of veterans are quite content with the care they receive at the V.A. and the quality of the physicians. Their main gripe is the time they have to wait in order to get to see their physicians.

I am a Vietnam veteran who developed lymphoma. I am being followed by a primary care physician and oncologist at the West Haven V.A. in addition to being in an experimental trial being conducted at Weill Cornell Hospital in New York that has arrested my disease. My local oncologist also participates in my care. However, the care I have received at the V.A. is top-notch and I have obtained all my medications (16 different pills) from the V.A. in a timely fashion over a number of years.

There seems to be little question that some data regarding appointments and waiting times were falsified by administrators (and possibly some physicians) at certain V.A. facilities to hide the inadequacies at these hospitals and bolster their standings. However, the vast majority of V.A. physicians were not involved in this deception.

The problem being seen at the V.A. regarding appointments is actually systemic in origin involving medical care in general and has been going on for years. There are just not enough primary care physicians to service the American population (as well as veterans) and they are not being paid adequately. Because of this, the number of primary care physicians will continue to decrease relative to the population in the future. And the Affordable Care Act will only exacerbate the situation as more Americans who were previously uninsured will now have coverage and can seek medical care.

A survey on medical compensation conducted by Medscape in 2013 showed orthopedists at the top of the heap with an average annual salary of $413,000. Other well-paid specialties near the top included cardiologists, urologists, gastro-enterologists, radiologists, and dermatologists. Primary care physicians, who work long hours as the main caregivers and are the bulwark of the system, are among the most poorly paid physicians. The average annual pay for an internist is $188,000 and for a family medicine doctor is $176,000. Not surprisingly, a large number of these physicians feel they are not being fairly compensated.

57% of internists spend more than forty hours per week in patients care and another 5-9 hours or more in paperwork and administrative tasks. The majority of PCPs spend 13-20 minutes with each patient they see.

So the problem is not because there are not enough primary care physicians at the V.A. but because the nation does not have enough of them overall. And the situation will only deteriorate further unless profound changes are made is the system of remuneration for physicians. There is no reason why orthopedists and other subspecialists should be making more than twice as much as primary care physicians when the latter provide just as valuable a service (if not more so) in the medical care which they provide.

Interestingly, when asked whether they would choose medicine again as a career, internists were at the top with 68% saying they would make this choice. However, they were at the bottom in saying they would choose a different specialty than internal medicine and were also near the bottom in affirming their overall career satisfaction.

While compensation may not be the main reason medical students choose internal medicine as a career, they have families to raise, loans to pay off, college costs for their children to consider, and so forth. If America wants to guarantee a steady supply of primary care physicians in the future for general care as well as for the V.A., the way we pay our doctors must be transformed dramatically.

So don’t blame the long waits for care at the V.A. on the physicians there. There just aren’t enough of them. (Congress could fix this situation quickly by increasing PCP pay at the V.A. and allotting funding to recruit more doctors. Don’t hold your breath waiting for this to happen.)

Resurrecting Democracy

www.robertlevinebooks.com

Author: ROBERT A. LEVINE, TMV Guest Voice Columnist

Political junkie, Vietnam vet, neurologist- two books on aging and dementia. Last book on health care reform- Shock Therapy for the American Health Care System. New book on the need for a centrist third party- Resurrecting Democracy- A Citizen's Call for a Centrist Third Party- will be available early October 2011

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11 Comments

  1. So, whats keeping the medical business from paying them more? Supply and demand laws would seem to apply here.

  2. Is there a differntial between VA physician pay and the private world?
    When the Shinseki firing broke, I googled his pay which was the same as other Cabinet officers at just under $200 000. The pay for a single hospital CEO is around $380 000. Hospital system CEO’s get 2 to 8 megadollars depending on the system size. Image what the debate would be if Obama asked for a two million a year salary to attract a highly qualified hospital system director to run the VA…after all you get what you pay for.

  3. Slamfu’s comment came in while I was typing mine.
    Supply and demand do not govern physician pay. It is governed by a system, called RVS, that divides medical procedures up and determines their “relative value.” This system tries to figure out how to divide up the Medicare pie by deciding that a brain surgery is worth some multiple of a gall bladder surgery or a primary care office visit. The values are decided by a AMA committee called RUC. Medicare accepts the RUC decisions; they don’t have to but always do. Since Medicare is the largest payor, everybody follows their lead. The RUC is a voting body with a lot of surgical specialists on the committee. To no one’s surprise this leads to more for surgical specialists and less for others including primary care. In my opinion, general surgeons who often do lengthy life saving procedures in the middle of the night are getting the short end of the stick compared to others such as orthopods who do primarily elective things.
    Like much of our economy, it has little to do with free markets. Markets in America are shielded by laws, regulations, patents, and political clout. The free market is an abstraction that does not exist in reality.

  4. The more I find out about the AMA, the more I think they are a huge part of the problem. They are not elected, yet wield an unbelievable amount of authority over the biggest, most important industry in this country. Who the hell are these guys and from where does this authority over dispensing medical resources come from?

  5. The problem began before the relative value system. Previously insurance companies typically paid significantly more for procedures as opposed to general office calls. The conventional wisdom back then was that primary care physicians had to do a lot of office procedures to make a living.

    The situation has actually improved since the change to relative values. The trend has been to increase the value for evaluation and management services (such as office calls) while decreasing the relative values for procedures.

    This has led to some improvement but it was still limited. The discrepancy in pay between primary care doctors and procedure-based specialties has decreased, but is still significant. Much of this is politics as those who would see their income decrease naturally put up the biggest fights over changes.

  6. “. (Congress could fix this situation quickly by increasing PCP pay at the V.A. and allotting funding to recruit more doctors. Don’t hold your breath waiting for this to happen.)”

    Having worked for the VAMC in Omaha, I can tell you that docs there are hired on at GS15 pay level step one. That’s almost $100k. with every step ( time in) add another 3K or so. That’s comparable to private hospitals and actually better than some.
    Congress may increase their pay by adding hiring bonuses I would imagine, but that is not the only problem. Money isn’t the issue. It is the specialties of the docs they need.
    Gp’s don’t cut it. They need oncologists primarily, then cardiologists, pulmonologists, and internal med. These are very much in demand everywhere…and difficult specialties. We don’t crank out enough of them for that reason.
    Many vets are in extremely poor health and need this type of medical care.

  7. And the Affordable Care Act will only exacerbate the situation as more Americans who were previously uninsured will now have coverage and can seek medical care.

  8. However this will be balanced by aspects of the Affordable Care Act which increase the number of primary care physicians and utilizes resources more effectively. Republicans predict a crisis from insuring more people while more honest health care economists disagree. So far all the Republican predictions have failed to come about.

    Only Republicans would argue that it is a bad thing to have more people covered by insurance.

  9. Hope, and more hope and little change of subject: “Only Republicans would argue that it is a bad thing to have more people covered by insurance.” And they eat their young too. LOL

  10. ? dduck…..most uninsured Americans are Republicans due to not allowing medicare expansion in the Red States….might fall under the category of eating one’s own?

  11. Great rebuttal OS and absolutely on the nose!!

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