The Center for Medicare and Medicaid Services, CMS, recently announced that it will be funding an additional 440 residency positions in 135 hospitals in 37 states. This is a good thing, and a step in the direction of reducing the glaring shortage of physicians in the US. CMS already funds most of the residency positions, something which is probably not intuitively obvious to those not involved in post-graduate medical education, but it is so even if it is not clear why (as opposed to, say, Congress directly appropriating such funding). This is important because while you are a doctor (physician) on graduation from medical school, you can’t obtain a license to practice anywhere without residency training (e.g., family medicine, pediatrics, surgery, psychiatry, radiology, etc.). Thus, past efforts to increase the number of physicians by increasing the number of medical schools (or the class size in existing medical schools) fail, because the residency pipeline has been static. It has only, perhaps, decreased the number of international medical graduates filling those positions.
CMS further states, per this piece in MedPage Today, that 2/3 of those slots will be in primary care and psychiatry, two areas in which the shortage of physicians and other clinicians is particularly acute. This is also good, but will continue to have limited impact, at least until we see exactly which specialties are getting those positions. “Primary care” is not a specialty in which there is a residency; usually the term is used to include family physicians, general pediatricians, and general internists (as well as those general practitioners who completed only one year of post-graduate training, ie., internship, when that was sufficient to receive a license). The problem is mostly with internal medicine. After completion of a 3-year internal medicine residency, the large majority (about 80%) of graduates go on to complete a fellowship in an internal medicine subspecialty (cardiology, nephrology, pulmonary medicine, endocrinology, etc.). They do not practice primary care. In addition, about half the remainder become hospitalists, caring for people in the hospital only, leaving only a small number of internal medicine residency graduates to practice primary care. While many pediatrics graduates also sub-specialize or become hospitalists, the percents are much lower. On the other hand, about 90% of family medicine graduates practice outpatient primary care. In addition, it likely includes OB/Gyn which is not primary care.*
It would be good if we could get an accurate accounting. There are “general medicine” or “primary care medicine” residency programs among the internal medicine programs which produce higher percentages of primary care outpatient practitioners -- but still not all, or even close to the 90% of family medicine. We need to know if the new CMS positions that are designated “primary care” include internal medicine; if they do, obviously the output, the number of new outpatient primary care doctors, will be significantly lower. Why should they be unclear about this? It is in the interests of many institutions to keep it fuzzy. Medical schools have long reported on the percent of their graduates entering primary care, and they have included all those entering internal medicine (and sometimes OB/Gyn or even Emergency Medicine) as well as pediatrics and family medicine, inflating the percent that is ostensibly primary care. This practice has been called “the Deans’ lie”. The Association of American Medical Colleges (AAMC), quoted in the MedPage Today piece, has a similar reason to obfuscate the truth; their members are those same medical schools (and the teaching hospitals associated with them) and their leaders, both in AAMC and in the individual schools, are overwhelmingly non-primary-care subspecialists.
One of the main reasons for the shortage of primary care physicians, and thus this purposely-inaccurate effort to paper over the dearth of them, is that, while physicians overall make much more than the average person, there is a great disparity in income between the specialties, often being 4-5 times as much for certain specialists as others. The shortage of primary care physicians and psychiatrists that this change is making a small effort to rectify is very likely because pediatricians, family physicians and psychiatrists are on the low end of the physician income scale. The table below, from “PhysiciansThrive.com”, is one example, although it may actually understate the income of the top specialties.
The lowest-paid physicians are doing well compared to most Americans, but they often come out of school with $250K + debt, which is, of course, owed with compound interest. The income gap between specialties has to be narrowed, and some studies suggest that if primary care physicians made 70% of what other specialists do, money would largely cease to be an issue in student specialty choice. But how could we do that? Isn’t it really complicated?
Well, not as much as you might think. A recent installment of the New York Times feature “The Ethicist” responds to the question from a reader “Should I Feel Bad About Joining a Concierge Medical Practice?”. This in itself is a complex, but separate, question. However, the Ethicist notes in their response that one of the reasons it is hard to find a primary care physician is that
‘Medicare, which effectively anchors compensation levels throughout the health-care system, reimburses physicians according to “relative value units,” and those are largely determined by an advisory committee dominated by specialists. Procedures are valued more than conversations.’
I was surprised to see this addressed in this column; while it is absolutely true, it is rarely discussed. The comment makes 3 points which together drive the income disparity:
1. CMS sets reimbursement rates for Medicare, but it essentially drives all reimbursement as insurance companies use Medicare rates (or multiples of them) to determine their own payments.
2. These Medicare rates are set by “relative value units”, or RVUs, so that some sort of equivalence can be made. For example, how many comprehensive examinations by a primary care doctor or assessments by a psychiatrist or chest x-ray interpretations by a radiologist is worth one gall bladder removal by a surgeon or joint replacement by an orthopedist? This is essentially dividing up a pie of set size; when one “gains” another “loses”.
3. While CMS sets these RVU ratios, they usually rely upon the recommendations of a little-known group called the “RUC”, appointed by the AMA. As the Ethicist notes, this committee is overwhelmingly specialists. And, so, not surprisingly, the distribution of the pieces of the pie tend to favor those specialists, and, indeed, procedures are valued more than conversations. And “conversations” kind of minimizes the communication between people (patients) and their primary care doctors, as people’s stories greatly inform both the diagnosis and the best treatment (and the one the patient is going to accept and follow through on), and are essential for the patients to know what is going on. And presumably interactions with psychiatrists are more than simple “conversations”. (I have written about the RUC several times, including Doctors' incomes and patient coverage: both need to be more equal, Jan 26, 2014 and Pay primary care more: Kennedy may be getting this one right!, July 23, 2025.)
So there is a clear-cut way to fix these disparities: CMS simply needs to adjust the RVU basis, increasing the value of “conversations” and really thinking and assessment and decision making relative to procedures. Of course, this means the highest-paid subpspecialists would make less than they do now, and so they are going to fight it, as are their organizations and groups like the AAMC. But really, even if they take a significant cut, they are a long way from the Food Bank!
The question is: Will CMS do this? Pressure from you, the people who can’t get into a doctor, is definitely going to help!
*Primary care is comprehensive care of the needs of the patient, with referral to specialists when needed; internists and geriatricians and pediatricians limit the ages of their patients but they provide comprehensive care for them. While some women only see an OB/Gyn, they only provide care for a woman’s reproductive tract, not comprehensive care.
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