COST: The Specialists Gap

Just about everybody who writes about health care has weighed in on the relative scarcity of primary care docs (including geriatricians) and the relative abundance of extremely well-paid specialists. Now the Wall Street Journal reports that we are even running low on certain specialists—the ones that don't make as much money.

The Journal story focuses (no pun intended) on neuro-ophthalmologists who treat complex, baffling visual disorders connected to the brain. They spend a lot of time testing, examining and talking to each patient. But our payment system doesn't reward time-consuming low-tech procedures. High-volume and high-tech is the way to go to maximize income. A neuro-opthalmologist has more training than a general ophthalmologist, but he makes about a third less money.

"Many in health-policy circles have focused on how the current health-care payment system is helping create shortages among primary-care doctors, internists and others on the front lines of medicine. But often lost is how the system is endangering some of the country's most highly trained specialties as well," the article continues, citing endocrinologists, rheumatologists, and pulmonologists.

It's even worse when looking for subspecialists who treat kids in fields like pediatric rheumatology. And the system contributes to what the paper called "the relentless rise in health-care costs" by driving patients and doctors alike into more expensive tech-heavy care. And sometimes, doctors have told me, a battery of high tech tests tells you less than you could have learned by sitting down and having a nice long chat with a patient.

Several other bloggers picked up on this item—the Journal's of course, and the Health Care Blog. But we particularly liked Gooznews reminding us that if you let highly paid specialists set payment policy, it really isn't any mystery that the result favors highly paid specialists.

There are a lot of ideas floating around about how to fix the system—bundled payments, pay for performance, medical homes and the like. Not much chance we'll see big changes before the 2008 elections but this needs to be a priority for the next Congress.