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A new survey shows doctors' salaries are slipping, down 7 percent from 1995 to 2003, and even more for some specialties. One group has been especially hard: family practitioners. They were already in short supply and at the low end of the physician pay scale.
NPR's Joanne Silberner reports on what the payment rates mean for the future of primary care medicine.
JOANNE SILBERNER, reporting:
Darlene Lawrence is as close to that old TV Dr. Marcus Welby as a young physician today can get. She does family practice.
Dr. DARLENE LAWRENCE (Family Practitioner): Hi Shay. How are you?
SILBERNER: Everything from pediatrics to geriatrics, to cutting the toenails of older patients. She's a minority physician in a minority neighborhood. The obstetrician for patients like Shay Darby who has come to Lawrence's cramped offices in Washington D.C.
Dr. LAWRENCE: What week is this?
Ms. SHAY DARBY (patient): The 38th.
Dr. LAWRENCE: You ready to have a baby?
Ms. DARBY: Yes.
Dr. LAWRENCE: You sure?
You been having any contractions?
SILBERNER: Lawrence is always on the go. That earned her an income of over $150,000 at first, but...
Dr. LAWRENCE: So my salary now is approximately $50,000, and that is taking into consideration what overhead I have for the staff and going electronic health records, not having to buy paper for charts anymore. So I've done some good things, but I really only take home around $50,000 now.
SILBERNER: Lawrence faces especially high overhead in malpractice costs in Washington. Incomes for other family practitioners across the country have come down too. Ten percent, between 1995 and 2003, according to the new survey from the Center for Studying Health System Change. The $146,000 annual income the survey found doesn't compare well with the $236,000 annual income for specialists.
Study co-author Paul Ginsberg suspects the reason primary care doctors overall are taking a hit is insurance payments.
Mr. PAUL GINSBERG (Author of study): I think it's happening because the structure of payment rates, in a sense, what's paid for a procedure, has not kept up with the realities of medical practice.
SILBERNER: Darlene Lawrence believes the same thing. She gets the same today for prenatal care, supervising labor and delivery, as she did in the mid-1990s. Specialists can make more money by doing more things - more x-rays more biopsies. But Lawrence can't speed up a woman's labor or answer questions about diabetes more quickly.
Analyst Ginsberg says there's not enough payment for the counseling and education that primary care doctors do.
Mr. GINSBERG: We have been inadvertently sending out signals to family physicians, the general internists. We don't value what you do. We don't want you.
SILBERNER: Meanwhile, family practitioner James Dikes of Durham, North Carolina has found a way around the insurance payment limitations. He stopped taking them. His mostly middle class patients have pay up front and apply to their insurers for any payments. Dikes doesn't even take Medicare or Medicaid.
Dr. JAMES DIKES (Family Practitioner): The downside is that the number of patients who can afford to come to see me is diminishing.
SILBERNER: He loves his independence, making enough to be able to spend time with patients. But he feels badly about not being able to treat patients who can't pay. So he does some pro bono work. Dikes provides the same sorts of care as Darlene Lawrence, except for the obstetrics, but he makes money.
Mr. DIKES: Last year I made $144,000, but that is at half-time practice.
SILBERNER: Dikes get $75.00 for the half hour he spends with a patient with a sore throat. Insurers pay Lawrence $24.00 for the same thing. Lawrence can't do what Dikes is doing.
Dr. LAWRENCE: You got to learn to hold on to the pacifier. Yes, because I don't want you to be crying.
SILBERNER: Her patients who couldn't afford services like this circumcision.
Dr. LAWRENCE: Even thought he'll be anesthetized, there will be a little bit of shock like with the cold from alcohol, but he shouldn't be able to feel anything after that.
SILBERNER: There may be hope for doctors like Darlene Lawrence. A spokeswomen for the Managed Care Insurers says since the survey was done some companies have started paying more for the counseling and planning and education services offered by primary care docs. And there is legislation before Congress that would stop the slide of government payments for Medicare patients. But payment improvements, if they happen, will come too late for Darlene Lawrence. She's got a $300,000 medical school debt, and she has to start making money now.
Dr. LAWRENCE: My son is 16, he's going to college in two years. And so I need to have some salary to put away for him.
SILBERNER: So she's taken a $125,000 a year academic appointment with Georgetown University's School of Medicine. She'll still be seeing patients at a Georgetown facility a few miles down the road. She's hoping her patients will follow her.
Dr. LAWRENCE: All right, you're done. You're done, you're done. Get dressed.
SILBERNER: So she can see patients, like this baby she's teasing, grow up. And she can continue to help people like her next appointment.
Dr. LAWRENCE: Have you taken medicine for it, the headaches?
Unidentified Woman: No, I've just been...
SILBERNER: A middle-aged woman with severe headaches.
Joanne Silberner, NPR News, Washington.
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