2.7 Million Reasons There Aren't Enough Primary Care Doctors

Specialists Have a Huge Advantage in Lifetime Earnings

A primary care physician's lifetime earnings are significantly less than a specialist's.

Choosing primary care over a specialty career costs physicians an estimated $2.7 million in potential lifetime earnings and wealth, according to a Duke University analysis.

The study looked at average lifetime income and wealth accumulation of specialist physicians, primary care physicians, physician assistants, MBAs and college graduates.

With 32 million more Americans about to be covered for primary care by the health care reforms, the current shortage of primary care providers may become more acute. Fixing the shortage could require policy changes to reduce this income gap, say Bryan Vaughn and Steven DeVrieze, 2009 graduates of the MBA program at Duke's Fuqua School of Business.

The pair's research, which began as part of a class project in Fuqua's Health Sector Management program, will be published in the May issue of the journal Health Affairs.

Using physician income data from the American Medical Group Association and the Association of American Medical Colleges, as well as publicly reported sources of salary data for physician assistants, MBAs and college graduates, the team created a model to estimate the net present value of career wealth potential for each group. The calculation accounted for years of schooling and work, student loan debt, income and investment income potential.Salary information for cardiologists was used to represent medical specialties as a whole, with the model allowing for differences in training time and residency stipends for primary care physicians and cardiologists.

According to the model, a physician who enters medical school at age 23 and practices until age 65 would have a lifetime wealth potential of $5.2 million as a cardiologist, and $2.5 million as a family medicine or internal medicine practitioner. Average wealth potential for MBAs was $1.7 million, compared to $850,000 for physician assistants and $340,000 for college graduates.

"Previous research has found that pay is an important factor in medical students' choice of career path, especially for those with higher levels of student loan debt," Vaughn said. "Although models can never fully represent reality, this analysis quantifies just how significant the gap between primary care and specialty pay is, especially when viewed in the context of a career that spans many decades."

The team also tested the effects of several possible policy interventions on the wealth gap, including increasing primary care pay and decreasing cardiologists' pay, medical school debt forgiveness programs, and eliminating pay during cardiologists' residency training period.

Increasing primary care physician pay by 50 percent, the most extreme pay change modeled, would reduce the wealth gap between primary care and cardiology from $2.7 to $1 million. Eliminating the wealth gap entirely would require a $148,000 decrease in cardiologists' annual income, or an annual increase of $122,000 for primary care doctors.

"There are many efforts in place to increase the supply of primary care doctors, from adding new training programs to changes in reimbursement practices, but it's clear that successfully addressing the shortage will require a reconceptualization of primary care," said Kevin Schulman, M.D., director of Duke's Health Sector Management program and a co-author of the paper.

The authors note that the primary care shortage will become increasingly problematic in the wake of health care reform. "An estimated 32 million previously uninsured people will gain greater access to care, and will increasingly seek out primary care services, within the next few years," DeVrieze said. "This increases the urgency with which we need to address the primary care shortage."

Bryan Vaughn is currently employed by Laboratory Corporation of America, and Steven DeVrieze works for Quintiles. Shelby Reed of the Duke Clinical Research Institute was also a co-author of the study, which received no external financial support.

The full article "Can We Close the Income and Wealth Gap between Specialists and Primary Care Physicians," including the authors' financial disclosures, is available at http://content.healthaffairs.org/cgi/content/abstract/29/5/933