Blog | Friday, August 16, 2019

Humongous health care salary disparity is not OK

In 1980 I worked as a nurse's aid for a summer. It was a great job, in its way. I had no training and I worked nights in a nursing home. This meant that I rounded pretty much all night long, helping when people woke up and needed something and changing the sheets of the many incontinent residents. I would feel for wetness, then gently roll up the soiled sheets on one side of the patient, replacing them with clean ones, roll the patient over the lump, wrap up the dirty ones and tuck in the clean ones. (This was before high quality disposable diapers were introduced.) I would walk the lost insomniacs back to their rooms and reassure anxious people. I was paid next to nothing, I'm thinking maybe $6 per hour, but that's what I expected and it paid the rent. For me it was just a stop on the way to a job as a doctor.

Just last week I was at a singing camp with a bunch of people of various ages and backgrounds and got to know a woman who is an EMT (emergency medical technician) in a small community. She goes out on calls throughout her 56-hour shift to see patients who could have anything from a sore toe to a cardiac arrest. Many of the patients she sees she is able to reassure and not transport to an emergency department. Some of them are frequent flyers, people who live with a high level of anxiety about their health and call the ambulance for evaluation sometimes a few times a week. She is able to take their vital signs, check an electrocardiogram if necessary and assess their complaint, giving a recommendation to transport or to stay home. If there is a patient who is unstable or in cardiac arrest, she will accompany the patient to the emergency department after having started an IV and given the appropriate medications. If the patient is close to a cardiac or respiratory arrest she will sometimes place an endotracheal tube and attach the patient to a ventilator. She will then take the patient to the ER (emergency room) where she will help the doctor with the initial resuscitation since she and her colleagues do that sort of thing all the time and the emergency physician may have less experience. She makes $15 an hour. Plus benefits. And time and a half for the number of hours per week over 40, for which she considers herself lucky. She is very thrifty, but this is barely enough to survive.

When she first considered what she wanted to do after graduating from high school, she thought maybe she would be a doctor, but the cost of the education, first a bachelor's degree with four years of being unable to work full time, then four years of medical school followed by three of residency, was beyond what she could afford. She considered going to Europe, where she had family, to get her education, which would have been free. Eventually she decided to get an associate degree at a community college and become an EMT. She's now been an EMT for over 10 years. She likes her autonomy and the fact that her job is meaningful and never boring, but EMT's usually don't grow old in that job and she will need to find something else eventually.

The emergency physician she helps out with critically ill patients probably makes about $400,000 a year, more than 10 times what she does. It's true that the doctor had to complete four years of undergraduate education, four years of medical school and at least three years of residency in which he or she definitely made more than an EMT, though not a whole lot more. The doctor probably had a hefty loan to repay and had to compete for the spot in medical school with some of the highest achieving students at university. Still. This is a ridiculous salary disparity.

Here are some other numbers that are interesting:
1. Nurses, RN's or BSN's (bachelor degree in nursing) make an average of $83,000 per year. This is a four- year course of training in college or sometimes an accelerated three-year course.
2. The average physician's salary is $299,000, but this is a little misleading since it represents quite a range. Orthopedists make over $480,000 and pediatricians around $225,000, women make 27% less than men and some states pay more than others. Physicians who are self-employed make more than those who are employees. But all in all physicians make a lot of money. Per Forbes magazine, physicians have the highest paying jobs in the U.S.
3. The average pay for a nurse's aide is $26,000. Training is a six- to 12-week course after high school graduation or a GED.
4. The average yearly salary for an EMT is about $30,000. Training can take between six months and two years, depending on the level of training and type of program. There are also accelerated immersion courses.
5. The average yearly salary for a licensed practical nurse is $46,000 or so and requires a year of training.

It doesn't seem fair that a physician should make 10 times more than an EMT and I would like it if someone could magically make that shameful fact go away. But it is not going away because I wish it. Salary is determined by many factors, but not whether I personally think it is fair. Doctors get paid well because what we do is highly compensated by patients or their insurance companies. Compensation is high because as a country we have decided that it is OK to pay a lot of money for health care. This is partly because doctors have traditionally been highly respected and so carry significant influence in policy making, but also because innovative medical products such as device and pharmaceuticals are a large part of our economy, including our exports. These contribute to the market share of health care and are part of the revenue stream that allows us to afford to pay so much. (Also other factors … third party payment etc.) Demand for health care is high because there has been successful marketing of our products: high profile cures of dread diseases, the rise of preventive medicine and the devastating consumer appeal of opiates and other habit forming controlled substances. Demand is also increased by the aging of our population. As powerful people get older they need more medical interventions and effectively demand medical advances in order for them to remain powerful. Supply continues to be limited by the high cost of medical education, the years required to complete it and the stress associated with the job. Supply of primary care physicians is even more limited since doctors find that specializing pays more than primary care and is often less stressful.

Doctors' salaries have managed to float high on the waves of supply and demand. EMTs, not so much. EMT pay comes out of city or county budgets that also fund firefighters and police. Their services don't get paid by medical insurance. Nobody actually pays for the services they provide so there is no fat pot of money from which their salaries can come. They beg for a share of a communally funded pot along with the people who try to keep houses from burning down (firefighters) and the people who stand between criminals and those of us who would be their victims (police and sheriffs.) They usually come out with the short end of the stick.

Nurses, LPNs and aides suffer from some of the same problems. They, too, don't clearly generate revenue. They do many things that, if not done, would shut down a hospital or clinic's operation, but their work is not usually paid for by an insurance company (exception: the nurse visit for a minor procedure, but this is usually paid as compensation to the doctor for whom the nurse is working.) When a person's work is not obviously connected to revenue it is hard to make the case for higher pay.

There is a lot of money in health care, for good or bad. Somehow we need to divert it to our EMTs who, despite having less training than we physicians, provide care that would be handsomely compensated if we were doing it. Maybe hospitals should subsidize these services. Maybe EMTs should bill health insurance. I'm not at all sure, but it is not right that the professionals who we depend on to treat life threatening emergencies in the field don't make a living wage.


I just read in JAMA, the Journal of the American Medical Association, that the Center for Medicare and Medicaid Innovation has approved a 5 year experiment in paying emergency medical services for management of conditions which don't lead to transport to an emergency department. This is only for 911 calls, but may result in some improvement in payments. This could also lead to closer communication with physicians and maybe more training for EMTs to allow them to provide more accurate and complete care. This program won't fix the whole problem, but could provide better revenue and maybe higher pay for paramedics.

Janice Boughton, MD, FACP, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.