I think your points on primary care are right on. It turns out that specialists do a lot of primary care work as well and get reimbursed at primary care rates for office visits. Perhaps this is because PMD’s are overworked or perhaps we rely on too many consults for medico legal reasons. Most specialists I know however, aren’t spending 30 min with each pt. In fact there are countless examples of orthopedic care that might benefit from increased office vist rates – one can imagine a surgeon taking a half hour to counsel a patient to AVOID a knee scope in a degenerative knee. i think this is one of the best examples. In one of the only examples of its kind, a true randomized placebo trial was published on this in NEJM and there was found to be no difference in outcome for knee scope in pts with joint space narrowing, yet the procedure continues to be done at a very high rate. Why? Because it pays $800-$1000. And it takes ½ hour. In fact there are studies showing that people who get scoped, go on to get a knee replacement sooner. I don’t know if any committee is the solution. Since patients don’t pay their own money, they are not incentivized to ask the right questions or be skeptical enough. And the CMS fixed pie system makes the PMD/ specialist war almost inevitible. Sad. We shouldn’t be fighting with each other, but against these corrupt forces.