Rfk confirmed as HHS secretary and has said he plans to cut CMS physician payments. Are procedural subspecialists about to get hosed?

[NewYorkDoctors]

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That is like saying a shotgun blast to the chest is a reasonable approach to treating lung cancer in someone who has refused treatment. These people aren't looking to fix anything--they are shutting down the NIH/CDC, stopped participating in WHO, going to kill medicaid funding etc etc. Destroying the system wholesale is an approach to forcing change I suppose but I certainly wouldnt be cheering for it.

Well that's one way to look at it.

I look at is as more of "factory resetting a PC to eliminate all malware, spyware, and bad faith actors" and then booting up the PC again and launching it properly.

Or perhaps the medical analogy might be "defibrillating a VFib / VTach to reset the rhythm versus cardioverting an arryhthmia back to NSR?"

The shotgun analogy only applies if there will never be any more funding of any kind to proper medical research every again.

But let's see how things go.

 

[lolthroaway]

hmm I am not quite sure what you are trying to say here. This is not an antagonistic reply. Rather I am just not quite sure what you are saying here.

I do agree with a few of the statements you posted in there. Although I am not sure if you were just pointing these out as talking points in quotations marks as a hypothetical statement or not.

Basically, I hear from ABIM, medical governing bodies, and "leaders of the field" basically that "you all need to do better everyone" when it comes to preventative health. Whether or not RFK is successful or not, I just feel the current/previous "therapeutic inertia" of Medicine as a whole just needs some shaking up.

Anecdotally (because no one is going to run an RCT on this. absence of proof is not proof of absence), i see more success from the (earnest ones that do not push for scam products) social media fitness influencers who sel services for nutrition and fitness guidance and coaching in helping ordinary Americans lose weight than I have from any regular doctors helping them (outside of using GLp1 agonist or bariatric surgery).

End of the day I am against government overreach. But that goes both ways. I do not want the government to ban sugary sodas anymore than I want the government to put GLP1 agonists and statins into the water. I jus want to be able to have my patients receive proper informed consent on everything and be educated. But there is so much "noise" coming from advertisement from big food, big pharma, and big whatever else you can think of.

You seem to have a problem with the sedentary lifestyle and diet of Americans (same), and hope RFK can shake things up. I won't speak for anyone else on the thread, but the issue is that while I agree with him on many of his chronic disease takes, I can't support him when his takes on another aspect of public health (vaccines) goes against medical science; potentially creating another public health crisis. The quotation marks are hypotheticals: if RFK was pro vaccine but questioned the science and sowed doubt around more active lifestyles and healthier eating, I'd be against him because he'd be going against medical science. I was wondering how you would feel. And in a related question, if you saw a 300 pound patient letting their obese kid munch on a Big mac while playing on their phone the entire visit, would you maintain the same non-judgmental or pushy attitude you have toward patients that refuse to vaccinate?

And I'm not trying to be snarky myself here, it's a genuine question. But if you are against government overreach, why be excited about him in the first place? To shake things up he (a government agent) is going to have to swing a pretty big stick to implement any truly meaningful changes. I mean, what will he do about the noise from big "whatever" that won't involve major government intervention?

 

[gutonc]

The shotgun analogy only applies if there will never be any more funding of any kind to proper medical research every again.

But let's see how things go.

Things are going to go spectacularly badly.

 

[gutonc]

You seem to have a problem with the sedentary lifestyle and diet of Americans (same), and hope RFK can shake things up. I won't speak for anyone else on the thread, but the issue is that while I agree with him on many of his chronic disease takes, I can't support him when his takes on another aspect of public health (vaccines) goes against medical science; potentially creating another public health crisis. The quotation marks are hypotheticals: if RFK was pro vaccine but questioned the science and sowed doubt around more active lifestyles and healthier eating, I'd be against him because he'd be going against medical science. I was wondering how you would feel. And in a related question, if you saw a 300 pound patient letting their obese kid munch on a Big mac while playing on their phone the entire visit, would you maintain the same non-judgmental or pushy attitude you have toward patients that refuse to vaccinate?

And I'm not trying to be snarky myself here, it's a genuine question. But if you are against government overreach, why be excited about him in the first place? To shake things up he (a government agent) is going to have to swing a pretty big stick to implement any truly meaningful changes. I mean, what will he do about the noise from big "whatever" that won't involve major government intervention?

Thank you for restating this because your original post was almost completely nonsensical and I couldn't decide if I agreed with you, disagreed with you or thought that I needed to call the county sheriff's office to go do a welfare check on you.

I agree that our public health and medical research systems could definitely use some help. But burning them to the ground isn't the help they need.

 

[collegestud2013]

Procedural specialties will still make more than cognitive. RFK plans to revamp physician professional component reimbursement. Procedural specialties are reimbursed somewhat independently of the professional component. Namely surgeons with huge hospital facility fees, cardiology with hospital facility fees and more recently OBL facility fees, GI with hospital facility fees and ASC facility fees, diagnostic radiology with technical component of radiologic exams. The hospital provides a subsidy to employed proceduralists or private groups with hospital contracts so surgery/imaging can keep running so they can make money off of the facility fees. Facility fees have been going up and even outpacing inflation for the last decade. Private groups with ASC/OBL can additionally do the above without direct hospital involvement.

If RFK targets hospital facility fees hospitals may have a tough time keeping doors open. There will be a huge lobby against this.

Moreover cognitive specialties bill 99213/99214/99215 which can also be billed by midlevels. Midlevels cannot get credentialed to do and bill for procedures that require an OR/anesthesia support in a hospital. (Not talking about small IR procedures like para/thora/biopsy). So I have a hypothesis that decreasing physician professional component reimbursement is going to **** over cognitive specialties more than procedural because cognitive specialties inherently do not have access to the same ancillary revenue streams as procedural. The only exception is oncology. But big pharma will keep lobbying on their behalf and 340b drugs will keep lining their pockets and big pharmas.

The vast majority of procedural physicians are employed and will not get any of these facility fees; the hospital system will keep them. Pay for most procedural specialties (which are being paid for by insurance) can still get cut by CMS if they decide to reimburse the specific procedural codes less (eg assigning lower RVUs or paying less per RVU for a given procedure). It comes down which specific codes get reimbursement cuts.

Given the more recent push to get more med student/residents to go into primary care (to fill in the primary care shortage and to close the pay gap between primary care and surgical specialties), the trend has been to cut reimbursements to procedures typically done by high-paying procedural specialties and reimburse more for office visit codes typically billed by a PCP. A good example of this is the G2211 add on code that outpatient providers can use (which started in 2024).

Hospitals may still be able to subsidize procedural specialties if reimbursements for their professional fees get cut, but how much hospitals decide to subsidize procedural specialties if reimbursements get cut will largely come down to supply and demand (for example how many grads are entering the market from residency/fellowship each year and how many are retiring).

 

[whoknows2012]

This has been a weird thread, to say the least. A couple observations. First off, as many of you are long members of sdn I distinctly remember back in the day the hysteria surrounding the ACA in 2008/2009. You’d think we would’ve had capped salaries at 150k and death panels by now.

I bring that up to highlight an interesting point that was made earlier in the thread about making less money and working less if there are cuts. Can I flip that around and say would those of you who may not be upset making less money (I sure would! I don’t have the option of working less) would you feel the same if instead of cuts we had a public option that insured more patients and invested MORE into public health and therefore reimbursements went down and we made less? This is rhetorical. The point is that if you are a partisan (which for the most part I am) you will likely be ok with the government doing or not doing something that fits your ideology even if there is small personal harm. This is not meant to call anyone out but I believe in the spirit of having these conversations it’s best to try to be objective. I also think this is a good thought experiment to get at what exactly lies at the base of our various opinions on things.

For example. I despise RFK, think he is a quack re; his views on AIDS (hiv doesn’t cause AIDS), vaccines, “natural supplements” autism (separate from vaccines) and SSRIs. On the other hand I generally agree with him on how unhealthy we are as a society.

A lot of the pro healthy lifestyle talking points ( exercise, healthy lifestyle, eating healthier) were literally promoted almost exactly (without the quackery) by Michelle Obama in 2010’s. The Obamas were ridiculed for this issue and many on the right suggested this was government overstepping controlling what they eat. Sugars in soda in nyc is another example. This was called government overstepping. When the left does it is socialist. When the right suggests or does its anything else? This isn’t a political statement. The point here is that what he is spouting isn’t anything new and the only reason those initiatives weren’t picked up by a broader coalition was because of opposition from one political party, their media and many voters. To be fair to the argument above, if RFK through his leadership is able to change public opinion and therefore broader perceptions of what a healthy lifestyle means leading to better health outcomes, this would be unequivocally good! And something no leader political or otherwise has been able to achieve. Color me
Skeptical though.

I’m all for healthy lifestyle. I think that the main reason we are where we are is that there is far too much money in politics, too much lobbying for big corporations, and generations of people who have contributed to our poor health, chronic medical conditions and the propagation of the status quo. I will gladly eat my words but there’s no way that by simultaneously dismantling the federal government, epa, nih, fda cfpb etc that these people will make us healthier, sorry just not buying it. There are good changes that could be made to the nih and fda. There are certainly areas where we can be creative about cutting spending. But this ain’t it …

Rant over

 

[IM_to_ortho_hopeful]

The vast majority of procedural physicians are employed and will not get any of these facility fees; the hospital system will keep them. Pay for most procedural specialties (which are being paid for by insurance) can still get cut by CMS if they decide to reimburse the specific procedural codes less (eg assigning lower RVUs or paying less per RVU for a given procedure). It comes down which specific codes get reimbursement cuts.

Given the more recent push to get more med student/residents to go into primary care (to fill in the primary care shortage and to close the pay gap between primary care and surgical specialties), the trend has been to cut reimbursements to procedures typically done by high-paying procedural specialties and reimburse more for office visit codes typically billed by a PCP. A good example of this is the G2211 add on code that outpatient providers can use (which started in 2024).

Hospitals may still be able to subsidize procedural specialties if reimbursements for their professional fees get cut, but how much hospitals decide to subsidize procedural specialties if reimbursements get cut will largely come down to supply and demand (for example how many grads are entering the market from residency/fellowship each year and how many are retiring).

While the push towards hospital employment is undeniable, ex. Cardiologists are 80% hospital employed in 2025 while it was the opposite in 2010, your argument assumes these specialties are all directly dependent on the hospital to function. That is not necessarily true. The highest earning specialties are private practice spine surgeons that operate in a physician owned ASC. They are able to capture both professional component and facility fees independent of a hospital and oftentimes have multiple ancillaries on top. I have no idea how adding a G code modifier to a cognitive specialty can even remotely compete with this set up lol.