The primary care reimbursement mess

[MedicineDoc]

Comparison of hourly wage by physician specialty. Probably a bit better than "my friend who is a .... car in the driveway" which is pretty ridiculous. Maybe your neighbor is working or maybe he is cheating on his wife.

Click on third link "medscape" to avoid having to login:

http://www.google.com/m/search?oe=U...alty+and+dollars+per+hour&hl=en&start=20&sa=N

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[deleted87716]

Comparison of hourly wage by physician specialty. Probably a bit better than "my friend who is a .... car in the driveway" which is pretty ridiculous. Maybe your neighbor is working or maybe he is cheating on his wife.

Click on third link "medscape" to avoid having to login:

http://www.google.com/m/search?oe=U...alty+and+dollars+per+hour&hl=en&start=20&sa=N

Not surprising:

Neurologic surgeons, the highest-paid physicians, worked only 1 hour more each week than the lowest-paid internists and pediatricians.

Nonetheless, I'm sure Jack won't let the facts get in the way of a good argument.

 

[deleted87716]

That's an interesting comparison (to global period). However, if the patient returns to the primary care clinic 1, 2, 3, or more times over the next 30-90 days, are each of those clinics reimbursed? or, are they considered care under the global period for the original primary care provided?

If they make another appointment, it's analogous to you doing another procedure.

Relatively few primary care patients are seen more than once in a 90-day period. Those who are also tend to be high generators of uncompensated work in between visits.

 

[JackADeli]

...information was self-reported and cross-sectional, prohibiting findings with regard to causality; 71% of the sample was not accessible for the 3 earlier rounds of data gathering;and the survey response rate was only 53%, and participation rates may vary among specialties...

...Nonetheless, I'm sure Jack won't let the facts get in the way of a good argument.

It's interesting data that does not necessarily equate fact. It also appears to be someone's analysis/interpretation of someone elses study. It is not about arguing. Incomplete data is not the answer to solve anything. It is about trying to get the discussion to be as accurate and complete as possible. I welcome the information. I just don't get why additional information is so unwelcomed by some.

Trying to analyze this individuals analysis is sub-optimal. It is not clear what hours they are speaking to or what information is being provided. I know most of my colleagues in medicine work greater then 40hrs/wk. However, the check stub and calculations for everything from retirement vetment to vacation earned are based on a "40 hour week". This was surprising to me even in residency when my check stub came from the hospital. I was working 80+hrs/wk and yet my check kept showing only 40hrs... even though the residency and hospital were very vigilant to assure I documented those 80hrs/wk. Thus, given this, again, I am not exactly sure how the hours per year were calculated.

Then the issues do arise about when those hours take place. 40hrs/wk by one person is not always the same as 40hrs/wk by someone else. Are the 40hrs Mon-Friday 9-5? Or, are they graveyard shift Mon-Fri? How much is comprised of weekends and holidays? Are they counting the on-call in which the physician comes into the hospital? I don't know the answer and I am NOT claiming any specialties days/hours/etc. I am simply saying those pieces of data are important components to consider.

If they make another appointment, it's analogous to you doing another procedure...

Well, surgeons don't generally have that option. Correct me if I am wrong in understanding what you are saying. But, if you have a patient with a pneumonia come in, get chest film, and started on antibiotics, that is one paid treatment. Now, said patient returns in 2-4 weeks for examination and maybe another chest xray for follow-up. Similarly for diabetes, COPD, CHF, asthma, etc.... That/those is/are another paid "procedure" and not considered as being included in the over-all care package of the original visit?

As a surgeon, I do a procedure. Patient then comes in 5-10 days post-op. That post-op (like the pre-op & in hospital daily rounding) visit is considered part of the over-all care package. Further, any additional visit outward to 90 days is also regarded as part of the over-all care package.

 

[deleted87716]

It's an analogy, Jack.

The point isn't that E&M codes are actually global fees, but rather that they are the only payment we receive to cover all of the non-face-to-face work involved in patient care.

 

[JackADeli]

It's an analogy, Jack.

The point isn't that E&M codes are actually global fees, but rather that they are the only payment we receive to cover all of the non-face-to-face work involved in patient care.

I understand that. My point is that in addition to not getting compensated for non-face to face care, surgeons also are not compensated for additional face to face care provided over the 90 day global period. Our phone conversations, script refills, lab reviews, etc are not compensated (or are felt to be compensated in the original bundle) and our additional face to face examinations and treatments go uncompensated as well. Those are factors that should be considered in the discussions of re-imbursement if the discussion is going to revolve heavily around comparing specialties and their incomes.

 

[deleted87716]

I understand that. My point is that in addition to not getting compensated for non-face to face care, surgeons also are not compensated for additional face to face care provided over the 90 day global period. Our phone conversations, script refills, lab reviews, etc are not compensated (or are felt to be compensated in the original bundle) and our additional face to face examinations and treatments go uncompensated as well. Those are factors that should be considered in the discussions of re-imbursement if the discussion is going to revolve heavily around comparing specialties and their incomes.

Your global fees do compensate you for the costs associated with pre- and post-op care. This is accounted for in the RVUs for the individual CPT codes.

The RVUs for our E&M charges do not include any care rendered outside of the office visit.

That's the difference.

 

[JackADeli]

Your global fees do compensate you for the costs associated with pre- and post-op care. This is accounted for in the RVUs for the individual CPT codes.

The RVUs for our E&M charges do not include any care rendered outside of the office visit.

That's the difference.

We are going in circles and back to my earlier points.

...As for RVUs...They don't really comment on global periods per my quick scan through the slides. However...involve pre-op clinic evals, in process to procedure center/OR, time to administer drugs for concious sedation, then the procedure ~30 minutes, followed by 30 minutes to an hour of recovery, physician re-eval and discharge, +/- return to clinic for post-procedure follow-up. So, to simply lump an operative procedure based on "skin to skin" time is deceptive...

Yes, the RVU value is different between a 30 minute primary care clinic visit and a 30 minute skin-to-skin procedure in part because it is supposed to cover all care associated with said procedure for a global period of 90 days. That is my point as to why it is innacurate to compare a 30 minute skin-to-skin operative time to a 30 minute primary care visit. Of course, we are also talking about how ever many in-patient visits/rounding and any unlimited number of return to clinic visits/follow-ups AND phone calls, script refills, etc, etc....

Correct me if I am wrong. If a patient with pneumonia (or asthma exacerbation, COPD, DM, Hypertension, etc...) is seen in primary care clinic, you are paid for that intial visit. If you (or patient) deems it necessary to return to clinic for follow-up however many times for these problems over the subsequent 30-90 days, you get some additional compensation/reimbursement for those additional clinic visits. This is an important distinction. Thus, there isn't the same sort of global period applied when you provide an episode of treatment. AND, so nobody tries to mis-represent what I am saying, I am NOT saying there necessarily should be a global period. I think there is a great deal of uncompensated care at many levels that needs to be compensated. I am also stating end of year gross check stub comparisons are innacurate as are simple RVU number comparisons without consideration of what care and how much is expected and/or rendered for said RVUs. The actual procedure time/skin-to-skin time provided by a surgeon is often the smallest amount of time/care provided to the patient.

 

[deleted87716]

Medically necessary follow-up office visits are, of course, reimbursable under the E&M system. That's not what I'm talking about. I'm talking about everything that happens in primary care between office visits. For the most part, this uncompensated work is generated in the course of chronic disease management, not so much from acute care.

I am also stating end of year gross check stub comparisons are innacurate as are simple RVU number comparisons without consideration of what care and how much is expected and/or rendered for said RVUs.

Speaking of going around in circles...

It's not the income differences...it's how the income differences have widened over time that's the real problem. Refer to Tom's presentation and to the graphic that I posted earlier.

 

[JackADeli]

Medically necessary follow-up office visits are, of course, reimbursable under the E&M system. That's not what I'm talking about...

But, that is part of what I am talking about. My point is the entire picture in real context should be considered. The original powerpoint takes RVUs out of context and makes comparisons to try and support his position. Medical students and others considering the discussions of compensation and reimbursement should consider the full picture. Taking a snap shot and comparing a procedure's "x" RVU value for 30 minute procedural time to a 30 minute primary care clinic visit for "y" RVU value is deceptive to the uninformed.

...It's not the income differences...it's how the income differences have widened over time that's the real problem. Refer to Tom's presentation and to the graphic that I posted earlier.

I have seen your graphics and his powerpoint and stand by my position as to how he makes his comparisons.... that he opens up trying to compare just the procedural time to a primary care clinic visit to demonstrate differences in RVUs. In his powerpoint, the issue of care provided over the global period seems strangely absent. He also fails to define what the reported hours of work were to be "full time".

 

[MOHS_01]

Comparison of hourly wage by physician specialty. Probably a bit better than "my friend who is a .... car in the driveway" which is pretty ridiculous. Maybe your neighbor is working or maybe he is cheating on his wife.

Click on third link "medscape" to avoid having to login:

http://www.google.com/m/search?oe=U...alty+and+dollars+per+hour&hl=en&start=20&sa=N

I guess that I'll resort to repetition: the argument being made by comparing hourly earnings is not a complete one. There are many variables that account for this final number. I am at a loss as to how this escapes some of you. The number of patients seen per hour, the CPT mix involved, the disease mix and complexity of the patients seen, the efficiency of the individual provider and his/her practice style, the variable overhead costs between physicians, practices, specialties, and locations, etc. The bottom line is that we are NOT paid an hourly wage. We are NOT salaried. We are paid a set amount for any given service. If we were to stick to something standardized, like Medicare, and you see someone with psoriasis, AKs, warts, acne, or a suspected basal cell -- we will all be paid the exact same for any given volume of work. The exact same. If we were to standardize for any given period of time, ensuring that we each provided the same services, the PCP would quite likely earn a higher hourly rate than would I because my costs are higher (for a variety of reasons).

If you were truly concerned with making a valid comparison, you would not choose snippets of information that support your cause ignoring all other factors. Compare the revenue and costs per hour. Compare the total revenue of the practice vs the physician compensation. Demonstrate an understanding that much of medical office overhead is quite fixed in nature.

E&M payment is ****ed up. OK. We have seemingly covered that time and time again. Make the argument that private insurers stick it to PCPs by paying specialists a higher % of Medicare. Make the argument that E&M is undervalued. Make the argument that specific procedures are overvalued (although that becomes problematic unless you have specific knowledge regarding the practice of said procedure). Any of those arguments have the potential to be substantively valid; arguments on hourly "wages" or aggregate totals are not.

I understand that economics, finance, and business management are not exactly the forte of most physicians... which explains the rather elementary comparative arguments being posed, but it would behoove everyone who wishes to comment responsibly to understand some of the fundamentals before throwing things out there. The greatest error to date continues to be the utilization of statistical classes rather than flesh and blood providers in these arguments... an error that has been repeated ad nauseum and to great harm to the very statistical classes they claim to help.

 

[deleted87716]

I have seen your graphics and his powerpoint and stand by my position as to how he makes his comparisons.... that he opens up trying to compare just the procedural time to a primary care clinic visit to demonstrate differences in RVUs. In his powerpoint, the issue of care provided over the global period seems strangely absent. He also fails to define what the reported hours of work were to be "full time".

None of which has anything to do with the issue of the reimbursement gap.

So, are you trying to say that surgery has gotten dramatically more difficult over the last ten years, and that primary care has gotten dramatically easier?

How else do you explain the widening reimbursement gap...?

 

[JackADeli]

None of which has anything to do with the issue of the reimbursement gap.

So, are you trying to say that surgery has gotten dramatically more difficult over the last ten years, and that primary care has gotten dramatically easier?

How else do you explain the widening reimbursement gap...?

Again... just going in circles and declaring a gap. But as stated repeatedly, one needs to examine how the "gap" has been defined. In the powerpoint you presented in this thread, the "gap" seems to be defined by showing a difference in RVU compensation between a 30 minute primary care clinic visit and a 30 minute procedural time devoid of considering the actuall other components considered in the RVUs for said procedure.

So, in the powerpoint (slide 3), he presents the concept of working full time but does not define or standardize what that means despite making a dramatic statement of 17% full time primary care earning under 100K. It's dramatic. But, it fails to describe if this is 40hrs/wk or 80hrs/wk and where and when those hours are spent.

Then, he gives the example of a 30 minute surgical procedure RVUs vs a 30 minute primary care clinic visit may be 10 RVUs vs 2 RVUs respectively (slide 4). It is again a dramatic difference when taken out of context and which fails to consider the global period, the time of pre-op, post-op (in or out of hospital), and any additional care provided over 90 days. The whole RVU comparison is continued to the dramatic slide 8 for the 274% difference for presumably the same 30 minutes of care or amount of work.

Of course slide eleven is where he goes for his money shot. He comments on the RVU composition and global periods, pre-op, follow-up, etc... strangely absent as if not a component. He then minimizes the components of the gastroenterologist work. God forbid I make such an inflamatory comment. Can you imagine the response if a surgeon said a skilled primary care physician can manage DKA almost in their sleep or manage hypertension or community pneumonia with little to no thought? All of which I think are inflamatory and innapropriate and not helpful. By his logic a skilled and experinced practitioner of surgery should be getting paid less because of their increased experience, knowledge, and skill. Then why not the same for a skilled primary care? I think not. I actually believe patients should pay more for the skill and experience of their primary care providers. I also think that when a patient shops for a surgeon and seeks one with special training and/or experience... they should pay more for it.

 

[deleted87716]

the argument being made by comparing hourly earnings is not a complete one.

Agreed. Of course, in fairness to the authors of the study that MedicineDoc referenced, they aren't saying that it is.

Compare the revenue and costs per hour. Compare the total revenue of the practice vs the physician compensation. Demonstrate an understanding that much of medical office overhead is quite fixed in nature.

That's what the RVU system is supposed to do. It fails miserably.

E&M payment is ****ed up. OK. We have seemingly covered that time and time again. Make the argument that private insurers stick it to PCPs by paying specialists a higher % of Medicare. Make the argument that E&M is undervalued. Make the argument that specific procedures are overvalued (although that becomes problematic unless you have specific knowledge regarding the practice of said procedure). Any of those arguments have the potential to be substantively valid; arguments on hourly "wages" or aggregate totals are not.

All of those arguments have been made.

Personally, I think the whole "hourly wage" thing is rather silly. Nonetheless, it makes the same point.

 

[deleted87716]

Again... just going in circles and declaring a gap.

"Declaring a gap...?" Are you graphically challenged?

Take off the blinders, Jack. It's hard to carry on a rational conversation with someone who denies the obvious.

 

[JackADeli]

Again... just going in circles and declaring a gap...

"Declaring a gap...?" Are you graphically challenged?

Take off the blinders, Jack. It's hard to carry on a rational conversation with someone who denies the obvious...

First, to put my original statement into more complete context:

Again... just going in circles and declaring a gap. But as stated repeatedly, one needs to examine how the "gap" has been defined. In the powerpoint you presented in this thread, the "gap" seems to be defined by showing a difference in RVU compensation between a 30 minute primary care clinic visit and a 30 minute procedural time devoid of considering the actuall other components considered in the RVUs for said procedure...

And again, a dramatic graphic with data points and no context. It/you are presenting an end of year gross salary comparison without any information as to what is done for these salaries. That data may be useful but should promote further expansion and analysis that goes deeper to identify what is done for those numbers as well as what care may be going uncompensated.

 

[MOHS_01]

Has anyone thought for a second that maybe some specialties are providing more services now per provider than they were 10 years ago? Maybe the orthopods are doing more joint replacements... derms are clearly doing more elective procedures and skin cancer/pre-cancer procedures than in years past... do GI's have more 50yo's in need of screening now than a decade ago? Are rads reading more studies (ordered by other specialties, I might add) per provider than they were a decade ago? Are these changes proportional to the changes experienced in the PCP office?

I don't know the definitive answer to all of these... and, to be honest, I doubt any of you do either. What I do know, however, is that I am paid less per cancer procedure than I was in 2005 when I started practice. I have dealt with decreasing reimbursements as a percentage of MC since that time as well. My hourly earnings have gone up as have my end of year net, but I am working harder and doing more out of proportion to the gains in earnings. This very well may be the case across the whole of medicine; if so, this infighting is ****ing ridiculous as we are cutting each others' throats... ignoring the real enemy facing us all (the State's attempted annexation of our services).

 

[deleted87716]

Has anyone thought for a second that maybe some specialties are providing more services now per provider than they were 10 years ago? Maybe the orthopods are doing more joint replacements... derms are clearly doing more elective procedures and skin cancer/pre-cancer procedures than in years past... do GI's have more 50yo's in need of screening now than a decade ago? Are rads reading more studies (ordered by other specialties, I might add) per provider than they were a decade ago?

That's a given. All of these services are procedural. The RUC has favored procedural reimbursement over E&M reimbursement for years.

That's the problem!

I am paid less per cancer procedure than I was in 2005 when I started practice.

You're one of the few exceptions. The RVUs for Mohs got reduced a few years back. That hasn't been the case with most other procedures, however.

All of this is in Tom's presentation.

this infighting is ****ing ridiculous as we are cutting each others' throats... ignoring the real enemy facing us all (the State's attempted annexation of our services).

Agreed. So...why don't y'all just stop arguing against the obvious...?

 

[deleted87716]

It/you are presenting an end of year gross salary comparison without any information as to what is done for these salaries.

We know exactly what's being done for those incomes...procedures! Lots of 'em.

Again...this is all in Tom's presentation.

 

[JackADeli]

Has anyone thought for a second that maybe some specialties are providing more services now per provider than they were 10 years ago?...

Yes. And has anyone thought about the fact that some of this surgical care is being provided to ever older and sicker populations. The care could not necessarily be safely provided to previously. Now, we can provide care with additional and more complex management during the peri-operative period. The technical components of the operation may not in most cases have gotten more difficult but the post-operative care continues to increase in complexity. Not really considered in the powerpoint... rather the implications are just the oposite in the powerpoint. The powerpoint suggests, ~ your a good surgeon, experienced, and can do the procedure faster and thus should be paid less for it. The reality is the ability to be faster is a service that should be paid for. The ability to get the patient through an operation with less time under anesthesia is the service paid for when one seeks out a more experienced/skilled surgeon.

We know exactly what's being done for those incomes...procedures! Lots of 'em...

Which means they are doing lots more work to achieve more compensation. To avoid being misquoted, I am saying THEY are doing more work compared to what THEY did preceding years. Are you saying the volume of work they are doing shouldn't be compensated or shouldn't be done?

...So...why don't y'all just stop arguing against the obvious...?

That's humorous.

 

[deleted87716]

Which means they are doing lots more work to achieve move compensation. To avoid being misquoted, I am saying they are doing more work compared to what THEY did preceding years. Are you saying the volume of work they are doing shouldn't be compensated or shouldn't be done?

I'm saying we should all be paid appropriately for what we're doing.

I've never "misquoted" you, Jack. Give it a rest.

has anyone thought about the fact that some of this surgical care is being provided to ever older and sicker populations.

You mean those same "ever older and sicker" patients that I'm seeing in my office?

Clearly, the current system is failing to provide equitable reimbursement to everyone.

 

[bronx43]

Which means they are doing lots more work to achieve more compensation. To avoid being misquoted, I am saying THEY are doing more work compared to what THEY did preceding years. Are you saying the volume of work they are doing shouldn't be compensated or shouldn't be done?
That's humorous.

Are you being facetious or are you just thick-headed? I mean, I really want to know, because I haven't read any post where BD claims more work shouldn't amount to more compensation. It's the reimbursement rate of said unit of service that is the crux of the argument.

 

[JackADeli]

I'm saying we should all be paid appropriately for what we're doing...

You mean those same "ever older and sicker" patients that I'm seeing in my office?....

And I agree, everyone should be getting compensated for their work. I know we provide care that we couldn't ten years ago for sicker populations. Just as IR provides interventional care that they couldn't ten years ago. This has increased not only volume but additionally the actual amount of non-operative peri-op care.

I do not claim to know if such a change in the amount of care primary care can now provide for these populations has occurred and/or has occurred at the same rate. I don't know that primary care is now able to provide increased levels of care that they couldn't provide ten years ago. I do think primary care and others should be compensated for increased complexity of work. I just have not seen it presented that the amount of complex disease and new therapies seen by primary care has dramatically changed over ten years. Again, that is not a statement that this may be or may not be true. That is a statement that I have not seen such data. Anectdotally, the primary care physicians I work with will almost routinely refer their patients for subspecialist management when they do become complex.

I've never "misquoted" you, Jack. Give it a rest...

Then my understanding (and others) of your comments and representations in this and other threads must incorrect.... Maybe terminology is wrong., misrepresentation may be more accurate then "misquote".

We're all well aware of the fact that you think you work way harder and deserve to be paid loads more than any of us...

Well, I never said that...

You really seem to like ...denying that you said what you've said in practically every post you've ever written.

Whatever.

...Jack has never said he works harder and thus should be paid more...

 

[deleted87716]

I don't know that primary care is now able to provide increased levels of care that they couldn't provide ten years ago.

I know you don't. It's obvious.

http://www.internalmedicinenews.com...tes-fell-24-from-1999-to-2008/8a6fe9467d.html

Major Finding: The age- and sex-adjusted incidence of acute MI decreased by 24% between 1999 and 2008.

The researchers said that the declining incidence of MI in the study population can be attributed at least in part to "substantial improvements in primary-prevention efforts" implemented at Kaiser. The decline occurred "despite the increased sensitivity of new biomarkers for the diagnosis of myocardial infarction" and the increasing prevalence of obesity and diabetes.

For those of you who don't already get it, that means better primary care.

 

[JackADeli]

I know you don't. It's obvious.

More snide remarks, very helpful.

We know exactly what's being done for those incomes...procedures! Lots of 'em...

So, yes, we are doing more operations. We are doing it for sicker populations then we had ten yeasr ago and in higher volumes. This represents increased volumes of both operative and non-operative work we are providing for this increased income. The powerpoint and the graph you have provided does not provide any information in relation to primary care. It doesn't show increased volumes of complex care being provided by individual primary care physicians. You or the powerpoint does not comment that primary care physicians are now providing complex care they couldn't provide ten years ago... I think such information would be useful for the discussion. If other specialists are seeing marked increase over ten years in their gross income because of marked increase in services provided, it seems to try and compare primary care one would demonstrate a similar trend/upward slope of services and/or complex care provided by individual primary care physicians.

There are subspecialists that are assuming care for more complex chronic diseases. As I mentioned, the primary care physicians I work with will almost routinely refer complex management issues to other subspecialists, i.e. geriatrics, adolescents, pulmonology, cardiology, urology, Gyn, etc....

 

[deleted87716]

The powerpoint and the graph you have provided does not provide any information in relation to primary care. It doesn't show increased volumes of complex care being provided by individual primary care physicians. You or the powerpoint does not comment that primary care physicians are now providing complex care they couldn't provide ten years ago... I think such information would be useful for the discussion.

All of medicine is more complex than it was ten years ago. Do you seriously think that the only doctors who are treating more complex patients are specialists...?

If other specialists are seeing marked increase over ten years in their gross income because of marked increase in services provided, it seems to try and compare primary care one would demonstrate a similar trend/upward slope of services and/or complex care provided by individual primary care physicians.

If reimbursement wasn't completely f'd up, you would.

the primary care physicians I work with will almost routinely refer complex management issues to other subspecialists, i.e. geriatrics, adolescents, pulmonology, cardiology, urology, Gyn, etc....

OM f'in G. Has anyone said that specialists weren't necessary...? The fact that we sometimes involve specialists in the care of our patients does nothing to reduce their complexity. Most of my CAD patients see their cardiologist once a year. Who's really managing the patient? Whose office do you think they end up in when the meds the cardiologist started them on cause side effects?

I hope you aren't as dense IRL as you come across online, I really do.

 

[JackADeli]

All of medicine is more complex than it was ten years ago. Do you seriously think that the only doctors who are treating more complex patients are specialists...?...

Never said that. Again, now we go down the path in which you try to destract and misrepresent what I have written. To assure appropriate context:

... I do think primary care and others should be compensated for increased complexity of work. I just have not seen it presented that the amount of complex disease and new therapies seen by primary care has dramatically changed over ten years. Again, that is not a statement that this may be or may not be true. That is a statement that I have not seen such data. Anectdotally...

...The powerpoint and the graph you have provided does not provide any information in relation to primary care. It doesn't show increased volumes of complex care being provided by individual primary care physicians. You or the powerpoint does not comment that primary care physicians are now providing complex care they couldn't provide ten years ago... I think such information would be useful for the discussion...

...If other specialists are seeing marked increase over ten years in their gross income because of marked increase in services provided, it seems to try and compare primary care one would demonstrate a similar trend/upward slope of services and/or complex care provided by individual primary care physicians...

...If reimbursement wasn't completely f'd up, you would....

I don't see how messed up reimbursements prevents you or others from presenting that information so more accurate comparisons are made.

...OM f'in G. Has anyone said that specialists weren't necessary...? The fact that we sometimes involve specialists in the care of our patients does nothing to reduce their complexity. Most of my CAD patients see their cardiologist once a year. Who's really managing the patient? Whose office do you think they end up in when the meds the cardiologist started them on cause side effects?....

Again not what I said. I am not speaking or implying for all primary care. As I stated, my experience was anectdotal. But, other then the powerpoint and your graph, you haven't presented very much on specifics in regards to either less, the same, or more volume of complex and/or new care being provided at the primary care level. You have made the comment that surgical specialists are doing more cases.

We know exactly what's being done for those incomes...procedures! Lots of 'em...

...I hope you aren't as dense IRL as you come across online, I really do.

And, let us close it off with the BD classic of insults and snide remarks.... yep, good for conversation and working together.

 

[deleted87716]

And, let us close it off with the BD classic of insults and snide remarks.... yep, good for conversation and working together.

It would only be an insult if it wasn't true. And, you have no idea how thankful I am that I don't have to work with you.

 

[JackADeli]

...I hope you aren't as dense IRL as you come across online, I really do.

It would only be an insult if it wasn't true. And, you have no idea how thankful I am that I don't have to work with you.

As I said, "and, let us close it off with the BD classic of insults and snide remarks.... yep, good for conversation and working together.". Yep, your choice of resorting to such commentary and attacks is at least consistent. Great for "rational" conversation...

 

[deleted87716]

Great for "rational" conversation...

I've given up hope for that.

 

[MedicineDoc]

to mohs. It to me longer to delete your reply than type my own which couldn't be posted under your reply as it was so long.



I won't play your game. You May impress yourself with your verbosity and feel as if you seem pretty smart but the impression you leave with me is quite the contrary. The sky is in fact blue and I don't need 1000s of words to prove it. I would rather carry on a conversation with a parrot than go back and forth with you and am fairly certain the conversation with the parrot would be much more educational.

 

[MOHS_01]

 

[loveoforganic]

To get this somewhat back on track...

Gross income as a measure for comparing income disparity is about as good as BMI for obesity. It's quicker and easier than alternative measures, but it comes at a cost of missing some important criteria. I think BD's ppt used "full time" as an equator between the fields of work, but it seems like "full time" isn't necessarily a well defined construct.

What would a fair income analysis be?

Gross income with adjustments for overtime, holiday work, early am/late pm work? How do you adjust for amount of call time? Are salaried workers excluded from analysis, considered separately, etc.?

 

[deleted87716]

I think BD's ppt used "full time" as an equator between the fields of work, but it seems like "full time" isn't necessarily a well defined construct.

What would a fair income analysis be?

Gross income with adjustments for overtime, holiday work, early am/late pm work? How do you adjust for amount of call time? Are salaried workers excluded from analysis, considered separately, etc.?

"Full time" generally means ~40 hours/week or more, although the Department of Labor hasn't defined what "full time" means in legal terms. It's up to the employer.

None of that other stuff matters, because none of it has anything to do with how reimbursement is determined. Reimbursement is determined by RVUs. Period. You can wax philosophical about length of training, amount of call, whether or not you work days or nights or whatever else.

It. Just. Doesn't. Matter.

It's all about the RVUs.

RVUs + volume = income.

 

[loveoforganic]

"Full time" generally means ~40 hours/week or more, although the Department of Labor hasn't defined what "full time" means in legal terms. It's up to the employer.

None of that other stuff matters, because none of it has anything to do with how reimbursement is determined. Reimbursement is determined by RVUs. Period. You can wax philosophical about length of training, amount of call, whether or not you work days or nights or whatever else.

It. Just. Doesn't. Matter.

It's all about the RVUs.

RVUs + volume = income.

I know what it generally means, but it seems there's some dispute as to what it means in the ppt.

What you said at the bottom is part of what I'm getting at. Volume is proportional to time. As far as amount of call and day/night, I don't think that's waxing philosophical. It's pretty standard practice across professions to increase reimbursement for those types of things.

On an unrelated note, more directed at MOHS, even though the real reasons for these arguments are essentially PCP's are unable to bill fairly for their work and should thus have RVU's for their work redefined, it's always ultimately going to involve comparisons with other specialty's incomes and altering their RVU's as well. Limited $$$ to go around, etc.

 

[deleted87716]

Volume is proportional to time.

Within reason, yes. However, as noted in the PowerPoint, there's a point beyond which you can't increase volume without compromising care.

As far as amount of call and day/night, I don't think that's waxing philosophical. It's pretty standard practice across professions to increase reimbursement for those types of things.

Nonetheless, it's not directly accounted for in determining RVUs.

 

[MOHS_01]

More fleshed out post to follow, but you are correct -- as long as we are going to have a federal commissary set pricing, some resource based relative value unit system is probably the best we can do. This is what I have argued for the duration of my time here; the system, while imperfect, is the best that anyone has been able to formulate to date. There are and will continue to be arguments about what is a "fair" RVU valuation, but unless someone can propose a better methodology for determining the cost to provide any given service.... we will continue to be stuck with this Soviet planning system.

 

[deleted87716]

For those interested in reading more about the RUC:

http://online.wsj.com/article/SB10001424052748704657304575540440173772102.html

http://www.studentdoctor.net/2010/1...-has-outsized-influence-on-medicare-payments/

...and the Independent Payment Advisory Board (IPAB), part of the recent health reform legislation, which would give the Government even more control over Medicare spending:

http://healthpolicyandreform.nejm.org/?p=3478

http://www.ama-assn.org/ama1/pub/upload/mm/399/hsr-payment-advisory-board.pdf

 

[JackADeli]

...I think BD's ppt used "full time" as an equator between the fields of work, but it seems like "full time" isn't necessarily a well defined construct.

...Gross income with adjustments for overtime, holiday work, early am/late pm work? How do you adjust for amount of call time? Are salaried workers excluded from analysis, considered separately, etc.?

Those are all points I have tried to raise as to the accuracy of that presentation. There are clearly differences in what individuals are doing for their incomes. Thus to simply look at check stubs at the end of the year and declare a disparity or to look at rates of increase in income between professionals and declare a disparity without looking deeper and analizing it further is deceptive. Also, failure to identify what those differences are makes it difficult to appropriately identify possible disparities and appropriately address possible disparities.

"Full time" generally means ~40 hours/week or more, although the Department of Labor hasn't defined what "full time" means in legal terms. It's up to the employer.

None of that other stuff matters, because none of it has anything to do with how reimbursement is determined. Reimbursement is determined by RVUs. Period. You can wax philosophical about length of training, amount of call, whether or not you work days or nights or whatever else.

It. Just. Doesn't. Matter.

It's all about the RVUs.

RVUs + volume = income.

Correct, my point exactly, "full time" generally refers to 40hrs or more per wk. Thus, pointing out a percentage of individuals' salaries with the generalization of "full time", while on the surface may be striking, can be deceptive. Maybe the individuals full time is 40hrs/wk and the comparative group is 80+hrs/wk.

Yes, the compensation/reimbursement is based on the RVU system. Again, the issue I have pointed out is that trying to make comparisons on RVUs as was done early in the ppt is innacurate or decptive. The ppt made the comparison of 30 minute operative procedures to 30 minute primary care visits. Then described a difference in RVUs paid. The problem as noted is that the RVUs for the procedure are to cover the "global period" and all care during said 90 day period. Thus, while not directly stated, this is to cover additional hours/days/nights/weekends/etc...

Specific volume of RVU does result in income. If one group wants additional RVUs, I think a closer analysis of the composition of what others are doing is required. If surgeons are doing lots of procedures, which equals volume, which equals increased hours and days and call, etc.... that should be considered in the discussion. RVUs are not just in a vacuum.

...In the powerpoint you presented in this thread, the "gap" seems to be defined by showing a difference in RVU compensation between a 30 minute primary care clinic visit and a 30 minute procedural time devoid of considering the actuall other components considered in the RVUs for said procedure.

...(slide 3), he presents the concept of working full time but does not define or standardize what that means despite making a dramatic statement of 17% full time primary care earning under 100K. It's dramatic. But, it fails to describe if this is 40hrs/wk or 80hrs/wk and where and when those hours are spent.

...the example of a 30 minute surgical procedure RVUs vs a 30 minute primary care clinic visit may be 10 RVUs vs 2 RVUs respectively (slide 4). It is again a dramatic difference when taken out of context and which fails to consider the global period, the time of pre-op, post-op (in or out of hospital), and any additional care provided over 90 days. The whole RVU comparison is continued to the dramatic slide 8 for the 274% difference for presumably the same 30 minutes of care or amount of work.

Of course slide eleven ...He comments on the RVU, composition and global periods, pre-op, follow-up, etc... strangely absent as if not a component. He then minimizes the components of the gastroenterologist work...

Again, doesn't make much sense the extent to which some are unwilling to even consider as part of the discussion additional factors that ARE a part of these considerations. The whole picture should be considered.

 

[deleted87716]

Maybe the individuals full time is 40hrs/wk and the comparative group is 80+hrs/wk.

Try 58.2 hours/wk. for general surgeons ( http://residency.wustl.edu/medadmin/resweb.nsf/L/FF39528F9FE236A286256F8F0072D3AE?OpenDocument )

...and 50.96 hours/wk. for family physicians ( http://www.aafp.org/online/en/home/aboutus/specialty/facts/14.html ).

Do you really think that extra ~7 hours/wk. adequately explains the difference in incomes between the two groups? I don't.

 

[JackADeli]

Try 58.2 hours/wk. for general surgeons ( http://residency.wustl.edu/medadmin/resweb.nsf/L/FF39528F9FE236A286256F8F0072D3AE?OpenDocument )

...and 50.96 hours/wk. for family physicians ( http://www.aafp.org/online/en/home/aboutus/specialty/facts/14.html ).

Do you really think that extra ~7 hours/wk. adequately explains the difference in incomes between the two groups? I don't.

Thank you for the information. Is it so hard to discuss with you a topic without your response implying I am saying or thinking something that I am not. I didn't say that nor do I think 7hrs more per week explains the difference in gross incomes compared at the end of the week.

The AAMC average presented on that webpage again may very well be out of context... Often, average hours per week published excludes hours outside of office and regular scheduled OR times. They will often fail to account for trips into the hospital and/or graveyard and or weekend/premioum times. Is that what the AAMC source being cited used? I don't know.

My point has been that accurate information should be presented and considered. The ppt that was put together should include accurate information and citations as to what said information actual pertains to.... Instead it appears to have presented incomplete data points for drama effect.

 

[deleted87716]

I didn't say that nor do I think 7hrs more per week explains the difference in gross incomes compared at the end of the week.

No, you suggested that one group could be working twice as many hours as the other. Clearly, that isn't the case.

The AAMC average presented on that webpage again may very well be out of context.

You can't just keep saying "out of context" every time the data doesn't support your argument. If you have better data, post it.

 

[MOHS_01]

A few things to keep in mind:

For much of CPT no single specialty holds a monopoly on the delivery of any given code. Sure, orthopods do most (if not all) of the joint replacements, neurosurg WTF ever it is they do, and derm provides the bulk of the micrographic surgery -- but we all provide E&M. Many specialties provide skin biopsies, local destructions, excisions, etc. It has to be appreciated that changes will not always have their desired effects; for example, boosting E&M reimbursement will have a more significant impact for high volume specialties (such as derm) more so than it will for specialties who deal with more complex / complicated / or intensive patients. Decreases in the RVU value for biopsies, excisions, local destructions, etc will have a greater impact on derm, but they will also have an impact on any specialty who provides those services. Bottom line is that income redistribution within medicine is not as simple and straightforward as some of our more simple and straightforward individuals proclaim.

on edit -- the reason that the above is important is the way the RUC works; codes undergo periodic (generally 5yr reviews, shorter time periods if CMS believes they are "overvalued" and thus driving too much utilization). Since many specialties provide some codes, the practice expense and physician work components will not always be equitable between specialties or providers. It may well be that it costs more for a PCP to perform a biopsy, destruction, or level 3 E&M than it does the dermatologist because the dermatologist has efficiencies of scale and a larger revenue/hr backdrop -- or vice versa if the dermatologist has a higher overhead/hr than the PCP, etc.... something that would be exceedingly difficult to factor in or otherwise account for within the confines of the RUC system.

It is equally important to realize that a ton of variables factor into the median income figure... and while CPT mix is a major component, it is by no means the only one. Workforce demographics, practice arrangements, and the income distribution within any given specialty varies significantly. For example, dermatology has amongst the highest percentage of solo practitioners for any specialty; we also have a very high single specialty percentage. These things, taken together, have the net effect of skewing the median higher for any given level of revenue; if we had a higher MSG mix our numbers would invariably be lower. If you have any reason to doubt this, one of the more useful sets of data reported by the MGMA is the compensation per RVU for different practice settings by specialty.

Lastly, there is no great single metric for determining the "fairness" of compensation because there is no way to control for these myriad of variables. If we are to go on median incomes alone we would at least have to study the distribution of income, RVUs produced, total revenues, and compensation per RVU within each repspective specialty... We must continue to reward productivity and efficiency in some way as people should be paid for the amount of quality services they provide. The real problem is in the valuation of the units of service... which is what the RVU system was designed to address. It's not perfect, that's for sure, but I have not heard a better plan to date (other than forgoing the whole CPT system and direct billing patients for the service provided, which is a pipe dream today for most).

 

[deleted87716]

one of the more useful sets of data reported by the MGMA is the compensation per RVU for different practice settings by specialty.

Link...?

Incidentally, for those who would characterize this whole thing as a "primary care vs. specialists" argument, you should recognize that there are some specialties that are not procedure-driven, like neurology. They deserve equitable reimbursement, too.

http://www.washdiplomat.com/February 2010/c1_02_10.html

 

[deleted87716]

We must continue to reward productivity and efficiency in some way as people should be paid for the amount of quality services they provide.

I agree with the quality part. Trouble is, the current system only rewards quantity.

 

[MOHS_01]

Link...?

Incidentally, for those who would characterize this whole thing as a "primary care vs. specialists" argument, you should recognize that there are some specialties that are not procedure-driven, like neurology. They deserve equitable reimbursement, too.

http://www.washdiplomat.com/February 2010/c1_02_10.html

I can't link to it -- it's proprietary info. For the cost of joining MGMA... plus a mere $435 you can have access to all of the data.

https://www.mgma.com/store/productdetails.aspx?id=38994&kc=BLOG10WE00

I'm not characterizing it any any one group vs another -- although, and I'll say it again, one group is advocating doing just that via a separate conversion factor for primary care designated providers, exemption from SGR related cuts, and rents in the form of PMPM. Not my words, theirs.

So, BD, how would you like to see this addressed? Increased E&M RVU valuations across the board? PMPM administration fees? I already stated that I am not vehemently opposed to this... unless it counts against the balance of physicians in the SGR formula. It may be the easiest way to addressing the non-reimbursed portion of the PCP's work.

What I find somewhat disheartening, while we're bitching, is the relentless and systematic devaluation of my services year in and year out due to some misguided system that ties the worth of my services to some BS cooked GDP number....

 

[MOHS_01]

I agree with the quality part. Trouble is, the current system only rewards quantity.

Agreed, but do you know of a concise and reproducible way to define "quality" for all of medicine?


No one else does either.

 

[deleted87716]

I can't link to it -- it's proprietary info. For the cost of joining MGMA... plus a mere $435 you can have access to all of the data.

My group is a member...I'll just have to ask our administrator for the info.

So, BD, how would you like to see this addressed? Increased E&M RVU valuations across the board? PMPM administration fees?

Both, actually.

What I'm far less excited about is the whole ACO thing. Unfortunately, that may be where we're headed.

 

[MOHS_01]

ACOs will be the final straw in the corporatization of medicine. We will all be relegated to high cost line item status.

 

[deleted87716]

ACOs will be the final straw in the corporatization of medicine. We will all be relegated to high cost line item status.

As long as I get a dacha at the beach, Comrade.