The Primary Care-Specialty Income Gap: Why it Matters

[SDN]

From the Annals of Internal Medicine 20 Feb 2007

http://www.annals.org/cgi/content/abstract/146/4/301

Abstract:
A large, widening gap exists between the incomes of primary care physicians and those of many specialists. This disparity is important because noncompetitive primary care incomes discourage medical school graduates from choosing primary care careers.

The Resource-Based Relative Value Scale, designed to reduce the inequality between fees for office visits and payment for procedures, failed to prevent the widening primary care–specialty income gap for 4 reasons: 1) The volume of diagnostic and imaging procedures has increased far more rapidly than the volume of office visits, which benefits specialists who perform those procedures; 2) the process of updating fees every 5 years is heavily influenced by the Relative Value Scale Update Committee, which is composed mainly of specialists; 3) Medicare's formula for controlling physician payments penalizes primary care physicians; and 4) private insurers tend to pay for procedures, but not for office visits, at higher levels than those paid by Medicare. Payment reform is essential to guarantee a healthy primary care base to the U.S. health care system.

It is my understanding that the visit codes 99213 / 99214 make up nearly 50% of the payments from CMS (Medicare). 99213 and 99214 are the bread-and-butter of primary care.

So, how can we expect CMS to increase payments to primary care via this model without bankrupting it? Pay based on number of diagnoses? Add a 'primary care' modifier for Peds, FM and IM docs?

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[Faebinder]

The problem is that we are fighting for the same bucket full of money. I.E. If they up the amount they pay primary care, they will drop say the amount they pay for procedure X and Y.

Medicare/Medicaid is a hopeless hopeless pie that is cut to too many uneven slices.

Primary care responded by taking less and less medicare/medicaid because the insurance patients are more like to pay.... But as a result there is a shortage of primary care access.....which resulted in a boost of mid-level care.

So what's the solution?

Nothing... let the system collapse... Medicare/medicaid will sooner or later be abandoned by more than primary care...

Already we hear surgeons complaining of lack of compensation of lap appendectomies and lap choleys, the basic bread and butter.

We will see less radiology tests reimburisement.

Basically here is what happens... someone... an idiot at the top looks at the pie with many slices and says... alright this pie is growing bigger, we need to reduce something cause we can't afford this growth... alright then primary care is a big piece of the pie, lets chop it... oh wait it's smaller this year than the radiology tests which are costing much more, lets chop those as well.

The moral of the story, they already have in mind how much money they want to spend on people on medicare/medicaid and its just a matter of allocating it. Primary care already suffered the cuts, they will now move on to specialties.

 

[SDN]

As you state, the pie can only be cut-up into so many pieces. However, when it comes to splitting-up the pie, CMS generally follows what the Relative Value Scale Update Committee (RUC) committee says.

The RUC committee is mostly made-up of specialists. So I don't see anything improving until the RUC committee is made-up of a balance of primary care and specialist physicians.

General surgery is in the same boat as primary care, reimbursement for all their bread-and-butter procedures has been whittled down to nothing.

Meanwhile many relatively simple specialist procedures are getting reimbursed at unrealistic rates that are not consistent with the effort or time involved.

 

[YouDontKnowJack]

how bad is it really?

if you had to calculate your hourly wage, what would it be in primary care?

 

[bkpa2med]

4 pts/hr at $90 = $360/hr

Minus ~ 50% for overhead and I believe it should be around $180/hr. Someone correct me if I'm wrong.

 

[Faebinder]

4 pts/hr at $90 = $360/hr

Minus ~ 50% for overhead and I believe it should be around $180/hr. Someone correct me if I'm wrong.

And dont forget collection percentage... After all, not everyone pays

+

4 per hour is a bit fast... it's more of a 3 per hour... i mean you will see them for 10-15 minutes but aren't you going to look at the chart/tests of the next patient and write/type a note/prescription after seeing a patient? Assuming maximum efficiency.. that's 10 minutes right there... i suppose you could do 4 if you are running like a chicken with its head cut off or if all three patients were simple viral infections.

 

[Faebinder]

As you state, the pie can only be cut-up into so many pieces. However, when it comes to splitting-up the pie, CMS generally follows what the Relative Value Scale Update Committee (RUC) committee says.

The RUC committee is mostly made-up of specialists. So I don't see anything improving until the RUC committee is made-up of a balance of primary care and specialist physicians.

General surgery is in the same boat as primary care, reimbursement for all their bread-and-butter procedures has been whittled down to nothing.

Meanwhile many relatively simple specialist procedures are getting reimbursed at unrealistic rates that are not consistent with the effort or time involved.

Honestly, that's not the solution... fixing RUC is important but its a temporary fix. We need to stop taking insurance starting with medicare/medicaid and maybe some day all insurances. When I say we, i include all physicians. Primary care is just not capable of doing this so well because of EMTALA which will allow someone to go to the ER for a prescription refill or a viral infection.

My prediction is that what we will see is a drop in total primary care providers. This will result in most people going to the ER for their little stuff and only the well insured will go to primary care docs because they will be able to pick and choose. Then we will see the standards of treatment in the ED department change drastically because that's where medicare will go for their cuts. Suddenly a head CT scan for passing out from a fall is 'recommended' rather than 'required'.

The drop in primary care providers from FM/IM/Ped will result in an increase mid level coverage and ER people going into primary care later in their career.

 

[MDWoochie]

Reality check FB, it's 4 per hour. Take this from someone who's been practicing for 5 years ( as a flight surgeon, but I still work in a clinic), 4 per hour (15 minute appointments) is the standard. Of course, you get more time for procedures. But I would expect to be busy. The FP doc in our clinic averages 32 patients per day.

 

[Faebinder]

Reality check FB, it's 4 per hour. Take this from someone who's been practicing for 5 years ( as a flight surgeon, but I still work in a clinic), 4 per hour (15 minute appointments) is the standard. Of course, you get more time for procedures. But I would expect to be busy. The FP doc in our clinic averages 32 patients per day.

Fine... 4 per hour. You're a great well-oiled machine all the time and you never get any cancellations.

 

[bkpa2med]

Even conservatively speaking, 3 pts per hour makes you bank. Also, lets say the average is $75.

3 x $75 = $225 x 8 hrs = $1800 x 5 days = $9000 x 48 weeks = $432k - 60% overhead =

A grand total of $172,800. I think that isn't bad at all and if you manage 4 pts / hr it only goes up.

 

[halal meat]

Couldnt you handle more patients if you had a PA too? Say you (a FP) see 3 and the PA can see 3 patients. Or is that not the way it works out?

 

[YouDontKnowJack]

Even conservatively speaking, 3 pts per hour makes you bank. Also, lets say the average is $75.

3 x $75 = $225 x 8 hrs = $1800 x 5 days = $9000 x 48 weeks = $432k - 60% overhead =

A grand total of $172,800. I think that isn't bad at all and if you manage 4 pts / hr it only goes up.

see, that hourly rate isn't shabby, though many doctors probably think they deserve more.

But at least you're not working 80 hour weeks and only making $172k. That would be just cruel.

I've been to a primary care doctor's office that probably has much less overhead. He has hundreds of pts, and just one person on his staff- the secretary. His office isn't even fancy. If you're a machine, great. Who has time to chit chat, right?


more and more primary care docs do stuff that is cash-only and not covered by insurance. This would help lessen the gap, eh?

 

[deleted6669]

Couldnt you handle more patients if you had a PA too? Say you (a FP) see 3 and the PA can see 3 patients. Or is that not the way it works out?

http://www.memag.com/memag/article/articleDetail.jsp?id=403834

 

[halal meat]

Fantastic link. Thanks!

 

[deleted87716]

I think this "hourly rate" business is silly.

Physicians are not hourly workers, and even for those of us who basically work a "nine to five"-type schedule, our office hours aren't the end of it.

Unlike your typical hourly worker, most physicians spend a considerable amount of time engaged in medicine-related activities that aren't compensated. These include on-call time, practice management, continuing medical education, professional societies, research, publishing, teaching, etc. Some of these we do because they're necessary, others we do because we enjoy them. But it's all part of the job.

If I just count office time, I make over a hundred bucks an hour. That's a pretty meaningless statistic when you get right down to it, though.

 

[deleted87716]

The RUC committee is mostly made-up of specialists. So I don't see anything improving until the RUC committee is made-up of a balance of primary care and specialist physicians.

Yep, that's a big part of the problem.

 

[YouDontKnowJack]

I think this "hourly rate" business is silly.

but how else would you quantitate or qualitate it?
I think [amount earned]/[time wasted] is a good measure for any job.

i know you wouldn't be happy if your rate came out to $25/hr.

 

[deleted87716]

but how else would you quantitate or qualitate it?

Annual income makes more sense to me. It's certainly more representative of the kind of standard of living you're going to be able to afford, which is really what we're talking about when we talk income.

i know you wouldn't be happy if your rate came out to $25/hr.

Honestly, I wouldn't care. We're not hourly workers, so it's meaningless to me. If you want to be an hourly worker, get a job on an assembly line in a Union shop. I hear they pay pretty well.