Here’s an interesting article, talking about stuff that’s not new to anyone who has read my blog for the last three years. The current relative value unit (RVU) system is a scam, perpetuated by a super-secretive group of subspecialists each inflating their own worth for the benefit of themselves, at the expense of primary care.
If you don’t understand what I’m talking about, first read about RVUs explained. Then come back and read this article put out by the National Institute for Health Care Management. It’s titled “Out of Whack: Pricing Distortions in the Medicare Physician Fee Schedule.“ In his essay, Dr. Robert Berenson shows how distorted primary care specialties are paid, relative to other specialties, in an all Medicare practice with the equivalent input of hours worked.
In addition to this graph, my other favorite quote from this article was:
MedPAC recently expressed renewed concern about basing the RVUs on estimates of work and practice expenses derived from specialty society surveys rather than using actual data from practices. For example, available data from operating room logs and appointment schedules demonstrate that service-specific time estimates provided by specialty societies are often inflated. MedPAC has urged CMS to consider ways to collect more objective data, and CMS recently sought public advice on how to do so.
This is like putting the fox in charge of the hen house. What did they think would happen? This article presents an accurate reflection of the amount paid, by the Medicare National Bank, on a time based axis, for primary care services relative to other medical specialties. This data is a true reflection on the value of the work provided by primary care compared to other specialties. It’s what I have been saying all along. Evaluation and management (E/M) codes, the thinking codes, are vastly undervalued when compared to the procedural codes, on a time based axis, even with recent attempts to improve payment equality. It’s not even close yet. Pay more for procedures, get more procedures. Pay less for talking to patients, get less talking to patients.
This is not rocket science. Medicine does not operate under a magic economic force field. Physicians are not special. They respond to economic pressures just like the garbage man does, only they do it on a different level.
This data confirms the reason why only 2 percent of medical students enter an outpatient field of primary care. When comparing the ratio of average hourly earnings for specialties vs the primary care specialties, Dr. Berenson’s analysis shows that non-surgical, procedure oriented, surgical and radiology specialties earn around 2.1, 1.6 and 1.9 times the income, respectively, for the same hours of work. Is three years of additional training worth a doubling of value? It is for no other reason than because the RUC committee says it is.
The question of why anyone would go into primary care when they can earn two times the income for the same amount of time worked is easy to answer. They won’t. Fix RVU and you fix primary care. Unfortunately, this will never happen under the current rules, because fixing RVU would mean decimating the incomes of every other specialty.
The current exception is the hospitalist medicine movement which has left the constraints of the WIN-LOSE fixed mentality of SGR economics. Hospitals see incredible value in the work hospitalists provide, with a return on investment often running into the millions of dollars for every $100,000 in subsidy they provide. And that’s why hospitalists are the fastest growing medical physician specialty, while outpatient primary care is the fastest growing nurse specialty.
*This blog post was originally published at The Happy Hospitalist*