Should payers add a "C" – to reflect 'cognitive value' – to the physician relative value unit (RVU) formula and thereby increase primary care physician pay? Would that help improve the supply of family physicians, pediatricians and internists?
The American Academy of Family Physicians thinks so, and has created a special task force to increase efforts to add cognitive value to the relative value unit physician fee formula, which now consists only of work, practice expenses and malpractice costs.
Yes, it's another task force. But this time, things are getting serious. The issue has been brewing for decades but recently reached a bubbling point – spawning the task force – because of two key factors, explains Lori Heim, MD, AAFP's immediate past president and task force chairwoman.
First, there's a gap – as there should be – between what primary care providers get paid by the RVU versus what specialists or proceduralists get paid, she says. But it is far too wide considering the amount of work a primary care provider has to do to take care of a typical patient, she says.
The mean compensation of a primary care provider is less than 55% that of other medical specialties, according to a report last December from the Council of Graduate Medical Education (COGME), these elements threaten the supply of primary care providers. It should be more like 70%, the report says.
Second, "the complexity of patients seen in primary care offices has changed over time so that today it is far more complicated, with far more co-morbidities," Heim said in a telephone interview. "People don't just come in with a sore throat. Today, it's 'I have depression, diabetes, a past heart attack and by the way, I also have a sore throat.' "
Forget just for a moment, the other controversial issues swirling around physician pay such as the GPCI (geographic practice cost index) and the SGR (sustainable growth rate). This is about recognizing that primary care doctors – geriatricians, internists and pediatricians in addition to family docs, have to really think about their patients in a different, more expansive way, now more than ever before.
In fact, Heim says, that level of skill required, and the difficulty involved may much more closely reflect the value now placed on a cardiologist's placement of a stent in a coronary artery or a gastroenterologist's removal of a polyp during a colonoscopy.
"We as the academy are saying there's a problem with the methodology by which we looked at payment for fee for service primary care," she said. Heim emphasized that this is not about saying, "Pay us more," although that is clearly one end result. "We're saying the way we've looked at fee for service, the formula is flawed because it does not recognize the work effort and complexity that goes into it."
AAFP says that if the nation does not want to further erode its supply of its front line physician workforce, it needs to find a way to compensate for this part of their extra workload.
"When the formula for the RVU was set up, the folks who did that did a fairly good job of being able to capture procedures, for example, how much work went into it, how much malpractice risk was there. The current system is pretty good about what that might be worth," she said.
"But even when those were designed, people were saying, we're just not good about getting to the 'thinking' part of what happens in that office. If you talk at length with a patient, for example. Or how much is it worth that I counsel you on not only your cough, but I also spend time talking about what to do about your smoking...which compounds the weight problem you have, and how weight affects your diabetes."
The doctor who gives the good physical exam is worth it for the payers and for patients, she explains. "Take someone who comes in with shoulder pain. The PCP would likely spend some time taking a complete history, asking what are the things you have been doing, could it be musculoskeletal, was there trauma or a fall, or could it be a heart or lung problem, or gastrointestinal? There's a multitude of potentials."
Isolating the problem as musculoskeletal early avoids sending the patient to the cardiologist, the gastroenterologist, the pulmonologist.
The issue is getting traction from Congress as well. The RVU is reviewed by the American Medical Association's 29-member RUC or Relative Value Scale Update Committee. But that committee, whose members are primarily procedural specialists, is under fire from Rep. Jim McDermott (D-WA), who also is a physician.
McDermott's 2011 proposed legislation, HR 1256, calls for the Centers for Medicare & Medicaid Services to pay for a "second opinion" of the RUC's determinations related to changes to the CPT billing codes used by all physicians to submit claims.
That's needed, McDermott says, because primary care physicians make up only one-sixth to one sixteenth of the RUC's membership, even though "primary care physicians provide about half of Medicare physician visits."
"CMS has depended on the AMA's RUC for recommendations as to the values assigned to Medicare service codes for over 90% of all code changes over the last 19 years," states language in the bill.
"The RUC lacks voting transparency and relies on self-reported and unrepresentative survey data that present serious conflict-of-interest concerns," the bill adds.
The RUC does identify and correct undervalued codes, but "it does not have the same incentives to find and correct overvalued codes. Specialists, especially those who derive the majority of their income through procedural codes, have no incentive to reduce the value of potential overvalued codes," McDermott's bill says.
Heim and Gary Rosenthal, MD, president of the Society of General Internal Medicine, said in a letter to House Speaker John Boehner they support McDermott's bill because analytical contractors – that second opinion – "will lend an element of depth, data, deliberation and inclusiveness not currently available to CMS or at the RUC."
The bottom line, Heim says is that "if we don't pay for the doctor who gives the good physical exam – methodologically, which is what we think needs to be better valued – if we don't do a better job of this, we're not going to have medical students going into primary care."
Consider these elements, excerpted from the COGME report.
- Barely one-third of U.S. doctors are primary care providers.
- 17%, nearly one in five, general internists certified just 20 years ago have since left internal medicine.
- The mean earnings difference between a specialist and a primary care doctor is $3.5 million in a lifetime.
- The percentage of U.S. medical graduates choosing family medicine has dropped from 14% to 8% between 2000 to 2005.
- Approximately 50 million Americans live in health professional shortage areas. While 20% of the U.S. population is rural, only 9% of the nation's physicians serve those areas.