Chiropractor vs Primary Care: An RVU Analysis of My Experience

Who makes more money?  I did my own RVU analysis from a recent visit comparing the chiropractor vs primary care.   As you know, I experienced acute onset back pain last week. I think it was an L5-S1 disk problem. I went to the chiropractor. I went back for a repeat visit several days ago and asked for an itemized billing statement. Are you curious to find out what how a chiropractor pays in comparison to a primary care doc?

I looked up the Medicare payment rates for my city. I came in at 3:03 pm. He asked me about 2 minutes worth of questions, if that. I laid on a chiropractor table for about 2 minutes. He moved the base of the table up and down as he palpated several spinal regions. Then he wound me up like a pretzel and realigned my facet joints. Two maneuvers. A total of 2 minutes. I would say I spent a total of six minutes tops on that table with history.

Then I went and lay for about 7 minutes, by myself, with an electrical stimulation device hooked up to my back. When I was done, the secretary took it off my back and I paid and left. I asked a couple of questions, he showed me the spinal model and explained what he did. How much did the chiropractor get paid for his 10 minutes of work (tops). ( I added in 4 minutes for the time he took to answer my questions).

My insurance is Blue Cross. I compared what they paid with what Medicare would pay.
CPT 99201 New patient, lowest level: Blue Cross paid $43 Medicare would pay $34
CPT 98941 Adjustment of 3-4 regions: Blue Cross paid $47 Medicare would pay $33
CPT 97014 Electrical stimulation: Blue Cross paid $18 Medicare would pay $12
So how much did he make for his 10 minutes? That's $65 for 10 minutes of work. If I had been a Medicare patient, $45.

Not bad. Not bad at all. How much would a hospitalist make for a 99232 spending 25 minutes documenting, talking with family, ordering studies, xrays, interpreting labs, calling specialists, filling out family medical leave act paper work? About $60. How about a high level, complicated patient with multiple medical conditions worsening condition for which I may spend 45 minutes or more on? A 99233 pays $90.

How about a primary care doc stuck in clinic evaluating granny complaining of dizziness, on 20 medications with 10 chronic medical conditions. A 99213 (mid level outpatient visit) will pay you under $60 (expected 15 minutes). The step up, a 99214 will pay about $85 (expected 25 minutes). None of these expected times include uncompensated work which will always take you past these time variables. Prescriptions, phone calls, referrals, preauthorizations...

In either case, whether you are dealing with hospitalist or clinic follow ups, it is clear that E&M codes are getting the shaft even when compared to codes being billed by chiropractors, who complete their training in 4 years with no residency.

The complexity of cognitive evaluations from the review of systems to the past medical history, medication review, side effect profiles, multiple simultaneous system complaints, vague and unusual symptom complexes. It doesn't matter. It all gets treated like the step child of the RVU world.

A chiropractor makes more, on a time based axis, with far less complexity than a primary care doctor. Even the lowest level new patient clinic visit, the 99201 paid the equivalent of the actual manipulation. And the time involved was double.

The payment reform necessary in this country, for there to be any chance of success will have to find a way to value cognitive evaluations in line with procedural compensation. With out an admission that cognitive interventions are equal, if not more important, than the technical based procedural intervention, there will be no payment reform. And therefore, no health care reform.

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11 Outbursts:

  1. So how is your back now?

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  2. So...why do many chiropractors have bene's coming back repeatedly? What is worse? Seeing the D.C. document "no improvement" over MONTHS of treatment, yet continue to recommend further care.
    They wonder why they are not taken seriously....

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  3. What was the charge for the "Happy" Ending?
    I'd still rule out metastatic lung cancer, from second hand smoke, of course...

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  4. No imagine if your primary care physician was also a chiropracter. That is what an Osteopathic physician is. Except we won't keep telling you to come back for more treatment when there aren't results.

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  5. Hehe, yeah payment reform ain't going to happen. Not with a projected 21% cut in medicare payments next year, and a 141 billion in payments to providers over the next ten years. Financially, it's either going to be a good tax and insurance rate increase, or pay cuts for all of us. Guess which way the public will want to go? PA's and NP's are going to be utilized even more in an attempt to lower costs. The next ten years are going to be bad financially.

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  6. Lower costs?
    NP's bill at 85% of MD's. Throw in IMO the increased consults to subspecialists due to lack of comfort with issues managed by good FP's/IM's. Result, no lower costs.

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  7. Your chiropractor's lazy. :) Mine does 30 minutes of work on me, no TENS machine.

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  8. I am sure that you would like to know that Osteopathic Manipulation pays just as well. As an Osteopathic Physician I can attest to the benefits of facet manipulation. In some respects this could be a money saving venture...fewer medications with their associated complications. Fewer dispensed narcotics, less radiation to chase down the ever elusive spondylolisthesis etc, etc.

    As a Hospitalist, I completely concur that cognitive evaluations are sorely underpaid and underappreciated.

    Wow! This seems to put DO's in the perfect position to critically evaluate low back pain and perform treatment that actually may work!

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  9. You forgot that the FP/Hospitalist would prescribe mm relaxors, NSAIDs, vicodin,percocet or oxy, with no change, then refer to specialist for epidural injections $80+,xrays $350, MRI $1500. You or your insurance is then in it for $2-2500. Then when your pain came back you would be referred to pain management for a possible round of facet injections and other services...Don't forget the neuro for surgical consult just in case. Then when the issue didn't resolve due to you having either a flexion or extension intolerance that has gone untreated by all including the "Single Lazy Chiro" that you chose as a representative of the entire profession(of which requires an undergrdauate degree along with a full 3 1/2 years of post graduate studies with 3x more radiology and neuroanatomy of a GP, 2/3's pathology,0 pharmaceutical) You would then come to someone like myself and many, many, more Chiros,DO's or therapists to get relief that would last a lifetime. There is good and bad in all professions. By the way, sounds like the chiro only adjusted your low back 98940 1-2 regions and estim (flat rate $34 medicare)Not to mention the Xrays that he is required to take by medicare without any re-imbursement. Also no re-imbursement for the exam if treated on same visit by Medicare. BCBS $43 exam, $34 adjustment, either bundled estim or not paid at all due to it being unattended and not meeting the 8 minute minimum...Post what you want but ttry to be somewhat accurate.

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  10. Seems like you are erroneously devaluing what was done. I say erroneously as you speak of RVU's but apparently do not know where these figures come from. Hint: the healthcare professionals do not make these numbers up. The RVU is a complex formula determined by Doctors Work, Doctors Office Expenses, and Doctors Malpractice Expenses in any given area. Then, this number is multipled by the National Conversion Factor for a given area as determined by the CMS/Medicare (e.g. Government)

    Your estimation of "10 minutes" of work is grossly misleading, if you are not even under reporting that.

    You remind me of the man who went to the mechanic with a engine problem in their car. He asked the mechanic how much to fix it. The mechanic says $500. The man agrees and observes the mechanic look and listen for 2 minutes tops, then strike some place on the motor with a hammer. The engine ran perfectly now and the mechanic asked for his money. The man explains, "But, you did not do anything but hit it with the hammer!" The mechanic replied, "Hitting it with a hammer was FREE, I am charging you for knowing WHERE to hit.."

    Moral is that there is a VALUE to the intangible KNOWLEDGE and EXPERIENCE that the educated doctor paid REAL money for.

    Additionally, the time you laid alone is not FREE time simply because you are not being constantly attended. That machine, space, and personnel to provide qualified setup and monitoring costs REAL money.

    *Other educated service professionals such as attorneys quote fees all the time without any objective justification. Look at any retainer that is typically asked. They just pick a number out of the air of their choosing. Quite different from the objective RVU system of healthcare providers.

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