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 $34CPT 98941 Adjustment of 3-4 regions: Blue Cross paid $47 Medicare would pay $33CPT 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.