Go to page 33661 (found via Clinical Cases and Images) to find out how your medical specialty will do in the upcoming proposed payment changes under the relative value unit (RVU) model. As many of you know from reading here, RVU is the Medicare National Bank's way of setting a value for every possible CPT encounter you have with a patient. It has three components. The physican work component which values the physicians time and education, the practice expense (PE) which is supposed to compensate for the business expenses of the practice and the malpractice component (MP).
So how do the different specialties come out? The biggest winners were optometry (+12%) and ophthalmology (11%). Family medicine comes in at +8%, as does geriatrics. Internal medicine +6%. The Biggest Losers are the diagnostic testing facilities, losing 24%.
If you go to page 33662-33663, you'll notice many specific procedures and E&M codes are taking a big hit. 32% reduction in heart cath? 21% reduction in upper endoscopy with biopsy? Even the hospitalist codes (admission and follow up codes) are taking huge hits of 13%-17%.
Until you read the fine print. These reductions assume that the required 21.5% across the board reduction in the sustainable growth rate formula takes effect in 2010. In other words, only if the monetary value of each RVU is decreased by 21.5% from the current $35. And that will never happen. Not in a million years. So for the individual E&M codes and procedures, I take the actual changes on page 720-721 to be what ever the reported % change is and ADD 21.5%.
That means for hospitalists, you are looking at an 8.5% increase in the high level admission (99233), a 5.5% increase in the high level follow up code (99223), a 6.5% raise in the greater than 30 minute discharge (99239) and a 3.5% increase in the critical care billing codes (99291,99292). For you outpatient docs, the office visit codes are getting a 10% raise. Congratulations to all docs that see patients in the clinic (as a fee for service). I didn't delve into the article great enough to see how it would affect bundled payments to surgical services. I did see general surgeons realizing on average a 4% raise, mostly due to increased payment for practice expenses. You ED docs will see about a 2-3% raise in your ED codes.
Since all physicians who see patients (in fee for service) in the hospital bill hospital E&M codes , all physicians will see a raise. That includes you GI guys, you heart guys, you lung guys, you ID guys, you kidney guys. All of you will see a raise in your E&M fees. Those that do fewer procedures will see see a bigger raise than those that don't since the money to pay for these increased E&M fees is being redistributed from non E&M procedural codes. If you make most of your money on procedures, than you'll come out a loser. How you feel about that depends on how you make most of your money.
It's my opinion that procedures/surgeries, on a time based axis, pay far more than can be expected by the value placed on the education required to achieve their proficiency. But remember, it's all relative. How do you value what an EP ablation is worth compared to a level two hospital follow up? If you can't use education and time committment, then what. I have blogged extensively about these opinions. The fact that my central lines I do pay me 2-3x more on a time based axis than my hospital follow up codes says it all.
If I had my way, procedures would pay equivalently on a time based axis as E&M codes AND subspecialists would get the same E&M fees as the specialties of family medicine and internal medicine PLUS a defined premium based on years of training. For example, using three years as the defined residency experienced, those doing 4 year programs would get a 6% premium. Those doing a five year program would get a 12% premium. Those doing a six year program would get an 18% premium. Those doing a seven year program would get a 24% premium. The program length being defined as standard based on the subspecialty. and all procedures would be paid the same premium on the time based axis as the E&M codes. When bundling of care comes, you could make the same premium argument as well.
Instead of paying physicians to proceduralize you, we should be paying them to talk to you. I can assure you, if procedures were paid at the same rate as cognitive encounters, we would be doing a lot less intervening and a lot more thinking.
What do you think, should subspecialists be paid an E&M premium based on the length of their training track and allow the procedural fees to come in line with the E&M fees?
14 Outbursts:
I read this as a reaction to the type of findings revealed by Atul Gawande in his piece on McAllen, TX, which show that unnecessary heart caths, unnecessary diagnostic tests, and medical procedures in general are being heavily abused for profit. Obviously the public has an interest in curbing these types of abuses, and, looking at these new reimbursement rates, it seems the government is trying to make ordering unnecessary testing and procedures less rewarding.
McAllen still has the highest per capita health care costs despite the Texas legislature so strictly capping malpractice awards that it's all but eliminating that issue. There has been too much abusing the system. Doctors will reap what they sow.
Nick
Nick, medical encounters are separated into two classical types of encounters. E&M encounters (evaluation and management) are the thinking codes. Then there are procedures codes. These are the doing codes. The proposed financing changes for CMS 2010 takes money from the procedure codes and gives it to the E&M codes. That means doctors who do mostly procedures and less E&M will be financial losers. Those docs that do mostly E&M and less procedures will be financial winners because each encounter with the patient will pay more.
Understand?
anon 440: A couple questions for you. Risk is paid for in the malpractice portion of the RVU. That doesn't account for the spread between payment for cognitive/procedures/surgery and cognitive only interventions. If you think your risk is higher, than you believe the malpractice component of the RVU system should be higher. That's a whole other topic.
I disagree at the core of the argument that procedures come with higher risk. If you perform your duties competently and within your scope of practice, your risk is no greater than I who does the same in my scope, a mostly non procedural based specialty. Now, will you get sued more often? Perhaps. But that's a broken malpractice system where bad outcomes drive the perception of negligence, where no negligence exists.
I disagree that subspecialists see sicker more complex patients. Most subspecialists can focus on their one organ. Us internists have to manage disease, even highly complex disease across many failed organs. You seem to believe it's harder to manage one really bad organ than say 5 bad organs. I would suggest it's easier to manage one really bad disease, no matter how hard it is than to balance the management of 5 bad disease. I see this daily as a hospitalist with subspecialists all around me writing brief episode plans for their one problem. They are educated in their skills as am I. They are different skill sets. One is not better than the other, only different.
I think all physicians bring their own unique set of skills to the table. I don't think surgery is any harder than managing complex patients on the brink of medical failure. I don't think my job is easier than yours. I have seen many stressed surgeons as I have internists. How you manage the stress of the job is more about your coping skills and less about the field itself.
I think surgeons deserve to make more because they spent more time training.
I don't think it has anything to do with working with your hands. If that was the case, carpenters every where would be averaging $300,000+ a year.
Your skills come in your training specific to your field, just like mine. Your skills are no more special than the internist or the cardiolgist. They are just different. And to believe your specific skill set is inherently worth more makes that thought process part of the problem and not the solution.
The longer you train, the more you should make. And that has nothing to do with what you end up doing.
No I don't think so.
There are a myriad of arguments against it. Surgery and "cognitive" medicine really are very different. "Procedural medicine" requires a much higher level of immediate risk. If something goes wrong during surgery, your bloody hands are right there. Further, the global period can be a killer. Essentially a patient owns the surgeon for 90 days for whatever they want, all unreimbursed.
This I think warrants some additional "reward". As far as basing the RVU's on training time, everyone will just suddenly need a fellowship.
Subspecialist by their nature see sicker/more complex patients in general. I don't know if the time in training factor will adequately compensate for that.
It remains suprising to me that so many of my "cognitive" medicine colleagues A. consider surgery to be non-cognitive and B. think we just operate without adequate indications all the time.
I guess that just goes to show you how successful the RUC has been in dividing and conquering the house of medicine.
jb-
Everybody thinks he or she is underpaid. Even for surgeons with stratospheric salaries this is true.
But I have a simple question: at what amount of income reduction as a surgeon would you have not chosen to pursue surgery as a career. I suspect this is a large number, given your stated inherent attraction to the field.
So, then, where's the argument for continuing to pay for procedures at such ridiculous rates? No other country even comes close to paying the prices we pay for surgeries. See Uwe Reinhardt on this subject if you don't believe me.
I (a "cognate") certainly don't begrudge you your thinking cap. But I do resent your income...not just as a cognate (though I can see how it's made your head swell) but as a taxpayer. I pay your damn salary. I pay you too much. Period.
HH, you did not address the point raised by Anon 440 that really chaps my fanny- that so many folks on your side of the blood-brain barrier think that we are not "cognitive." I doubt that there is or will ever be a way to truly quantify cognating, but I challenge you to walk a mile in my shoes and then believe that the quality and quantity of data integration and judgement that a busy surgeon has to process over the course of a day is less for me than it is for you and your hospitalist colleagues.
We both have our "routine" situations- when faced with a new patient with diabetes or hypertension, or gallstones or a hernia, in the absence of multiple comorbidities we both have our algorithms to follow, and the vast majority of cases go according to plan. When there are complicating factors, we both have to step back, obtain more information, reassess, get help from consultants, and then make our best judgement as to how to proceed with the patient. As an exclusive E/M practitioner, you will do this more times in a week than I will, but I don't believe you when you claim that the E/M that you do is more challenging than what I do.
The difference is that after the initial E/M that I do, I often take the patient to surgery. That's the proceduralist part of the deal, but you will have to take my word for it (because you have not and never will be able to do a surgical procedure) that during the procedure, I do as much cognating as you do on the wards. While I am operating. The patient's anatomy may throw me a curve ball, or the tumor may be more extensive than the imaging indicated, or previous surgery may have caused scarring or distortion, or any other of a number of things may go astray, and it's my responsibility to assess the situation, make midcourse correction or change the plan, and get the patient through the operation. I do not have the opportunity to call a consultant, formal or "curbside," sit down at a computer and look at Up to Date Online, or think about the situation and come back later. It's just me and my training and experience, with the patient's welfare at stake. All this occurs during what is not just mentally stressful, but often physically difficult as well, especially with the plus-size patients that we often see these days.
It's borderline insulting for you to think that my higher salary, which you grudgingly agree I deserve, is justified only by my longer training period. Especially insulting is that you have carved out a specialty where you work your shifts and then offload your responsibility to another colleague, while I am responsible for my patient 24/7- even when a colleague is covering for me, if I did the operation, it's my problem if the patient has a problem.
One more thing I hope you will comment on. I chose surgery because I (correctly) believed that it was the most interesting way to earn a living that I could think of, and (I hope correctly) that I would be pretty good at it. You likely feel the same about your specialty. The difference is that I know that I could do what you do, given 3 years of IM training. It may not be true in your specific case, but many of my "cognitive" colleagues in their more honest moments have confided in me that they never could have withstood the rigors of a surgical residency and would not survive the lifestyle that I currently enjoy in my 3rd decade of practice. People who do what most others can't do earn a premium over those whose labors are more pedestrian. I earn every cent that I get, and then some.
I do strongly agree that "cognitive encounters" should be reimbursed at the same rate as procedures are. That would immediately improve quality of care and reduce unnecessary procedures drastically.
jb. I never begrudgingly said anything. I think you deserve to make more than me, not because surgery is inherently a more difficult field, but because it takes longer to master. There is nothing special about what you do that makes your field more special than any other. If you believe you "are it" and there is nobody else to consult, then ID docs, who do no procedures, must be worth the same you are. The poor endocrinologist who does no procedures must be paid like you as well. Or perhaps the nephrologist should too.
Doing procedures/surgery does not make you any more special than other doctors who are experts in their field.
You are trained in surgery. I am trained in internal medicine. Both have their respective fields of value. I come to you when I need a surgeon. You come to me when you need an internist. Your work and expertise hold no extra value to a diabetic with no surgical needs than does my value to a healthy female who needs a surgical intervention and no internist related problems.
The value of you to your patients presents itself when your patient needs you and your value is zero when a patient does not need your service. To imply your service is more valuable than mine depends on whether your patient needs you or not. You are more valuable because there are fewer of you and your training is longer. Your value is not because surgery itself if intrinsically more valuable.
I can assure you I have little value to your healthy surgical patients and you have little value to my non surgical medical patients.
With that said, it doesn't matter what you feel your economic value is worth. As long as you accept third party medicine your economic value is what the RUC committee says it's worth. And the RUC currently opperates on a WIN-LOSE philosophy. The current losers are primary care, on a relative basis, despite your belief that you are worth every penny. The current winners have, on a time based axis, on average been those physicians who do procedural interventions. You say that's the way it should be. I'm saying procedures have no more an intrinsic value than the cogitation that goes into them. You believe other wise.
What you feel you are worth doesn't matter. If you feel you are worth more than the RUC says you are, you should stop accepting insurance, or go into contracts of care by other means. Perhaps cash only, concierge.
How I have decided to carve out my work schedule has no bearing on what I am worth economically in a fee for service model. Could I work double my current schedule and make twice as much? Of course. I don't because I choose not to. If you want to work 100 hours a week and avoid other aspects of your personal life to fulfill your professional satisfaction, I think that's between you and your family. You should be paid for working more. That does not mean you should be paid more on an individual encounter because you choose to do more of them.
"Those that do fewer procedures will see see a bigger raise than those that don't since the money to pay for these increased E&M fees is being redistributed from non E&M procedural codes. If you make most of your money on procedures, than you'll come out a loser."
HH, I want to blog about this, but I don't understand how exactly this works; how will doctors make more money by doing FEWER procedures?
HH, you post statements that are superficially sensible, but do not stand scrutiny. Your blaming the RUC ignores the absolutely irrefutable fact that differential pay scales for the various specialties predate the existence of the RUC and any external non-market driven salary determinants by nearly a century. You assert that I have no value to your medical patients. Your patients disagree- they often ask me if they should continue meds prescribe by your colleagues, or if side effects that they have are caused by the meds. I never interfere with other docs’ management, but recommend that they bring it up at the next office visit. That does not mean that I have no ability to assist these patients, just that I recognize that you have greater ability in this area and it’s not my business to interfere in your management. If your specialty were to suddenly disappear, I could keep the vast majority of your patients alive. Not nearly as well as you do- A1Cs would be higher, BP would be higher, function of people with severe rheumatic disorders would suffer, and overall they would die a few years earlier, but there would not be a large pile of corpses stacked behind my office. Reverse the situation- you are suddenly tasked with complete definitive management of the acute gallbladder, bowel obstruction that does not respond to NG suction because it’s due to a malignancy, the woman with breast cancer. You would likely be wise enough not to try to do the laparotomy or whatever I would do as a matter of course, and manage the patient in a way to minimize suffering until nature took its course. That’s hospice care- again, valuable in the proper context, but not exactly a demonstration of professional worth.
We will disagree that it doesn’t matter what I feel my economic value is worth. Like you, in certain markets I can earn more than I bring in because hospital administrators realize that a surgeon brings $2mil to the hospital top line per year. Anon above asked at what number I would stop doing what I do. He resents paying my salary, as a taxpayer. I resent paying for the feeding and education and health care of people who line up every day at the welfare office, and at least I perform a useful service every day. He deserves an answer to his question. I don’t have a specific number for him, but I can state that I would not do what I do every day for what he is paid. It’s just too hard. I’ll go back to residency for a couple of years and be a hospitalist if the dollars are the same. Again, I have absolutely no doubt that I have the mental and physical resources to get through an IM residency and pass the ABIM exam. I know that most of my IM colleagues, when faced with the prospect of a 5 year surgery residency, know deep down that despite their resentment at my paycheck, they just did not have what it takes to earn it.
does that article prove or only suggest that (1)tests are unnecessary and (2)are being abused for profit?
sheesh
Neither of you answered my question, and I really want your thoughts on this matter. I’ll be more specific in my questions:
1. Do you believe the cognition that occurs in my consultation room is quantitatively or qualitatively inferior to that which occurs in your exam room?
2. In a typical workday, I spend several hours in the operating room. Do you believe that cognition ceases during this time, or is of a lower quality than at other times?
3. If you concede that cognition occurs during my time in the operating room, do you believe that that fact that it occurs while wearing sterile clothing, standing up under hot lights, under the stress of trying to stop bleeding, find a lesion, dissect scarred tissue, or any of a number of other technical challenges, renders that cognition more difficult, or is it in your mind qualitatively similar to the conditions under which you solve challenges with your patients in the clinic?
Having done “cognitive” work both in the clinic and in the OR, and technical work in the OR, I know what my answer is. I agree with your statement that “Your value is not because surgery itself if intrinsically more valuable.” It’s not surgery that is more valuable, it’s the surgeon that’s more valuable.
Happy, care to venture on the big raise for ophtho? It's already one of the "ROAD" to happiness specialties. I know a few got hit hard on the elective LASIK business with the down economy, but do we really need to encourage more eye docs? When I was in training I was asked to admit a patient with orbital cellulitis sent to the VA ER from ophtho clinic ( we did not have an EM residency, internists ran the ER - no trauma). I called the resident and asked what gives?, as they had admitting privileges. The resident said it had been so long since she had written a set of admit orders she forgot how to!! I said remember "VANDISMAL" from 3rd year med school? She said " Huh?" Smart as a fox that one. I just went ahead and did the admit ( she was happy to follow as a consult of course). Yeah, we need to push more money to the ophtho's.
Yes, and that's a positive step if, as you've said, you want the cognitive services (that are so needed to coordinate the proper care and prevent unnecessary treatments) to be compensated more. Maybe this is the way to achieve parity with procedures?
Post a Comment
By Posting Here I Promise To Do Something Nice For Someone Today