Tuesday, January 21, 2014

Primary Care vs. Specialist Pay, the RUC, and the News.

The Relative Value Scale Update Committee (RUC) of the American Medical Association (AMA) is back in the news, courtesy of the New York Times.  It's more of the usual story, published by the WSJ less than 4 years ago: specialists are paid too much, primary care physicians are paid too little, and it's all because of an evil committee of doctors who are members of the evil medical trade union group known as the AMA who set payments.  (Full disclosure, I'm a proud member of the AMA).  A good perspective on the debate from Paul Levy, a former non-physician hospital CEO, is here.

I also remember an interesting take on this subject from the American College of Physicians (ACP) via Kevin MD.  The post is by a member of the RUC selected by the ACP- the group which represents the internists who comprise a large part of the primary care physician workforce (the American Academy of Family Physicians- AAFP- is the largest pure primary care group).  In theory, this guy would have the most problems on the RUC- after all, he's one of the few reps from primary care specialties, and could theoretically be outvoted by the evil endocrinologists in cabal with the nasty neurosurgeons and greedy gastroenterologists.  Instead, his money quote is this, "...the RUC members are not advocates for their specialties.  They are charged with using their expertise to evaluate recommendations for physician work RVUs that are presented by the specialty societies...  I was impressed by the fact that I could not tell who was from what specialty based on their comments at the table."

Actually, part of why primary care is under compensated because of a vicious feedback loop.  Reimbursements for all specialties get cut every now and then to save money.  Specialists- whose rate of patients is somewhat capped by the actual incidence of the diseases their specialties cater to- couldn't really increase their volumes (with some exceptions- some specialist researchers have done a remarkable job of turning normal people into patients needing specialty care- more on that sometime in the future).  But PCPs, to keep their incomes high, starting seeing more patients- with the consequence that they spent less time/patient.  Once they started spending 30 minutes instead of 45 per patient, the value they provided in a lot of cases went down, and consequently soon after the amount they were compensated went down even more.  And the cycle repeated.  I appreciate the value of primary care- but is a PCP who burns through 3 15-minute visits for colds and the like really providing the same value as a 45 minute appendectomy by a surgeon?  Especially when most of those visits can supposedly be handled by an NP or PA with only 2-4 years of post-college training?  Not to mention, a lot of research shows that for the average person, well-person visits (known as annual physical exams to the lay public) are not really useful.

I don't say this as an unappreciative, arrogant medical student who's planning on ditching primary care for the lucrative fields of specialty work (Okay, arrogance I'll cop to).  I worked as a primary care tech under my aunt, Dr. Krishna Bathina, who is one of the most amazing doctors I've ever seen.  She's a large part of the reason why I went into medicine.  I can tell you, the value she provided was amazing- she saw patients for as long as they needed- visits frequently went 15, 20, or even 30 minutes for complex cases.  45 minutes wasn't unusual for intake.  She is a solo practitioner, and I can tell you her income suffered, but that's the kind of doctor she is- someone who does something right, and who cares enough for her patients to put their well-being above her income.  No matter how late she was running, I never witnessed her cut a patient off for any reason- she always let them speak.  (She was originally the first female surgeon and then the first female plastic burn surgeon in Andhra Pradesh, our home state in India, before retraining in Primary Care after immigrating here).  But when the average visit time drops and keeps dropping, what kind of value can doctors provide?  When you spend more time charting and typing than looking at a patient and thinking about a problem, where's the value for most patients?

To reverse this, payments have to go up- with the promise of longer visit times for complex patients.  Physicians need to  triage better: 25 year olds with head-colds go to the local NP, 50 year olds with a 2 day history of new-onset pain on exertion go to the ED, and 70 year olds with weakness and fatigue see them for 30 minutes.  And finally, physicians have to play on our strengths: we apparently order less useless tests and prescribe fewer useless medications (like anti-biotics for head colds) than a PA or NP.  If we can take more minutes per patient, seeing perhaps half as many but also cutting the amount spent on tests and anti-biotics, I think we can make a good argument for paying more for Primary Care.  But, current quality measures seek to grade physicians and average their incomes around their current levels.  Instead, we ought to be paying physicians more and in exchange expect a reduction in prescriptions and the like (we can dream right?).

However, there are a host of problems for paying more per quality measure in a field as complex as medicine.  After all, it is possible that paying for longer visits will lead to more problems discovered, and thus more tests and treatment are prescribed.  The one rule about making changes in healthcare is that there's a massive chance that it blows up in your face.  (Summary and explanation of how increased numbers of ultrasound techs hired to speed things up in the ED led to longer wait times in said ED)

In short, is primary care worth paying more for?  Yes, I think.  Should it be tied to concrete quality measures?  Probably not unless it definitely should be.