Tag: specialists

Why Medical Specialists Should Want to End the Reign of the RUC

Dec 1, 2018

By PAUL M. FISCHER, MD

The old doctors know. The practice of medicine has changed in a very basic way over the last 20 years. Physician relationships have lost their civility and have been replaced by a level of tension that takes the fun out of collegial interactions. I remember my first year of family medicine as the only doctor in Weeping Water, Nebraska. My personal medical community had gone from an entire medical school campus with limitless lectures and many physicians to share in “interesting cases” to an occasional phone call with a consultant in Omaha. These contacts became my primary source for medical education and updates for Weeping Water’s health care. The phone calls were collegial, respectful, and focused on what was best for my patients.

What happened?

The RUC is the secretive committee of the AMA that has been CMS’s primary source of physician payment data over the past 20 years. It has elaborately articulated the complexity of medical procedures but ignores and confuses the cognitive work involved in patient care – collapsing it into a few evaluation and management codes. As a result, many medical specialties have found that their financial success is tied primarily to doing things TO patients, rather than caring FOR patients.

The RUC has shifted these physicians’ attention away from the hard work of knowing patients over time and fine-tuning their treatments based on subtle changes discovered by history and physical toward focusing on which procedure can be done to a patient and legitimized to an insurance company. Let the “primary” do that other stuff.

Roulette

Nov 1, 2018

By Rob Lamberts, MD

“I want you to get me a new doctor,” she told me, a bit of disgust coming out in the sharp tone in her voice.

“What happened?” I asked.

“He asked me if I was nauseated, and I told him no, I was just vomiting. Then he asked if I was feeling pain in my stomach, and again I told him no, it was just vomiting. He then told his nurse to write down nausea and abdominal pain. When I objected, he just gave me a bad expression and walked out of the room.”

I tried to come up with a plausible explanation for his action, but there was none. ”I’m sorry,” I said. ”There are a lot of people who come back from him feeling really happy and listened-to. It’s obvious that you saw none of that from him.”

“I asked his nurses if he aways acted this way,” she continued, “and they just shrugged and told me that he sometimes did.”

“I’m happy to send you to a different doctor,” I said, shaking my head.

I hate it when this happens.

I send people to specialists for two main reasons:

I am not qualified to offer the treatment or procedures the specialist can give.
The specialist has far more experience with the problem, and so can offer better care.

10 Things You Can Do With CMS Data

Jun 9, 2014• 17

By Farzad Mostashari,MD

Five years ago, my mother needed an orthopedic surgeon for a knee replacement. Unable to find any data, we went with an academic doctor that was recommended to us (she suffered surgical complications). Last month, we were again looking for an orthopedic surgeon- this time hoping that a steroid injection in her spine might allay the need for invasive back surgery.

This time, thanks to a recent data dump from CMS, I was able to analyze some information about Medicare providers in her area and determine the most experienced doctor for the job. Of 453 orthopedic surgeons in Maryland, only a handful had been paid by Medicare for the procedure more than 10 times. The leading surgeon had done 263- as many as the next 10 combined. We figured he might be the best person to go to, and we were right- the procedure went like clockwork.

Had it been a month prior to the CMS data release, I wouldn’t have had the data at my fingertips. And I certainly wouldn’t have found the most experienced hand in less than 10 minutes.

It’s been a couple of months since the release of Medicare data by the Centers for Medicare and Medicaid (CMS) on the volume and cost of services billed by healthcare providers, and despite the whiff of scandal surrounding the highest paid providers (including the now-famous Florida ophthalmologist that received $21 million) the analyses so far have been somewhat unsurprising. This week, coinciding with the fifth Health DataPalooza, is a good time to take stock of the utility of this data, its limitations, and what the future may hold.

Too Many American Physicians Or Too Few?

Feb 7, 2014• 11

By Robert Pearl, MD

The goal of the Affordable Care Act, also known as “Obamacare,” is to make affordable, quality health care coverage available to more Americans. But how many physicians will America need to satisfy this new demand?

The debate over doctor supply rages on with very little conclusive evidence to prove one case or the other.

Those experts who see a shortage point to America’s aging population – and their growing medical needs – as evidence of a looming dearth in doctors. Many suggest this shortage already exists, particularly in rural and inner city areas. And still others note America maintains a lower ratio of physicians compared to its European counterparts.

This combination of factors led the American Association of Medical Colleges to project a physician shortage of more than 90,000 by 2020.

On the other side of the argument are health policy experts who believe the answer isn’t in ratcheting up the nation’s physician count. It’s in eliminating unnecessary care while improving overall productivity.

The solution, they say, exists in the shift away from fee-for-service solo practices to more group practices, away from manually kept medical records to electronic medical records (EMR), and away from avoidable office visits to increased virtual visits through mobile and video technologies. Meanwhile, they note physicians could further increase productivity by using both licensed and unlicensed staff, as well as encouraging patient self-care where appropriate.

The Doctor Divide: Global And Domestic Insights

Among the 34 member countries of the Organization for Economic Co-operation and Development (OECD), the U.S. ranks 30th in total medical graduates and 20th in practicing physicians per 1,000 people.

Despite these pedestrian totals, there is one area where the U.S. dominates. It ranks first in the proportion of specialists to generalists – and there’s not a close second.

These figures don’t resolve the debate on America’s need for physicians but they do reveal an important rift in the ratio of U.S. specialists to primary care practitioners.

The Most Powerful Health Care Group You’ve Never Heard Of

Aug 8, 2012• 17

By Brian Klepper and Paul Fischer

Excessive health care spending is overwhelming America’s economy, but the subtler truth is that this excess has been largely facilitated by subjugating primary care. A wealth of evidence shows that empowered primary care results in better outcomes at lower cost. Other developed nations have heeded this truth. But US payment policy has undervalued primary care while favoring specialists. The result has been spotty health quality, with costs that are double those in other industrialized countries. How did this happen, and what can we do about it.

American primary care physicians make about half what the average specialist takes home, so only the most idealistic medical students now choose primary care. Over a 30 year career, the average specialist will earn about $3.5 million more. Orthopedic surgeons will make $10 million more. Despite this pay difference, the volume, complexity and risk of primary care work has increased over time. Primary care office visits have, on average, shrunk from 20 minutes to 10 or less, and the next patient could have any disease, presenting in any way.

By contrast, specialists’ work most often has a narrower, repetitive focus, but with richer financial rewards. Ophthalmologists may line up 25 cataract operations at a time, earning 12.5 times a primary care doctor’s hourly rate for what may be less challenging or risky work.

Are Female Physicians Underpaid?

Jun 14, 2012• 2

By Peter Ubel, MD

In a new study published in JAMA, my colleagues and I found that even after accounting for productivity, women working as physician researchers at American Medical Schools are paid $13,000 less per year than their male colleagues, a difference that amounts to hundreds of thousands of dollars over the course of their careers.

But does this difference stand as evidence of discrimination?

Many claims of gender inequity in pay have suffered from an apples vs. oranges problem. For example, consider gender disparities across different careers. Many traditional male careers, like construction work, pay better than traditionally female careers, like nursing and teaching. It’s plausible that these disparities result, at least in part, from societal bias about how relatively important it is for men and women to make enough money to provide for their families. However, these disparities could also result from more justifiable factors. Maybe the physical demands of the work differ in important ways, or perhaps the marketplace is simply responding to supply and demand.

Medical experts have long noticed gender disparities in physician pay. Traditionally male fields like neurosurgery pay substantially more than fields preferred by more women, such as general pediatrics. If women are voluntarily choosing lower paying fields—perhaps for lifestyle reasons or maybe because they don’t value money as much as men do—then it’s arguable that we should not fret over pay disparities. It’s America, after all, where people have the right to choose.

The Wonks Are Wrong

Sep 1, 2011• 50

By RICHARD REECE, MD

I’ve heard critics express the idea a thousand times in a thousand ways.

The idea goes like this:

The system is terrible. It is fragmented. It is inefficient. It is too costly. It relies too much on specialists. Patients with chronic disease see too many over-paid specialists who don’t talk to each other. What we need is more well-paid primary care practitioners. They will provide accessible, continuous, comprehensive, coordinated, connected-electronically, and patient-centered rather than specialist-centered, care.

The Shadow

The problem is between the idea and reality falls a shadow. Patients aren’t listening.

They prefer the choice and freedom of picking their own doctor. In many cases, this doctor is a specialist who treats their specific problem. Patients feel they have enough information to make their own decisions as to what physician to choose. The American public is specialist-oriented. This is why the typical Medicare patient with chronic disease sees 5 or 6 specialists a year, rather than going through a personal primary care doctor who directs their over-all care

Primary Care Revolt: Replace the RUC

Apr 21, 2011• 1

By RICHARD REECE, MD

An under-the-radar revolution is going on out there. It is a revolt of primary care physicians against the AMA and CMS. It is a request for parity with specialists. It is a movement to replace how primary care practitioners are paid.

Why the revolt against the AMA and CMS? Because primary care doctors yearn to correct myths about primary care vis-à-vis specialists, and because they believe, by altering how the AMA and CMS pay doctors, health costs can be brought down, and primary care can be re-invigorated. Health systems with a broad primary care base have lower costs. In the U.S., two-thirds of doctors are specialists, and one-third are in primary care, the reverse of most nations, which have 50% or lower costs.

In the early 1990s, the AMA formed the Relative Value Scale Update Committee (RUC), which specialists now dominate. RUC sets payment codes for doctors. Since RUC’s inception, the payment differential has been growing between primary care doctors and specialists, so much so that the typical primary care doctor now makes only 30% of what an orthopedic surgeon makes. On average, primary care incomes are 50% of those of specialists.Continue reading…

So That’s How The Rates Are Set

Oct 29, 2010• 9

By PAUL LEVY

The Wall Street Journal published a very important article this week. Written by Anna Wilde Mathews and Tom McGinty, it is entitled, “Secrets of the System: Physician Panel Prescribes the Fees Paid by Medicare.

Here’s the lede:

Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars.

The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement.

Yet the influence of the secretive panel, known as the Relative Value Scale Update Committee, is enormous. The Centers for Medicare and Medicaid Services, which oversee Medicare, typically follow at least 90% of its recommendations in figuring out how much to pay doctors for their work. Medicare spends over $60 billion a year on doctors and other practitioners. Many private insurers and Medicaid programs also use the federal system in creating their own fee schedules.

How Can We Encourage Medical Students to Choose Primary Care?

Jun 14, 2010• 39

By ED PULLEN, MD

A Radical Suggestion – Pay Specialists Less

Since 1997 the number of US medical students choosing to go into primary care has decreased by more than 50%. It seems that sources as diverse as the Obama Administration and the Wall Street Journal think that we should find a way to encourage medical students to choose primary care specialties in order to allow Americans to have the best and most cost effective care. This is very problematic when primary care specialists earn considerably less, often 50-70% less than physicians in specialties where most of the revenue is produced by doing procedures. For years when asked about the disparity in physician salaries I’ve said, “I think primary care physicians are fairly compensated. I just think a lot of other physicians are overpaid.”

If you look at the 2009 AMGA survey of physician income it is clear that the pay you can expect as a physician has little to do with how hard you work, how long you train, or how stressful or difficult your work is, and everything to do with whether you perform procedures that are highly compensated. It is hard to think of specialties less demanding in terms of afterhours call, emergent life-threatening care, and overall lifestyle than dermatology ($350,627), diagnostic non-interventional radiology ($438,115) and Radiation Therapy ($413,518) (median salary in parentheses). Compare these to what I’d consider some of the most difficult, intellectually challenging, and demanding specialties: Pediatric Oncology ($205,999), Infectious Disease ($222,094) and Adult Neurology ($236,500). Family Medicine is one of the very few specialties where the first number in the median salary is a 1.