Medicare Payment for Cognitive vs Procedural Care

By Christine A. Sinsky, MD and David C. Dugdale, MD
JAMA Internal Medicine, August 12, 2013

Conclusions and Relevance

Our analysis indicates that Medicare reimburses physicians 3 to 5 times more for common procedural care than for cognitive care and illustrates the financial pressures that may contribute to the US health care system’s emphasis on procedural care. We demonstrate that 2 common specialty procedures can generate more revenue in 1 to 2 hours of total time than a primary care physician receives for an entire day’s work.

The medical literature has highlighted the decline in the number of physicians entering cognitive specialties, with accompanying warnings about the impending collapse of primary care. The number of physicians in training who choose the primary care field of internal medicine dropped by 50% from 1998 to 2003, and primary care physicians (PCPs) in practice are leaving at a faster rate than other specialties. Increased workloads, administrative hassles, demanding time commitments, and low compensation relative to other specialties are major contributing factors.

Fewer physicians are choosing primary care fields while the needs of an aging population with multiple chronic diseases are projected to require an increase in the supply of primary care by at least one-third. This mismatch between supply and demand for PCPs has serious implications for the future of US health care. Health care costs in the United States are among the highest in the world and continue to rise. The quality of health care that Americans receive has been questioned. Worldwide and within the United States, health care costs are lower and quality is higher in regions with more PCPs. In addition, the quality of care is higher and costs are lower for patients whose first contact with the medical system is with a PCP.

The US health care reimbursement system rewards procedural services while providing financial disincentives for physicians to spend time on cognitive care, the main professional activity of PCPs and other nonprocedural specialists. In a comparison of international health payment systems, Wilson concluded that “the current system in the United States offers little incentive for PCPs to provide the kind of care coordination that is known to improve health quality.”

Several proposed or implemented changes, including an increase in the relative value of evaluation and management (E&M) codes, pay-for-performance programs, and primary care adjustment, may modestly address this issue, but each of these policy changes is projected to increase PCP compensation by only 1% to 10%. Herein we identify the magnitude of the payment gap for physician time spent on common procedures vs cognitive tasks.

Wonkbook: Doctors for higher health-care costs!

By Ezra Klein and Evan Soltas
The Washington Post, August 15, 2013

Everyone knows American health care costs too much.

Identifying the problem is easy. Doing anything about it is hard. But there’s one thing states can do that isn’t particularly hard: Allow more nurse practitioners — who charge much less than doctors — to treat patients directly, without a physician’s oversight.

Doctor’s groups oppose this strenuously. They say patient safety is at risk. What’s really at risk is their incomes.

This is a protection racket. Any state legislature that extends it is choosing higher health-care prices — and health-care costs — for no good reason.…

Perspectives of Physicians and Nurse Practitioners on Primary Care Practice

By Karen Donelan, Sc.D., Catherine M. DesRoches, Dr.P.H., Robert S. Dittus, M.D., M.P.H., and Peter Buerhaus, R.N., Ph.D.
The New England Journal of Medicine, May 16, 2013

Proposals that focus on the potential for nurse practitioners to help meet current and expected future gaps in the supply of primary care providers have met with wide interest and considerable controversy. At the core of the controversy is whether nurse practitioners have the education and experience to provide high-quality services and lead clinical practices without supervision by a physician.

Respondents in the two groups were far apart in their views on equal pay for providing the same services. Physicians’ opposition to equal pay is consistent with their perception, expressed in these data, that for any given service, they provide a higher quality of care than do nurse practitioners. Nurse practitioners’ support for equal pay is consistent with their majority view that physicians do not provide a higher quality of care for any given service. These survey data cannot provide evidence of the relative value of the training and expertise of these professionals. Nevertheless, the data suggest that physicians do not think that increasing the supply of nurse practitioners would have a positive effect on either the cost or the effectiveness of care, whereas more than 80% of nurse practitioners believe that increasing their numbers would improve the cost savings and quality of health care. From a societal perspective, we might consider whether expanding the supply of nurse practitioners and paying them equally for the same services that physicians provide would negate current savings from the disproportionately lower payments nurse practitioners now receive. More information is needed on the economic implications of the division of work between physicians and nurse practitioners before policymakers can definitively answer the question of whether employing a greater number of nurse practitioners and expanding their role would result in overall cost savings.

Our data provide evidence to inform ongoing public debates among physicians and nurse practitioners about their roles, responsibilities, and scope of practice. Both physicians and nurse practitioners will be needed to address the many challenges of developing a workforce that is adequate to meet the need for primary care services. It is our hope that the stark contrasts in attitudes that this survey reveals will not further inflame the rhetoric that has been offered by some leaders of the two professions but rather will contribute to thoughtful solutions for health care workforce planning and policy.

With concerns about our very high health care costs, we have to ask if procedure-oriented specialists are overpaid, or if the cognitive services of primary care physicians are underpaid? Further, are nurse practitioners underpaid when they are providing many of the same services as primary care physicians?

It seems that the consensus in the popular literature is that specialists are overpaid for procedures, whereas, listening to cynics like Klein and Soltas, primary care physicians are also overpaid when you consider that they can be replaced by nurse practitioners “who charge much less than doctors.” They contend that limiting the independence of nurse practitioners is a “protection racket.”

Yet nurse practitioners want their pay to be comparable to that of primary care physicians, “equal pay for equal work.” They do not want pay for cognitive services to be decreased; they want their own pay for these services to be increased.

What about the fundamental issue of filling the void in primary care with independent nurse practitioners? Even if medical schools increased the numbers of graduating physicians who would want want to become primary care physicians, there is a lack of residency programs and clinical training sites to train the numbers that we need. So does that mean that there is a plethora of comparable clinical training programs for nurse practitioners that would fill the void? Where are those programs that will produce an adequate number of nurse practitioners through training that will provide them with the same level of competence as primary care physicians? It is specious to assume that there is a paucity of clinical training programs for primary care physicians in a country that supposedly has a great abundance of comparable comprehensive training opportunities that are limited to nurse practitioners, while excluding physicians.

Try this mind game. Define primary care physician. Define nurse practitioner. Except for the duration and intensity of their training programs, are they exactly the same? If not, what are their differences? Should these differences be reflected in either their clinical independence or in their pay?

There is absolutely no dispute that nurse practitioners are an important addition to the clinical team that includes primary care physicians, specialists, and other health care professionals. It should not be difficult to integrate all clinical health services into a well oiled machine, as long as we can set aside turf issues. But we need to chastise the Ezra Klein’s of the nation who would throw a monkey wrench into the machine by characterizing this as a “protection racket.” It’s the patients who need protection through improved integration of our health care system.