Paying for Primary Care

Bradley Flansbaum

Posted 3/5/12 on the Hospitalist Leader

I recently gave grand rounds at my hospital, and spoke on specialty over primary care dominance in the U.S. system.  I focused on the difficulties of care coordination, i.e., “the stress” of ambulatory practice, and touched the third rail of reimbursement and salary.  Surprisingly, on the latter point, I received little venom or push back from the specialists.  I was shocked–literally, and staved off my own electrocution.  Maybe we are accruing more evidence to support non-specialty practice and reality is setting in?

Despite that, at the annual AMA House of Delegates meeting, no other subject generates more sizzle than physician pay (putting the ACA aside).  However, given the national budget, no new money will enter the system, and solving the primary care provider crisis will entail multiple fixes:

  • Loan Forgiveness
  • Stipends and financial support
  • GME incentives, including lifting training caps
  • Restructuring office practice to improve quality of life
  • Utilization of midlevels and other venues of care to offload low acuity patient volume
  • A National Health Care Workforce Commission (currently without appropriations)

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A Modest Proposal:What if all Specialty Procedures Were Coded with Four CPT Codes?

Paul Fischer

In a recent Wall Street Journal article, Barbara Levy, Chairwoman of the Relative Value Scale Update Committee (RUC), commented on the American Medical Association’s (AMA’s) decision to have minimal primary care participation on the RUC, saying the committee is an “expert panel” and not meant to be representative.  Since the committee is made up of 27 specialists, one family doc, and a pediatrician, the AMA apparently believes it requires little in the way of primary care expertise but lots of experts from every minute surgical specialty.

This is, of course, reflected in the AMA’s coding system.  Most of primary care is condensed into four Evaluation and Management (E/M) codes: a “focused” encounter, an “expanded” encounter, a “detailed” encounter, and a “comprehensive” encounter (99212-99215).  It does not matter whether the problem is a cold or an acute myocardial infarction.  It does not matter if you worked with just the patient or the entire family spanning three generations.  It does not matter if the problem was simple and common (eg, essential hypertension) or rare and complex (eg, pheochromocytoma).  It does not matter whether you completed everything in a single visit or spent hours fighting with an insurance company for payment.  And it does not matter whether you dealt with a couple of well-established problems or a dozen new ones.  It is clear that the AMA has little expertise in this area.  What is amazing is that they think they have enough!

Continue reading “A Modest Proposal:What if all Specialty Procedures Were Coded with Four CPT Codes?”