03 July 2009

I never knew I was so powerful

Here it is, barely two weeks since I wrote in the New York Times that the best way to give doctors the right incentives was to reduce the pay for specialty-based procedural medicine and to increase the pay for primary care services.  And what happens?
Medicare Plans to Cut Specialists' Payments - WSJ.com
The Obama administration said Wednesday that it plans to cut Medicare payments for imaging services and specialists, and will use the savings to increase payments to physicians providing primary care.

Under the proposal, Medicare would put specialists' payments for evaluating and managing illnesses on par with those of primary-care physicians starting in January.

That, combined with other changes, would boost payments to internists, family physicians, general practitioners and geriatric specialists by 6% to 8% next year, said the Centers for Medicare and Medicaid Services
Wow. What should I wish for next? (Note to humor-impaired: this is facetious.  I may be paranoid, but I'm not delusional.)

Seriously, this is pretty good news.  Pediatrics, another poorly-compensated specialty will see a 4% increase, and just for the record, Emergency Medicine is pretty flat at 2% increase.  Hardest hit among specialists are Radiation Oncology, Nuclear Medicine, Interventional Radiology, Cardiology, and Radiology, all of which see >10% decreases in direct compensation.  This may in fact be understating the impact, in that the compensation will also be cut for certain diagnostic procedures such as echocardiography (-42%), coronary angiography (-24%), as well as the payments for CT, MRI and PET scans, and radiologists often (though certainly not always) own the equipment being used to perform the scans. The full proposed rule can be donwloaded here (PDF, 1128 pages -- pg 716 has the list), and is summarized here.

This is being accomplished in a variety of ways: Medicare will no longer pay for lucrative consultation codes, treating them instead as less-valuable Evaluation & Management (E/M) codes.  This is the big hurt for cardiology in particular.  The cuts in payment for radiology studies come from a change in the estimate of the utilization of the scanners, which were previously assumed to be in use only 50% of the time, but data showed were in use closer to 90% of the time; as a result the expected cost per study will be reduced.

There are also some minor fudges to the professional liability and practice expense components of the RVUs.

The good news is that this will help primary care docs and that is sorely needed.  The bad news is that the cost of this assistance seems to fall disproportionately on a few specialties.  My feeling is that the cost of a primary care bailout should be shared throughout the specialist world (yes, including Emergency Medicine if need be), not that the cardiologists and radiologists alone should fund it.  Under this plan, the compensation for general surgery, neurosurgery, orthopedic surgery, opthamology, anesthesiology and others actually go up, some as much as the primary care specialties!  And some "medical" specialties who do not perform a lot of procedures, such as oncology and allergy, wind up losing revenue.

It's also unclear to me whether this will be applied to all payers, or only Medicare.  Presuming that this change does not effect commercial payers, the net effect on primary care will actually be pretty small -- far too small to induce dramatic changes in physician compensation that are needed to drive physicians back towards the practice of primary care as a specialty.

So while the predictable histrionics are already beginning from the most affected specialty societies, it seems pretty clear that this is only a small first step and that further and more broad-based physician payment reform will be needed before primary care is restored as a viable area of medical practice.  And while I like the gesture towards acknowledging the importance of funding primary care, I'm not at all happy with the process by which CMS has arrived at this first step.  Worse, will it induce a sense of "fixed that, what's next?" which will preclude further revaluation of primary care services?   I dunno.  A for effort, guys, but minus ten points for execution.


  1. the proposed cuts are unlikely to be maintained in the final version (i hope). disclaimer i am a cardiologist.
    the impact to practices will be devastating. those are overall revenue cuts, not physician salary cuts. the response is going to be a tightening of the practice budget-less nurses, less receptionists, less ma's. maybe less call coverage at lower volume hospitals. young physicians will not be offered partnership. plans for hiring physicians will be dropped. less money for emr. less echo technologists. less technology purchases. longer waits for studies and visits.

    all those cardiology/radiology groups who sold ownership to the hospitals are probably congratulating themselves about now.

  2. You do a good job, all powerful horsey boy. I just added my voice to the mix: http://distractible.org/2009/07/03/can-i-play/

    You inspire me.

  3. Well I hate to say it but from my background as a cardiovascular ultrasound tech EKGs & ultrasounds (echo & vascular) have been an, im my opinion, unwarranted gravy train for these guys. I remember at one point I think they made $200 to interpret an EKG... so that's about $40/sec at the rate our guys read EKGs.

    I think Echo interpretation was billed at around $1,000 so maybe $100/min ? Unless they just read our written report and not the images...

    I realize the insurers probably didn't pay what they billed -- but still crazy. They would make more reading my exams for 30 min then I made in 10 hours doing the actual cognitive & physical work (for lay readers: your doctor's interpretation of your ultrasound is only as good as your tech, if the tech didn't see it -- there probably isn't a picture of it to interpret.)

    I got out of medicine, but I don't feel bad that the docs I knew will have to drive their BMWs for a few more years before trading up in the future.

  4. I thought general surgery was in need of an increase for similar reasons to primary care, so I don't have any complaints there.

  5. Hey Shadowfax,
    If one of your family members, in the PNW, were diagnosed with Pancreatic Cancer (so far looks like Stage IA T1, N0, M0 - 60 yo male, otherwise healthy) to whom would you send them for treatment?

    My understanding is that Virginia Mason has the best 5 year survival rates at as much as 55%. Is this your understanding also? Any specific docs you'd recommend?

    Sorry to hit you up for what amounts to medical advice, but you know with a dx like this we want only the best care. You can email me directly if you prefer - aimgrrrl at gmail.


  6. Shadowfax, I wonder if you might answer one question- have you figured out if the EM 2% increase is net of the 21.5% cut
    or not?

    Or in other words, does the 21.5% total CMS provider cut mean that EM will be spared 2% of this cut and therefore only see a 19% reduction while cardiology, radiation oncology, etc.. see greater than a 31.5% cut in rates?

    I have not been able to clarify this and prefer not to read several hundred pages.

  7. On page 221, it shows that Emergency department E&M level 3s and 4s are cut by 19% and critical care charges 99291 and 99292 are cut by 18%.

    Based on this, we are simply less hurt than other specialties.

  8. typo page 721

  9. Thai & Red Baron,

    1. The 2% update in ER E/M is the budget-neutral effect of the changes outlined in the press release, and is irrespective of the -21.5% PFS update.

    2. The changes on pg 720-1 include, as described in the paragraph above the chart, the -21.5% update. If that is canceled as we expect it to be, then you will see the small positive update of about 2%

  10. "Surgeons can easily earn three to five times the average salary of a family doctor"-Uh, surgeons SHOULD earn more than a family doc. Opening an abdomen is more complicated than treating an ear infection. Do you really think a cardiothoracic surgeon should make the same as a family doctor!? I want the person doing my mothers bypass to make WAY more than my family doc. This encourages the best and brightest to enter the field.

  11. Seriously...typical socialist BS

  12. Ok, I do not make $200 to read an ECG.

    As a cardiologist, I make 5 bucks to review an ECG and about $150 to review an Echo.

    Can YOU look at an ECG decide whether or not to call in the cath lab??

    How much should I make for that skill?

  13. Anon 11:09

    yeah, $25 is more typical compensation for reading an ECG. But yes, I can and do read and ECG and call in the cath lab. That's about the easiest ECG there is to read.

  14. Yeah, last Anon - I call in the cath team myself for a STEMI before I call the interventionalist.

  15. the cuts you describe as so deep would occur only if the planned 21.5% cut across the board goes through in 2010. That will never happen.

    What you need to do is remove 21.5% of the planned cuts to get the real numbers.

  16. Sometimes the ECG is easy. Sometimes the ECG is not easy.

    I suspect you would like your cardiologist to be well paid when you call them at 3 am to consider one of the more tricky ECGs.

    The machine can read the easy ones.

  17. I have to take exception to comments here about the root of our problems in healthcare being related to overcompensation of specialists. Primary care physicians like to conveniently ignore the fact that more of us overpaid specialists are near the top of our medical school classes. They also like to conveniently ignore the fact that specialty residency is far more demanding physically, emotionally, and chronologically (2-5 years of life for the training) It is unfathomable that all physicians should be paid the same amount. Just like anything in life,we get paid for higher achievement and for working harder. Get real.
    As I continue my “rant” as a specialist, also consider this fact. Most family physicians are employed these days. Incentives and productivity formulas are in place but rarely translate into increased productivity. My primary care brethren rarely squeeze in patients at the end of the day (when I call and ask for a medical clearance or a patient has an urgent problem) Why should I work harder if I’m not getting paid. Usually I’m told to send them to “walk-in or the PA of NP”. When they call me, I’m expected to jump and “expand” my day. Most primary care physicians would not be appreciative if they sent a new patient to me and the patient was only seen by the ENT PA-C. My partner and I employ 15 office staff and contribute to the economy as a small business. I spend countless hours running my business. I could hire a practice administrator for $60-100K/year, but they wouldn’t do it as well as I can. I take personal and financial risks on new technology and innovation. In my 13 years of practice this clearly has translated into better outcomes in most cases. It has also cost me financially when they didn’t. The payoff…I make more money, but I work harder for it. I don’t, however, compromise care of patients for higher income as has been implied. I resent this common and sickening assertion. There are crooks in every branch of medicine as there are in every branch of life.
    Employed physicians doing different duties like little soldiers. Let the government decide what specialty you practice and pay you what they decide is appropriate. We will be like the Chinese Olympic athletes channeled into their sport at a young age without the benefit of using their own free will. When we fail to glorify “mother country” are we then cast aside for the next in line. Sounds like socialism/communism to me. I may seem melodramatic, but it is a slippery slope.
    Another point is that almost all of those overused radiology tests are not ordered by the radiologist or the specialist. The vast majority are ordered by the primary care physician in need of some butt cover. My partner and I routinely marvel at the number of foolish and inappropriate tests ordered by our primary care referral base and our Emergency physicians.

    If you tell me that tort reform is needed to achieve this utopia you seek, ask president/attorney Obama what he thinks about limiting liability judgements. This problem has dimensions that go way beyond some of the perspective offered here.


  18. "Another point is that almost all of those overused radiology tests are not ordered by the radiologist or the specialist." Agree...last night on call..3 facial cts for rule out sinus disease in twenty somethings. I wasn't aware that a runny nose was an emergency.

  19. As someone accurately pointed out, the machine reads EKGs correctly >80% of the time.
    The other 20% are where 3-5 years of subspecialist training comes in, and don't insult our intelligence by pretending you can do as good a job as I can.
    Thanks to our president, I will now get paid even less for skills that took 8 years to acquire. Why couldn't have McCain picked someone with an actual brain as a VP?

  20. Anon 4:20

    I agree that the machine reads the ECGs right about 80% of the time. of the other 20%, I can read those accurately about 90% of the time. I need a cardiologist to "help" me read an ECG maybe 2% of the time. And yes, I *can* do as good a job as you can in the 98% of ECGs that I provide a definitive read on. The trick, of course, is being able to recognize which ones are the 2%! But don't make the mistake of thinking that the awesomeness of your training means that reading ECGs is harder than it is or that others do not possess the same skill set.

  21. Shadow-

    I can intubate 80% of people, but this does not qualify me to be an anesthesiologist.

    "But don't make the mistake of thinking that the awesomeness of your training means that reading ECGs is harder than it is or that others do not possess the same skill set."

    Don't be ridiculous. You cannot read 98% of ECGs. I know that for a fact because I know that I cannot read 98% of ECGs perfectly.

    As a cardiologist, I have seen patient, ECG, cath thousands of times.

    It takes specialization and time to learn art of ECG reading (and to learn that sometimes, you just can't tell by the ECG).

  22. I'll stand by my record, then. I'll guesstimate that I've read about 15,000 ECGs over the last decade in the ER. Twice have I been accused of a misread (once was a rookie error, once I was right and the cardiologist refused the case). Even if you uncharitably assume that I've sent 100 MI's home to die I'm still below 99%.

    Now if you are making an argument about the ECG as an imperfect tool and the indeterminacy of the read with regard to the patient's illness, then I'm in complete agreement. We've all had the cases of the trivial changes that turned out to be real or the "obvious" MI that turned out to be Tako-Tsubo syndrome or what-not. The point in these cases is that my pre-test assessment of the ECGs has never differed substantially from the cardiologists'.

    It's just not that hard. Now there are parts of your job that are really hard -- I can't perform or interpret a cath, nor an echo, etc. But ECGs are comparatively easy.


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