Saturday, December 1, 2007

RBRVS-For Primary Care No Good Work Goes Unpunished

The results are in - Medical Residents are not choosing to enter the Generalist fields of medicine in the United States. With current trends, less than 10% of those training in Internal Medicine will work as general internists. Compare this with JAMAs report that all European countries have a broad Generalist foundation comprising 70-80% of practicing physicians. The consequences of our failing primary care infrastructure will be higher costs, greater inefficiencies, lower quality, more uninsured and inability to get care even if you have insurance. If you think we have problems with financing health care now, you don't even want to see what is coming in the future!

In the U.S., current reimbursement substantially favors procedures and technical interventions and offers financial advantages for expensive care. This applies to all medical services, both hospital and physician. Hospitals are quietly closing routine care services all across the country in favor of specialty ortho (joint replacement, exotic spine treatment) and cardiac interventions. Routine obstetrics, pneumonia, diabetes and emphysema care are financial losers for the hospitals. The ever expanding preventions, vaccines, need for evaluation, counseling, talking with patients and guiding their health are financial losers for doctors.

What is the origin of these gross payment inequities? The Centers for Medicaid and Medicare Services (CMS) determines the reimbursement for professional services using a resourced base relative value scale (RBRVS). This complicated system is then adopted by health insurance payers also so it drives all reimbursement.

The committee that decides the value that determines $$ is called the RUC. It is made up mainly of specialists from the specialty societies. Only 3/30 seats have term limits. Specialties that account for a very small portion of all professional Medicare billing such as neurosurgery, pathology, otolaryngology, urology and plastic surgery sit in the seats that determine reimbursement. The proceedings are proprietary and are not publicly available for review.

This committee is a powerful force in the US medical economy. They create more and more incentives for specialty care and fail to accurately assess the practice expenses of primary care.
The new Medicare Part D drug benefit has created more non-reimbursed time and expense for primary care as they endeavor to match formularies for their senior patients. The RUC doesn't have a clue what it takes to practice primary care in America.

Residents are walking with their feet and who can blame them? The system is designed to get the result is is getting. Goodbye Primary Care! Hello expensive procedures and medical spas on every block.

We talk about universal coverage and health care reform without understanding that there will not be a solid base of physicians to deliver care to the population. A large portion of the population will not be able to have continuous and personalized care provided by Generalist physicians who have excellent clinical skills and good bedside manner. Having an insurance card (government or not) is not the same as receiving care.


Vance Esler said...

Well said. I practiced general Internal Medicine for over a decade before I went into Heme/Onc.

You are exactly right. We half-joke among ourselves: "What is an oncologist?" Answer: "A really slow internist."

In other words, we spend a lot of time answering questions about chemo, investigating minor symptoms to be sure there is not an incipient major problem developing, and trying to find ways to settle anxieties among patients and family members.

Very little of this type of primary care is reimbursable. Thus one big reason the number of oncologists is decreasing every year even though the number of cancer cases is growing.

Don't know if you saw this post on my blog, but we are saying the same thing -- probably not coincidence!

Isadora said...

This appears to be a very difficult issue to resolves satisfactorily in most countries. Don't know the reason why when it affects every living individual, but Hungary is going through some incredibly difficult times in the health care field as they are attempting to transition into an HMO style of care.

K said...

I guess I just don't know what to do when I read things like this. Usually, I get pretty angry, frustrated, and anxious, because MAN this is my dang future and it is not looking terribly awesome (not even terribly so-so). I know some people would tell me to just take a breath and accept it, because there's nothing I as an individual can do. The problem I see with that assessment is that if everyone who has a problem with things thinks that, there is absolutely no motivation for any kind of change whatsoever, except the change which The Powers That Be are ok with, and which might not actually lead to a good-for-everyone-else change.

On the other hand, it seems like it'd be a kind of full-time job, and a thankless one at that, to try and fight this horrible downward spiral.

To sum up: Ugh.

Raymond Bouchayer said...

No matter what national health care is the answer . the system that we have now only benefits insurance companies and drug companies . Our system is not working and more and more Doctors are living ....they are fed up .

James Logan said...

I'm a family practice doctor just finishing my residency. I wonder if my feelings on this issue will change once I've been in paractice for a few years. But, I like to put things into perspective. So many of my friends are unemployed or underemployed right now. I'm just really grateful that, coming out of residency, I not only have a job, but I have work that I find meaningfull and which pays really well compared to the average national income. I think it's hard to expect more out of a profession than that.

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