Crisis in Primary Care

Crisis in primary care: The specialist-primary caregiver income gap

May 1, 2007
Patient Care Newsline

Primary care providers gripe to each other about how underpaid they are, but they may not be aware of how large the gap really is between their incomes and that of their specialist colleagues. Unhappily, the gap is very large indeed, and it is getting larger over time. And, according to a recent article in the Annals of Internal Medicine, the reasons are the increasing volume of procedures specialists perform and a bias in the Resource-Based Relative Value Scale (RBRVS) that overvalues procedures at the expense of cognitive services in determining reimbursement levels for Medicare patients. The Medicare bias in favor of procedures is widely copied?-and often magnified?-in the reimbursement policy followed by private insurers.1

As medical technology evolves, specialists have more procedures?-especially imaging procedures?-to offer and can perform them more quickly. Primary care providers, on the other hand, cannot see more patients more quickly without reducing the quality of care and their own and their patients' satisfaction. Further, the fees per procedure that specialists can command keep rising, despite the fact that the RBRVS system was initially intended to lessen the disparity between fees for office visits and fees for the surgical and imaging procedures performed by specialists. In 2005, for example, Medicare paid a typical primary care provider practicing in Chicago, Ill, $89.64 for a typical, half-hour office visit for a patient with a moderately complex condition (CPT code 99214). That same year in the same city, Medicare paid $226.63 to a gastroenterologist taking the same amount of time to perform a colonoscopy in an outpatient department and $422.90 to do it in a private office. The difference is fees for cognitive services versus procedures is reflected in physician income: In the years from 2000 to 2004, median physician income for family practice physicians increased 7.5% to $156,000; median income for invasive cardiologists went up 16.9% to $428,000; for hematologists and oncologists, income rose 35.6% to $350,000; and for diagnostic radiologists, income went up 36.2% to $407,000.

According to the authors, the bias in the RBRVS system is traceable to the overrepresentation of specialists on the RBRVS Update Committee (RUC) that makes fee recommendations to Medicare. While the ratings for procedures have been rising, ratings for evaluation and management (E&M) codes did not increase at all in the years from 1995 to 2005. While some revisions favoring E&M reimbursement were made in 2006, the net effect will be very small: Family physicians and internists will receive 5% more in allowed Medicare charges in 2007 than they did the year before.

The resulting income gap between specialists and primary care providers has serious consequences. Primary care providers may resort to shorter patient visits, with adverse affects on the satisfaction and well-being of their patients. Medical students carrying heavy student-loan burdens shun primary care careers, increasing the pressures on already overburdened primary care practitioners. And health care costs continue their relentless rise. Payment reform, the authors conclude, is essential "if the US is to maintain a healthy primary care base to its health care system."

1. Bodenheimer T, Berenson R, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. 2007;146(4):301-306