Cognitive Versus Procedural Care

Researchers Highlight Pay Disparities for Physician Services

October 30, 2013 11:28 am Sheri Porter

A study in the October 14 issue of JAMA Internal Medicine highlights disparities in Medicare payments to physicians who perform cognitive services versus physicians who perform procedures.

[Colored makers on stacks of gold coins]

According to the study "Medicare Payment for Cognitive vs. Procedural Care; Minding the Gap,(" which was based on two specific examples of procedures, "Medicare reimburses physicians for procedural care at 368 percent (screening colonoscopy) and 486 percent (cataract extraction) of the rate of cognitive care."

"Our model demonstrates that an ophthalmologist will receive more revenue from Medicare for four cataract extractions, typically requiring one to two hours of time, than a PCP (primary care physician) will receive for an entire day of delivering complex care for chronic illness to Medicare patients," wrote the authors.

The study results closely align with the Academy's long-standing efforts to procure better payment for family physicians through payment reform mechanisms.

Story highlights
  • A study in JAMA Internal Medicine compares how Medicare values cognitive health care services versus procedural services.
  • Using two specific procedures as examples, researchers found that Medicare reimburses physicians for procedural care at 368 percent (screening colonoscopy) and 486 percent (cataract extraction) of the rate of cognitive care.
  • The variance in pay undermines efforts to attract medical students to primary care, a situation that has serious implications for the future of U.S. health care.

Study researchers pointed out that there is a growing need for a stronger primary care workforce to provide health care services to an aging population, but they also acknowledged the difficulties inherent in attracting young physicians to primary care specialties. For many years, these specialties have been undervalued and underpaid by Medicare and Medicaid and, ultimately, by private insurers, who often follow the lead of the federal programs.

"This mismatch between supply and demand for PCPs has serious implications for the future of U.S. health care," wrote the authors.

The study's corresponding author, Christine Sinsky, M.D., practices internal medicine with some 120 physician colleagues at a multispecialty group practice in Dubuque, Iowa, where she also leads the clinic's medical home initiative.

Sinsky told AAFP News Now that although the "direction" of the study's findings -- that procedural time is paid far better than that spent on cognitive care -- was expected, the magnitude of the variance was somewhat surprising. "While it's commonly considered that Medicare and other payers pay more per hour for procedural care, this had not, to our knowledge, been formally studied," said Sinsky.

She pointed out that for years the health care system has financially rewarded physicians in all specialties for "doing things" to patients rather than talking with patients and thinking through how best to address their health care issues. The resulting emphasis on procedural care "creates strong incentives that are not always in the best interest of patients or the health care system," said Sinsky.

"At the big picture level, the U.S health care system needs more primary care physicians," she noted. And research shows that regions with more primary care physicians provide good quality health care for less money than regions overstocked with subspecialists.

But too often, debt-conscious medical students avoid primary care because of the historically low payment rates. "Office visits make up the majority of primary care physicians' income," said Sinsky, adding that, like the tires on a car, the U.S. health care system needs to be rebalanced.

"We need doctors who are skilled at performing procedures. We also need physicians who are skilled at managing patients with chronic illnesses," she emphasized. "And in all specialties, we need physicians who are willing to take the time to thoroughly evaluate patients for their need for the procedures in the first place."

Sinsky added that future research should focus on alternative payment models that support the kind of health care that the vast majority of U.S. patients need most of the time, which is the kind of care family physicians provide every day.

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