Comments on: The problem with the Relative Value Scale Update Committee http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html medical blog Mon, 23 Nov 2009 01:35:28 -0500 http://wordpress.org/?v=2.8.4 hourly 1 By: Anonymous http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html/comment-page-1#comment-72805 Anonymous Tue, 13 Mar 2007 02:37:00 +0000 http://clients.emmense.com/kevinmd/2007/02/the-problem-with-the-relative-value-scale-update-committee.html#comment-72805 After reading most of these comments it becomes clear that most of the specislists commenting do not have a good understanding what primary care docs do. Additionally, why do all the specialists focus on their length of training as criteria for getting paid more? It is a valid point but what about radiology, neurology, anesthesiology,dermatology, occupational medicine, shall I go on? When we refer our patients to you, it is typically for a focused, one- organ- system problem. We are asked to manage the entire patient, keep tract of their medicine and medical problems all in one 15 minute visit. Do any of you have any idea how many of the patients we refer to you call us to make sure the treatment plan you have advised is ok before they proceed? Has it occurred to you that the reason we "turf" the patients to the specialist is not only because we do not have the expertese but in many cases we do not have the time or equipment to focus on one problem at our visits? Medicare and private insurers are requiring more and more forms and prevention outcome data to assure quality of care, yet no one wants to increase salaries to primary care. If our lifestyle, call schedule, etc. are so wonderful, why aren't any med. students entering our field? After reading most of these comments it becomes clear that most of the specislists commenting do not have a good understanding what primary care docs do. Additionally, why do all the specialists focus on their length of training as criteria for getting paid more? It is a valid point but what about radiology, neurology, anesthesiology,dermatology, occupational medicine, shall I go on? When we refer our patients to you, it is typically for a focused, one- organ- system problem. We are asked to manage the entire patient, keep tract of their medicine and medical problems all in one 15 minute visit. Do any of you have any idea how many of the patients we refer to you call us to make sure the treatment plan you have advised is ok before they proceed? Has it occurred to you that the reason we “turf” the patients to the specialist is not only because we do not have the expertese but in many cases we do not have the time or equipment to focus on one problem at our visits? Medicare and private insurers are requiring more and more forms and prevention outcome data to assure quality of care, yet no one wants to increase salaries to primary care. If our lifestyle, call schedule, etc. are so wonderful, why aren’t any med. students entering our field?

]]> By: Anonymous http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html/comment-page-1#comment-72284 Anonymous Tue, 27 Feb 2007 21:29:00 +0000 http://clients.emmense.com/kevinmd/2007/02/the-problem-with-the-relative-value-scale-update-committee.html#comment-72284 I agree that primary care docs should earn more than they do but it certainly should not come at the expense of surgical specialists. With differences such as 7 years of rigorous training requiring sacrifices of family and self (not to mention debt and lost income) versus 1 mildly challenging year for primary care (intern year) and career expectations of operating in the middle of the night versus few calls at night or weekends for pcp's there is no other real correlation to the jobs so why should salary correlate? I agree that primary care docs should earn more than they do but it certainly should not come at the expense of surgical specialists. With differences such as 7 years of rigorous training requiring sacrifices of family and self (not to mention debt and lost income) versus 1 mildly challenging year for primary care (intern year) and career expectations of operating in the middle of the night versus few calls at night or weekends for pcp’s there is no other real correlation to the jobs so why should salary correlate?

]]> By: Anonymous http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html/comment-page-1#comment-72156 Anonymous Fri, 23 Feb 2007 01:41:00 +0000 http://clients.emmense.com/kevinmd/2007/02/the-problem-with-the-relative-value-scale-update-committee.html#comment-72156 RVS and CPT should be discarded, and physicians should charge by the hour in 5 min increments like other professionals. Payors, including Medicare would pay whatever their contracts with their enrollees required. Physicians could balance bill. Physicians whose extra skills and training justified it in the eyes of the public would charge higher rates. Excellence would again be rewarded and fostored. People would once again start taking histories instead of just scheduling procedures. Patients would get examined, managed and treated instead of just canulated and scoped. RVS and CPT should be discarded, and physicians should charge by the hour in 5 min increments like other professionals. Payors, including Medicare would pay whatever their contracts with their enrollees required. Physicians could balance bill. Physicians whose extra skills and training justified it in the eyes of the public would charge higher rates. Excellence would again be rewarded and fostored. People would once again start taking histories instead of just scheduling procedures. Patients would get examined, managed and treated instead of just canulated and scoped.

]]> By: Anonymous http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html/comment-page-1#comment-72148 Anonymous Thu, 22 Feb 2007 23:00:00 +0000 http://clients.emmense.com/kevinmd/2007/02/the-problem-with-the-relative-value-scale-update-committee.html#comment-72148 I would agree with the idea that if you have 3-4 years of extra training compared to a primary care doctor you should bill at a higher rate than one.It is very hard to get a fellowhip spot in any of the competitive specialties these days and usually the people getting them are at the top of their residency class, more published and more driven so if they make more in the end it is hard earned and well deserved.In the end it is about doing what you like and NOT money.The friends I had in residency who chose primary care did so knowing howmuch they would make but did it because it was what they wanted to do.if you are making 160-180 K with 3 years of training I think it is decent money.If a PCP thinks they can CATH,Scope or give chemo as well as a specialist they are clearly dellusional and to say people should be paid the same for these as a 30 minute PCP visit is ludicrous.Lets no forget people are refered to a specialist when a PCP doesnot know what to do or needs something done that they are not trained to do....if you are asking for help from someone sho is better trained in something don't hold it against them if they get paid more than you...Don't forget they are fixing something you couldn't... I would agree with the idea that if you have 3-4 years of extra training compared to a primary care doctor you should bill at a higher rate than one.It is very hard to get a fellowhip spot in any of the competitive specialties these days and usually the people getting them are at the top of their residency class, more published and more driven so if they make more in the end it is hard earned and well deserved.In the end it is about doing what you like and NOT money.The friends I had in residency who chose primary care did so knowing howmuch they would make but did it because it was what they wanted to do.if you are making 160-180 K with 3 years of training I think it is decent money.If a PCP thinks they can CATH,Scope or give chemo as well as a specialist they are clearly dellusional and to say people should be paid the same for these as a 30 minute PCP visit is ludicrous.Lets no forget people are refered to a specialist when a PCP doesnot know what to do or needs something done that they are not trained to do….if you are asking for help from someone sho is better trained in something don’t hold it against them if they get paid more than you…Don’t forget they are fixing something you couldn’t…

]]> By: Anonymous http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html/comment-page-1#comment-72106 Anonymous Thu, 22 Feb 2007 00:40:00 +0000 http://clients.emmense.com/kevinmd/2007/02/the-problem-with-the-relative-value-scale-update-committee.html#comment-72106 The above thread shows exactly the problem with the RVS and why the AMA should have never in any way, manner, or form cooperated with it. It pits doctor against doctor and specialty against specialty arguing with each other about the relative value of their services.<br/><br/>The relative value of any service can only be determined by a customer seeking to purchase it.<br/><br/>In my practice of psychiatry, I recognize the plain fact that no one places much value on my services except those in need of them. Most physicians discount the specialty entirely until they have a psychiatric problem disrupting their practice. I decided long ago that I will not allow anyone but the actual purchaser of my services to decide their value. I much prefer the free market to committees of non-customers. That mean no medicare and no insurance contracts but so be it. <br/><br/>Many physicians are afraid of the free market, but I welcome it. There is not a single service that I provide that can not be obtained by people in other specialties or other professions. It keeps me on my toes giving good service, yet I thrive. Pride of craft is a great reward itself The above thread shows exactly the problem with the RVS and why the AMA should have never in any way, manner, or form cooperated with it. It pits doctor against doctor and specialty against specialty arguing with each other about the relative value of their services.

The relative value of any service can only be determined by a customer seeking to purchase it.

In my practice of psychiatry, I recognize the plain fact that no one places much value on my services except those in need of them. Most physicians discount the specialty entirely until they have a psychiatric problem disrupting their practice. I decided long ago that I will not allow anyone but the actual purchaser of my services to decide their value. I much prefer the free market to committees of non-customers. That mean no medicare and no insurance contracts but so be it.

Many physicians are afraid of the free market, but I welcome it. There is not a single service that I provide that can not be obtained by people in other specialties or other professions. It keeps me on my toes giving good service, yet I thrive. Pride of craft is a great reward itself

]]> By: Anonymous http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html/comment-page-1#comment-72086 Anonymous Wed, 21 Feb 2007 18:01:00 +0000 http://clients.emmense.com/kevinmd/2007/02/the-problem-with-the-relative-value-scale-update-committee.html#comment-72086 Happyman, you have some serious class envy clouding your judgement. I assume you're a physician, so it's hard to believe that a board certified practitioner would go on in such an illogical way.<br/><br/>The top three diagnoses in at least one ER where this was studied were: otitis, sinusitis,pharyngitis. If you can't get thes mundane things right on the first at-bat 90% of the time, it's easy to see the magnitude of the problem, i.e. knowledge base. Again, please do the math.<br/><br/>With respect to the accusation that another interlocuter is advocating a system of NP's and PA's, it's already happening - much to the chagrin of both primary and specialty physicians. And it is intimately related to the problem wiht mundane disorders as outlined above. Happyman, you have some serious class envy clouding your judgement. I assume you’re a physician, so it’s hard to believe that a board certified practitioner would go on in such an illogical way.

The top three diagnoses in at least one ER where this was studied were: otitis, sinusitis,pharyngitis. If you can’t get thes mundane things right on the first at-bat 90% of the time, it’s easy to see the magnitude of the problem, i.e. knowledge base. Again, please do the math.

With respect to the accusation that another interlocuter is advocating a system of NP’s and PA’s, it’s already happening – much to the chagrin of both primary and specialty physicians. And it is intimately related to the problem wiht mundane disorders as outlined above.

]]> By: Happyman http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html/comment-page-1#comment-72076 Happyman Wed, 21 Feb 2007 13:17:00 +0000 http://clients.emmense.com/kevinmd/2007/02/the-problem-with-the-relative-value-scale-update-committee.html#comment-72076 I didn't say they shouldn't make more, but can you really honestly say that the financial incentive isn't a factor in the growth of nuclear stress and echo? <br/><br/>A cardiologist friend of mine once told me that echo was "the best bang for the buck of any medical procedure reimbursed by medicare". He echoes some patients 2-3 times a year!<br/><br/>And if I send someone to a GI for abd pain, first question is "you want me to scope from above, below, or both?" If those tests don't yield an answer, I'm back to square one, usually without an opinion, consult note, etc.<br/><br/>And cardiologists DON'T do everything IM docs do, even though they completed an IM residency, nor do most want to. fellowship trains them to (appropriately) see everything through the lens of cardiovascular disease. <br/><br/>By your logic, we shouldn't have IM at all - maybe the system should be primary care provided by NPs and PAs, referring to specialists who saved the 3yrs of IM residency. But if you ask me, I want a DOCTOR seeing me for routine care and knowing me well, rather than an NP or PA. I didn’t say they shouldn’t make more, but can you really honestly say that the financial incentive isn’t a factor in the growth of nuclear stress and echo?

A cardiologist friend of mine once told me that echo was “the best bang for the buck of any medical procedure reimbursed by medicare”. He echoes some patients 2-3 times a year!

And if I send someone to a GI for abd pain, first question is “you want me to scope from above, below, or both?” If those tests don’t yield an answer, I’m back to square one, usually without an opinion, consult note, etc.

And cardiologists DON’T do everything IM docs do, even though they completed an IM residency, nor do most want to. fellowship trains them to (appropriately) see everything through the lens of cardiovascular disease.

By your logic, we shouldn’t have IM at all – maybe the system should be primary care provided by NPs and PAs, referring to specialists who saved the 3yrs of IM residency. But if you ask me, I want a DOCTOR seeing me for routine care and knowing me well, rather than an NP or PA.

]]> By: Anonymous http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html/comment-page-1#comment-72070 Anonymous Wed, 21 Feb 2007 05:16:00 +0000 http://clients.emmense.com/kevinmd/2007/02/the-problem-with-the-relative-value-scale-update-committee.html#comment-72070 You are full of sh*t. Why don't you tell that cardiogist that you think 95 percent of what he does is ridiculous. That is the most ridiculous accusation I have seen on this board for a while. Yes, they have really pulled the wool over the eyes of everyone. Geez, why don't we just pay them 5 percent of their average 275,000 dollar income. Oh what, you thought they were all millionaires? Oh, crap!!! So let's see here primary care docs average around 175,000 and cardiogists average around 300,000. Yet, cardiogists train for three-four more years and can do everything a primary care doc does (Internal Medicine wise). Why shouldn't they make more? You are full of sh*t. Why don’t you tell that cardiogist that you think 95 percent of what he does is ridiculous. That is the most ridiculous accusation I have seen on this board for a while. Yes, they have really pulled the wool over the eyes of everyone. Geez, why don’t we just pay them 5 percent of their average 275,000 dollar income. Oh what, you thought they were all millionaires? Oh, crap!!! So let’s see here primary care docs average around 175,000 and cardiogists average around 300,000. Yet, cardiogists train for three-four more years and can do everything a primary care doc does (Internal Medicine wise). Why shouldn’t they make more?

]]> By: Happyman http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html/comment-page-1#comment-72059 Happyman Wed, 21 Feb 2007 00:47:00 +0000 http://clients.emmense.com/kevinmd/2007/02/the-problem-with-the-relative-value-scale-update-committee.html#comment-72059 "Specialist takes care of problem (and CORRECTLY to boot) in one visit vs. three. Do the math."<br/><br/>Yeah, for like 5% of their income. The other 95% is a mix of a little useful care and mostly TONS of unnecessary procedures (true of cardiologists and GIs especially). This is where the cost concerns and solutions lie. <br/><br/>And don't expect any primary care doc to believe that "defensive medicine" is the reason for an ANNUAL nuclear stress test / echo /holter in every medicare patient referred to a cardiologist - we see the truth every day. “Specialist takes care of problem (and CORRECTLY to boot) in one visit vs. three. Do the math.”

Yeah, for like 5% of their income. The other 95% is a mix of a little useful care and mostly TONS of unnecessary procedures (true of cardiologists and GIs especially). This is where the cost concerns and solutions lie.

And don’t expect any primary care doc to believe that “defensive medicine” is the reason for an ANNUAL nuclear stress test / echo /holter in every medicare patient referred to a cardiologist – we see the truth every day.

]]> By: Anonymous http://www.kevinmd.com/blog/2007/02/problem-with-relative-value-scale.html/comment-page-1#comment-72055 Anonymous Wed, 21 Feb 2007 00:13:00 +0000 http://clients.emmense.com/kevinmd/2007/02/the-problem-with-the-relative-value-scale-update-committee.html#comment-72055 So you think that lack of knowledge base is a small deal? Here's an exercise:<br/><br/>Patient with "Otitis Media" sees PCP for 3 visits. 3 antibiotics prescribed. No improvement. Sees otolaryngologist. Patient informed he does not HAVE an OM, but a referred otalgia secondary to TMJ. (Happens ever day)<br/><br/>Specialist takes care of problem (and CORRECTLY to boot) in one visit vs. three. Do the math.<br/><br/>Still thnk the PCP should be paid "just" $50K less than the sepcialist?? So you think that lack of knowledge base is a small deal? Here’s an exercise:

Patient with “Otitis Media” sees PCP for 3 visits. 3 antibiotics prescribed. No improvement. Sees otolaryngologist. Patient informed he does not HAVE an OM, but a referred otalgia secondary to TMJ. (Happens ever day)

Specialist takes care of problem (and CORRECTLY to boot) in one visit vs. three. Do the math.

Still thnk the PCP should be paid “just” $50K less than the sepcialist??

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