The primary care reimbursement mess

[deleted87716]

An excellent PowerPoint presentation on physician payment and the RUC can be accessed at:

http://healthcaredisclosure.org/docs/files/BodenheimerPaymentMay2006.pdf

It's a few years old, but things haven't really changed much.

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[Fredsgotslacks]

That is a good powerpoint. As a 4th year med student going into Family med I think a lot about reimbursement and discrepencies in rates between specialties but it has not really hit home until I saw it broken down like that. Having seen well run practices I am confident that its possible to make a very good living in family med with the current system and it is hard for me to put much faith in drastic changes to the system to favor primary care financialy. That does not mean i do not want to be an advocate for improvement and ultimately reducing the cost of US healthcare through a strong primary care foundation but in the back of my mind I keep making the analogy of primary care to public education. I think its safe to say that if asked, almost anyone would agree that we need to invest more in public education and pay teachers more etc. but it never happens. As a society we like instant fixes, fancier things, shiney new procedures and such and continue to neglect public education as a foundation for a strong society and primary care as a foundation for a great healthcare system.

 

[JackADeli]

I think we have discussed this in multiple threads before, front to back and side to side. The powerpoint is interesting but, For med-students it may be deceptive.

The definition of gaps and disparity often fails to present more then 12 month gross pay check stubs and not what is involved in achieving that gross amount at the end of the year. yes, I appreciate all the RVU comparisons.... but:

1. they mention working "full time" in one of the early slides. The question is, what is defined as full time, 40hrswk or 60hrs/wk or 80+hrs/wk? Does that take into account any weekends and/or holidays? Does that include on-call? etc, etc....

2. As for RVUs, they use colonoscopies as a "30 minute" procedure example. I don't know if colonoscopy has a "global period". They don't really comment on global periods per my quick scan through the slides. However, all the elective colonoscopies I performed and/or observed involve pre-op clinic evals, in process to procedure center/OR, time to administer drugs for concious sedation, then the procedure ~30 minutes, followed by 30 minutes to an hour of recovery, physician re-eval and discharge, +/- return to clinic for post-procedure follow-up. So, to simply lump an operative procedure based on "skin to skin" time is deceptive.

They talk about skilled surgeons being faster and suggesting they should therefore be ~penalized for their improved skill. Thus, by their logic a new surgeon that takes two hours to do a lap appy should be paid more then the senior surgeon that has 10yrs mastery and can perform a complex lap-appy in 30 minutes. And, again, they are not to my read even addressing the subsequent care provided under the global period. If that appy patient gets seen post op in clinic 3 times in the global period, the surgeon still sees the same amount for the initial procedure and does not get reimbursed for each additional clinic visit. I am not sure if PC physicians have a global period, i.e. they see a CHF/DM patient and has return to clinic in two weeks.... is that return reimbursed or a global under the first visit.

I am all for looking at the payment structures, etc.... But, I would like to see more honest and accurate discussions. Again, can primary care physicians get increased compensation? sure. But, let's stop trying to make innacurate comparisons and continue the specialty classwarfare arguments that fail to take into account actuall factors involved in the differences in compensation.

Will a med-student that chooses primary care earn less income at the end of the year as compared to a GSurgeon? Very likely. But, I strongly recommend the medical students carefully analyze what it will take to earn the GSurgeons income as opposed to the primary care income. You start with duration AND intensity of training. Then, you need to consider what are the actual hours worked to earn that income by the end of the year. Is the primary care physician working weekends, holidays, taking the same level of on-call? There is a trade-off for the lifestyles and income.

I will edit this post shortly to add references to links in which we previously discussed this topic.
http://forums.studentdoctor.net/showthread.php?t=753007

...As you know, the CPT reimbursement for an operative procedure includes pre-operative components, post-operative care and a GLOBAL PERIOD. It is far more then the 30 minutes to 5-6 operative hours any particular procedure takes to perform.

Again an attempt to debate the issue of compensation with pieces taken out of context and... probably not fair comparatives for EITHER party. Though, I am certain the tactic makes for good drama...

Another thread that discusses uncompensated care and healthcare waste...
http://forums.studentdoctor.net/showthread.php?t=757659

 

[deleted87716]

Jack: You use the term "class warfare" quite a bit. However, here's a surgeon hanging out in the FM forum...none of us are posting any of this in the general surgery forum. Who's the "class warrior...?"

There's only one version of reality. You can deny the facts all you want, but that doesn't change anything.

 

[JackADeli]

...here's a surgeon hanging out in the FM forum...none of us are posting any of this in the general surgery forum...

There's only one version of reality. You can deny the facts all you want, but that doesn't change anything.

FM/PC folks are welcome in the surgery forums to participate if they so choose. I have tried, and I believe succeeded in being polite when participating in discussions here... As for the "version of reality" and "facts"... again, I leave individuals to read my replies and the additional points of consideration I have posted.

I suspect you have been around long enough to understand the politics. You and others can continue to use comparatives to other specialties. You can bemoan the injustice/disparity/etc.... It will likely result in decreasing reimbursement of other specialists. Politicians will cite the comparisons, the proclaimed "disparity" as justification. They will then likely not significantly increase PC medicines reimbursements.

Chances are, politicians will then cite reverse comparisons. They will point to the actual hours, the global periods, etc.... as reason why PC at that point is comparatively overpaid. They will also reference all the current altruistic arguments used by PC medicine, etc... Thus, maintain current or lower reimbursements. The "saved" monies will go to pay the increased number of primary care ranks (and others...Gsurgery & NPs/PAs, etc...) the same or less then current reimbursements. In summary, will probably be all about scaling everyone's income back... including PC.

There is plenty of unreimbursed care provided by physicians accross the board that IMHO should be paid for... It doesn't require pointing fingers at other specialties, commenting on the income out of context and making incomplete and innaccurate comparisons. IMHO, our system and its waste needs improving AND patients should be paying a larger chunk of their healthcare. Current problem is much related to separation of patient from actual costs of healthcare.

 

[deleted87716]

FM/PC folks are welcome in the surgery forums to participate if they so choose.

Why...?

It doesn't require pointing fingers at other specialties

Indeed.

 

[bronx43]

FM/PC folks are welcome in the surgery forums to participate if they so choose. I have tried, and I believe succeeded in being polite when participating in discussions here... As for the "version of reality" and "facts"... again, I leave individuals to read my replies and the additional points of consideration I have posted.

I suspect you have been around long enough to understand the politics. You and others can continue to use comparatives to other specialties. You can bemoan the injustice/disparity/etc.... It will likely result in decreasing reimbursement of other specialists. Politicians will cite the comparisons, the proclaimed "disparity" as justification. They will then likely not significantly increase PC medicines reimbursements.

Chances are, politicians will then cite reverse comparisons. They will point to the actual hours, the global periods, etc.... as reason why PC at that point is comparatively overpaid. They will also reference all the current altruistic arguments used by PC medicine, etc... Thus, maintain current or lower reimbursements. The "saved" monies will go to pay the increased number of primary care ranks (and others...Gsurgery & NPs/PAs, etc...) the same or less then current reimbursements. In summary, will probably be all about scaling everyone's income back... including PC.

There is plenty of unreimbursed care provided by physicians accross the board that IMHO should be paid for... It doesn't require pointing fingers at other specialties, commenting on the income out of context and making incomplete and innaccurate comparisons. IMHO, our system and its waste needs improving AND patients should be paying a larger chunk of their healthcare. Current problem is much related to separation of patient from actual costs of healthcare.

Nice scare tactics, but class warfare won't end up causing decreases in primary care incomes, because there's literally nothing left to cut. The only scenario where primary care incomes go down is if incomes are equalized amongst all specialties, and all incomes go down together. I don't think this would ever occur, as that level of compensation wouldn't be able to attract enough talent into the medical profession.

 

[JackADeli]

FM/PC folks are welcome in the surgery forums to participate if they so choose...

Why...?...

I guess from my perspective the question is why not? Are we all not in healthcare, are we not able to have multidiscipline discussions, do we not learn from each other (I have learned much from PC physicians and I believe I have had the opportunity/privilege to participate in the education of medical students and primary care physicians' education). And, particularly in this topic of discussion, doesn't it involve everyone in all specialties accross the board....

... It doesn't require pointing fingers at other specialties...

...Indeed.

Just to keep some actual original context....

...There is plenty of unreimbursed care provided by physicians accross the board that IMHO should be paid for... It doesn't require pointing fingers at other specialties, commenting on the income out of context and making incomplete and innaccurate comparisons...

 

[deleted87716]

If you came here to offer support, that would be one thing.

However, the majority of your posts are decidedly oppositional, which raises the question...why?

 

[JackADeli]

If you came here to offer support, that would be one thing.

However, the majority of your posts are decidedly oppositional, which raises the question...why?

I guess that depends on what you deem oppositional. I am in the conversation to discuss things and provide additional points of consideration. If the "help" sought is simply to agree with all that is said.... No. I support changes to healthcare and reimbursement. That is a point I have stated repeatedly.

What I oppose if you want to use that word is incomplete and out of context representations. I think I am decidely opposed to that. But, I am not "decidely" opposed to reforms and improvements in the healthcare and reimbursement system.

As for "why?". Because this is an issue that effects all current and future physicians in all specialties. It is also an issue important to properly inform medical students when they choose their specialty. I encourage med-students everyday at work. I urge them to be completely informed in making their choices. I have ~said through out that this needs to be a joint effort that does not simply pit primary care against other specialties. And, I fully believe the current tactics are not just destructive to other specialties but ultimately self-destructive to primary care physicians as far as it relates to addressing issues of reimbursement.... you can see earlier posts.

 

[deleted87716]

Whatever, Jack.

Point is, you're here, for some reason. I guess we can figure that one out.

 

[JackADeli]

Whatever, Jack.

Point is, you're here, for some reason. I guess we can figure that one out.

I've explained the reason. You can choose to ignore it as you can choose to ignore other pesky components involved in the issues of reimbursement. You don't need to "figure" it out as I have stated it.

If you came here to offer support, that would be one thing....

I guess if I simply accepted what you stated, provided no additional information that might deviate from your agenda, then "that would be one thing"...

 

[deleted87716]

I've explained the reason. You can choose to ignore it as you can choose to ignore other pesky components involved in the issues of reimbursement. You don't need to "figure" it out as I have stated it....

Actions speak louder than words.

 

[JackADeli]

Actions speak louder than words.

So, I guess goes to my point:

...I guess if I simply accepted what you stated, provided no additional information that might deviate from your agenda, then "that would be one thing"...

Thus, the actions that would speak to you is not provide additional information that may be helpful to students and others as to what is actually involved in this issue.

Rather, I should simply agree to paycheck stub comparisons and allow innacurate comparisons between an office visit and skin to skin procedure times without considerations for global periods and other included care....

 

[deleted87716]

You could start by sticking to the subject of the thread.

If you take exception to Tom Bodenheimer's analysis, feel free to e-mail him.

http://profiles.ucsf.edu/ProfileDetails.aspx?From=SE&Person=4646367

 

[JackADeli]

You could start by sticking to the subject of the thread.

I think I have done just fine with that. You opened the thread with:

An excellent PowerPoint presentation on physician payment and the RUC can be accessed at:

http://healthcaredisclosure.org/docs/files/BodenheimerPaymentMay2006.pdf
....

My replies have been on point in discussing what you presented and the issue of reimbursements....

What I have never really understood is the apparent close mindedness you show when it comes to taking into considerations the other factors. They actually are significant both from physician earning standpoints and from the perspective of students understanding this issue. It is almost as if this is blasphemy to point out the issue of "global period" actually exists or that care occurs beyond the "skin to skin" time of an operation or that there may be a difference in the hours worked in relationship to the end of the year paycheck stub comparisons. Why shouldn't students and others consider these factors and be informed...

 

[deleted87716]

We're all well aware of the fact that you think you work way harder and deserve to be paid loads more than any of us.

Frankly, it's getting pretty tedious.

Incidentally, I always find it comical when people cite "close-mindedness" as the reason that others don't agree with their viewpoint. It could be that you're just wrong.

 

[JackADeli]

We're all well aware of the fact that you think you work harder and deserve to be paid more than any of us.

Frankly, it's getting pretty tedious.

You really seem to like polarizing and marginalizing on that statement. Well, I never said that. It doesn't matter medicine or a non-medical field of some sort. When discussing payment/income/salary, I do think the discussion should and can involve actual assessment of the work/labor that is involved. That statement does not mean I am saying I or anyone else works harder. That statement means what it means.... from a simple business standpoint, salary/pay/compensation requires assessment of what will be done for said compensation. I just don't think it is that hard a concept. I have NOT stated how many hours you work or anyone else. I have stated what someone actually works needs to be considered. The feigned insult and making it out as a point of non-discussion is very convenient and not helpful.

...Incidentally, I always find it comical when people cite "close-mindedness" as the reason that others don't agree with their viewpoint. It could be that you're just wrong.

I do consider it "close minded" when you choose to exclude a significant portion of what is actually involved in compensation. My points consider additional factors that ARE involved in this issue. Your position seems to exclude those factors, i.e. closed to their consideration.

 

[deleted87716]

You really seem to like throwing around words like "polarizing" and "marginalizing" when they don't make any sense, and denying that you said what you've said in practically every post you've ever written.

Whatever.

 

[JackADeli]

You really seem to like throwing around words like "polarizing" and "marginalizing" when they don't make any sense, and denying that you said what you've said in practically ever post you've ever written....

Sure.... I have read plenty of your misquotes and misrepresentations of my statements throughout. But, I agree that folks can go back and read my posts. You can also resort to snide remarks and/or insults, etc... You have done that previously.

Either way, not the point. I will continue to try and inform others and help individuals have a more complete understanding of this and other matters. I will continue to push that I believe this and other issues are, IMHO, best served by specialties come together as opposed to being pitted against each other.

 

[deleted87716]

I'm sure you will.

 

[Endolas]

He was the first person I put on "ignore." :-/

(A long time ago)

 

[tony montana]

I think Jackadeli gives an interesting balance to every conversation. His insights have helped me expand how I see some things in medicine.

 

[Charlie0318]

I think Jackadeli gives an interesting balance to every conversation. His insights have helped me expand how I see some things in medicine.

I agree, and would say the same thing of Blue dog.

Jack has never said he works harder and thus should be paid more. He just points out that one reason why surgical procedures are weighted more with RVUs is because of the pre-op, post-op etc work that goes in outside the time under the knife.

He has also pointed out that part of the reason FM docs have lower salaries is because they have some of the lowest hours worked.

Neither of these things are mean or denigrating, they are just true. If an FM doc wants to work 70 hours a week he/she could easily make 300+ k a year, which is not far off many higher paid "specialties". The fact that as an FM doc though you could work 40-50 hours, make low 200s a year, develop relationships with patients, and still have time for family is a big draw for me to the field.

 

[JackADeli]

I think Jackadeli gives an interesting balance to every conversation. His insights have helped me expand how I see some things in medicine.

...Jack has never said he works harder and thus should be paid more. He just points out that one reason why surgical procedures are weighted more with RVUs is because of the pre-op, post-op etc work that goes in outside the time under the knife...

I appreciate that some have read and understood what I said beyond the altered ~translation or re-interpretations posed by others. I am glad to see these factors can be discussed. Thank you.

...He has also pointed out that part of the reason FM docs have lower salaries is because they have some of the lowest hours worked...

I do not believe I pointed this out as I do not claim to know the hours in general of other specialties PC/FM/OB/etc... Though, I do know plenty of primary care physicians that have chosen a certain work model to include 4 days a week, outpt only with limited call and no weekends or holidays. However, I have posed repeatedly the question of what amount of labor folks want for what income.

I think that is critical, especially for medical students to consider (and critical in just about any business & profession outside of medicine too). Individuals need to not simply look at a published specialties' median anual income. Rather, you need to ask what is done for that income and is that what you are willing to do. To that, I pose the question to anyone declaring they want "x" dollars per year practicing medicine. The question/s is/are what sort of practice (i.e. 9-5 outpt vs evenings, etc...), how many days a week, what frequency and type of on-call obligations, weekends, holidays, etc...? How much time do you want to dedicate to training to be able to practice? Where do you plan to practice? These are questions medical students should ask honestly and discuss with family/significant others in making a specialty/career choice. There will be trade offs. The balance of gross income to job labor requirements to region/location of practice need to be carefully assessed. It is unfortunate to meet people in a specialty that they ultimately are not happy with and quit during training.

I also believe the above questions are critical when trying to analyze financial compensation between specialties. Without answering those questions it is simply comparing figures out of context. Might be good for drama but not good for honest discussion or accurate representation.

...The fact that as an FM doc though you could work 40-50 hours, make low 200s a year, develop relationships with patients, and still have time for family is a big draw for me to the field.

These are the sentiments my friends in shift work and/or outpt practices have told me. It is the balance they prefer and makes them happy.

 

[deleted87716]

one reason why surgical procedures are weighted more with RVUs is because of the pre-op, post-op etc work that goes in outside the time under the knife.

Likewise, primary care physicians should receive fair compensation for all of the uncompensated work that they do outside of office visits.

Currently, they don't.

http://www.fiercehealthcare.com/story/primary-care-docs-days-packed-uncompensated-tasks/2010-04-29

 

[MOHS_01]

Likewise, primary care physicians should receive fair compensation for all of the uncompensated work that they do outside of office visits.

Currently, they don't.

http://www.fiercehealthcare.com/story/primary-care-docs-days-packed-uncompensated-tasks/2010-04-29

Is the bolded portion above not the very same argument that I have made time and again?

You take the very same tone and tact with me that you do with Jack, friend. The "reality" is that Jack has and continues to make some very valid points; one side is actively advocating for a vindictive redistribution -- including petitioning for direct subsidies -- while the other side is defending the right to be paid per unit work (in concordance with the manner with which the work is provided). If PCP's would only make the sounder and less offensive argument that their services are undervalued given the amount of uncompensated (or bundled) work it would play much better than the current battle cries.

I'll look at the .ppt later... but my hunch is that it largely ignores several important factors (inherent differences in productivity between flesh and blood people, preferring instead to focus inappropriately on statistical groups being a major factor), overplays some factors, and places far too much emphasis on a very nebulous / problematic factor (time).

 

[deleted87716]

Is the bolded portion above not the very same argument that I have made time and again?

Dunno. You tell me.

Nobody I know is advocating anything "vindictive" or for "direct subsidies." If you're offended, it's not because we're being offensive.

You take the very same tone and tact with me that you do with Jack

You say that like it's a bad thing.

 

[MOHS_01]

I don't know where he gets the "specialists can perform procedures faster but we cannot" BS... that's nuts. Unless there is a major technological advance, the time (or intensity, whatever) required to perform any of the procedures I do will be essentially the same next year as it was five years ago. That's nonsensical.

Who exactly argues that E&M codes should not be paid higher again? I must have missed that memo.

The entire presentation should serve as a study case for why Soviet style planning never work, the easily predictable shortfalls and problems that will ensue as a direct result of the inherent incentive structure it creates, the political games that are inevitable, and the general overall suckiness of the system.

 

[MOHS_01]

Dunno. You tell me.

Nobody I know is advocating anything "vindictive" or for "direct subsidies." If you're offended, it's not because we're being offensive.



You say that like it's a bad thing.

Do I have to do a search for you? I have stated time and again that the single greatest reimbursement issue PCP's face is the amount of work provided that has no reimbursable CPT code. The direct subsidy is two-fold -- a PMPM direct payment and a carving out of PCP provided services from the SGR adjustment.

Perhaps a management fee is a valid method of compensation, I don't know.... apparently some agree -- which is the reason concierge medicine has a functioning market. The discussion changes, however, when we are talking about government dictating this market... and choosing to fund it by arbitrarily defunding other services.

I am absolutely that you cannot appreciate the difference in the following two statements:

"I believe that I am worth more than what my services are valued at."

and

"I want you to take from the man who does X, Y, and Z and give those monies to me."

Those are two completely different arguments... and come from two completely different places.

 

[deleted87716]

A picture is worth a thousand words.

 

[JackADeli]

As I stated earlier....

...There is plenty of unreimbursed care provided by physicians accross the board that IMHO should be paid for... It doesn't require pointing fingers at other specialties, commenting on the income out of context and making incomplete and innaccurate comparisons...

As for the picture.... again, the context is lacking. We can continue to point to different specialties annual gross incomes. That does not provide context or necessarily address any individual specialties issues of uncompensated and/or bundled care.

I can't post images. But the following link is to Cejka median salaries accross specialties:
http://www.cejkasearch.com/compensation/amga_physician_compensation_survey.htm

 

[MOHS_01]

Regarding your pretty 1,000 word essay, BD:

Half story -- care to show the number of visits per week? The number of hours worked per week? It is also interesting to note the variance in the numbers provided from supposedly the same source...

Beyond that, the practice of many (if not all, I don't know) specialties change over time. Take dermatology: it was predominantly an E&M medical specialty for decades. Starting somewhere around 2000 there was a huge increase in the availability of minimally invasive cosmetic procedures (which helped boost the bottom line completely and totally removed from the CPT reasoning provided above)... and, when combined with the aging boomer population, has fed upon itself. The aging boomer population has driven up the need for small in office procedures, including skin cancers. This will be a relatively short lived phenomenon -- several decades at most -- and represents an increase in the amount of work being provided. Now why again should that not result in higher compensation? Do PCP's really want to see a decrease in the reimbursement for many of the procedures they provide (biopsies, destructions, excisions)? Or do they simply want them decreased for the dermatologist who happens to do more of them? Perhaps the same can be said for GI's -- I don't know.... but I do not presume to know, either, which is a major distinction between myself and those who line up for "change".

Imaging is another matter entirely; much of the cost associated with it is in relation to the technical component and utilization rates...

 

[deleted87716]

Guys, I'm not interested in arguing with you. The articles and links that I have posted speak for themselves. They don't need any re-interpretation.

You can take exception to anything you want. But, where reimbursement is concerned, you're arguing against well-established facts, not opinions.

 

[deleted87716]

the following link is to Cejka median salaries accross specialties:
http://www.cejkasearch.com/compensation/amga_physician_compensation_survey.htm

Regarding your pretty 1,000 word essay...It is also interesting to note the variance in the numbers provided from supposedly the same source..

The AMGA (American Medical Group Association), which Jack referenced, and the MGMA (Medical Group Management Association), whose data produced the graphic that I posted, are two different organizations. The AMGA data is current, while the MGMA graph is almost five years old.

 

[JackADeli]

An excellent PowerPoint presentation on physician payment and the RUC can be accessed at:

http://healthcaredisclosure.org/docs/files/BodenheimerPaymentMay2006.pdf

It's a few years old, but things haven't really changed much.

...If you take exception to Tom Bodenheimer's analysis, feel free to e-mail him...

Guys, I'm not interested in arguing with you. The articles and links that I have posted speak for themselves. They don't need any re-interpretation.

....But, where reimbursement is concerned, you're arguing against well-established facts, not opinions.

It's rather amazing. You start a thread in which you present someone elses powerpoint and endorse it. You are pretty vehement about not even considering factors that are excluded in Bodenheimer's analysis. You go so far as to say, ~ here it is, I like it, but if you disagree don't speak to me about it, contact the guy who isn't here or in the discussion. You then argue and/or proceed with your opinions and interpretations, again not even allowing for consideration of factors that are involved in the RVU compensation issue. It seems more like a political campaign then any real willingness to discuss and find means of working together.

 

[deleted87716]

Why would you think I'm not interested in working together?

You're the ones over here starting arguments, not me.

And, just to clarify, posting a link to something doesn't qualify as an "endorsement". I post links to things all the time that I may not agree with 100%. That doesn't mean they don't have merit.

 

[MOHS_01]

The AMGA (American Medical Group Association), which Jack referenced, and the MGMA (Medical Group Management Association), whose data produced the graphic that I posted, are two different organizations. The AMGA data is current, while the MGMA graph is almost five years old.

Don't get all defensive.

on edit -- the .ppt used 2004 MGMA; your pic used 2006. Both were MGMA, though.

 

[deleted87716]

Your .ppt cited 2006 MGMA stats with different numbers, I believe, than the graphic you later posted.

Tom's PowerPoint cited MGMA data from 1995 and 2004. Neither year is shown on the graph that I posted. Tom's percentages are slightly different because he's looking at a slightly different time period. The point remains the same, however.

 

[FlyDoc34]

I'm an FPer recently freed from military service and living in a neighborhood where one of the hospital general surgeon's lives with his family. I can say that I'm home a hell of a lot more than he is. I would never begrudge the guy's salary. He makes more than me, and deservedly so.

Now the guy that works for Merrill Lynch is home more than me, gets to go on company sponsored runs to the local NFL stadium for box seats, and makes more than me. That guy, I begrudge.

 

[JackADeli]

...here's a surgeon hanging out in the FM forum...none of us are posting any of this in the general surgery forum. Who's the "class warrior...?"....

Why would you think I'm not interested in working together?

You're the ones over here starting arguments, not me...

Sure, I will leave it to others to read your replies and snide remarks here and elsewhere. You posted a link. I commented to your post to provide additional factors to be considered that were absent in the link you provide.... Then your comments followed. Here and other threads you have repeatedly mistated my comments and re-interpreted them. In this thread and others, anytime I suggest or ask about how much labor, on-call, etc... you will almost religiously accuse me of claiming primary care doesn't work and/or I work harder. These comments distract and result in a great deal of time repeating the same thing and spelling it out and pointing out that I have not actually written what you accuse. Now, in this thread the implication suggests as a surgeon I shouldn't be commenting in this forum. Yep, you are correct. It is US that are simply trying to be argumentative.

...And, just to clarify, posting a link to something doesn't qualify as an "endorsement". I post links to things all the time that I may not agree with 100%. That doesn't mean they don't have merit.

As you seem to make snide remarks and commentary about being "precise" and clear in what I say, endorsement does not equate agree 100%. However, your descriptor preamble to the link can be very easily misunderstood as an endorsement for the material you presented and have fairly aggressively argued against commentary on considering factors left out of the powerpoint. And yes, it has not escaped my attention that you have not directly argued in this link against the points of global periods. Rather, you basically just attacked the messenger.

An excellent PowerPoint presentation on physician payment and the RUC can be accessed at...

 

[deleted87716]

I'm an FPer recently freed from military service and living in a neighborhood where one of the hospital general surgeon's lives with his family. I can say that I'm home a hell of a lot more than he is. I would never begrudge the guy's salary. He makes more than me, and deservedly so.

Nobody has said that a general surgeon shouldn't earn more than a family physician.

 

[deleted87716]

I will leave it to others to read your replies and snide remarks here and elsewhere.

Seriously, Jack...if you're going to throw stones, you need to move out of that glass house.

 

[JackADeli]

Seriously, Jack...if you're going to throw stones, you need to move out of that glass house.

As I have said earlier, they are free to read my postings. Furthermore, this is not the first thread in which others have concurred that I did not say what you accused me of. I have even left links to I think the major discussion threads from previous. Leaving it to folks to read both your commentary and mine I don't see as throwing stones...

 

[MOHS_01]

I'm an FPer recently freed from military service and living in a neighborhood where one of the hospital general surgeon's lives with his family. I can say that I'm home a hell of a lot more than he is. I would never begrudge the guy's salary. He makes more than me, and deservedly so.

Now the guy that works for Merrill Lynch is home more than me, gets to go on company sponsored runs to the local NFL stadium for box seats, and makes more than me. That guy, I begrudge.

I lived across from a general surgeon for three years. While I am generally always at home at night and he was not, my day always started earlier and lasted longer than his did... and I worked more hours and days per week. He made about double what I did at that time. As my practice matured there was an evolution from an E&M heavy practice to a procedure heavy practice and I saw my income rise accordingly. I now make just a hair more than he did then (don't have any idea what he makes now, we no longer talk about such things)... so I understand better than most the difference CPT mix plays in net income.

I've never been a banker, though.

 

[JackADeli]

Nobody has said that a general surgeon shouldn't earn more than a family physician.

My point throughout is that the discussion shouldn't be about specialty a, b, or c should be making more then specialty x, y, or z. Rather, physicians should be working to identify appropriate compensation for a given amount of work/labor and also identify those areas in which service is being provided uncompensated to assure we are compensated.

 

[deleted87716]

physicians should be working to identify appropriate compensation for a given amount of work/labor and also identify those areas in which service is being provided uncompensated to assure we are compensated.

Theoretically, that's what the RUC is supposed to do.

http://www.ama-assn.org/ama/pub/phy...ve-value-scale/the-rvs-update-committee.shtml

Fail.

 

[deleted87716]

.As you seem to make snide remarks and commentary about being "precise" and clear in what I say...

That's not what I said. I said "concise and specific."

it has not escaped my attention that you have not directly argued in this link against the points of global periods. Rather, you basically just attacked the messenger.

Your first post in this thread accused me of being dishonest and inaccurate, and of engaging in "specialty class warfare".

I would like to see more honest and accurate discussions. Again, can primary care physicians get increased compensation? sure. But, let's stop trying to make innacurate comparisons and continue the specialty classwarfare arguments that fail to take into account actuall factors involved in the differences in compensation.

So, who attacked who...?

As for your question about global periods, since the only thing I can get paid for are face-to-face office visits, every E&M charge is essentially a global fee. All of the work that we do in between office visits (phone calls, test results, prescription refills, prior authorizations, etc.) is uncompensated.

 

[bronx43]

I'm an FPer recently freed from military service and living in a neighborhood where one of the hospital general surgeon's lives with his family. I can say that I'm home a hell of a lot more than he is. I would never begrudge the guy's salary. He makes more than me, and deservedly so.

Now the guy that works for Merrill Lynch is home more than me, gets to go on company sponsored runs to the local NFL stadium for box seats, and makes more than me. That guy, I begrudge.

Wait, so hours is the only thing we're using to gauge the "worthiness" of a man's income? I was under the impression that something called "context" must be utilized, as well.

 

[JackADeli]

...Your first post in this thread accused me of being dishonest and inaccurate, and of engaging in "specialty class warfare".

...I would like to see more honest and accurate discussions. Again, can primary care physicians get increased compensation? sure. But, let's stop trying to make innacurate comparisons and continue the specialty classwarfare arguments that fail to take into account actuall factors involved in the differences in compensation....

So, who attacked who...? ....

Again, a nice little partial quote/excerpt of what I wrote presented very much out of context. I will repost below so others can get an idea of the original context and what it was in reference to:

...The powerpoint is interesting but, For med-students it may be deceptive.

....I appreciate all the RVU comparisons.... but:

1. they mention working "full time" in one of the early slides....

2. As for RVUs, they use colonoscopies as a "30 minute" procedure example...

They talk about ...Thus, by their logic a...

I am all for looking at the payment structures, etc.... But, I would like to see more honest and accurate discussions. Again, can primary care physicians get increased compensation? sure. But, let's stop trying to make innacurate comparisons and continue the specialty classwarfare arguments that fail to take into account actuall factors involved in the differences in compensation...

You've presented the powerpoint.
My responses to the powerpoint and its content.... are ~in some way an attack on you personally.
My discussion of considering the factors in what one is compensated for ~is to you a statement as to how much you, I, or primary care as a whole works.
And, of course, your earlier reply that if I disagree with the powerpoint (you presented), ~should address them to the author of the powerpoint that is not present or involved in the discussion.

IMHO, when discussing with you, it seems as if any discussion is going to consistently involve responding to the misrepresentations and accusations. That continues to be a distractor.

...As for your question about global periods, since the only thing I can get paid for are face-to-face office visits, every E&M charge is essentially a global fee. All of the work that we do in between office visits (phone calls, test results, prescription refills, prior authorizations, etc.) is uncompensated.

That's an interesting comparison (to global period). However, if the patient returns to the primary care clinic 1, 2, 3, or more times over the next 30-90 days, are each of those clinics reimbursed? or, are they considered care under the global period for the original primary care provided?

As I noted, if I provide surgical care to a patient that involves a 30 minute skin to skin time, not only are additional phone calls, prescription refills, review of any labs, etc. (i.e. not direct patient contact but ongoing management components)... But, my rounding on the patient in the hospital and any additional clinic evals, wound care, etc is all regarded as part of the package under the 90 day global period.