Revaluing Primary Care — Going Beyond RVU Increases
Revaluing Primary Care — Going Beyond RVU Increases Elizabeth P. Griffiths
A recent change in Medicare reimbursement for evaluation-and-management codes hasn’t had a substantial effect on some primary care physicians, particularly those working in academic medical centers.
She’s giving up at least six figures so she can get holiday gifts from her patients,” one of the other medical students said, as the rest of them laughed. During an annual meeting of the American Medical Association (AMA) policymaking body, my fellow students judged my decision to go into primary care while they pursued emergency medicine or a procedural specialty. In internal medicine residency, the same dynamics played out, as my colleagues joked about how they couldn’t wait to get to cardiology fellowship so they could write “defer to PCP” in their notes for all but one problem.
As a legislative staff member, a medical trainee, and now a faculty member in a division of general internal medicine, I have heard policymakers lament the shortage of primary care physicians in the United States while merely tinkering at the edges of the health care system, hoping to create a different outcome. I spent years as a medical student and resident in the AMA’s policymaking body advocating for improved reimbursement for primary care, expansion of primary care residency programs, and broader recognition of the value of primary care, among other issues. After numerous setbacks, I was surprised to learn in the fall of 2020 that change was finally coming: the Centers for Medicare and Medicaid Services was increasing the relative value units (RVUs), and thus the payment rates, for the evaluation-and-management codes used to reimburse cognitive work in ambulatory care as part of its updated 2021 payment guidelines. This change represented an effort to correct decades of proven overvaluation of the work and time required for procedural services relative to cognitive services1 and was intended to reduce the disparity in overall compensation between procedural and nonprocedural specialties, including primary care, which is often hundreds of thousands of dollars per year.2
When I heard about this increase in revenue, I dreamed of the conversations our faculty would have: Should we raise salaries, hire more interdisciplinary team members, or spend more time with each patient? As months went by with no further announcements, however, I grew concerned. I had seen many policy changes fail to have the expected effect and had witnessed the challenging politics of redistribution, both in a local context and on the national level, so I began to worry that the change might not bolster primary care as intended.
In town-hall meetings with institutional leaders, my fears were confirmed: although RVUs would increase for services provided by primary care physicians and other nonprocedural specialists, our RVU targets would also increase such that we would be expected to see the same number of patients per day, and our annual compensation wouldn’t increase. Although RVUs don’t directly affect my salary or the salaries of my colleagues as they might at other institutions, we are expected to meet an annual RVU target. At my institution, there was little recognition that the policy change was designed to more appropriately compensate primary care physicians for the work involved in providing cognitive services. Instead, leaders tried to reassure us that at least we weren’t being asked to see more patients per clinic session or having our pay cut in the midst of the Covid-19 pandemic. I’ve subsequently reached out to colleagues throughout the country and found that my experience is commonplace.
I’ve heard two major explanations from my health care system’s leaders for the decision to maintain the existing compensation arrangements. First, whereas Medicare increased the value of cognitive services relative to procedural services, other payers haven’t followed suit, which limits the positive financial effects of the RVU increases for primary care. My health care system has made the principled decision not to compensate physicians differently for seeing patients with different forms of insurance, despite insurers paying widely varying rates, so it’s been especially affected by this limitation.
Second, when Medicare increased the relative value of cognitive services, it was statutorily required to reduce the amount paid per RVU so that the policy change would be budget-neutral, thereby tempering the financial benefits for primary care physicians and reducing payments for services in other fields. Because I work in a large, multispecialty health care system, passing the full benefit on to primary care physicians would require reductions in other departments, which have sometimes subsidized primary care during the decades in which it has been undervalued by payers. Despite the recent revaluation of evaluation-and-management codes, systemic overvaluation of procedural services means that the procedures that specialists perform still prop up hospitals’ often thin margins, and reducing investment in them remains challenging.
It’s important for policymakers to understand that the revaluation of evaluation-and-management codes hasn’t had a substantial effect on the practices of many primary care physicians, particularly those working in academic medical centers and potentially others practicing in large, multispecialty health care systems. A decision by other payers to adopt Medicare’s revaluation would be helpful, but real change would still require large health care systems to redistribute payments — a process that’s made more challenging by misaligned incentives that continue to favor investment in procedures with higher profit margins.
As another strategy, many advocates and policy experts have suggested that a move toward value-based or risk-based payments could improve investment in primary care. But health care systems that become or join accountable care organizations (ACOs) don’t necessarily change how they compensate clinicians or invest in primary care, as the National Academies of Sciences, Engineering, and Medicine (NASEM) have noted.3 My health care system participates in several ACOs, but these arrangements haven’t affected my day-to-day practice or compensation.
Investment in and access to primary care are associated with improved patient experience and outcomes and lower health care costs.4 If policymakers want to expand access, they will need to increase investment at the state and national levels. The NASEM recommends that states increase the portion of health care spending going to primary care. Six states have set targets for the percentage of total health care spending that’s invested in primary care, and 13 states require that health plans report on primary care spending5; according to NASEM, states that have implemented these policies and other primary care payment reforms “have achieved reduced cost trends and improved quality.”3 Given the incentives facing large health care systems to maintain the status quo, more states — or, ideally, the federal government — would have to enact similar policies to guarantee investment in primary care. Policymakers would have to design such policies carefully to ensure that the relevant payments are directed to primary care practices and departments.
As a medical student, I ignored other students’ financial advice and chose to pursue primary care, dreaming not of holiday gifts but of meaningful relationships with my patients. Today, I continue to work as an academic primary care physician despite the challenges because I love my relationships with my patients and sharing with trainees the joy and meaning I derive from this work. Although primary care physicians are still very well compensated overall, given enormous educational debts and the high cost of living in our area, some of my colleagues who shared my passion couldn’t find a sustainable path within our practice. Over the past year, our division has seen seven stellar physicians leave — some for concierge practices that pay salaries closer to what our proceduralist colleagues make and potentially allow them to work fewer hours, and others for payment models that don’t rely on an RVU system. As I advise medical students today, my hope is that policymakers will take the steps needed to require greater investment in primary care, particularly within academic medical centers, which would allow students to see my path and that of my colleagues as a joyful, rewarding one that they can choose without as much sacrifice.
Disclosure forms provided by the author are available at NEJM.org.
This article was published on December 17, 2022, at NEJM.org.
Author Affiliations
From the Department of Medicine, University of California, San Francisco, San Francisco.