Poor pay for much-needed cognitive services threatens primary care

LETTER — Posted Aug. 7, 2006

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Regarding "Medicare takes AMA advice, proposes E&M pay boost" (Article, July 17): CMS has proposed physician payment reform for evaluation and management services. This is a step in the right direction to address payment inequities that are the major cause of a diminishing work force in primary care.

The workload in primary care has increased significantly over the past five years; evaluation and management codes should be modified to reflect this.

Five years ago, a patient of mine with a blood pressure of 143/82, creatinine of 1.4, fasting blood sugar of 128, and cholesterol of 189 was doing fairly well, and would have been provided with recommendations for exercise and weight loss. That same person today has hypertension, stage 3 chronic kidney disease, diabetes and dyslipidemia, and could be a candidate for four medications with ongoing monitoring. The result is a multiplying effect in terms of complexity of care.

The primary care visit is becoming increasingly complex: lower thresholds for diagnosis, stricter targets for management, increasing comorbidities, intricate coding rules, growing numbers of clinical practice guidelines, administrative requirements for voluntary reporting, Medicare Part D and pay-for-performance all add to the workload of the primary care visit.

Medicare physician payment reform is critical for future access of an aging population to primary care. This access in turn determines both the quality and costs of health care. Patients who have a strong primary care home have better outcomes and lower costs, yet established physicians are leaving this specialty faster than other specialties, and new physicians are choosing alternative fields.

The major reason for this exodus is the reimbursement disparity between procedural care and cognitive services. Reform of the work RVUs associated with outpatient evaluation and management services is one step toward redress of these disparities.

Christine A. Sinsky, MD, Dubuque, Iowa

Note: This item originally appeared at http://www.ama-assn.org/amednews/2006/08/07/edlt0807.htm.

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