Correspondence
What's Keeping Us So Busy in Primary Care?
N Engl J Med 2010; 363:495-496July 29, 2010
- Article
To the Editor:
The article by Baron (April 29 issue)1 paints a fascinating picture of the reality of a five-member single-specialty primary care group practice. One interesting aspect of that practice is that although it employed four medical assistants, five front-desk staff, one business manager, and one billing manager, it did not have any nurse or midlevel practitioners on board at the time of the study. After the study, they hired a registered nurse (RN) to take on “information triage” to reduce some of the physicians' workload. This is a good example of the value of an electronic health record, which enabled them to review their activities and discover a staffing need. It would be even more fascinating to redo the analysis now with the nurse on board. Not having a nurse as a member of the team could have made their practice not very representative of other single-specialty practices. The implementation of a patient health record to enhance patient engagement could also enhance their productivity, not in the narrow sense of visit volumes, but in improving the quality of care.
Ming Tai-Seale, Ph.D., M.P.H.
Palo Alto Medical Foundation Research Institute, Palo Alto, CA
tai-sealem@pamfri.org No potential conflict of interest relevant to this letter was reported.
1 References1
Baron RJ . What's keeping us so busy in primary care? A snapshot from one practice. N Engl J Med 2010;362:1632-1636
Full Text | Web of Science | Medline
To the Editor:
The work detailed by Baron matches the description of postservice work for evaluation-and-management visits in the database of the Relative Value Update Committee of the American Medical Association.1 Descriptions of postservice work were last modified during the third 5-year review in 2005. Postservice times in the committee's database range from 4 to 15 minutes for most established outpatient visits, so payment to do this work is already provided under the Resource-Based Relative Value Scale (RBRVS). According to this scale, the value assigned for evaluation and management is the same for all specialties and is essentially the same for such visits that are bundled into a global period, such as the 90 days after major surgery. Future research comparing evaluation-and-management work among specialties and in different global periods might validate or challenge that assumed homogeneity of such work. In the meantime, increased hourly payment rates for procedures, imaging, and test interpretations under the RBRVS weigh against not only primary care but also all “cognitive” care.
Marc Raphaelson, M.D.
107 Royal St., Leesburg, VADr. Raphaelson reports being a member of the AMA's Relative Value Update Committee, appointed by the American Academy of Neurology. No other potential conflict of interest relevant to this letter was reported.
1 ReferencesAuthor/Editor Response
I agree with Tai-Seale that having a nurse on board is likely to alter physician workloads, but most small primary care practices do not employ RNs. According to 2008 data reported by the Medical Group Management Association, among 218 single-specialty family medicine practices of all sizes, 29.8% reported having an RN.1 I would expect similar results for general internal medicine practices, so our practice was not unusual in being without an RN. Though RNs may take on some of the work we describe, their presence will also increase overhead in a way that may or may not increase productivity in the narrow sense of visit volumes. Since visits are what drive revenue, and physician income is what remains after the payment of all overhead, having an RN may potentially decrease physician income even as it may improve the quality of care.
Raphaelson asks whether the work we describe is already paid for through the RBRVS system. There are significant structural and political issues that are related to the process of the Relative Value Update Committee, which have been well documented recently2,3 and have militated against appropriate updates for primary care services. And, of course, the increased hourly payment rates “for procedures, imaging, and test interpretation,” as compared with codes for evaluation and management, could well be a major factor depriving primary care practices of the resources required to meet their patients' needs, making this form of practice less satisfying to practitioners4 and unattractive to medical students.
Perhaps the larger question is whether a visit-based payment system is appropriate for primary care at all. Berenson and Rich have recently reviewed the impact of fee for service on primary care and discussed other options.5 Visits are a crude way to adjust payment for the clinical work of modern primary care. We found that patients over the age of 65 years were 1.6 times as likely to generate an office visit as were younger patients but were 9.3 times as likely to need a prescription refill. We need payment systems that encourage and support services of high value to patients rather than anchoring payment to visits.
Richard J. Baron, M.D.
Greenhouse Internists, Philadelphia, PASince publication of his article, the author reports no further potential conflict of interest.
5 References1
Cost survey for single specialty practices: 2009 report based on 2008 data. Englewood, CO: Medical Group Management Association, 2009.
2
Bodenheimer T ,Berenson RA ,Rudolf P . The primary care-specialty income gap: why it matters. Ann Intern Med 2007;146:301-306
Web of Science | Medline3
Poses RM. RUC off — The New England Journal once again fails to mention the unmentionable. Health Care Renewal blog. June 1, 2010. (Accessed July 8, 2010, at http://hcrenewal.blogspot.com/2010/06/ruc-off-new-england-journal-once-again.html.)
4
Baron RJ . The chasm between intention and achievement in primary care. JAMA 2009;301:1922-1924
CrossRef | Web of Science | Medline5
Berenson R ,Rich EC . US approaches to physician payment: the deconstruction of primary care. J Gen Intern Med 2010;25:613-618
CrossRef | Web of Science | Medline
