Quote-of-the-day mailing list
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Subject: qotd: Are nurse practitioners a solution for the
cognitive/procedural pay gap?
Date: Fri, 16 Aug 2013 11:19:36 -0700
From: Don McCanne <email@example.com>
To: Quote-of-the-Day <firstname.lastname@example.org>
JAMA Internal Medicine
August 12, 2013
Medicare Payment for Cognitive vs Procedural Care
By Christine A. Sinsky, MD and David C. Dugdale, MD
Conclusions and Relevance
Our analysis indicates that Medicare reimburses physicians 3 to 5 times
more for common procedural care than for cognitive care and illustrates
the financial pressures that may contribute to the US health care
system's emphasis on procedural care. We demonstrate that 2 common
specialty procedures can generate more revenue in 1 to 2 hours of total
time than a primary care physician receives for an entire day's work.
The medical literature has highlighted the decline in the number of
physicians entering cognitive specialties, with accompanying warnings
about the impending collapse of primary care. The number of physicians
in training who choose the primary care field of internal medicine
dropped by 50% from 1998 to 2003, and primary care physicians (PCPs) in
practice are leaving at a faster rate than other specialties. Increased
workloads, administrative hassles, demanding time commitments, and low
compensation relative to other specialties are major contributing factors.
Fewer physicians are choosing primary care fields while the needs of an
aging population with multiple chronic diseases are projected to require
an increase in the supply of primary care by at least one-third. This
mismatch between supply and demand for PCPs has serious implications for
the future of US health care. Health care costs in the United States are
among the highest in the world and continue to rise. The quality of
health care that Americans receive has been questioned. Worldwide and
within the United States, health care costs are lower and quality is
higher in regions with more PCPs. In addition, the quality of care is
higher and costs are lower for patients whose first contact with the
medical system is with a PCP.
The US health care reimbursement system rewards procedural services
while providing financial disincentives for physicians to spend time on
cognitive care, the main professional activity of PCPs and other
nonprocedural specialists. In a comparison of international health
payment systems, Wilson concluded that "the current system in the United
States offers little incentive for PCPs to provide the kind of care
coordination that is known to improve health quality."
Several proposed or implemented changes, including an increase in the
relative value of evaluation and management (E&M) codes,
pay-for-performance programs, and primary care adjustment, may modestly
address this issue, but each of these policy changes is projected to
increase PCP compensation by only 1% to 10%. Herein we identify the
magnitude of the payment gap for physician time spent on common
procedures vs cognitive tasks.
The Washington Post
August 15, 2013
Wonkbook: Doctors for higher health-care costs!
By Ezra Klein and Evan Soltas
Everyone knows American health care costs too much.
Identifying the problem is easy. Doing anything about it is hard. But
there's one thing states can do that isn't particularly hard: Allow more
nurse practitioners — who charge much less than doctors — to treat
patients directly, without a physician's oversight.
Doctor's groups oppose this strenuously. They say patient safety is at
risk. What's really at risk is their incomes.
This is a protection racket. Any state legislature that extends it is
choosing higher health-care prices — and health-care costs — for no good
The New England Journal of Medicine
May 16, 2013
Perspectives of Physicians and Nurse Practitioners on Primary Care Practice
Karen Donelan, Sc.D., Catherine M. DesRoches, Dr.P.H., Robert S. Dittus,
M.D., M.P.H., and Peter Buerhaus, R.N., Ph.D.
Proposals that focus on the potential for nurse practitioners to help
meet current and expected future gaps in the supply of primary care
providers have met with wide interest and considerable controversy. At
the core of the controversy is whether nurse practitioners have the
education and experience to provide high-quality services and lead
clinical practices without supervision by a physician.
Respondents in the two groups were far apart in their views on equal pay
for providing the same services. Physicians' opposition to equal pay is
consistent with their perception, expressed in these data, that for any
given service, they provide a higher quality of care than do nurse
practitioners. Nurse practitioners' support for equal pay is consistent
with their majority view that physicians do not provide a higher quality
of care for any given service. These survey data cannot provide evidence
of the relative value of the training and expertise of these
professionals. Nevertheless, the data suggest that physicians do not
think that increasing the supply of nurse practitioners would have a
positive effect on either the cost or the effectiveness of care, whereas
more than 80% of nurse practitioners believe that increasing their
numbers would improve the cost savings and quality of health care. From
a societal perspective, we might consider whether expanding the supply
of nurse practitioners and paying them equally for the same services
that physicians provide would negate current savings from the
disproportionately lower payments nurse practitioners now receive. More
information is needed on the economic implications of the division of
work between physicians and nurse practitioners before policymakers can
definitively answer the question of whether employing a greater number
of nurse practitioners and expanding their role would result in overall
Our data provide evidence to inform ongoing public debates among
physicians and nurse practitioners about their roles, responsibilities,
and scope of practice. Both physicians and nurse practitioners will be
needed to address the many challenges of developing a workforce that is
adequate to meet the need for primary care services. It is our hope that
the stark contrasts in attitudes that this survey reveals will not
further inflame the rhetoric that has been offered by some leaders of
the two professions but rather will contribute to thoughtful solutions
for health care workforce planning and policy.
Comment: With concerns about our very high health care costs, we have
to ask if procedure-oriented specialists are overpaid, or if the
cognitive services of primary care physicians are underpaid? Further,
are nurse practitioners underpaid when they are providing many of the
same services as primary care physicians?
It seems that the consensus in the popular literature is that
specialists are overpaid for procedures, whereas, listening to cynics
like Klein and Soltas, primary care physicians are also overpaid when
you consider that they can be replaced by nurse practitioners "who
charge much less than doctors." They contend that limiting the
independence of nurse practitioners is a "protection racket."
Yet nurse practitioners want their pay to be comparable to that of
primary care physicians, "equal pay for equal work." They do not want
pay for cognitive services to be decreased;, they want their own pay for
these services to be increased.
What about the fundamental issue of filling the void in primary care
with independent nurse practitioners? Even if medical schools increased
the numbers of graduating physicians who would want want to become
primary care physicians, there is a lack of residency programs and
clinical training sites to train the numbers that we need. So does that
mean that there is a plethora of comparable clinical training programs
for nurse practitioners that would fill the void? Where are those
programs that will produce an adequate number of nurse practitioners
through training that will provide them with the same level of
competence as primary care physicians? It is specious to assume that
there is a paucity of clinical training programs for primary care
physicians in a country that supposedly has a great abundance of
comparable comprehensive training opportunities that are limited to
nurse practitioners, while excluding physicians.
Try this mind game. Define primary care physician. Define nurse
practitioner. Except for the duration and intensity of their training
programs, are they exactly the same? If not, what are their differences?
Should these differences be reflected in either their clinical
independence or in their pay?
There is absolutely no dispute that nurse practitioners are an important
addition to the clinical team that includes primary care physicians,
specialists, and other health care professionals. It should not be
difficult to integrate all clinical health services into a well oiled
machine, as long as we can set aside turf issues. But we need to
chastise the Ezra Klein's of the nation who would throw a monkey wrench
into the machine by characterizing this as a "protection racket." It's
the patients who need protection through improved integration of our
health care system.