Robert M. Centor, MD; Larry Culpepper, MD, MPH; Robert W. Morrow, MD; Roy M. Poses, MD


March 05, 2013

In This Article

Commentary From Robert Morrow, MD (Family Physician)

Thank you, Robert. I think your point is well taken that the RUC is one aspect of the problem of payment, not the entire thing.

Payment is a funny fish. In my 33 years in private practice, I have seen many systems come and go. These include:

No payment for a visit if a procedure is done at the same time (a shoulder injection and blood pressure check, for example), and vice versa (only payment for the visit and none for the forms for home care);

Monthly payment for a patient, with no extras (pure capitation);

Capitation plus visit fees, with or without procedure fees, or procedure fees with no visit fee;

Payment calculated weeks after a visit, with small or large or "none-of-the-above" patient copays to be collected after the calculation;

Capitation with bonuses, multipliers, or end-of-year withholds or extra pay; and

Pay for performance, calculated with administrative data that are not visible or requiring chart reviews for hundreds of patients.

But I won't bore you (that happened early in the list, I'm sure). The key issue is whether primary care is adequately paid to make it worth the effort for doctors and students. The rest is political shadow play.

Right now, we are faced with a commercial system that collects more corporate income if things cost more. If an MRI costs $100 or $1000, and you as payer can charge 20% as your fee, what would you do? If you are the government and get 3% but must answer to your voters, then $100 makes much more sense. And that is what France does. But if special services can drive up the costs, would a commercial carrier object? Should radiation therapists be on the top of the payment heap for pushing a button after the physicist adjusts the settings? Should big-branded systems be paid more for care with quality measures than smaller systems? For a commercial payer in 2013, both of these strategies lead to higher premiums with higher income for itself.

This year, my insurance at a major academic health center rose to $10,000 annually, deducted from my wife's pay to cover both of us -- the only insureds -- and adds a $3000 deductible. A very large deductible.

So, say you are a commercial firm, and you have defeated Clinton's 1993 health plan. Your next step? Historically, lower your loss ratio (the amount paid out for healthcare services) from 97% to 80% over the next 10 years. Make healthcare a profit center for investors (ie, banks), not a cost center. Collect $20 rather than $3 per $100 of premiums, to cover your expenses and profit.

And say you want to increase moneys on health services to maximize your 20% (or higher, up to 30% or more), how would you feel about primary care lowering the cost of healthcare? My personal primary care income crashed in 2001. Healthcare became a profit center rather than a cost center. Primary care became a loser.

So we have the RUC raising prices for proceduralists and slamming primary care. We have our commercial providers doing the same. But the Veterans Administration starts to invest in primary care. And CMS finally overcomes some political inertia brought about by lobbyists from the financial sector, and encouraged by the Affordable Care Act, starts to gently nudge the payment systems. But recall, 20% of the economy's commercial healthcare sector is at stake here. Not small change indeed.

The solution for primary care? Leverage our health information technology to have clinical integration so that we can negotiate with our payers, and ensure that primary care continues to exist to serve the urgent healthcare needs of a country that is lowest in most health indicators of all advanced countries: 17th, I believe. Don't wait for the politicians!

Let's go for the 17% solution -- commercials get 3%, and the United States goes back to the top of the list of healthy countries, with health budgets substantially lower than currently. Now that's an arms race!