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


March 05, 2013

In This Article

Commentary From Larry Culpepper, MD (Family Physician)

What seems to be missing in these commentaries is stepping back and linking compensation to goal. This is the only way to avoid the growth of perverse incentives. It seems like where we are currently in the United States is that the goal of primary care involves the merging of panel size (adjusted for complexity) and quality of care as reflected in outcome measures, or at least process measures, as proxies for outcome (eg, percent control of hypertension). We have developed considerable experience with these metrics, but not as the primary base for compensation.

This diverges from the goals of specialty referral care practice goals. The difficulty for me is in conceptualizing the goals of specialty care in ways that do not continue the RBRVS perverse incentives around quantity of services. I do not have an answer to present here.

However, the key take-home point is that the compensation framework for primary care and specialty care should fundamentally differ in terms of the mechanics. Then we might have a national system -- translated down to individual third-party payers, Accountable Care Organizations, or practice plans -- that initially divides the dollars between primary care and specialty care, and then uses different methods to link pay to service provision. In primary care, this would involve a panel size X quality factor. In specialty care, it will involve a different framework.

However, this would translate the politics that play out at the RUC level into a fundamental and direct discussion of the relative portion of the pie to go to primary care and to specialty care. This inevitably will be a highly political discussion, but at least the outcome will be much more transparent. The difficulty with the current RUC-engaged system is that the final outcome in terms of primary care vs specialty care is hidden by the smoke screen and detail of the RBRVS system.