PCPs Use More Diagnostic Codes; Pay Should Follow

Marcia Frellick

December 05, 2014

Primary care physicians, especially family physicians, use many more diagnostic codes than specialists do, and that complexity of care should be reflected in their pay, say authors of an article published in the December issue of American Family Physician.

Joshua Freeman, MD, a researcher from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in Washington, DC, and colleagues used data from the 2010 National Ambulatory Medical Care Survey to count diagnostic codes used by primary care physicians in comparison with other specialists. Family physicians, they found, use 23 diagnostic codes in 50% of their coding. Among specialists they studied, cardiologists use six in half their coding, and psychiatrists use three.

Longstanding assumptions that specialists are paid more because of the training and skill required to master a specialty miss the skill that primary care providers need to manage many interacting conditions, they say. "Even a complicated task, such as managing a single chronic condition, becomes simpler and more routine when it is constantly repeated," the authors write.

They conclude that the Centers for Medicare & Medicaid Services should account for the complexity of primary care physician care, and the time it takes, and adjust the fee schedule accordingly.

A Bit More Complex

Harold Miller, president and chief executive officer of the Center for Healthcare Quality and Payment Reform in Pittsburgh, Pennsylvania, told Medscape Medical News that diagnosis codes should not be the measure of complexity.

"If you have nasal congestion and a bruise on your arm, does that mean you're harder to manage than if I have a brain tumor?" he says. "Some of those diagnoses have fairly straightforward, well-known, evidence-based treatments. Others do not and require a lot of judgment and a lot of choices."

He does agree that the fee structure does not reflect the complexity of treating each patient and also does not account for how severe a patient's condition is, nor reflect the difficulty primary care physicians are faced with in diagnosing across such a broad range of diagnoses.

"We basically have forced family physicians into trying to do all of that in the course of a 15-minute visit," he notes.

Benjamin Sommers, MD, PhD, a primary care physician and assistant professor of health policy and economics at Harvard School of Public Health in Boston, Massachusetts, told Medscape Medical News that it is not the complexity of the office procedures that are currently driving pay scales, but the number of procedures.

"For instance, if you look at subspecialists who are managing thyroid or diabetes care, or infectious disease doctors who are not doing a lot of procedures but are dealing with the same kinds of evaluation and management visits that primary care doctors are facing, there's not a big pay disparity there."

Regardless, pay scales continue to be debated, but the gap between primary care and most specialists' pay is unlikely to change anytime soon, he says.

The authors, Miller, and Dr Sommers have disclosed no relevant financial relationships.

Am Fam Physician. 2014;90:790. Full text


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