PCPs' Incomes Grew Faster Than Specialists' Following ACA

Ken Terry

July 31, 2020

The rate of growth in inflation-adjusted compensation was higher for primary care physicians than for specialists during the period in which the Affordable Care Act (ACA) was implemented, according to a study.

The study, by Walter Hsiang, BS, a fourth-year medical student at Yale School of Medicine, and colleagues, was published online July 28 as a research letter in JAMA.

From 2008 to 2017, specialist compensation increased by a weighted mean (SD) of 0.6% (1.2%) per year, from $378,600 to $399,300, whereas primary care compensation increased by 1.6% (2.2%) per year, from $214,100 to $247,300.

The average difference between primary care and specialist compensation declined during this period, from $164,500 in 2008 to $152,000 in 2017, or from 77% to 61%.

Overall, however, the ACA had fairly little effect on physician compensation, Hsiang told Medscape Medical News.

When the ACA was passed in 2010, Hsiang said, some observers believed that the law would depress physician income. "There were concerns at the time that the ACA would decrease provider payments because of cheaper insurance reimbursement models and lower reimbursement from insurers."

The faster growth in primary care compensation coincided with two incentive programs authorized by the ACA. First, the law authorized the Centers for Medicare & Medicaid Services to increase Medicaid payments to primary care physicians to the same level as Medicare payments in 2013 and 2014. The federal government paid the full amount of this increase.

Second, the ACA authorized a quarterly incentive payment program from 2011 to 2015. Known as the Primary Care Incentive Payment Program, this initiative added an extra 10% to Medicare payments to eligible primary care practitioners.

In addition, Hsiang said, some states continued to provide the Medicaid "fee bump" to primary care physicians even after the federal government stopped doing so. An Urban Institute study found that as of July 2016, 19 states were fully or partially continuing this incentive program to increase the access of Medicaid patients to primary care.

Other factors not associated with the ACA could have contributed to the higher growth in primary care compensation, Jonathan Weiner, DrPH, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, told Medscape Medical News.

"I'd give the ACA some credit, but it wasn't just the ACA. You also have to consider the move toward value-based payment and patient-centered medical homes," he said.

Both primary care and specialty compensation plateaued from 2015 to 2017, the Yale study found. One possible reason for this with regard to primary care, Hsiang said, might have been the cessation of the federal incentive programs.

Hsiang attributed the trimming of specialty income growth to "the transition to value-based reimbursement and ACOs [accountable care organizations]. More specialty organizations started adopting these value-based models."

Specialist Premium

In discussing their results, the authors note, "There continues to be a sizeable gap between compensation for primary and specialist care. More importantly, small changes in the specialty premium [the difference between primary care and specialist compensation] cannot necessarily be attributed to any specific policy or intervention."

The specialist premium will continue to be significant, the researchers say, because of the opportunity cost of additional training for specialists and the differences between what specialists and primary care doctors do.

Weiner agreed but said the method of compensation also contributes to the specialist premium. "There have been positive changes for primary care income, and I believe those will continue. On the other hand, there's a long history of specialty preference, due entirely to opportunities for fee-for-service payment. It will take a long time for that to change."

Weiner reiterated that it's hard to separate the influence of the ACA from other factors in explaining the growth of primary care compensation during the study period.

"The ACA was important, but what percentage did it add [to income]? It's hard to say. Also, 60% of the ACA's additional coverage was in Medicaid, much of which is in managed care. Other than giving people an insurance card and improving primary care physicians' likelihood of being paid, it's hard to see how the ACA would have disproportionately impacted primary care."

The Yale researchers obtained their data from the physician compensation survey of the Medical Group Management Association (MGMA), which represents more than 20,000 physicians from private practices, hospitals, academic departments, and other organizations.

The authors acknowledge that MGMA data overrepresent physicians in larger groups, "which could overestimate the observed increases in compensation, because physicians from larger systems or hospitals tend to earn more money than those in private practice."

Nevertheless, they say, the MGMA survey "is the only nationally representative compensation survey with samples of all specialty types."

Gross has received grants through the National Comprehensive Cancer Network in partnerships with Pfizer and AstraZeneca. He has also received research grants from Johnson & Johnson and travel and speaking fees from Flatiron Health, Inc, outside the submitted work. Maroongroge is a resident in a subspecialty training program. The remaining authors have disclosed no relevant financial relationships.

JAMA. Published online July 28, 2020. Full text

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