Response

Abstract

With reference to my recentCHESTarticle,1Laugesen MJ The Resource-Based Relative Value Scale and physician reimbursement policy.Chest. 2014; 146: 1413-1419Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar as well as the prior work of Kumetz and Goodson2Kumetz EA Goodson JD The undervaluation of evaluation and management professional services: the lasting impact of Current Procedural Terminology code deficiencies on physician payment.Chest. 2013; 144: 740-745Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar in this journal, Dr Mathers asks whether relativity between cognitive and procedural service reimbursement in the Resource-Based Relative Value Scale (RBRVS) is feasible. Existing evidence points to persistent differences in cognitive and procedural service reimbursement.3Maxwell S Zuckerman S Berenson RA Use of physicians' services under Medicare's resource-based payments.N Engl J Med. 2007; 356: 1853-1861Crossref PubMed Scopus (45) Google Scholar, 4Sinsky CA Dugdale DC Medicare payment for cognitive vs procedural care: minding the gap.JAMA Intern Med. 2013; 173: 1733-1737PubMed Google Scholar Reimbursement for cognitive services should reflect the work associated with providing the service. One problem is that certain structural features of the RBRVS constrain and may contribute to undervaluation. Physicians providing cognitive services have a smaller bandwidth of billable codes; their billing is also more heavily scrutinized due to documentation requirements. The cut points are less precise for many cognitive services: Surgical and procedural services often appear to be more precisely distinguished. These gradations make a difference for physicians providing cognitive services—but especially if they are already operating at the margin of the work time and intensity involved. In the case of evaluation and management services, for example, the Relative Value Scale Update Committee time estimates used by the Centers for Medicare & Medicaid Services are closer to independently measured times for evaluation and management services than they are for surgical and procedural services.5Cromwell J Hoover S McCall N Braun P Validating CPT typical times for Medicare office evaluation and management (E/M) services.Med Care Res Rev. 2006; 63: 236-255Crossref PubMed Scopus (12) Google Scholar Current reimbursement for cognitive services likely fails to capture the full range of patient severity and/or the wide range of patient scenarios because a small number of cognitive service codes describe these services. However, this is not necessarily an argument to expand the complexity or number of codes for cognitive services. It suggests we should explore how to accurately translate the severity of patients and demands on physicians providing a wide range of services into meaningful payments. At the same time, generalizing across the entire RBRVS is problematic since not all procedural and surgical services are alike. Many physicians providing cognitive services may support existing fees for high stakes and highly complex services. Cognitive physicians are likely to bristle at the reimbursement levels for less intensive and lower-risk services; these kinds of services usually decline in difficulty as familiarity increases. Unlike evaluation and management services, the times initially estimated by the Relative Value Scale Update Committee are likely to increasingly diverge from actual times. As Dr Mathers suggests, the valuation of colonoscopies is a prime example; likewise, endoscopy services and less complicated or low-risk surgeries are sometimes given as examples. Among noncognitive specialists, income from just a few highly valued services such as these significantly enhances practice revenue. Specialty society representatives refer to these kinds of codes that provide a good basis for their revenue as “bread and butter” codes. At its core, there is a lack of clarity about how to measure different kinds of physician work. Before the RBRVS was created, people thought reimbursement for cognitive services would increase because the RBRVS sought to standardize physician work across a wide range of physician activities. The effort to standardize the estimates of physician work has been difficult to realize, or the standardization has not served cognitive services well; simultaneously, technological changes likely increased the gulf between procedural and cognitive physician reimbursement. New ways of understanding and calibrating the work of cognitive physicians are needed.