Medicare payment for cognitive vs procedural care: minding the gap

Abstract

Importance: Health care costs in the United States are rising rapidly, and consensus exists that we are not achieving sufficient value for this investment. Historically, US physicians have been paid more for performing costly procedures that drive up spending and less for cognitive services that may conserve costs and promote population health.

Objective: To quantify the Medicare payment gap between representative cognitive and procedural services, each requiring similar amounts of physician time.

Design: Observational analytical study comparing the hourly revenue generated by a physician performing cognitive services (Current Procedural Terminology [CPT] code 99214) and billing by time with that generated by physicians performing screening colonoscopy (Healthcare Common Procedure Coding System code G0121) or cataract extraction (CPT code 66984) for Medicare beneficiaries.

Setting: Outpatient medical practice.

Participants: Medical care providers of outpatient services.

Exposure: Work relative-value unit assigned to physician services.

Main outcome and measures: Payment for physician services.

Results: The revenue for physician time spent on 2 common procedures (colonoscopy and cataract extraction) was 368% and 486%, respectively, of the revenue for a similar amount of physician time spent on cognitive care.

Conclusions and relevance: Our analysis indicates that Medicare reimburses physicians 3 to 5 times more for common procedural care than for cognitive care and illustrates the financial pressures that may contribute to the US health care system’s emphasis on procedural care. We demonstrate that 2 common specialty procedures can generate more revenue in 1 to 2 hours of total time than a primary care physician receives for an entire day’s work.