Blood, sweat & time: Why heart surgeons make more than family doctors

Differences in the time estimates for physician work accounted for almost 90 percent of the variance in a measure used to determine pay for doctors, a finding that helps explain the income gap between proceduralists and primary care physicians. The results were published online Sept. 18 in the Annals of Surgery.

Procedure-focused specialists typically report much higher incomes than office-based physicians. For instance, the American Medical Group Association’s 2013 survey showed interventional cardiologists making a median of $547,112; cardiac and thoracic surgeons, $525,944; interventional diagnostic radiologists, $504,772; and primary care physicians, $186,475.

Compensation largely is determined by work relative value units (wRVUs), the basic unit the Center for Medicare & Medicaid Services (CMS) employs to calculate reimbursement. The wRVUs are based on an estimated time to perform a service, such as a procedure, test or office visit, plus the relative intensity of the task and assigned to codes. The question is whether differences in time or payments for procedure and test vs. Evaluation and Management (E/M) codes tipped the scales.

For the analysis, Kevin A. Kerber, MD, MS, a neurologist at the University of Michigan Health System in Ann Arbor and a researcher in its Institute for Healthcare Policy and Innovation, and colleagues assessed 6,522 Current Procedural Terminology codes in CMS files from 2011. Their goal was to identify differences in the valuation of time in procedure and test codes compared with E/M codes. Codes fell under the categories of E/M, surgery, radiology, pathology and medicine.  

They found that total time explained 89 percent of the variance in wRVUs. Eye procedures of short and intermediate duration tended to have higher than expected RVUs, as did cardiovascular, musculoskeletal and hemic/lymphatic procedures of a long duration. The researchers suggested that those procedures may have a higher intensity than average surgical procedures.  

“[P]hysician time was the dominant contributor to wRVUs,” Kerber et al wrote. “Adjusting for time, we did not find evidence for a systematic higher valuation of physician work in procedure/test codes than in E/M codes.”

Kerber said in a press release that the results debunk arguments that the cards are stacked against primary care physicians in terms of reimbursement. “What this research shows is that the largest and most influential payer in healthcare–-Medicare–-and the panel of doctors that advises them–-the RUC [RVU Update Committee]–-are not overtly setting payment rates higher for surgeons and proceduralists than primary doctors.”

But it is possible that the time estimates may be skewed. Time estimates are based on self-reported data, which the authors noted as a limitation in their study.