We are glad that Dr. Rich has entered into a dialogue about the RUC's role in the multifactorial causation of the primary care–specialty income gap. He is correct that relative value units (RVUs) for E&M services have increased while values for some procedural codes have decreased. However, in its 2007 report to Congress, MedPAC states (1): "The three five-year [RUC] reviews, completed in 1996, 2001, and 2006, led to substantially more recommendations for increases than decreases in the relative values of services, even though many services are likely to become overvalued."

The RUC's method for estimating procedure times—a key factor in determining RVU values—is flawed and overvalues many procedural services. Dr. Rich cites the CMS Web site as indicating that the total time for diagnostic colonoscopy is 70 minutes; however, this is actually based on RUC estimates. The RUC has also estimated intraservice colonoscopy time at 30 minutes. Yet, a recent New England Journal of Medicine article found that the average diagnostic colonoscopy intraservice time is 13.5 minutes (2). These findings mirror a study of operative logs for 60 procedures, demonstrating that actual procedure times were, on average, 31 minutes shorter than the RUC's time estimates on which RVU values are based. The RUC overestimated time spent on several procedures by more than 60 minutes (3). The RUC and CMS should consider using objective data rather than physician-generated estimates to determine procedure times.

Our main concern, and we hope Dr. Rich agrees, is the impact of the primary care–specialty income gap on medical student career choices. If the pipeline into primary care continues to dry up, the decline of primary care will be a catastrophe for everyone, including specialists. Thus, we need to look at the bottom line: dollars. In 2007, a colonoscopy pays $196.69, where as a CPT code 99214 office visit pays $90.20 (amounts vary by location), even though the times spent are similar and—we would argue—the complex office visit has higher intensity. Moreover, colonoscopies require fewer rather than more resources because they are generally done in a facility in which the physician is not paying overhead costs for personnel and equipment.

Ultimately, we must consider a fundamental change in physician payment, moving from a fee-for-service system toward a blended payment system that rewards high-quality, team-based primary care practices that are adequately compensated for the challenge of managing an aging population with multiple chronic conditions (4).