Medicare wRVU payment rates edged closer between medical and surgical specialties
Medicare’s work relative value unit payment structure moved toward smaller specialty differences between 2018 and 2024, but the shift was modest rather than sweeping. In a repeated cross-sectional analysis spanning 42 specialties, the medical-surgical gap in annual wRVU payment rates narrowed from 5.4% in 2018 to 1.6% in 2024. In practical terms, the average rate rose from 0.0405 versus 0.0426 wRVUs per minute in 2018 to 0.0428 versus 0.0435 in 2024, with the later-year difference no longer statistically persuasive at P=.26.
The trajectory matters because Medicare valuation is often treated as a proxy for how the program prices physician work across specialty lines. Yet the annual movement here was incremental, not dramatic. The divergence compressed most clearly in 2021 and 2023, the same years that evaluation and management work was revalued. Those revisions pushed higher-value cognitive and longitudinal care closer to the rates typically associated with procedures, but they did not erase the underlying spread.
A one-sentence clinical reality sits inside the finance data: reimbursement systems can shift incentives without equalizing them.
Investigators linked Medicare Part B fee-for-service claims with the CMS Physician Time File, Addendum B, and the Physician/Supplier Procedure Summary Master File at the CPT-specialty-year level. The analysis included 27 medical specialties and 15 surgical specialties, allowing a broad look across the physician workforce rather than a single discipline or niche service line. Linear regression mapped how specialty-level payment rates changed over time, and a counterfactual scenario held service times at their 2018 values to separate the effect of valuation changes from shifts in time assumptions.
Primary care rose faster, while surgery moved more slowly
The clearest directional change involved primary care and nonsurgical nonprocedural specialties. Primary care specialties increased at 1.7% per year, while nonsurgical nonprocedural specialties rose at 1.8% per year. Surgical specialties advanced far more slowly, at 0.4% per year. Those separate slopes help explain why the gap narrowed: the medical side gained ground faster than the surgical side rather than because surgical valuation collapsed.
The pattern is consistent with the policy emphasis of recent Medicare Physician Fee Schedule revisions, which have sought to correct the long-standing imbalance between cognitive work and procedural work. Still, the data show only partial correction. By 2024, the rate gap had compressed, but the convergence remained small enough to suggest that fee schedule changes alone are not likely to redraw the broader compensation map between medical and surgical practice.
The counterfactual analysis makes that point more sharply. When service times were held at 2018 values, 2024 rates would have exceeded the actual observed values by 8.9% for primary care, 6.9% for nonsurgical nonprocedural specialties, 5.0% for nonsurgical procedural specialties, 4.5% for surgical specialties, and just 0.1% for facility-based specialties. Under that scenario, the medical-surgical gap would have narrowed further, to 0.8%.
Why service-time assumptions matter
In Medicare valuation, time is not a neutral bookkeeping detail. Work RVU payment rates depend on how much physician labor the schedule assumes a service requires, so even small changes in time assumptions can shift relative compensation across fields. When service times are shortened or reestimated, the same code can appear more efficient on paper and generate a different payment rate per minute of physician work. Across a national fee schedule, those adjustments accumulate into measurable specialty-level drift.
The findings point to a central limitation in fee schedule reform: recalibrating work values can narrow differences, but it does not necessarily overcome the structural features that keep procedural and cognitive specialties compensated differently. The observed gap in 2024 was smaller than in 2018, but it was not eliminated. Medicare pricing can trim the distance between specialties; it does not flatten it.
Primary care’s faster rise is especially relevant because it reflects an intentional policy direction rather than a random fluctuation. Evaluation and management services form the backbone of longitudinal care, diagnostic synthesis, and chronic disease oversight, all of which are increasingly central to Medicare populations. Still, the annual change remained measured in tenths of a percent when viewed against the entire specialty spectrum, which makes the overall story one of gradual reweighting rather than redistribution.
A limited tool for a broader compensation problem
The study’s conclusion is straightforward: from 2018 through 2024, the Medicare medical-surgical wRVU payment-rate gap narrowed from 5.4% to 1.6% under current CMS valuation assumptions. Even so, the data argue that the Medicare Physician Fee Schedule is a limited instrument for narrowing broader specialty compensation differences. Fee schedule updates can alter the relative price of physician work, but compensation in real-world practice is shaped by much more than the Medicare conversion of minutes into RVUs.
The analysis also helps explain why debate over specialty pay persists despite repeated valuation updates. If policy changes are concentrated in selected code families, and if time assumptions continue to evolve, specialty rates may converge in one year and diverge again in the next depending on the mix of services billed. The convergence seen in 2021 and 2023 shows that the system can move, but the movement is uneven and sensitive to coding structure.
For clinicians, the bedside effect is indirect but real. Payment formulas influence which services are rewarded, how practices organize visits, and how time is valued within medical care. In a system where longitudinal cognitive work has historically been discounted relative to procedures, modest upward adjustment in medical specialties may improve alignment with the work that drives diagnosis, coordination, and chronic disease management. The present data suggest progress, but not resolution, and they leave open how much further Medicare valuation can move before other forces dominate the compensation equation.