Replace The Ruc

©2012 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

On February 1, the American Medical Association’s Relative Value Scale Update Committee (RUC), Medicare’s primary advisor on physician payment, announced the addition of two seats: a permanent one for geriatrics and a rotating one for primary care. The American Geriatrics Society and the American College of Physicians praised the move as a step forward that will amplify the RUC’s appreciation of their physicians’ contributions.

But the RUC’s maneuvers are a cynical sleight of hand. They attempt to assuage charges of sub-specialty bias while continuing the RUC’s sub-specialty dominance. The additions reduce proceduralists’ share of votes from 27 of 29 (93 percent) to 27 of 31 (87 percent), hardly a power shift. Primary care comprises about 35 percent of US physicians, but cognitive medicine would have only 13 percent of the votes.

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Electronic manufacturing has come a long way in recent decades. New technologies have allowed companies to build Printed Circuit Board Assembly and wiring harnesses cheaper and more quickly. This has lead to great strides in lowering the cost of medical equipment like ultrasounds and MRI machines which in turn can help lower the cost of healthcare. Following are just a few ways that affordable electronic manufacturing can lower the cost of healthcare:

Computer and Network Systems – Medical practices and hospitals make use of computers and networking systems just about every minute of the day. As more and more medical records move online the importance of networking systems grows. Lowering the costs of printed circuit boards used in the servers that drive these systems can help control costs at hospitals and even small medical practices. These savings can be passed on to patients. It’s not just the guts of computer systems that have undergone an update in manufacturing techniques, wiring harness are benefiting from new technologies as well. Lower overhead costs and the ability to easily share records among healthcare providers will drive costs lower.

Medical Equipment – Computers and networking equipment are not the only machines to benefit from lower Electronic Manufacturing Services costs. Ultrasound machines, MRIs and even something as simple as a blood pressure machine make use of printed circuit boards and other electronic components. As the cost of these machines drop, that cost savings can be passed on to patients and insurance companies. Increasing the quality of the internal components while lowering costs makes used equipment more attractive as well. As these machines function longer the need to replace them disappears, creating additional cost savings.

Improved Technology – As electronic components become cheaper they are also making leaps and bounds in technology. Improved imaging technology often means that a hospital or medical practice can get the images they need using an ultrasound instead of the more expensive MRI. Getting quality results using equipment that cost less will lower the cost of healthcare for both insurers as well patients. As the cost of technology drops new machines and techniques can be developed and implemented which can further lower the cost of healthcare.

Long Distance Medicine – Keeping in touch with patients, reminding them of appointments and immunizations can help them stay healthy which keeps them out

of the office, lowering the yearly cost of their healthcare. Educating patients on healthy living choices and monitoring existing medical conditions can all be done through the use of technology, and all of these computers have printed circuit boards and other electronic components. Lowering the costs of electronic manufacturing is intensely linked to the cost of healthcare.

While it many not seem like it, the cost of electronic manufacturing is directly linked to the cost of healthcare, improvements in technology and lowering the costs of printed circuit boards will lower the costs of medical treatments. Technology is at the heart of healthcare these days and improvements in cost and manufacturing improvements will directly affect rates that patients and insurers pay for healthcare.

©2012 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

Americans increasingly distrust what they perceive as poorly run and conflicted government. Yet rarely can we see far enough inside the federal apparatus to examine what works and what doesn’t, or to inspect how good and bad decisions come to pass. Comparing the behaviors of two influential federal advisory bodies provides valuable lessons about how the mechanisms that drive government decisions can instill or diminish public trust.

The Health Information Technology Policy Committee (HITPC) advises the Office of the National Coordinator for Health Information Technology (ONC) on matters pertaining to the ARRA/HITECH legislation. ONC is responsible for deciding how to spend the roughly $25 billion Congress authorized in 2009 to stimulate doctors’ and hospitals’ adoption of electronic health records (EHRs) and other health information technologies. HITPC, a 24-member Federal Advisory Commitee (FAC) as defined and governed by the Federal Advisory Committee Act (FACA), makes recommendations to ONC on many topics – from certification of EHR technology and privacy/security regulations to governance and oversight measures for the Nationwide Health Information Network – that affect how that money will be spent, who is eligible to receive it, and what rewards and penalties will apply in the process.

The Relative Value Scale Update Committee (RUC) is far more influential. Over the past twenty years this group of 29 physicians convened by the American Medical Association (AMA) has been CMS’ primary advisor on how Medicare should value doctor visits and procedures. Many Medicaid and commercial health plans follow Medicare’s lead on payment, so the RUC’s influence on the $2.7 trillion health care economy is sweeping. While the RUC is not formally a FAC, it has been challenged as being a “de facto” FAC, a designation that has legal precedent.

Both HITPC and the RUC are comprised of volunteers. But the similarity stops there. A chasm separates their behaviors as advisory bodies, primarily because HITPC operates in the open and under public view, whereas the the RUC acts virtually in secret.

HITPC’s formal organization as a FAC obligates it and more than a thousand other similarly constituted entities to operate under FACA’s strict management and reporting rules, which seek to ensure that the regulatory agencies’ activities are in the public rather than the special interest. HITPC must have balanced representation in its membership. Its proceedings must be transparent, and its analytical methodologies must be scientifically credible. Indeed, FACA established a federal database that incorporates the proceedings of HITPC and all other federal advisory committees, and that facilitates government-wide advisory committee management and accountability audits.

HITPC is scrupulously compliant with FACA. Its mission and goals, membership roster, meetings schedules, and all documents issued by the committee are available to the public on its website. All HITPC meetings are open to the public and are broadcast over the Web or by teleconference. ONC makes audio recordings available within a day following a meeting, and a draft transcript is posted within a week. HITPC members must declare conflicts of interest, and must recuse themselves from votes that involve real or apparent conflicts.

By contrast, and despite its immense influence over Medicare and commercial health expenditures, the RUC proceedings are opaque. Its meetings are closed to the public – participation requires an invitation from the Chair – and transcripts are not publicly available. Members vote secretly by electronic ballot, and the AMA discards records of the votes.

Still, CMS has accepted more than 90 percent of the RUC’s 7,000 recommendations since 1991, often without further due diligence.

The RUC is also rife with conflict. Until 2009 the AMA would not reveal the RUC members’ names. While primary care physicians represent some 55% of all doctors, 27 of the RUC’s 29 members are specialists effectively lobbying their specialist societies’ interests. Roy Poses MD, who studies financial conflicts in medicine, recently wrote, “14 of 29 members of the RUC have financial relationships with pharmaceutical companies, biotechnology companies, device companies, companies that directly provide health care, and health care insurance companies.” None of these are publicly disclosed as a condition of RUC membership. Nor is there any publicly available record of whether real or potential conflicts of interest have caused RUC members to recuse themselves from votes.

These two advisory models represent different frameworks for operationalizing federal policy. The RUC’s secretive membership and proceedings hinder scrutiny. CMS near-total reliance on a clandestine special interest group is precisely the kind of governmental behavior that the public no longer trusts.

HITPC’s recommendations occur in the sunshine and are observable in real-time. Important regulatory decisions are forged in an environment of expert opinion, public discourse, and frequent opportunity for comment and debate. They follow FACA’s mandates for openness and broad representation, and offer a path to rebuilding trust that the American people now clearly desire.

©2012 – Brian Keppler

In early August, six primary care physicians from the Center for Primary Care in Augusta, GA, filed suit against the US Department of Health and Human Services (HHS) and its subsidiary agency, the US Centers for Medicare and Medicaid Services (CMS).

The filing was a critical step in a campaign that David Kibbe MD and I began in January 2011 against the excesses that have arisen from CMS’ inappropriate relationship with the American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC).  But the effort was really given life by Paul Fischer, MD, the Augusta physician who brought a focused, practicing primary care perspective to the issue, and Kathleen (Kitty) Behan, the DC-based constitutional attorney who has orchestrated the legal process.

The case’s foundational argument is that the RUC near sole-source advisory relationship with CMS has rendered it a “de facto” Federal Advisory Committee (FAC). Therefore the RUC should be subject to the Federal Advisory Committee Act (FACA)rules that govern the behaviors of these entities, seeking to ensure that regulation is shaped in the public rather than the private interest. Even so, over time CMS has accepted more than 90 percent of the RUC’s valuation recommendations without further due diligence. The agencies’ clear failure to require the RUC’s financially conflicted and secretive behaviors to be adhere to these requirements has resulted in Medicare payment distortions and excesses that have directly harmed primary care, as well as patients and purchasers.

We believe that this case has profound ramifications that go to the heart of the ways American health care is practiced and the cost crisis that has resulted.

For those who wish to monitor the progress of the suit, here are the first three primary legal documents. If you’re willing to wade into the world of legal argument, you’ll find the discussion both fascinating and compelling.

First is the initial complaint, which lays out the legal argument. Next is the Defendants’ Motion to Dismiss. Third is the Plaintiffs’ Opposition to the Motion to Dismiss.

We will continue to make materials available as the process unfolds.

Thanks for your ongoing interest in this.

Copyright 2011 – Paul M. Fischer, MD

The old doctors know.  The practice of medicine has changed in a very basic way over the last 20 years.  Physician relationships have lost their civility and have been replaced by a level of tension that takes the fun out of collegial interactions.  I remember my first year of family medicine as the only doctor in Weeping Water, Nebraska.  My personal medical community had gone from an entire medical school campus with limitless lectures and many physicians to share in “interesting cases” to an occasional phone call with a consultant in Omaha.  These contacts became my primary source for medical education and updates for Weeping Water’s health care.  The phone calls were collegial, respectful, and focused on what was best for my patients.

What happened?

The RUC is the secretive committee of the AMA that has been CMS’s primary source of physician payment data over the past 20 years.  It has elaborately articulated the complexity of medical procedures but ignores and confuses the cognitive work involved in patient care – collapsing it into a few evaluation and management codes. As a result, many medical specialties have found that their financial success is tied primarily to doing things TO patients, rather than caring FOR patients.

The RUC has shifted these physicians’ attention away from the hard work of knowing patients over time and fine-tuning their treatments based on subtle changes discovered by history and physical toward focusing on which procedure can be done to a patient and legitimized to an insurance company.  Let the “primary” do that other stuff.

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Copyright 2011 – Brian Klepper

On Wednesday, 47 American medical specialty societies sent Rep. Jim McDermott (D-WA) a letter, with copies to all members of Congress, containing a detailed defense of the American Medical Association’s (AMA’s) Relative Value Scale Update Committee (RUC). For 20 years, the RUC has exclusively advised the Centers for Medicare and Medicaid Services (CMS) on physician procedure valuation and reimbursement. On its face, the letter responds to a seemingly minor piece of legislation introduced by Rep. McDermott, H.R. 1256, the Medicare Physician Payment Transparency and Assessment Act, that would require CMS to use processes outside the RUC to verify the RUC’s recommendations on medical services values.

Conspicuously absent from the letter’s signatures were the nation’s three main primary care societies: the American Academy of Family Physicians (AAFP) – which has formally endorsed Mr. McDermott’s bill – the American College of Physicians (ACP) and the American Academy of Pediatrics (AAP). Last week, the New Jersey Academy of Family Physicians sent a letter to its parent organization, AAFP, “strongly encouraging” it to quit the RUC. It is as though the long-compromised primary care physician community, that makes up one third of American physicians and handles half of our office visits, is suddenly mobilizing.

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First published on 6/15/11 on MedPage Today

A few weeks ago, the Board of the American Academy of Family Physicians (AAFP) announced that, for now, it would continue participating in the Relative Value Scale Update Committee (RUC), the secretive American Medical Association committee that, through a longstanding relationship with the Centers for Medicare and Medicaid Services (CMS), has heavily influenced physician reimbursement.

At nearly the same time, Medicare announced that it will go broke in 2024, a decade sooner than expected and only 13 years away.

During the 20 year reign of the RUC, the average excess in lifetime earnings of specialists compared with primary care physicians has increased from $1.5 million to $3.5 million. Yet, the need for primary care has never been greater or its future foggier.

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Copyright 2011 – First posted 7/13/11 on AAFP News Now

Brian’s Note: Regular readers will recall that in January, David C. Kibbe and I wrote a piece calling on America’s primary care societies to quit the RUC, the secretive, specialist-dominated AMA committee that has been the sole advisor to CMS on medical services valuation and reimbursement for the past 20 years. It is not unreasonable to assert that the RUC’s relationship with CMS is one of the deep roots of America’s health care cost crisis, an extraordinarily destructive mechanism that has had severely negative impacts on patients, purchasers and, of course, primary care physicians.

All that said, her comments below are a good description of how they’re approaching this very complicated set of dynamics.

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