Why Primary Care Needs A New Organization

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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Dealing Strategically With the RUC to Boost Family Physician Payment

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.

The AAFP initially rejected our suggestion, but has thought better of it over time. As Dr. Heim describes in this explanation to AAFP’s members, they issued a series of requests to the RUC: more primary care seats, a permanent seat for Gerontology, the sunsetting of some rotating sub-specialty seats, and the addition of some non-physicians (e.g., consumers, purchasers, health economists) to the committee. Obviously, the real question remaining is whether, if the RUC rejects these changes, the AAFP Board will have the will to walk.

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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Facing Uncertainty: Why Primary Care Docs Must Act Now

Copyright 2011 – Brian Klepper

Over the past four months, the germ of a long overdue primary care uprising has sprouted and begun to flower. When David Kibbe and I first tried to think through how to neutralize the RUC’s terrible influence on American health care, we realized the first steps had to be the primary care community’s refusal to continue “enabling” the RUC – we meant this very much in the clinical sense – through its continued participation and complicity. When the game is rigged against you, there is no benefit in staying at the table.

Primary care societies would visibly and noisily abandon the RUC, with the understanding that quietly walking away would be counterproductive in the extreme. It should be a highly publicized exit, filled with righteous indignation and clarifying for the American public how the RUC’s actions and relationship with CMS have shafted patients, primary care physicians, and the people who pay for health care in America.

This won’t go unchallenged, because virtually everyone else in health care has financially benefited from a system that has stifled primary care’s moderating influence on unnecessary services throughout the continuum while incentivizing more intense interventions. Employers, who foot the bill for half of US health care and its extravagances, are the natural allies here, but as the health care reform process made clear, galvanizing and mobilizing them can be difficult.

Several weeks ago, the New Jersey Academy of Family Physicians took a bold step by being the first state chapter of family physicians to “strongly encourage” its parent, the American Academy of Family Physicians (AAFP), to quit the RUC. Around the country, other state chapters are chewing on whether to follow suit, though so far none have done so.

This matters. In two weeks, the AAFP Board will meet to consider whether to sever its relationship with the RUC. It is a big decision so, presumably, the Board members have their ears to the ground. Hearing little or nothing from the trenches could easily be interpreted as non-support for a monumental step.

It is important to face the uncertainty here. After all, what happens if the AAFP votes to leave and nobody notices? Will they have a place at the table that seeks to replace the current valuation mechanism? What if that replacement approach is worse than the RUC?

These are fair questions. In the real world, the devils you don’t know CAN be worse than the ones you do. It’s fine for people like me to advocate overthrowing the RUC, but in the end, practicing primary care docs will have to live with the results of this action.

At this point, though – to my knowledge, at least – no clear alternative path has been defined if the RUC’s relationship with CMS is destabilized. But several possible reasonable paths have been suggested. For example:

In his December article about the RUC in the New York Times Economix blog, Princeton health economist Uwe Reinhardt suggested that any medical services valuation panel should include a broader array of health care constituents and experts, like patients, health economists, purchasers and health plan administrators. Dr. Reinhardt’s approach seems obvious, unless of course you’re trying to control the process for a very specific special interest agenda. The RUC Chair, the AMA CEO and 47 medical specialty societies made clear they are intent on doing this in their letters a couple weeks ago to Congress and the health care community.
Rep. Jim McDermott (D-WA) recently proposed legislation (HR 1256) that would require CMS to hire experts to independently review and evaluate the RUC’s recommendations. This approach seems sensible as well, as a check on the RUC that would hold it to a higher standard and make it far more transparent and accountable.
Bob Berenson, MD, Senior Fellow at the Urban Institute, a highly respected and thoughtful health care analyst, former Deputy Secretary of the Health Care Finance Administration (HCFA, CMS’ pre-Bush era name), and now Vice Chair of the Medicare Payment Advisory Commission (MedPAC), argues that Congress should fund direct surveys of medical practices and hospitals to determine the resources required for each medical procedure. This would simply bypass the RUC, making it irrelevant.

There are undoubtedly other reasonable approaches as well. But there is one thing that the primary care community can be certain about. If the health care industry or any sectors in it sense the slightest threat to their current revenue streams, they will mobilize their powerful and well-financed DC lobbying machines to protect their interests. That effort could find expression in any of many different forms that are impossible to anticipate.

Still, this outcome is not a foregone conclusion. Because it occupies the front end of care delivery, primary care is the most strategically positioned of all medical specialties. In the past, primary care physicians have not exercised or leveraged their strengths – e.g., ownership of the referral base, the ability to restrict access to obtain financial concessions, or the deep, abiding relationships that most of us – and (because we have coverage) certainly most of us in the middle and upper income classes – have with OUR primary care doctors. If push came to shove, using those kind of assets should certainly be an option. Primary care, American health care and America’s economic prosperity are at stake, after all.

And then there’s the message that would be sent if AAFP actually pulled the trigger and walked away from the RUC with some fanfare. This is an organization representing more than 10 percent of America’s doctors and probably one-quarter of the nation’s annual office visits. Could CMS NOT take heed and invite them to the table? Not likely.

The remarkable upwelling of primary care indignation in the past few weeks has the potential to begin to remake American health care in a way that the tortured, purchased and highly political health care reform process could never do. At least in part, that possibility has emerged because there’s finally been a demand that we stop listening to the contorted defenses of an obviously flawed process, and start looking at what that process has brought us:

A medical system in which half or more of all expenditures provide zero value, and in which the excesses currently cost us something on the order of $1.4 trillion a year, nearly the equivalent of this year’s national debt.
A primary care workforce shortage approaching critical status, simply because the income disparity between generalists and proceduralists is too great for medical students to ignore. This translates into reduced management of care appropriateness downstream.
Compromised quality, as patients are routed to unnecessary and unnecessarily intensive diagnostics and treatments, often for little reason other than money.

Former JAMA and Medscape Editor George Lundberg MD, an icon of America medicine, recently observed to me that, “The whole pitch about the national RESULTS/OUTCOMES of the RUC approach is the final nail…” THIS is the point.

After 20 years of being slowly strangled by the RUC’s relationship with CMS, primary care physicians have an opportunity to stand up and stand together by simply urging their societies to not participate in it anymore. If you are a family doc and you agree, please do three simple things:

Call your state chapter’s Board and Executive Director and DEMAND that they send a letter in the next week to the AAFP Board, strongly encouraging them to quit the RUC.
Go here and sign the petition. The AAFP Board wants to know whether there is grassroots support for their action.
Send this article to your colleagues, so the campaign becomes viral in a way that can benefit the larger effort.

Now is the time to strike. And then we can get the real process started.

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Why Primary Care Parity Matters

Copyright 2011 – Paul M Fischer

After an exciting and challenging day of caring for patients and teaching students, a third-year medical student on his family medicine rotation says to me, “I really like what you do, but I just cannot afford to go into family practice.” I realized that by “afford,” he was referring not only to finances but also to the expectations of his parents, friends, and medical school. After spending 35 wonderful years as a family doctor, I have been “dissed’ by a kid who wants to become a dermatologist.

So I am of two minds. Part of me is fulfilled by being needed, loved, and respected by my patients.

Over time, they have increasingly looked to me to diagnosis, advise, reassure, and guide them through a complex healthcare environment in which few others offer them help. Another part of me sees that what I do is increasingly devalued by forces outside the exam room ― those who pay for health care, those who question the “medical necessity” of each test I order or drug I prescribe, and those in medicine who are more likely to know a procedure’s CPT code than a patient’s name.

We are in this position because we have failed to define ourselves, instead allowing others to perpetuate myths about what we do. The first such myth is that what we do is easy. Nothing can be further from the truth. In about 15 minutes, we are asked to treat a long list of chronic problems (e.g., diabetes, obesity, hypertension), resolve a few new problems (eg cough, headache), address preventative health recommendations (eg, smoking, flu shot), integrate the psychosocial issues that impact the patient’s health, and figure out how to get it all paid for by an insurance company using codes that don’t really match either my patient’s problems or the care I provide. Oh, and by the way, can you look at this rash and fill this prescription for my husband? Recent research has shown that an average primary care visit is 50% more complex than a visit to a cardiologist and five times more complex than one to a psychiatrist. So no, it is not easy.

The second myth is that it requires less training than other medical specialties. This has resulted in some assuming that primary care can be left to “midlevel” clinicians. While physician assistants and nurse practitioners can work effectively in primary care settings, it is a mistake to believe that they provide equivalent care to patients with complex problems, and we have suffered by the wide acceptance of this assumption. OR techs can work effectively in an operating room, but no one suggests that they replace surgeons.

A third myth is that all we diagnose is colds. Patients present with a vast sea of undifferentiated complaints. Most of these are diagnosed in primary care. After all, most patients’ cancers are diagnosed before the patient gets to the oncologist, and someone has already figured out that the problem is renal before a visit to the nephrologist. For a cardiologist, the biggest diagnostic dilemma is really whether the patient has or does not have coronary disease. There are, in fact, few medical specialties other than primary care where the doctor doesn’t know the disease before opening the door to meet the patient. And many common complaints are complex. Consider for example, “I’m tired all the time.” Does the patient need a TSH, a cardiac echo, an SSRI, or a little time and reassurance? Sorting all this out is beyond the talents of the endocrinologist, cardiologist, or psychiatrist. It requires a good family doctor.

A final myth is that we function as “gatekeepers.” The image here is that the good stuff is behind the gate and family physicians are barriers blocking patients’ access to it. This obnoxious concept was perpetrated by managed care organizations, which did a great deal to misrepresent the value we bring to healthcare. My goal is to match the right patient with the right treatment at the right time. In this day of unnecessary heart caths and back surgeries, patients need someone they can trust to have their best interest at heart.

These myths and others have resulted in devaluing the image of primary care at a time when it is needed most. Thirty million Americans will be added to the insurance rolls by 2014 and state Medicaid budgets will go broke. It did not have to be so bad, but my student became a dermatologist instead.

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A Growing Chorus on the RUC

Copyright 2011 – Brian Keppler

Yesterday on Kaiser Health News, Barbara Levy MD, the Chair of the AMA’s Relative Value Scale Update Committee (or RUC), published a glowing defense of the RUC’s activities. Her article extols the work of the 29 physician volunteers who, “at no cost to taxpayers…generously volunteer their time,” “supported by advisers and staff from more than 100 national medical specialty societies and health care professional organizations.” She fails to mention that the physicians’ and organizations’ efforts to craft the RUC’s recommendations have direct financial benefit to the physicians, specialty societies and health care professional organizations whose representatives dominate the RUC proceedings.

She points to the openness and transparency of the RUC’s proceedings, noting that ”the general public is able to comment on individual procedures, and processes are in place to ensure that input from all stakeholders is considered by CMS. Finally, the AMA ensures transparency of the process, making the data and rationale for each RUC recommendation publicly available.” This, from an immensely influential Committee that refuses to share the identities of its members except by their societal affiliation, that keeps its proceedings private, and that can not be observed except by an invitation from the Chair. If anything, the RUC’s goings-on have been secretive and opaque. Go into any health care professional audience and ask, as I have, for a show of hands of people who know what the RUC is. It has been virtually unknown except in the wonkiest circles.

Dr. Levy also points out that, in Medicare’s budget-neutral environment, hard decisions have to be made, and that in 2006, $4 billion – a little more than one percent of that year’s Medicare allocation – was transferred to primary care. The clear implication is that this came at the expense of specialists. But she conveniently ignores the vast majority of coding valuations that have increased specialty income while strangling primary care. (More comprehensive background on the RUC, including articles by the AMA that describe the RUC’s perspective in detail, may be found here.)

Dr. Levy’s article presumably responded to a growing chorus of recent voices that have detailed the RUC’s disastrous impact on American health care, beginning most recently last October with a Wall Street Journal expose by Anna Mathews and Tom McGinty, and anexplanation on the New York Times Economix Blog by Princeton health care economist Uwe Reinhardt. With David Kibbe MD, I wrote about this topic on Kaiser Health News inJanuary, calling on the American Academy of Family Physicians (AAFP) to abandon the RUC. Then Paul Fischer MD joined in with his Family Physician’s Manifesto. All this work built on the foundation of many health care professionals – John Goodson, MD; Robert Berenson, MD; Thomas Bodenheimer, MD; Roy Poses, MD to name a few – who have carefully documented the biases and excesses that have been wrought by the RUC’s shadowy process.

Rep. Jim McDermott (D-WA), a psychiatrist, published a powerful argument against the RUC in New England Journal in January, and then, more recently interviewed MedPAC Chair Glenn Hackbarth on the RUC’s corrosive role in front of the House Ways and Means Committee. Interestingly, his comments found common ground with Rep. Tom Price (R-GA), an orthopedic surgeon. These activities have raised enough profile that they have been followed by publications like Politico and National Journal. Suddenly, the RUC is becoming more visible.

Yesterday, the New Jersey Academy of Family Physicians wrote a clear, to-the-point letter to Lori Heim, MD, Board Chair of the American Academy of Family Physicians. Here are a couple extracts.

We fear that our work towards building medical homes, reshaping the way primary care is delivered and how the system pays for it, and providing the care that our patients deserve will be wasted if the current payment policies are maintained, and we see no motivation for the subspecialist-dominated RUC to make those policy changes.

Then,

…we encourage in the strongest terms possible, that the AAFP Board … vote to publicly withdraw from the RUC, encourage other primary care organizations to do so as well, and simultaneously bring our advocacy efforts to bear on CMS to immediately replace the RUC with the alternative body that our policy supports.

So it has started. My most fervent hope is that this respectful, thoughtful nudge by a state chapter of family doctors will be what’s needed for other state chapters to also prevail on the AAFP to leave the RUC. Doing that publicly – meaning with as much visibility as can be mustered – would advance this effort to far greater notice and bring the bright light of public scrutiny on the RUC’s actual impacts on American health care, the one thing Dr. Levy’s article so scrupulously avoided.

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The RUC – Providing Valuable Expertise To The Medicare Program For 20 Years

Today, much of the dialogue related to Medicare payment refers to the need to infuse value into the system. Medicare beneficiaries and American taxpayers deserve the best care possible, while conserving limited resources to ensure the long-term viability of the program. Confusion persists, however, regarding how values are assigned to physician services under the current Medicare payment system, as well as the impact that this process actually has on payment levels for physicians of different specialties. As policymakers and others consider alternative payment models, it is critical that the mechanisms that are used to update the current fee-for-service system are better understood.

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An Open Letter To Primary Care Physicians

Copyright 2011 – Paul M. Fischer and Brian Klepper

If you agree with this letter, please redistribute, particularly to other primary care physicians.

Friends:

As many of you know, we have developed an effort to shine a bright light on the Relative Value Scale Update Committee, or RUC. This site provides a wealth of expert background information, and we’re working now to get more visibility on this issue.

A specialist-dominated panel within the AMA, the RUC is little known and under-appreciated, but extremely powerful and opaque. More important, through its longstanding relationship with CMS, it is central to the explosion in health care costs over the past 20 years, why primary care physicians are paid so poorly compared to their specialist colleagues and why few medical students now choose to enter primary care as a career. Meaningfully address the RUC, and you relieve America of more health system waste than all the cost control measures in the health care reform law combined.

In its present form, the Resource-Based Relative Value Scale (RBRVS) financially undervalues the challenges associated with primary care management of complicated patients, but favors complex procedures. It is fair to suggest that a significant percentage of the US’ rapid health care premium cost growth – 4 times as fast as general inflation over the past decade – is directly attributable to the RUC’s distortion of this system. Many health care economists now believe that half or more of all American health care expenditures are inappropriate and provide no value. This translates to nearly $1.5 trillion annually, a sum nearly equal to this year’s national debt, twice what we’ll spend on the military this year, or two-thirds again what we’ll spend over the next decade on the economic stimulus package. The health care cost drivers, as they’ve been constituted through RBRVS and the RUC, are the difference between America’s economic prosperity and decline.

We have undertaken a four-pronged effort aimed at replacing the RUC and RBRVS.

Make the public aware of the RUC’s role and urge the primary care societies to stop “enabling” the RUC through their participation.While one of the main goals of RBRVS was to rectify the payment gap between primary care physicians and specialists, the RUC has intensified it. After 20 years of minority participation on the RUC, the average primary care physician can expect to make $3.5 million less over a career than his/her specialist colleagues. Worse, though, is that often unnecessary but expensive procedures dramatically drive up cost while diminishing quality. If the societies loudly and visibly walked away from the RUC, with clear, at-the-ready explanations of why payment parity is critical to the future of primary care and how the lack of it has negatively impacted American health care and the nation’s economy, it would bring the issue to the fore and set the stage for the RUC’s and RBRVS’ replacement by better approaches that appreciate all kinds of complexity and measurable value. Health care funds are and should be limited. In an market that empowers primary care, fewer unnecessary services may translate to lower compensation for specialists.
Recruit experts who can credibly calculate the economic impacts of the RUC’s actions, and who can devise alternative payment methodologies. We believe it will be critically important to not simply demand an end to the current system, but to offer sensible alternatives.
Demonstrate the unlawfulness of CMS’ (and HCFA’s) two-decades long reliance on the RUC. We are exploring a lawsuit that would challenge CMS’ longstanding abrogation of its due-diligence process by outsourcing medical procedure valuation to the RUC, an informal, private, financially-conflicted group employing a highly questionable evaluation methodology. Even so, CMS has accepted 94% of the RUC’s recommendations, which most often increase cost.
Develop a collaboration between primary care and non-health care business. Most of the health care industry benefits handsomely from the excess associated with the current payment system. If it is threatened, they are likely focus considerable resources on blocking change. (The health care industry contributed $1.2 billion to Congress in 2009 to influence the health care bill.) Non-health care business is primary care’s best ally. They understand primary care’s value, are large enough, have the resources and the motivation to counterbalance the health industry’s influence.

We hope you’ll support this effort in several ways.

Contact your primary care society to demand that they withdraw from the RUC.
Broaden awareness of what we’re doing and why by rebroadcasting to your primary care colleagues.
Get in touch to help us with resources, relationships or approaches that can strengthen this project.

Thanks much for your time and consideration.

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