The Augusta Primary Care Physicians Lose Their Appeal

On January 7th, the 4th Circuit of the US Court of Appeals rejected Fischer et al’s appeal. The opinion gave their arguments short shrift and dismissing the case out of hand, with much discussion. As a practical matter, this exhausts the Augusta primary care physicians’ legal remedies to CMS’ and HHS’ sole source relationship with the AMA’s RUC.

There are still paths to pursue, particularly if Congress and/or the White House were to find reason to bring pressure on CMS to change either the way it determines the value of medical services, or the parameters of its relationship the RUC as an advisory organization.

More later.

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The Most Powerful Health Care Group You’ve Never Heard Of

Brian Klepper and Paul Fischer

Posted 8/06/12 on Medscape Connect’s Care and Cost Blog

Excessive health care spending is overwhelming America’s economy, but the subtler truth is that this excess has been largely facilitated by subjugating primary care. A wealth of evidence shows that empowered primary care results in better outcomes at lower cost. Other developed nations have heeded this truth. But US payment policy has undervalued primary care while favoring specialists. The result has been spotty health quality, with costs that are double those in other industrialized countries. How did this happen, and what can we do about it.

American primary care physicians make about half what the average specialist takes home, so only the most idealistic medical students now choose primary care. Over a 30 year career, the average specialist will earn about $3.5 million more. Orthopedic surgeons will make $10 million more. Despite this pay difference, the volume, complexity and risk of primary care work has increased over time. Primary care office visits have, on average, shrunk from 20 minutes to 10 or less, and the next patient could have any disease, presenting in any way.

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Will Anyone Listen When Former CMS Chiefs Call For More Objective Physician Payment?

Brian Klepper

Posted 7/7/12 on Medscape Connect’s Care & Cost

On May 10th, the US Senate Finance Committee, co-chaired by Senators Max Baucus (D-Mont) and Orrin Hatch (R-Utah), convened a remarkable panel of four former Administrators of the Health Care Finance Administration (HCFA) and the Centers for Medicare and Medicaid Services (CMS): Gail Wilensky, Bruce Vladeck, Thomas Scully and Mark McClellen. (See the video here.) Against a backdrop of intensifying budgetary pressures, the roundtable was to provide perspectives on Medicare physician payment, including several controversial issues: the Sustainable Growth Rate (SGR) formula, the Resource-Based Relative Value Scale (RBRVS), and the RVS Update Committee (RUC).

Ironically, the day before, a Maryland Federal District judge dismissed a suit brought against HHS and CMS by six Augusta, GA primary care doctors over CMS’ longstanding relationship with the RUC, based on a procedural technicality and without weighing the substance of the complaint. The physicians challenged CMS’ refusal to require the RUC to adhere to the public interest rules of the Federal Advisory Committee Act (FACA) that typically apply to federal advisory bodies. The suit described the harm that has accrued to primary care physicians, patients and purchasers as a result of the RUC’s highly politicized process. To a large extent, the plaintiffs’ concerns closely reflected those of the former CMS Chiefs.

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An Overview of the RUC and the Problems It Represents

This PowerPoint provides the background on the RUC that Brian Klepper presented at the National Medical Home Summit in Philadelphia in February 2012. It tries to deliver a concise explanation of the structural issues involved.

BKlepper-MHS-Replace-the-RUC

 

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The RUC’s Hollow Victory

Brian Klepper

Posted 5/18/12 on The Health Affairs Blog

On May 9th, William Nickerson, Senior Judge in the Southern Maryland Federal District Court, issued a 15 page ruling against the six Augusta, GA primary care physician plaintiffs who challenged HHS’ and CMS’ longstanding relationship with the American Medical Association’s Relative Value Scale Update Committee (RUC). The opinion did not weigh the substance of the case, but instead focused on a procedural provision in which Congress bars the judicial system from considering how the relative value units (RVUs) of medical services are determined. Judge Nickerson wrote:

Accepting as true that RUC plays a major role in the formation of the PFS [Physician Fee Schedule] and also accepting as true that this role unfairly skews the PFS toward certain medical professions and procedures, the Court, nonetheless, finds that Congress has precluded courts from reviewing, not only the final relative values and RVUs, but also the method by which those values and units are generated.

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The RUC’s Empty Gesture

Brian Klepper and Paul Fischer

Posted 5/11/12 on Medscape Internal Medicine

Recently, the leaders of the American College of Physicians and the American Geriatrics Society lavished praise on the American Medical Association’s Relative Value Scale Update Committee (RUC) for announcing the addition of a rotating primary care seat and a permanent geriatrics seat, and for promising to post vote tallies. Welcoming these maneuvers not only betrays a poor understanding of history, but misguided political and strategic instincts that will continue to harm patients, purchasers and primary care physicians.

Over the past 13 months, we have spotlighted the RUC’s secretive, self-interested mechanisms. With 5 primary care colleagues, Dr. Fischer has sued HHS and CMS over the fact that, despite their longstanding, near sole-source reliance on the RUC for the valuation of physician services, they have refused to require it to adhere to the stringent legal requirements associated with the Federal Advisory Committee Act.

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Adding Seats: The RUC’s Sleight of Hand

Paul Fischer and Brian Klepper

Posted 3/14/12 on The Health Affairs Blog

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

On February 1, the American Medical Association’s Relat ive 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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