Trusting Government: A Tale of Two Advisory Groups

David C. Kibbe and Brian Klepper

Posted 2/2/12 on the Health Affairs Blog

©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.

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Why Primary Care Doctors Sued CMS over Its Reliance on the AMA’s RUC – and Why the RUC Should Be Changed or Replaced

Brian Klepper

Published 2/1/12 in Medical Home News

L-R: Bob Clark, Becca Talley, Paul Fischer, Edwin Scott, Rob Suykerbuyk, Les Pollard - Click to Enlarge

Six Augusta, GA primary care physicians filed suit last August against the Centers for Medicare and Medicaid Services (CMS). They charged that for two decades the agency has relied primarily on the American Medical Association’s (AMA’s) Relative Value Scale Update Committee (RUC) to value medical services. But CMS has not required the RUC to adhere to the stringent management and reporting rules associated with the Federal Advisory Committee Act (FACA) that ensure that regulation is in the public rather than the special interest.

The RUC, a voluntary committee dominated by specialists — only two of 29 are primary care physicians –scores medical procedures in terms of Relative Value Units (RVUs). After a multiplier is applied, higher RVUs receive more reimbursement. CMS has historically accepted more than 90 percent of the RUC’s recommendations without further due diligence.

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Tracking the RUC Trial

Brian Klepper

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.

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Residents and Medical Students Should Support Efforts to Revalue Cognitive Services

Kevin Bernstein

First posted 9/17/11 on The Future of Family Medicine

The numbers do not lie.  As stated in a previous post and its referenced links, the payment gap between primary care and specialists has increased since the American Medical Assocation started the Resource-Based Relative Value Scale (RVS) Update Committee (“RUC”) in the early 1990s.  It is difficult to separate the two when the Center for Medicare and Medicaid Services (“CMS”) has accepted over 90% of the RUC’s recommendations throughout the years.

This can be interpreted in a number of different ways but let’s be honest – I am a current intern and do not have enough time to go through the different interpretations –  I will leave that up to your comments.

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Another Modest Proposal*: Paying for Physician Training

Paul Fischer

One of the main considerations in physician pay under CMS’ relative value system is the training required to complete a task. This is generally thought to be well understood but is, in fact. a quagmire of controversy.

Take for example the specialty of family medicine compared with dermatology, anesthesiology, or ophthalmology. Family physicians make between 1/2 and 1/3 of what these other specialties make, so one would think that there is a huge training difference. The truth is that each of the four require 16 years before medical school, 4 years of medical school, and 3 years of residency.  The 3 highly paid fields require 1 additional year in a transitional internship.  So the family physician education represents 23/24 or 96% of the length of education required for the others.  Since when is a 4% investment worth a 200% to 300% return?

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The Need for a Level Playing Field for Physician Pay

Paul M. Fischer

Everyone in medicine knows that some physicians are overpaid for the services they provide and some are underpaid. The list of specialties in each category is no secret, though we don’t talk about it much.  It’s part of the same ethic that teaches us not to criticize another doctor’s care.

But the sad fact is that in medicine, money is tied to prestige, power, public credibility, and medical student interest.  If we don’t deal with this problem, medicine will continue to fall hopelessly into the “haves” and the “have nots,” that is, those who “own” lucrativeCPTcodes and those who don’t. So the question is how did this inequity come to be and how can it be remedied?

History shows that physician pay rarely follows value, but rather aligns with power.  When I was a medical student, heart caths were new and were the domain of invasive radiologists. But it wasn’t long before the cardiology socialites took on the radiologists and successfully claimed heart imaging as their own.  Power and wealth followed.

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Why Medical Specialists Should Want to End the Reign of the RUC

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.

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