NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # LIGHTHOUSE Healthcare. Illuminated.

AAFP

Last April, the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question carefully. Today, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Association of Family Physicians (AAFP) have joined the campaign, drawing national attention to the overuse and misuse of induction of labor. ACOG and AAFP are telling women and their maternity care providers:

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.

(“Favorable” means the cervix is already thinned out and beginning to dilate, and the baby is settling into the pelvis. Another word for this is “ripe,” and doctors and midwives use a tool called the Bishop Score to give an objective measurement of ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally.)

Much work has already been done to spread the first message. Although ACOG has long advised against early elective deliveries, the practice has persisted. But a confluence of recent reforms has made it increasingly difficult for providers to perform elective deliveries before 39 weeks. Quality collaboratives have supported hospitals to implement “hard stops” that prevent these deliveries. Payers have used carrots and sticks to disincentivize them. CMS has funded a national public awareness campaign to reduce consumer demand.

Continue reading “Delivering Progress. Choosing Wisely.”

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Three months ago a post argued that America’s primary care associations, societies and membership groups have splintered into narrowly-focused specialties. Individually and together, they have proved unable to resist decades of assault on primary care by other health care interests. The article concluded that primary care needs a new, more inclusive organization focused on accumulating and leveraging the power required to influence policy in favor of primary care.

The intention was to strengthen rather than displace the 6 different societies – The American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the Society for General Internal Medicine (SGIM), the American Academy of Pediatrics (AAP), the American Osteopathic Association (AOA), the American Geriatrics Society (AGS) – that currently divide primary care’s physician membership and dilute its influence. Instead, a new organization would convene and galvanize primary care physicians in ways that enhance their power. It would also reach out and embrace other primary care groups – e.g., mid-level clinicians and primary care practice organizations – adding heft and resources, and reflecting the fact that primary care is increasingly a team-based endeavor.

We came to believe that a single organization would not be serviceable. Feedback on the article suggested that several entities were necessary to achieve a workable design.
Continue reading “Strengthening Primary Care With A New Professional Congress”

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This week the American Academy of Family Physicians (AAFP) issued a new report describing its vision of primary care’s future. Not surprisingly, the report talks about medical homes, with patient-centered, team-based care.

More surprisingly, though, it makes a point to insist that physicians, not nurse practitioners, should lead primary care practices. The important questions are whether nurse practitioners are qualified to independently practice primary care, and whether they can compensate for the primary care physician shortage. On both counts the AAFP thinks the answer is “no.”

AAFP marshals an important argument to bolster its position. Family physicians have four times as much education and training, accumulating an average of 21,700 hours, while nurse practitioners receive 5,350 hours.

It is unclear how this plays out in the real world but, intuitively, we all want physicians in a pinch. Researchers with the Cochrane Database of Systematic Reviews reviewed studies in 2004 and 2009 comparing the relative efficacy of primary care physicians and nurse practitioners. They wrote “appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients.” But they also acknowledged that the research was limited.

There is no question that nurse practitioners can provide excellent routine care. For identifying and managing complexity, though, physicians’ far deeper training is a big advantage. In other words, difficult, expensive cases are likely to fare better from a physician’s care.

Continue reading “The Wrong Battles”

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Last Thursday Anna Wilde Mathews of the Wall Street Journal ran an article detailing the activities surrounding primary care’s gradual awakening and mobilization. With Tom McGinty, Ms. Mathews authored a damning expose on the RUC last October that precipitated our efforts against CMS’ 20 year reliance on the AMA’s RVS Update Committee (RUC) for valuation of medical services.

There is the lawsuit by six Augusta, GA primary care physicians, spearheaded by Paul Fischer MD. (See his most recent article below). The suit claims that CMS’ and HHS’ longstanding primary relationship with the RUC has rendered that panel a “de facto” federal advisory committee. That would make it subject to the management and reporting rules of the Federal Advisory Committee Act  - transparent proceedings, representative composition, scientifically valid methodologies - that attempt to ensure the public over the special interest. The fact that CMS has never required the RUC to adhere to those rules presumably means that the relationship is out of compliance with the law.

The American Academy of Family Physicians (AAFP), after declining to join the suit, issued a series of demands: more primary care seats, a sunsetting of rotating sub-specialty seats, a dedicated gerontology seat, seats for non-physicians like patients, purchasers and economists. The RUC has until March to respond. If they reject the demands, the question is whether the AAFP Board will vote to walk, as David Kibbe and I urged them to do when we began this campaign last January.

Continue reading “The Primary Care Revolt”

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This morning, the American Academy of Family Physicians, the largest and “purest” of the major primary care societies – the American College of Physicians (ACP), the American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA) are all heavily influenced by sub-specialists – announced that it has convened a national task force charged with identifying new, better approaches to value primary care services.

This initiative is nationally significant for several reasons. By definition, it challenges the methodology used for nearly two decades by the American Medical Association’s Relative Value Scale Update Committee (AMA RUC), which has drastically under-valued primary care services while over-valuing many specialty services. By taking on this effort, it not only announces that the fruits of the AMA RUC’s labors are unacceptable, but also points out that the methodology the RUC uses to value medical services – this is founded on the Resource-Based Relative Value Scale (RBRVS) “input” taxonomy developed by William Hsaio’s team in the late 1980s – is incomplete and outdated. For example, the RUC’s methodology for calculating value doesn’t consider whether a service produced a worthwhile benefit to the patient or society, whether it was evidence-based or even necessary. More on this in a future article.

Next, the task force is not limited to AAFP members, but a wide range of professionals drawn from other primary care medical societies, business, the health plan sector, policy groups and subject matter experts. See the bios here. (I’ve been asked to participate, and will be honored to do so.) In other words, unlike the RUC, this group is more representative of the sectors whose interests it will focus on. Continue reading “The AAFP’s Bold New Valuation Initiative”

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By 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’s (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 physician and handles half of our office visits, is suddenly mobilizing.

The medical societies’ letter is more than a response to just Rep. McDermott’s bill. It also responds to the primary care physician community’s stirrings. Marshaling the influence and discipline of a medical establishment obviously distressed by the prospect of having its economic franchise disrupted, it was the third public defense of the RUC in a little more than a week, following a column on Kaiser Health News by the RUC’s Chair, Barbara Levy MD, and a letter this past Tuesday to Rep. McDermott by AMA CEO Michael Maves. After 20 years of easily-validated intentional obscurity – ask virtually any room of physicians what the RUC is and watch the majority’s blank responses – this open activity favoring the RUC is unprecedented.

The letter is also obviously orchestrated, using many of the same tactics and arguments that Drs. Levy and Maves employed in their defenses. It carefully avoids talking about the abysmal real world consequences of the RUC’s historical approach. It ignores the dramatic under-valuing of primary care, the plummeting rates of medical students choosing primary care, the over-valuing and over-utilization of a wide variety of specialty procedures, and the inherent incentive for the RUC to focus on under-valued rather than over-valued procedures.

Instead, it obfuscates. To counter the McDermott proposal that CMS should use means other than the RUC to assess the RUC’s recommendations, the letter argues that past efforts to use contractors have failed. Therefore, it is senseless to go down this path again. Continue reading “The RUC’s Defense”

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As a third-year medical student in 1977, I joined the American Academy of Family Physicians (AAFP).  In those culturally tumultuous years, it was a way to declare my belief that America needed physicians who cared for the whole person, family and community. It was also a declaration that, in choosing the primary care path in a field ripe with tempting medical specialties, money was not my primary goal.

For much of my 33-year membership, I have considered the AAFP to be “my” organization. However, there is a time when one must step back and declare independence from organizations that have lost touch with their members.  The AAFP does much that supports my day-to-day life as a busy family doctor, but for 33 years, its leadership has failed to fix the central problem for primary care in America: poor reimbursement.

I deal every day with complicated health problems of complex patients who are insured by companies singularly focused on limiting even the smallest cost.  In return for managing these patients, which often involves critical and life-or-death decisions, I am paid by Medicare 60% less per hour than is a dermatologist, who, for the most part, treats trivial disease that involves no nighttime emergencies and little intellectual challenge. Continue reading “A Family Physician’s Manifesto”

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