The AAFP’s Bold New Valuation Initiative

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Relative Value Scale (RBRVS) “input” taxonomy developed by William Hsaio’s team in the late 1980s – is incomplete and outdated.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.

Finally, a representative from CMS, Edith Hambrick MD, will participate as an observer. Dr. Hambrick has been one of CMS’ liaisons with the RUC for many years. But her presence at the task forcle will convey a gravity, along with the impression that CMS is taking this effort seriously.

It is worth noting that the AAFP is still an active participant in the RUC, but has been reassessing their role since January, when David Kibbe and I first called on all primary care societies to quit. About 5 weeks ago, they issued a letter to the RUC containing a series of demands:

§ 4 more primary care seats.

§ A permanent seat for gerontology.

§ Sunsetting of the RUC’s rotating sub-specialty seats.

§ New seats for non-physicians, like economists, purchasers and consumers.

These are all reasonable, well-considered requests, especially for a body that has had the most influence over medical services valuation for the past 20 years, and whose recommendations are core to the public interest. Still, acquiescing would be a big leap for the RUC’s leadership. The real question here is whether the AAFP Board will have the will to walk if the RUC rejects their entreaties.

In the meantime, given the influence that reimbursement policy has over the ways medicine is practiced and services are delivered, AAFP’s valuation task force has the potential to be exceedingly and positively disruptive to the current paradigm.

Brian Klepper is a health care analyst and the Chief Development Officer of WeCare TLC Onsite Clinics.

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6 replies »

  1. But John at least Brian & David are helping Voldemort’s army by compiling a list of the Order of the Phoenix in advance….. (yes I saw the Harry Potter movie last night)

  2. Unfortunately, this is not transformative enough – not by a long shot. Dr. Klepper believes that by having the right people making the right decisions on the right committees the government will become better at dictating centrally fixed prices for primary care than it is now.

    I regret that this cannot happen. Gosplan is gosplan. Bread prices in the Soviet Union would not have been more socially optimal if bakers had been adequately represented on the committee that set bread prices.

    Primary care will always be the worst compensated specialty because it is the hardest for the central planner to observe. The state is awful at setting any price, but when setting prices for hip replacements or CABGs, at least it can measure the quantity delivered.

    Primary care, especially, needs to be reimbursed by the patients directly.

  3. Hmmmm…I seem to recall the AAFP talking about getting tough before, once or twice, or thrice or four score. The AAFP may have not got tough in this way before, but this is just one more mode they will try. I wish them success, I really do (it would be good for me). But I do not understand how they can succeed. We live in a medical culture that does not value primary care; not patients, not colleagues, not payors.

    Fortunately, I was well trained. Thank you, my teachers! I can do general surgery, ortho, OB, peds, IM, geriatrics, airway management and palliative care all reasonably well. That may not be valued or recognized in the USA, but my patients at missions certainly appreciate it. That is good enough reward for me.

    So I do wish you success, but I really don’t see how you can succeed in a society where general medicine and surgery are systematically denigrated. So I don’t *really* blame the AAFP. Good luck!

  4. Dear Quack,

    For reasons that anyone who has followed Dr. Fischer’s and my campaign against the RUC knows, I have plenty of reason to agree with you. But you’re flat wrong about being underwhelmed about the task force to value primary care services. As I argued, this step is as strategic and smart a move as they can make, and potentially hugely transformative. Be dismissive if you want, but I would argue that’s because you don’t really appreciate what you’re seeing. I’d urge you to reconsider.

  5. I am underwhelmed. Countless radiologic studies have been done on the AAFP. None so far has detected even the hint of a spinal column. Nothing to see here, move on please.

  6. Brian and David,
    Both of you should be congratulated on your leadership on this important issue. Primary care is an essential component of any meaningful reform for our ailing healthcare system. Modernizing the methods for how primary care is compensated is a wise place to start. After all, incentives drive behavior in all industries.
    Thank you for your tireless efforts. Keep up the good work!