The Primary Care Revolt

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.

The AAFP has also established a new task force that is charged with developing a more modern approach to valuing primary care services. To my mind, this is an important and strategic effort. It seeks to remove financially conflicted specialists from determining the value of colleagues who hold them accountable. But it also is being conducted in precisely the way the RUC is not – its proceedings are transparent and methodologically rigorous, and its composition includes both physicians and non-physicians (including me). It is important to note that CMS and MedPAC are observers at the task force’s table, the first time attention has been paid to a physician payment advisory body other than the RUC.

The RUC’s response to this unwelcome attention has been awkward. First was a coordinated effort extolling the RUC’s value last April that involved a Kaiser Health News commentary by RUC Chair Barbara Levy, and two letters to Congress, one by AMA Executive Director Michael Maves and the other from 47 medical specialty societies. (The 4 major primary care specialty societies were conspicuously absent.) Since that effort, though, Dr. Levy has repeatedly used a prepared response that, at once, tries to appeal to every American while coming off like something delivered by a Stepford wife. Here’s her quote in the WSJ article:

“[The RUC is] an independent panel of physicians from all medical specialties, including primary care, who make recommendations to CMS as all citizens have a right to do.”

Actually, there are problems with both parts of this statement. One is that the RUC only has seats for the largest, most powerful medical specialties. Smaller societies don’t participate (and therefore can’t advocate to CMS for their own interests like the others), and those that do get outsize influence relative to their numbers. For example, there is no representation for the Society of Nuclear Medicine, the Society of General Internal Medicine, the American College of Gastroenterology, or the American College of Allergy, Asthma and Immunology.

Then there’s the part about making “recommendations to CMS as all citizens have a right to do.” Folksy but sleight of hand. CMS has had a special, highly organized most-favored relationship with the RUC that has included lavish meetings attended by CMS staff. How far do you think you’d get if you tried advocating for a physician payment approach outside of the RUC? If medical societies that aren’t seated at the RUC can’t get traction, what chance do you think “any citizen” would have?

The really great thing about this problem is that it is easy to understand. Unlike health care reform, which is Byzantine in its complexity and filled with nuance, CMS’ relationship with the RUC is a straightforward example of “regulatory capture.” A few people sitting in a room, secretly in cahoots with a government agency, have steered immensely excessive funds from the richest country on earth to its largest industry. The relationship has ginned up health care cost so that it is now double that of most other developed nations. That largess has come at the expense of patients, who have been exposed to unnecessary procedures and their risks. It has come from purchasers, who have paid huge sums unnecessarily. And it has compromised primary care physicians, who were unwittingly shortchanged, and then neutralized from their classical role of managing the care process.

Ms. Mathews’ article provided a comprehensive overview of the players and their antagonisms, which has given the issue visibility and, hopefully, traction. There will undoubtedly be more in-depth coverage now, which is sorely needed.

The most difficult truth to convey is that this one mechanism bears significant responsibility for America’s health care cost crisis, and for health care’s threat to the larger national economy. The more important truth is that it is fixable, though that will require the resolve to beat back the web of special interests that have brought us to this point at such great cost.

By broaching it in the national press, Ms. Mathews and her editors made the topic fodder for national mainstream dialogue. That’s exactly what was needed and it was a great service to us all.

19 replies »

  1. Business is so black and white, so, what do you tell the patients who are not able to access medications that do what, keep them alive?

    I understand why some of you are so hell bent on insisting on a business model in health care, some of you are closet sadists.

    Must love shoving that square peg into that round whole and ripping the margins apart.

    Oh, by the way, what happens when this kind of situation happens here in the US, perhaps to someone you know. Going to tell that person in the hospital room, “hey, the hospital doesn’t pay the bills, so get your ass out of bed to the pharmacy down the street if you want to live.”

    So simple, so cut and dried, until, it happens close to home?

  2. “As has been noted many times in this and other forums, the RUC is an independent panel of physicians who make recommendations to Medicare decision-makers on the work and resources involved in patient care. More than 300 attendees participate in typical RUC meetings and all specialties in the house of medicine are invited to participate in the process.”

    And?? Where has anyone stated that this is not the case? Your generic definition of the RUC answers nothing. The point at hand is that the RUC is under-weighted with primary care providers and thus undervalues primary care in favor of procedural care and specialty care; the myriad of consequences of this have been discussed ad nauseum..and why no transparency? Also, please give your definition of misogynisitc.

  3. “since the RUC has been CMS’ primary advisory panel on Medicare (i.e., government-funded) physician payment for almost 20 years (and is therefore a de facto federal advisory committee), its proceedings should be transparent and made available to all taxpayers.”

    The crux, really. All else is just a noisy sideshow.

  4. What is wrong with Roche expecting to be paid for the drugs they produce. Nothing. Yes it is a business. The hospitals that are being cut off have not paid the bill in years, so what do they expect.

  5. Last refuge of a scoundrel, resorting to calling people discriminating or just dismissing a dissenter’s opinion as irrelevant
    By the way, check put the Wall Street Journal Sep 17 edition per what drug companies are doing to Greece Hospitals.
    Obscene is a kind interpretation.
    Hey, it’s just about the money, right?
    Profit trumps compassion with some in this group!

  6. So now an AMA staffer – hiding anonymously – says I’m an unprofessional misogynist making personal attacks because I said that Dr. Levy’s incessantly repetitious and corporately sanitized responses sound like something a Stepford wife would have said. I’ve never met Dr. Levy, so certainly don’t know if she seems like a Stepford wife. My guess is that my friends at Planned Parenthood and other feminist organizations I’ve publicly supported for 40 years would find the charge that I’m a misogynist surprising.

    But I do know that leading and defending an organization that has, for two decades, systematically undermined primary care while advocating for procedural valuations that, as a practical matter, financially incentivize the delivery of unnecessary and often-risky medical services does raise the question of whether Dr. Levy is anti-patient, valuing money more than patient well-being.

    Instead of trying to smear me, maybe you should suggest that, since the RUC has been CMS’ primary advisory panel on Medicare (i.e., government-funded) physician payment for almost 20 years (and is therefore a de facto federal advisory committee), its proceedings should be transparent and made available to all taxpayers. You might also note that while others are allowed to participate – if, of course, Dr. Levy, as the Chair, invites them – they are not allowed to vote, and therefore don’t really have a say in this public interest process, as all citizens have a right to..

    I stand by my comments. If the AMA doesn’t wish to provoke similes that describe the quality of the copy for their executives, maybe it should think about recruiting more imaginative writers.

    (By the way, the opening word you were looking for was “Resorting,” not “Reverting.” I hadn’t previously attacked Dr. Levy personally. Only professionally. Perhaps the AMA should think about finding spokespeople who know the language. I’m assuming with that the tactics you used here, they found you in the Bachmann or Perry campaigns.)

  7. There was definitely a “tone” violation in the main post here. But when you orchestrate a systematic enterprise to steal taxpayer dollars through regulatory capture, hurt feelings should be the least of your worries.

    It’s time to replace the RUC with a body that has less conflict of interest, that bases its recommendations in credible science (as opposed to crap surveys by incompetent or knowingly negligent policy hacks), and that makes all of its voting and deliberation records freely available to the general public. MedPAC is a good example of how to be transparent, rigorous, and unconflicted.

    That, or just get rid of Medicare’s centrally determined price schedule in favor of better payment models. Without FFS, the RUC will have no reason to exist.

  8. I don’t think AAFP will be missed if they withdrawl from RUC. If anything, it would be a welcome break. I don’t think it would hurt the legitimacy of the RUC and maybe some other speciality that isn’t represented could fill their seat.

  9. Reverting to personal, misogynistic attacks against Dr. Levy is reprehensible. Dr. Levy, along with all physicians on the RUC, dedicates her time and expertise to this panel as a way to give back to her profession outside of her work with patients. This type of statement demonstrates a deficiency of professionalism that has no place in a public policy discussion.

    As has been noted many times in this and other forums, the RUC is an independent panel of physicians who make recommendations to Medicare decision-makers on the work and resources involved in patient care. More than 300 attendees participate in typical RUC meetings and all specialties in the house of medicine are invited to participate in the process.

  10. Consider the Health Affairs report this month


    showing not only significantly elevated Ortho physician (US) reimbursement but also noting that US primary care is ‘overpaid’ compared to other developed countries. Not sure ‘increasing’ PCP pay is our answer here.

    Unfortunately, as I have stated previously, we have arrived at a status that is going to be difficult from which to extricate. Once again we must consider the Pareto-style economics of supply-demand that leave specialists at their current pay level. Justified or not, higher pay attracts medical grads to many of the specialties that include the sacrifice of overnight call, malpractice risk (emotional as well as monetary), long hours and long training. Simply cutting pay to these specialists will negatively impact the supply-demand dynamics in the mid-term.

    While other countries see less of a distance between specialist and primary pay, the specialists are frequently protected with 40-60 hour work weeks and get paid more for call and weekends, tort is not as prevalent, and status is balanced. Simply cutting specialist pay with no concomitant change in work hours, call etc. might negatively impact access (mid-term). Eventually this will correct, but the continued badgering of the RUC by the PCP community is counter-productive and unlikely to affect change.

    The RUC is at its base formulaic, and puts significant weight on hard factors of time, risk, and technical complexity. The corollaries for PCPs which mostly include decision-making and time are simply not as translatable. The better ‘political’ strategy might be to start chipping away at the reduced costs that PCP can offer by better management i.e. keep your patients from unsubstantiated cardiac caths and cut the difference with payers. PCPs have to prove this though. Cronyism or not, in the end money talks.

  11. “So, to summarize:

    1. Primary care doctors need to control the RVU system.
    2. When they do, they will make more money, and…
    3. Specialists will make less money, and…
    4. American health costs will be significantly reduced. ”

    Tim, your “summary” is based on what statement that PCPs need to “control” the system?

    Yes, no one ever wants to reduce anything in healthcare, just increase their share, but an office visit reimbursement is an office visit reimbursement for many afflictions, and PCPs don’t get paid for feathering their own nest as do specialists. I doubt you also read Brian’s links that show how skewed (the polite term) the system is. In any other business environment the system would be prosecuted for price fixing.

  12. So, to summarize:

    1. Primary care doctors need to control the RVU system.
    2. When they do, they will make more money, and…
    3. Specialists will make less money, and…
    4. American health costs will be significantly reduced.

    Sure, nothing can backfire about that.

  13. Well, what do you think that move would do to the RUCs legitimacy?
    What is the difference between a nurse and a physician?
    Food for thought.

  14. Rbaer,

    I don’t understand how the AAFP withdrawing from the RUC makes any difference. Won’t the RUC just carry-on without them?
    It is true that I don’t see the need for primary care physicians when nurses could easily do their job, but my question wasn’t about that issue. Thank you for responding.

  15. Yep, genericPeter, because we know from previous posts that you don’t understand the problem.

    The US and medicare spends way too much money on care that is not effective, at best marginally effective (or placebo effective) or even destructive (i.e. bad outcomes after procedures/surgeries that are not indicated). There are 3 important reasons for that:
    1) patient expectations (like yours, genericpeter, who does not think that his medical problems could be addressed by anyone but a specialist)
    2) defensive medicine
    3) financial incentives – procedures simply pay too much.
    I think that 1+3 are probably the strongest factors, although 2 needs correction as well. Let medicare pay reasonable rates, and 3 will decrease greatly; however, anyone is free in this country, and will remain free, to pay top dollar for a not needed tonsillectomy or lumbar fusion surgery.

  16. The Junta — uh, Bipartisan Joint Select Committee On Deficit Reduction — is coming soon to a Reimbursement Near You, irrespective of your specialty (PL 112-25, Title IV). Domestic Discretionary Spending is firmly in the crosshairs. And health care in particular, e.g., HIT/QI programs like mine, providers, and benes (probably in that order).

    It’s gonna be ugly. Up-Or-Down vote on the Junta Bill, or punting to automatic cut “triggers.”

  17. Great news hearing what is happening to expose the RUC’s man-behind-the-curtain. Hopefully dragged kicking and screaming will bring us change.

  18. On Wall Street this is called insider trading and it is illegal only in health care is this a cherished form of communication and participation.

    Don’t we need a new set of ethical standards where we are honest to at least acknowledge the practice of medicine is now and has been for many years a business, it is no longer a profession. Let’s just regulate it like a business.