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A Legal Challenge To CMS’ Reliance On The RUC

By BRIAN KLEPPER & DAVID KIBBE, MD

This week in a Maryland federal court, six physicians based at the Center for Primary Care in Augusta, GA filed suit against HHS Secretary Kathleen Sebelius and CMS Administrator Donald Berwick. The complaint, spearheaded by Paul Fischer MD with DC-based lead counsel Kathleen Behan, alleges that the doctors have been harmed by the Medicare payment structure developed through the agencies’ reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC).

The suit also claims that the agencies have functionally treated the RUC as a federal advisory committee. But they have not required the RUC to adhere to the Federal Advisory Committee Act’s (FACA) stringent management and reporting rules – e.g., balanced representation, transparent proceedings, and scientifically valid analytical methodologies – that keep the proceedings in the public interest. The plaintiffs request injunctive relief, which would freeze the relationship between CMS and the RUC until the advisory group complies with FACA’s requirements. Of course, compliance would drastically change the way the RUC conducts its affairs, something it is almost certainly loathe to do.

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The Year of Going Paperless

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By DINOSAUR MD

Seven months into 2011, things look very different than they did this time last year at my office. Not only have I been using an electronic medical record for nine months now, but I’ve also been submitting claims electronically (through a free clearinghouse) using an online practice management system. I’ve also begun scanning patients’ insurance cards into the computer, as well as converting all the paper insurance Explanation of Benefits (EOBs) into digital form. I’ve even scanned all my office bills and business paperwork and tossed all the actual paper into one big box. As of the first of the year I even stopped generating “daysheets” at the end of work each day. After all, with my new system I can always call up the information I want whenever I need it.

How did such a committed papyrophile get to this point? It is the culmination of a process that actually began last summer with the purchase of an adorable refurbished little desktop scanner from Woot ($79.99, retails for $199, such a deal!) The organizational software is useless for my purposes, but it does generate OCR PDFs, which makes copying and pasting ID numbers from insurance cards into wherever else they need to be a piece of proverbial cake. The first step was to start scanning the office’s administrative paperwork (phone bills, electric, etc), since that didn’t affect the staff’s workflow. Suddenly, instead of having to sort the increasingly teetering piles of paper bills into file folders in an upstairs desk drawer, I had a single file on my computer where I could access any document I needed with a click or two.

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Dropping the Price of Surgery

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By JEFFREY RICE, MD

I would like to share a story about my son’s recent surgery that, while only one simple case, reveals the foundational problem with the U.S. health care system.

I write this story as a father of a 12 year old boy who has cerebral palsy. Jack is fortunate to be healthy and active with minor medical needs. As he has grown he experienced some issues with contractures in his right lower leg which recently required a minor 2 hour outpatient surgical procedure. That is where our saga begins.

When Jack’s surgery was scheduled I started the time consuming process of getting price estimates from the surgeon, anesthesiologist and the facility since we have a high deductible insurance plan. The physician fees were straight forward and relatively easy to obtain, not so with the facility. Jack’s surgery was scheduled at the local hospital’s outpatient surgical facility. I called the hospital to request a price for the surgery and they said they couldn’t really tell me. They offered to send the procedure codes to an external reviewer who would provide a general idea of the anticipated charges. Three days later the answer came back at $37,000. I reiterated that I had high deductible insurance and needed to know the actual price they would bill me after an insurance adjustment to the network fee schedule.

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The Economic Urgency of Health Care Reform

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By GOV. PETER SHUMLIN

Watching the events of the past several weeks in Washington has been sobering. Decades of failed fiscal policy have finally come home to roost and Congress is tied in knots trying to find a compromise solution and avoid American default. Americans rightly are scared that our leaders can’t find a way out of this muddle. But the really sobering part is this: the solutions under consideration don’t fix the problem. Even if Congress enacts the most draconian spending cuts advanced by the Tea Partiers, and all of the tax increases advanced by the liberals, we will not be out of the mess. The crisis will still loom. Why? Because health care costs continue to increase at an unsustainable rate, and health care spending is the single largest category of federal spending. Without real, sustained health care cost control, we still face a crisis, no matter what package of cuts and revenues the new “gang of 12” develops.

As a Governor, I can’t ignore this problem. Health care spending more than tripled in Vermont between 1992 and 2009. Between 2000 and 2009, health care spending as a share of our gross state product rose from 12.9 percent to 18.5 percent.

We come face to face with the impact of growing health care costs every year in our state budget process. Health care squeezes out all sorts of other priorities, and we (state government) aren’t even paying our fair share of the increase. The state can’t afford to sustain a rate of growth that far exceeds growth in our economy and growth in our tax revenues. So we shift costs from state health care programs to the private sector. The private sector can’t sustain the growth, either, so they cut jobs and reduce insurance coverage for their employees. That’s why, despite aggressive efforts to expand government-sponsored insurance coverage in Vermont, nearly one in ten Vermonters is uninsured, and nearly a quarter of our population is underinsured — they have coverage, but could still go bankrupt if they had a major illness.

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Quality Improvement Under the Microscope

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By MARYA ZILBERBERG, MD

So much media and journal space has been devoted to financial conflicts of interest, particularly within and related to pharma and device manufacturers, that to write any more about it may be redundant. On this site we have also intermittently addressed COI from other perspectives, such as financial interest of the members of the American College of Radiology in maintaining mammography screening status quo, thinly veiled in its own version of the pernicious “death panel” language. We have also spoken a bit about the non-financial COI. And even though we are so very much aware of COI’s potential to lurk around every corner, there are still some surprises.

Take the sacred cow of “quality improvement” in healthcare. Even the name, much like the “pro life” moniker, suggests that it is untouchable in its purity and nobility of purpose. So necessary is it because of the epic magnitude of morbidity and mortality attributed to healthcare itself, that the billions of dollars spent on it seem unquestionably justified. Indeed, much like our public education system, the QI movement garners higher and higher allocations simply due to the sheer face validity of the assumption that more of it is better.

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CER Kills?

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By JOE FLOWER

According to the Pacific Research Institute recently, because of “Comparative Effectiveness Research” (CER) “under conservative assumptions, R&D investment in new and improved pharmaceuticals and devices and equipment would be reduced by about $10 billion per year over the period 2014 through 2025, or about 10-12 percent. This reduction in the advance of medical technology would impose an expected loss of about 5 million life-years annually, with a conservative economic value of $500 billion, an amount substantially greater than the entire U.S. market for pharmaceuticals and devices and equipment.” [Study available here.]

I haven’t read the study. I don’t need to, since it is so obviously true, if we just make certain assumptions, such as:

  • Every dime spent on R&D for drugs and devices is wisely spent, on advances that will save and improve lives.
  • Every dime spent on finding out whether those drugs and devices actually work as advertised, and don’t actually kill people, and do it better or cheaper than other drugs and devices, is a dime wasted. CER just slows down legitimate, helpful research.
  • Experience does not show us any examples of wasteful or unnecessary drugs or devices. Those multiple peer-reviewed research papers showing that we waste hundreds of billions of dollars every year on useless complex back surgeries, the 22% of  implanted defibrillators that are unnecessary, tens of millions of unnecessary scans, coronary stents put in people with stable heart disease and no heart pain, the heartburn surgeries that work no better than over-the-counter drugs—those studies are all false, wrong, some kind of mumbo-jumbo that we can safely ignore.

If we just make those few simple assumptions, the study has a valid point. If we don’t accept those assumptions, we have to wonder about the mental state, motivations, and personal finances of someone who would cook up such an obvious bit of flim-flam.

Joe is a healthcare speaker, writer, and consultant, working with clients ranging from the WHO, the Global Business Network, and the U.K. NHS, to the majority of state hospital associations. Joe writes at imaginewhatif.

Learning Hard Lessons from the RIM Story

By JONATHAN BUSH

One of our account managers sent me a link to this open letter written by a high-level employee to the leadership of Research in Motion or RIM, makers of the BlackBerry, laying out their concerns about the company. The company faces stiff competition in the smart phone market and recently announcedplans for 2,000 layoffs.

The account manager thanked me for what I have done to lead us in a way that has avoided this fate for athenahealth. So, thanks to him.

HOWEVER, I don’t think we are totally free of all eight concerns rattled off by one anonymous OG RIMMER. Here are some of her/his pleas to management and some of my thoughts on them as they apply here at athenahealth. (If you could see our internal blog version of this post, you’d see more than a dozen thoughtful comments from athenahealth employees on how they think we can learn from this story.)

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A Technology in Search of a Market

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By JOHN MOORE

PHRs are much like the tides, news about them ebbs and flows. Right now, with the relatively recent demise of Google Health, Dossia’s attempts at rebirth, and the significant inquiries we are receiving regarding meaningful use requirements to host a PHR (patient portal). But in and amongst all this Chilmark has heard on more than one occasion the following statement: “The problem with PHRs is that they are a technology in search of a market.”

This statement is simply wrong for the following reasons:

1) As we have said countless times before in previous posts, very few people are interested in a digital filing cabinet for their health records. Unfortunately, many PHRs in the market today are just that, digital filing cabinets. In this case it is not an issue of a technology in search of a market, it is just a bad product that really has no market.

2) Technology adoption does not occur for its own sake, it occurs when there is perceived value by the user that leads to adoption. PHRs, PHPs (personal health platforms), patient portals, etc., is certainly a technology, that when well-designed, and implemented can deliver significant value and subsequently see high adoption rates. Just look to Kaiser-Permanente’s instance of MyChart, where patient adoption is well over 40%. Up in the Pacific Northwest, the Group Health Collaborative (GHC) is seeing PHR adoption that is well over 50%. That’s a market!

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US Rumor and Hospital Report

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By PAUL LEVY

It has been almost four years since I commented on the annual hospital ranking prepared by US News and World Report.  I have to confess now that I was relatively gentle on the magazine back then.  After all, when you run a hospital, there is little be gained by critiquing someone who publishes a ranking that is read by millions.  But now it is time to take off the gloves.

All I can say is, are you guys serious?  Let’s look at the methodology used for the 2011-12 rankings:

In 12 of the 16 [specialty] areas, whether and how high a hospital is ranked depended largely on hard data, much of which comes from the federal government. Many categories of data went into the rankings. Some are self-evident, such as death rates. Others, such as the number of patients and the balance of nurses and patients, are less obvious. A survey of physicians, who are asked to name hospitals they consider tops in their specialty, produces a reputation score that is also factored in.

Here are the details:

Survival score (32.5 percent). A hospital’s success at keeping patients alive was judged by comparing the number of Medicare inpatients with certain conditions who died within 30 days of admission in 2007, 2008, and 2009 with the number expected to die given the severity of illness. Hospitals were scored from 1 to 10, with 10 indicating the highest survival rate relative to other hospitals and 1 the lowest rate. Medicare Severity Grouper, a software program from 3M Health Information Systems used by many researchers in the field, made adjustments to take each patient’s condition into account.

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The Debt Ceiling and Health Care

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By LINDA BERGTHOLD

Over the weekend, I watched Twitter as drops of information about the debt ceiling leaked out bit by bit. There was a deal. No deal. Well, maybe a deal.The deal would require Congress to wait until a Balanced Budget Amendment passed in the states before it acted. Well, no it actually didn’t include that. Medicare was on the chopping block. Well, not cuts to members, only cuts to physicians and other providers. What’s an ordinary person to think?

There was plenty of humiliation to go around. Speaker Boehner didn’t return the president’s phone calls. Speaker Boehner couldn’t rally his own party to support his deal. Majority Leader Reid couldn’t get Republicans to talk to him. Sen. McConnell would only talk to Biden not Reid, and his unfortunate facial expressions left us with the impression that he had a serious digestive problem. The classic picture was Boehner in the House elevator letting out a long groan as the doors closed. He was not the only one groaning.

Pundits made the worst cliché pronouncements. Everything was a “crisis”; there was lots of “kicking the can down the road.” TV time had to be filled and fill it they did. Those smart folks who spent the weekend outside, barbecuing or swimming, were the wise ones. We all knew it would come down to the last moment, but oh, was it painful to watch those last agonizing hours.

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