As physicians, our primary concern is ensuring the health and safety of our patients. The Food and Drug Administration has offered a new concept to make more prescription drugs available over the counter (OTC). Proponents claim it could improve patient health and outcomes, reduce patient costs and promote proper medication use. We are skeptical that it would achieve any of these goals.
The American Medical Association is concerned about patients taking certain drugs without physician involvement — especially patients with chronic diseases. No evidence has been offered that the innovative technologies underpinning this concept would actually allow patients with high blood pressure, high cholesterol, asthma or migraine headaches to self-diagnose and manage these serious chronic medical conditions safely on their own.
As a chronic condition evolves, treatment changes are often needed from a physician. Without physician involvement, patients might take the wrong medication or dose for their needs, potentially causing harm. Self-diagnosis and treatment conflict with the care coordination and disease management that new health care payment and delivery models are trying to achieve.
After years of telling us they are serious this time and everyone in the health care system had better be ready on time to implement the new disease coding system, CMS said today the whole project is going to be delayed indefinitely.
The new ICD-10 system requires payers and providers to convert from the old system of 13,000 codes to the new system of 68,000 codes.
All payers and providers were supposed to be ready by October 1, 2013. The acting CMS Administrator said, “There is a concern that folks cannot get their work done around meaningful use [of information technology], ICD-10 implementation, and be ready for [insurance] exchanges. So we decided to listen and be responsive.”
Apparently, a new timeline will be developed through a “rule making process.”
Fine, but that has not been the message for months now and lots of people have spent lots of money for apparently no good reason.
The concerns that particularly physicians would not be ready on time have not been minor. CMS conducted a survey between January and March of 2011 that clearly showed there were big problems ahead. But in the year since that survey, they continued to tell stakeholders to keep going ahead full speed, spending big money to be ready.
But in the last few weeks, the American Medical Association has been sounding the alarm–their people wouldn’t be ready.
Sounds like the lowest common denominator in the health care system wins out.
Here are the results from a survey CMS conducted from January to March of 2011 by type of industry participant. AHIP is the insurance industry trade association, HBMA and AAPC are associations of industry coding and billing providers, ACP is the American College of Physicians and the AMA is the American Medical Association. The survey also measured readiness for the Version 5100 standards for electronic health transactions that were effective in January 2012, but for which enforcement has been delayed until March 31, 2012.
I have been asked to write up some of the core takeaways from the health care social media presentations I have been giving recently, so I am sharing a version of this narrative on HealthBlawg, in two parts. You may wish to begin with Part I.
Professional responsibility and malpractice liability
The American Medical Association has promulgated a social media policy; so has the Veterans Administration. The two represent very different approaches. The AMA essentially advocates proceeding with caution, and being cognizant of the damage that one’s own social media activities – and one’s colleagues’ – may do to the profession. The VA, on the other hand, is out in front on this issue – just as it was with electronic health records – encouraging the use of social media tools to disseminate information and engage patients and caregivers in productive dialogue likely to improve overall wellbeing and health care outcomes.
Patient care should not be provided in open social media forums, but appropriate disclaimers on blogs, Facebook pages, YouTube channel pages, and the like, should be sufficient protection for providers seeking to use these tools for sharing of general advice and information.
We’re seeing a lot of pushback against ICD-10 implementation, with the American Medical Association’s “vigorous opposition” at the extreme. Gloom and doom types equate to potential IT disaster to Y2K. Ever since watching T. Bedirhan Üstün, M.D. — curator of the International Classification of Diseases, the master coding set from which ICD-10 is derived – present at the American Health Information Managers (AHIMA) annual meeting last October, a question’s been gnawing at me:
If flipping the switch on ICD-10 come Oct. 1, 2013 will be such a disaster as groups like the AMA claim it will be, then why didn’t it bring down the European and Asian health systems that implemented their own flavors of ICD-10 years ago?
The reporter in me – especially when hearing people couch ICD-10 in terms like “unfunded mandate” and “sky-is-falling” hyperbole – suspects it’s all about politics. During the course of debate in these times, it seems as if people on both the left and right resort to browbeating rhetoric faster than I’ve ever seen in my life. And why not? Reciting the catchphrase du jour requires far less reasoning than a well-constructed, original thought.
In a recent Wall Street Journal article, Barbara Levy, Chairwoman of the Relative Value Scale Update Committee (RUC), commented on the American Medical Association’s (AMA’s) decision to have minimal primary care participation on the RUC, saying the committee is an “expert panel” and not meant to be representative. Since the committee is made up of 27 specialists, one family doc, and a pediatrician, the AMA apparently believes it requires little in the way of primary care expertise but lots of experts from every minute surgical specialty.
This is, of course, reflected in the AMA’s coding system. Most of primary care is condensed into four Evaluation and Management (E/M) codes: a “focused” encounter, an “expanded” encounter, a “detailed” encounter, and a “comprehensive” encounter (99212-99215). It does not matter whether the problem is a cold or an acute myocardial infarction. It does not matter if you worked with just the patient or the entire family spanning three generations. It does not matter if the problem was simple and common (eg, essential hypertension) or rare and complex (eg, pheochromocytoma). It does not matter whether you completed everything in a single visit or spent hours fighting with an insurance company for payment. And it does not matter whether you dealt with a couple of well-established problems or a dozen new ones. It is clear that the AMA has little expertise in this area. What is amazing is that they think they have enough!
In contrast, there are 400 pages in the CPT book to help proceduralists get maximum pay for their work. In general, procedure coding follows a scheme based on the part of the body, the number of times you repeat a procedure, how fancy the equipment is, and how many different names you can come up with to do the same work (eg, vein ablation, injection, sclerosing, ligation, interruption, excision, or stripping). This is obviously a boon for many physicians’ income.Continue reading…
An under-the-radar revolution is going on out there. It is a revolt of primary care physicians against the AMA and CMS. It is a request for parity with specialists. It is a movement to replace how primary care practitioners are paid.
Why the revolt against the AMA and CMS? Because primary care doctors yearn to correct myths about primary care vis-à-vis specialists, and because they believe, by altering how the AMA and CMS pay doctors, health costs can be brought down, and primary care can be re-invigorated. Health systems with a broad primary care base have lower costs. In the U.S., two-thirds of doctors are specialists, and one-third are in primary care, the reverse of most nations, which have 50% or lower costs.
In the early 1990s, the AMA formed the Relative Value Scale Update Committee (RUC), which specialists now dominate. RUC sets payment codes for doctors. Since RUC’s inception, the payment differential has been growing between primary care doctors and specialists, so much so that the typical primary care doctor now makes only 30% of what an orthopedic surgeon makes. On average, primary care incomes are 50% of those of specialists.Continue reading…
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…
At a recent talk, Dartmouth’s Elliott Fisher facetiously remarked that we cannot yet be sure whether accountable care organizations (ACOs) will actually be accountable, caring, and organized. Well, if some providers have their way, they certainly won’t be accountable.
This story by Jordan Rau in the Washington Post relates comments being made as Medicare writes its rules governing the ACOs. Here are some quotes:
[S]ome prominent doctor and hospital groups are pushing for features that some experts say could undermine the overall goal – improving care while containing costs. They’re seeking limits on how the quality of their care will be judged, along with bonus rules that would make it easier for them to be paid extra for their work and to be paid quickly.
Here’s the one I like best:
The Federation of American Hospitals, representing for-profit facilities, goes further, urging that ACOs be allowed to choose their patients. “Providers are better positioned than CMS to determine which of their patients would be appropriate candidates,” the federation wrote.
So, we are happy to be held accountable, but only if we get to choose which patients are part of our network.
A few weeks ago, my writing partner David C. Kibbe and I ran an article on Kaiser Health News called “Quit the RUC!“ that has caused some turmoil within the physician community, particularly in DC.
First, it noted that the RUC, the informal specialist-dominated AMA panel, has made recommendations for 20 years about the value of medical procedures within the highly arcane and jiggered Resource-Based Relative Value Scale (RBRVS). As the Wall Street Journal recently reported, CMS (and its predecessor, HCFA) has accepted some 90 percent of its recommendations, apparently almost without question. It shouldn’t surprise anyone that the vast majority of recommendations involve payment increases to specialists that have come at the expense of primary care.
This combination – a highly conflicted advisory panel making methodologically questionable recommendations about payment to a blithely accepting regulatory agency – is at the heart of the American health care cost crisis and the greatest reason why the American economy is literally being bankrupted by its health care costs. This year alone, we’ll spend about $1.3 trillion on health care products and services that provide no value. This is two-thirds again more than we’ll spend over the next decade on the economic stimulus package.Continue reading…
American Medical News, the award-winning newspaper published by the American Medical Association (AMA), announced today it is offering unrestricted access to its online news archive at amednews.com.
The online news archive dates back to January 2000, with selected earlier content. It represents a rich resource on issues confronting physicians and trends in medicine. Content includes in-depth reporting on the business and regulatory sides of health care, practice management and hot issues in public health and patient care.
“The American Medical Association hopes the accessible online news archive, and digital conveniences offered by American Medical News, will better help readers stay on top of the trends and forces shaping a complex, ever-changing medical environment, said AMA President Cecil B. Wilson, M.D.