by ROY POSES, MD

(Note by Brian Klepper: At Health Care Renewal, Dr. Roy Poses, a Clinical Associate Professor at Brown University’s School of Medicine, writes a consistently excellent blog on health care financial conflict . Both he and I have written extensively – a link to his most recent column is provided below; mine is here – about the obscene sole source advisory relationship that CMS maintains with the conflicted, lopsided and secretive AMA’s RVS Update Committee (or RUC).

Essentially, the facts are that the RUC, a proprietary committee within the AMA overwhelmingly dominated by specialists, has been the only advisor to CMS on physician reimbursement for many years. It has consistently urged CMS to increase specialty reimbursement at the expense of primary care.

The result has been to drive medical students into specialties. Over the last five years, the percent of medical school graduates going into Family Practice has dropped from 14 percent to 8 percent. Only 25 percent of Internal Medicine residents now go into office-based practice; the rest become hospitalists or subspecialists.

Here is Dr. Poses’ most recent post, reprinted from Health Care Renewal, this time on a recent report from the RUC that makes recommendations for paying physicians under the Medicare’s Patient-Centered Medical Home pilot. As you might suspect, this does little to change the current corrosive paradigm.)

We have posted a number of times, (most recently here, and see links to earlier posts) about the RBRVS Update Committee’s (RUC) responsibility for Medicare’s relatively poor reimbursement of primary care and other “cognitive” physicians’ services compared to procedures. This imbalance has rippled through all of US health care, affecting how private insurers and managed care organizations reimburse physicians, and generally how the US systems favors procedures over talking, examining, thinking, diagnosing, prognosticating, deciding, and prescribing and super-specialization over generalism and primary care.

The RUC ostensibly is just an advocacy group sponsored by the American Medical Association, yet it seems to be the only source of outside input about physicians’ reimbursement used by the US Center for Medicare and Medicaid Services (CMS). Given this influence, it is dismaying that it is secretive, unrepresentative, and unaccountable. Neither its membership nor proceedings are public. It is dominated by proceduralists and sub-specialists. It is unaccountable to US physicians, much less the general public.

CMS in its wisdom also put the RUC in charge of figuring out how physicians’ practices participating in trials of the patient-centered medical home (PCMH) would be paid. The PCMH has gotten a lot of buzz lately. It purports to be the modern way to characterize a well-functioning primary care practice. Various powers that be that now want to support primary care seem only interested in supporting such care that fits the PCMH model. Yet putting the RUC, which seems to be the single most important cause of the decline of primary care, in charge of payment for this new version of primary care, appears to be a great case of putting the fox in charge of the hen-house. On the Retired Doc’s Thoughts blog, Dr James Gaulte first pointed this out.

The RUC just released its report on how physicians providing medical homes ought to be paid. Now, on the Happy Hospitalist blog, this post dissected how the RUC came up with its recommendations, in all their mind-numbing detail. That blog summarized the results as “punching primary care in the face,” and furthermore,

The payment rates that are recommended are insulting and downright degrading. Do they think nobody is paying attention? These people have no business trying to create public policy.

Unless I’m completely off base in my interpretation, if I was an outpatient doc, I would run faster than Forest Gump from this proposed financial disaster.

This is a reminder of what can go wrong with a “single-payer health care system,” which is what Medicare is. When the government sets what physicians are paid, which is what happens in Medicare, (and de facto happens for our entire health care system, as private insurance companies and managed care organizations seem to slavishly follow the CMS’ lead as engineered by the RUC), the government ought to provide a rational, transparent, accountable method of doing so. The current RUC based system is the opposite, irrational, opaque, and unaccountable. If we don’t fix it, we can kiss primary care goodbye, with all the negative consequences that would entail. And further woe unto us if the calls for health care reform lead to “Medicare for all,” with the RUC based system intact.

Roy Poses can be contacted at Ro*******@***wn.edu.