Out of the RUC - the American College of Physicians Initiates an Open Discussion

We and the other bloggers have been trying to provoke an open discussion of the secretive, unrepresentative, unaccountable process which the US Center for Medicare and Medicaid Services (CMS) uses to fix payments to physicians. That process may largely be responsible for the implosion of primary care in this country, and substantially responsible for how we manage to pay so much for health care, yet have worsening problems with access and quality.

See our previous discussions of the process, and the central role of the RBRVS Update Committee (RUC), most recently here, and in earlier posts (here, here, here, here, and here) and important articles by Bodenheimer et al,(1) and Goodson.(2)

The ACP Advocate blog, the apparently official voice of the American College of Physician on its advocacy efforts, took up the issue in this post authored by Robert B Doherty, ACP Senior Vice President for Governmental Affairs and Policy.

Doherty summarized some of the points made on Health Care Renewal and on DB's Medical Rants. He appeared not unsympathetic to some of the criticisms of the RUC and the process that Medicare uses to fix physician payments.

I will summarize some of the points he made in his responses below, and interpolate my replies. I have also submitted the same material as a comment to his post.

- The RUC just provides advice.

The RUC provides [just] recommendations to the Centers for Medicare and Medicaid Services (CMS) on the physician work relative value units (RVUs) under the resource-based relative value scale.

++ My comments: The RUC may say that all it provides is advice, but that advice is almost always uncritically accepted by CMS. Per the also excellent article by Goodson(2), the AMA itself claims that CMS follows more than 90% of the RUC's "recommendations." ++

- The RUC did propose some increases to payments to primary care physicians. (Regarding this point, he quoted from a letter written by the Chair of the RUC:

The RUC recommended significant increases to E&M (evaluation and management) services, which were implemented by the CMS on 1 January 2007. These permanent increases result in an additional $4.5 billion in E&M services payments each year! To imply that they are small and insignificant is preposterous. Family physicians may see their overall Medicare payment increase by 5% or more.

++ My comments: The RUC did very belatedly recommend some increases in evaluation and management codes, but these hardly made up for its years of neglect of primary care (to use polite terms), and this increase, as Dr Larson pointed out, benefited all physicians, not just primary care, or cognitive specialties, to the extent it was not nullified by across the board cuts necessitated by the SGR. ++

- The RUC is helping promote the concept of the medical home.

The RUC deserves credit for the evaluation and management increases, and more recently, for estimating the physician work involved in care coordination for the Medicare medical home demonstration project.

++ My comments: How well the RUC did in the case of the proposed medical home is unclear. See this post and its links to a serious critique of this work. ++

- The RUC ought to be reformed, but not abolished.

But the RUC does need to look at its own composition and processes. It needs to be more representative of primary care and more transparent in its deliberations. The new Obama administration and Congress would be well-advised to insist that the processes Medicare uses to determine the values of physician services be as transparent as possible, and include sufficient and appropriate representation and expertise from primary care. They should also require a better process for identifying overvalued services.

But making the RUC the main villain in a system created and run by the government misses the mark. We have to remember that it is Congress and CMS, not the RUC, who makes the rules. As long as the Medicare payment system pays based on volume instead of rewarding prevention and care coordination, primary care physicians' incomes will lag behind specialties that can generate more volume, because primary care doctors can only increase volume by cramming more patients into an already over-scheduled day. This would be true even if the RUC were reconstituted to include more primary care doctors.

And, we need to ask if the RUC were to disappear, who should recommend the work involved in physician services? Economists and physicians hired by the federal government?

++ My comments: I surely agree that the RUC ought to be more representative of primary care and more transparent. As noted in Dr Goodson's article, primary care has had a very small representation on the RUC. There is not a single designated seat for general internal medicine, but orthopedics effectively has two (one for orthopedics, one for spine surgery, which has a separate society).

Note further that many of the specialty societies that support RUC members are supported heavily by industry, that is, by pharmaceutical, biotechnology, and device companies. Such corporations benefit from irrational exuberance about procedures, since they sell the drugs, devices and supplies that are used in procedures. See posts here and here, for example, on some of the industry sponsorship of the AAOS, which sponsors an "orthopedic" seat on the RUC.
Such institutional conflicts of interest affecting the RUC have never been publicly
discussed.

The transparency issue is not trivial. The identities of the people who sit on the RUC have been SECRET. A few members have admitted publicly that they are, but the AMA - I'll say it again - keeps the membership roster of the the RUC secret. One wonders what they have to hide. Not only is the membership secret, of course, but the group's deliberations are also secret.

It is the privilege of the AMA, a private group, to keep the membership of the RUC secret. But I would note, that secret is also kept from the general AMA membership, who are presumably paying their dues to support this secret committee.

On the other hand, since the RUC functions as a de facto government agency (note again that CMS seemingly gets input from no other source for its revisions of RBRVS), having such important government decisions, which have nothing to do with national security, made in secret is offensive.

It is true that Congress and CMS made the rules that allowed all this to happen. There are very big questions about why CMS pursued this course. Maybe some investigative reporter, some congressional agency, or in a new administration, CMS itself will investigate how this happened.

But the AMA did not have to go along with it. They could have insisted on an open,
transparent, representative, accountable process, and refused to participate were that not allowed. Instead, they at least went along with a fee setting process that is opaque, unrepresentative, unaccountable, and not obviously subject to any ethical standards.

The RUC should disappear. Medicare should develop an open, transparent, representative, accountable process to negotiate what it pays physicians. The names of the people involved should be public. The people involved should be free of obvious personal conflicts of interest, and should not be sponsored by organizations with obvious institutional conflicts of interest.++

At any event, I salute Mr Doherty for getting this important policy issue more into the light. The RUC seems to be one of those things that it was not considered polite, or politically correct, to talk about, much less criticize. Maybe an open dialog will lead to some measurable reform of a physician payment system that badly needs it.

References
1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. Link here.
2. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. Link here.

Post Title → Out of the RUC - the American College of Physicians Initiates an Open Discussion

On ACP's Endorsement Of "Single Payer", And A Call For An End To Irrational Exuberance over EMR's

A letter to the Philadelphia Inquirer that likely will never make it into print due to its iconoclastic, "reality that nobody wants to hear" content. Also cc'd to the leaders of the American College of Physicians, on the ACP's endorsement of "single payer" and the oft-stated panacea of the EMR as the tool "to reduce medical administrative costs."

I believe it's time to put the brakes on the "irrational exuberance" that characterizes today's EMR efforts. Healthcare IT is a field that unless brought back to sanity will transfer countless dollars to the IT sector that healthcare and patients cannot afford, and will develop tools that make patient care even more unbearable for clinicians than it is today through inept design and inept or disingenuous "performance metrics." For much more on these issues, see my web site "Common Examples of Healthcare IT Failures" at this link.

In fact, EMR's are still an experimental technology and should be thought of as such. They were invented by researchers and experimenters in medical informatics and were slowly and deliberately being perfected, until massive reductions in costs of computing hardware and increases in speed and ubiquity gave many in the IT, government and payer sectors (via a leap of logic of supernova proportions) the technologically deterministic idea that every aspect of medicine could and should be easily automated. And that it would be hysterically profitable to do so: profitable for everyone except, of course, practitioners and patients.

To: sburling@phillynews.com
From: MedInformaticsMD
Date: 12/04/2007 01:29PM
Subject: Re: American College of Physicians endorse single-payer

Re: American College of Physicians endorse single-payer (Phila. Inquirer, Dec. 4, 2007, http://www.philly.com/philly/business/12109247.html)

Dear Ms. Burling,

While one can argue the merits and demerits of creeping socialism, and while I find it ironic that the ACP endorsed "single payer medicine" at the same time that the people of Venezuela rejected socialism, there is one item in your story reflecting another "irrational exuberance" that should not be taken at face value.

That item is the oft-repeated statement that electronic medical records work miracles, in this case that the "greater use of electronic medical records (EMR) reduces medical administrative costs."

In fact, I increasingly believe the opposite is true, even when the electronic medical record project is successful, which most are not.

The majority of information systems developments in most sectors are unsuccessful, and the larger and more complex, the harder they fall ("Pessimism, Computer Failure, and Information Systems Development in the Public Sector." Public Administration Review 67;5:917-929, Sept/Oct. 2007). Healthcare is no exception.

A number of organizations have spent billions on EMR systems, such as Kaiser Permanente, have had massive delays and cost overruns, and are still years away from anything resembling "reduction of administrative costs." See my post at http://hcrenewal.blogspot.com/2006/11/kaiser-healthcare-it-meltdown.html.

Electronic medical records require a huge investment and significant "upkeep.' This "cost of ownership" puts a big doubt upon EMR projects as a cost-reducing endeavor. Rather, EMR's should better be thought of as a cost center.

An EMR for small-group and solo-practice physicians costs $44,000 per physician, and generates an average ongoing $8,500 per year in annual costs, the past ACP president herself, Lynne Kirk, MD told the house Subcommittee on Regulations, Healthcare and Trade of the House Committee on Small Business in October 2007. "The business case does not exist to make this kind of capital investment," Kirk told the Subcommittee.

In fact the use of EMR's will not significantly reduce overall health care costs, the director of the Congressional Budget Office said at the release of the agency's 2007 report on long-term health care spending. Peter Orszag , CBO's director, said that according to data from the report, the return on investment for EMRs "is not going to be as substantial as people think."

My own university's faculty practice plan at Drexel attempted to implement electronic medical records. Due to failure of the billing component, the exact component that was supposed to help "reduce administrative costs" but instead raised it by a few million dollars to manually correct the errors, the result was a multimillion dollar lawsuit (link to online court records here) by Drexel against the EHR vendor AllScripts and Allscript's partner Medicomp System s , a "corporation specializing in the development of point-of-care tools for Electronic Medical Records ... to help overcome physician resistance to adoption. " Temple University Health System delayed electronic medical records rollout due in part to unaffordability and a likely, justified fear of costly problems, which came to my attention due to the decision's delaying the doctoral thesis work of a graduate student here.

I also believe the EMR is rapidly becoming a tool for payors to minimize their costs and maximize their profits, while inconveniencing physicians trying to take care of patients under increasingly pressured timelines due to poor design. EMR's are largely designed under processes led by technologists, not clinicians.

Finally, with regard to effectiveness of EMR's in actually improving healthcare quality, even that is doubtful. A research article in the Archives of Internal Medicine entitled “Electronic Health Record Use and the Quality of Ambulatory Care in the United States” (Arch Intern Med. 2007;167:1400-1405, link to abstract here ) reached what to many was a counterintuitive conclusion. The authors, EMR experts, examined EMR use throughout the U.S. and the association of EMR use with 17 basic quality indicators. They concluded that “ as implemented, EMR’s were not associated with better quality ambulatory care ,” and were bold enough to publish their findings, sure to be unpopular in the health IT industry.

It appears the clinical case may not exist, either, for EMR's as they are designed and implemented today.

These issues are international in scope. Richard Granger, former head of the UK's “Connecting for Health” national EMR program, had this to say about a program described by some UK members of Parliament as “the largest government IT debacle ever” (see here for more):

"Sometimes we put in stuff that I'm just ashamed of ... Some of the stuff that [our large American clinical IT vendor] has put in recently is appalling ... [vendor] and [prime contractor] had not listened to end users ... Failed marriages and co-dependency with subcontractors ... A string of problems ranging from missing appointment records, to inability to report on wait times ... Almost a dozen cancelled go-live dates ... Stupid or evil people ... Stockholm syndrome -identifying with suppliers' interests rather than your own ... A little coterie of people out there who are "alleged experts" who were dismissed for reasons of non-performance."

So, next time you hear that single payor systems enhanced by EMR's to "reduce administrative costs" are a panacea, think of Hugo Chavez' wondrous plans for a socialist utopia as President for Life of Venezuela.

You can read much more and see examples of EMR failure and mishaps at my web site "Common Examples of Healthcare IT Difficulties" at http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm

-- SS

Addendum: an editorial from a health IT publication whose editor understands reality, FierceHealthIT - Weekly News for Health IT Leaders:

The EMR rollout dilemma: The necessary evil
December 3, 2007

When it comes to EMRs, big healthcare organizations have a big, nasty problem on their hands. The problem? While they pretty much have to invest in an EMR system to stay competitive, by most IT industry standards this is a lousy time to jump in and do it. At the same time, however, they seem determined to move ahead.

Compared with other types of enterprise IT spending, EMR investments are a major crapshoot at this point, given the lack of support from some clinical staffers and the questions still floating around as to what features they should have. But in this case, providers are facing huge pressure from the federal government, some payers and hanks to ongoing PR efforts, even consumers to bring up an EMR system.

Sure, if they're going to spend the money, now's probably the time, rather than waiting five or ten years for the EMR product category to mature [I actually disagree with that - ed.] After all, organizations the size of Kaiser Permanente and Sutter Health--both rolling out the Epic EMR--will spend years integrating such systems into their already formidable infrastructure. So they have to begin getting their hands dirty with the technology now.

But there's still something odd [I would say "monstrously odd" - ed.] in how many formidable organizations are choosing to invest in a product whose feature set is still in question and whose popularity among key users is in doubt. In most industries, billion-dollar enterprises don't get pressured into buying a product this early in its lifecycle and cramming it into their operation. (The closest I can think of is the wave of ERP platform adoptions over the past decade or so--another very expensive boondoggle which only seems to be creating real value after years of heartache and expense.)

If nothing else, let's admit that the talk about avoidance of medical errors and efficiency improvements is a bit of a smokescreen--because if Kaiser was spending a few billion for that, it'd certainly be losing its shirt for quite some time into the future. While quality is a factor, I'd argue that most execs want to see EMRs in place so they can gather data needed for pay-for-performance incentives and shunt quality and outcomes stats to regulators.

As I see it, if health system leaders, health plans and government officials want EMRs in place so badly, they might want to start by being honest about their motives. Once they do that, they might get clinicians to see EMRs as more than just a necessary evil. - Anne

To which all I can add is "indeed."

-- SS

Post Title → On ACP's Endorsement Of "Single Payer", And A Call For An End To Irrational Exuberance over EMR's

The AAFP Opens the Door for No Free Lunch

An email press release by the organization No Free Lunch today reveals that the American Academy of Family Physicians (AAFP) has reversed its previous decision (see post here), and will now allow No Free Lunch to have a booth in the exhibition hall during the AAFP annual meeting in San Francisco.
The email stated,

Following an outcry from among its members, the American Academy of Family Physicians has reversed its earlier decision to deny a booth to No Free Lunch and has invited the organization to exhibit at its meeting next week in San Francisco.
In August, The AAFP rejected No Free Lunch’s application to exhibit at its annual meeting—which will be attended by some 5,000 family physicians and slightly fewer exhibitors—stating that No Free Lunch’s position was “not within the character and purpose of the Scientific Assembly.” This despite the fact that the Coca-Cola Company, The McDonald’s Corporation, and The Distilled Spirits Council of the U.S. were all allotted space in the hall, as were countless pharmaceutical companies.
Many members were upset and even outraged that a society which they had supported for many years, and which gives industry almost unlimited access to physicians at its meetings, would not allow a small organization of health professionals to voice an opposing view. Allen Pelletier, for example, a family physician from Memphis, Tennessee, a long time AAFP member and newly elected fellow of the Academy, in an e-mail to AAFP CEO Dr. Douglas Henley, wrote “To my embarrassment, the organization that represents me as a practitioner and teacher of family medicine has shut down the possibility of open (and yes, critical) dialogue about how our practices are influenced by the pharmaceutical industry.” A family physician and AAFP member for 25 years from East Lansing, Michigan, wrote “. . . if an organization like No Free Lunch, well known for the role that it has played in encouraging awareness among physicians of the negative impact of pharmaceutical marketing, is denied the opportunity to set up a booth at the meeting, while commercial sponsors are encouraged to pay extra for more access to members and attendees, then the professional values of our specialty society have truly reached a new low.”

Good for AAFP for reversing course here. The issue, as the above AAFP members' emails made clear, was not whether AAFP should adopt No Free Luncrecommendationsomendations. The issue was a free speech issue, whether AAFP was willing to give No Free Lunch the opportunity to speak out about recommendationsomendations, even if their mode of expression is not as gentile as the AAFP might prefer, and everecommendationsomendations may upset some people. The AAFP already allows commercial interests to speak out about their wares. Their mode of expression may be polished, but is backed by plenty of money and marketing muscle.
Finally, the reasons the American College of Physicians (ACP) banned No Free Lunch from their last meeting remain murky. The public documentation about this decision only includes press releases by No Free Lunch and the ACP, and an article in the Wall Street Journal (available here). The ACP contended that No Free Lunch "caused trouble at its 2001 meeting, even sneaking in an undercover TV crew. Dr. Goodman [the leader of No Free Lunch] says that even if there were some problems, which he isn't sure is[sic] the case, that they weren't orchestrated by the organization" (per the Wall Street Journal). Again, in my humble opinion, an organization with an ethical and academic mission (like the ACP) ought to bend over backwards to ensure free expression and open communication , especially when one side of the argument is made by large, rich, and powerful organizations like big pharma corporations.

Post Title → The AAFP Opens the Door for No Free Lunch

The Primary Care Squeeze: Who Will Be Part of the Solution?

In stark contrast to stories of ever more expensive drugs for ever more expansively defined ills, government research leaders getting six figure consulting fees, and multi-million dollar CEOs, ... primary care is in progressively worsening crisis.
Last week the American Medical News reported that family medicine has seen its eighth consecutive yearly decline in the number of US medical students matching to its residency positions. Since 1997, the number of US students going into family medicine training has dropped from 2340 to 1117, more than a 50% decrease. Fewer US students have matched in all primary care fields over the last 5 years.
This data still seems to puzzle the leadership of major US medical organizations. For example, the article quoted Steven F. Weinberger, Senior Vice President of the Medical Knowledge and Education Division of the American College of Physicians, "There's a concern that being the physician responsible for the ultimate care of the patient means life becomes a little more unpredictable in terms of hours. But there are wonderful ways to build models of practice to counter that." Furthermore, he said "another important issue is giving students the sense of the long-term gratification of the longitudinal care of patients." This is similar to previous comments made by him, and by leaders of the American Association of Medical Colleges (AAMC) and the American Academy of Family Practice (AAFP), (see this post) suggesting that the main reason that students were not going into primary care is that they hadn't learned about all its positive aspects.
I certainly agree that there are intellectual and emotional benefits to primary care practice. Maybe we aren't adequately teaching students about them. But it seems as if some of the folks leading large organizations like the ACP don't understand just how grueling primary care has become.
One way to understand its challenges is simply to page through some of the stories on Health Care Renewal.
On the other hand, see two articles from the Miami Herald last week. The first, "Primary Care MDs Under Pressure," described anecdotes of primary care doctors leaving practice "because they couldn't overcome the squeeze between low fees from insurers and soaring costs, or they refused to survive by cutting their time with patients." Ted Fisher, of the Florida Academy of Family Physicians, said as a result, "we see a big shortage coming in Florida...." The article included figures that primary care reimbursement has gone up 4.4% annually, while primary care overhead costs have gone up 7.7% annually. Discussions with physicians here in Rhode Island and southeastern Massachusetts suggest that we are being squeezed just as hard.
Why this story hasn't reached the leadership of the ACP, the AAMC, and the AAFP is not clear.
Robert Forster, Vice President, Health Care Services, and Medical Director of Blue Cross Blue Shield of Florida, was quoted as acknowledging that reimbursement to primary care physicians has not kept up with inflation, much less their rising costs. However, in the second article ("Primary Care is Often Undervalued"), he blamed it on society: "The importance of the primary care doctor doesn't have societal backing. The problem is that it's hard to measure the value of talking to a patient." Furthermore, "since the 1950s, American medicine has emphasized specialties and procedures over primary care. It's going to take some major changes in our society and our thinking to turn that around." Of course, "society" may be enchanted by the marvels of high-technology, sub-specialized care. However, in 2004, Blue Cross Blue Shield of Florida announced it has 28% of the Florida market, more than twice the share of any competitor. Why its Vice President, Health Care Services and Medical Director denies any personal or organizational responsibility for inadequate reimbursement for primary care is not clear either.
In summary, primary care is under seige by progressively rising costs and lower reimbursement. Since this seems to be public knowledge, it shouldn't be surprising that medical students are increasingly going into other fields. What is surprising, and troubling, is that leaders of major medical organizations either fail to recognize how hard it is to practice primary care, or recognize it, but fail to acknowledge any responsibility to do anything about the problem.
By avoiding any responsibility for the solution, such leaders become part of the problem.

Post Title → The Primary Care Squeeze: Who Will Be Part of the Solution?

Big Medical Organizations Still Don't Understand Why Medical Students Don't Choose Primary Care

In Internal Medicine News Online is this gem of an article about how our fearless leaders are trying to attract more students into primary care fields. According to Michael Whitcomb MD, Senior Vice President of Medical Education for the American Association of Medical Colleges (AAMC), and Steven Weinberger MD, Senior Vice President for Medical Knowledge and Education at the American College of Physicians (ACP), and someone anonymous from the American Academy of Family Practice (AAFP), the reasons students don't go into primary care include:

• "the way students see primary care"
• students don't see "the proper management of chronic care patients"
• "students often don't recognize the gratification of building relationships over many years"
• students don't have "access to competent role models in family medicine"

Some still-dedicated medical school faculty who toil with ever less support from medical schools (even as tuition rises much faster than inflation) might feel insulted by the leaders of the AAMC, ACP, and AAFP who think they aren't demonstrating "proper management of chronic care patients," and aren't "competent role models."
For a good response see KevinMD:
" Graduates today finish with more debt and higher practice costs than at any time in the history of U.S. medicine, while facing a resource-constraining reimbursement system that has been racheting down physicians' incomes for many years now. Let the researchers puzzle over this: why would anyone want to go into a field where every indication is that the annoying stressors become ever more burdensome while the costs of operating a practice rise relentlessly and reimbursement is nearly flat. "
As Medical Rants put it:
"Understanding student decision making is not rocket science. Kevin does primary care - and he understands what our leaders apparently do not understand. "

Well, actually, Dr Weinberger of the ACP also said that "repairing the payment system, reducing administrative hassles, articulating the value of internal medicine, and redesigning training to better meet the scope of practice" are also important.

But it still seems like the leaders of the organizations that are supposed to support primary care don't understand the pressures on primary care physicians. The rising tide of paperwork and bureaucracy are far more than "hassles." The AAMC, ACP, and the AAFP should fight to support physicians' core values, not merely "articulate" the value of primary care and market it as "attractive"

The relatively small Society of General Internal Medicine recognized that primary care physicians face "chaos," not just "hassles." (Its annual meeting this year has the explicit theme of "Out of Chaos.") But the bigger, powerful, better funded AAMC, ACP, and AAFP still don't get it.

Post Title → Big Medical Organizations Still Don't Understand Why Medical Students Don't Choose Primary Care