Hitting A Nerve

Brian Klepper

Earlier this week, a comment arrived on a new site I developed to promote ending CMS’ cozy relationship with the RVS Update Committee (RUC). The RUC is the AMA’s specialist-dominated panel that has distorted the value of health care services, been most responsible for strangling primary care and driven the health care cost explosion.

It was from a  physician responding to the article “Replace the RUC,” which tried to place the rationale and approach for this effort within a larger context. It urged primary care physicians to read up on the RUC’s background, and then demand that their societies publicly abandon it. He said:

Thank you, thank you, thank you.

This is exactly what many of us felt the AAFP should have done 15 years ago. The willingness of the primary care societies to continue to participate in the AMA’s intentional destruction of primary care must be some strange variant of the Stockholm syndrome!

It is difficult to precisely gauge the response so far, because it is just beginning. The site, up for just 10 days, has had over a 1,000 page views, not a big deal, but a firm start as the information travels virally between busy primary care physicians.

What is clear is that many, many primary care physicians harbor deep resentment and anger over their societies’ complicity in their own compromise. They see the problem as foundational to American health care’s near term viability, and they’re also adamant that the way we favor specialists and more expensive approaches compromises patient care and forces cost skyrocketing up. Paul Fischer, MD, the Augusta, GA-based Family Physician, I’m collaborating with on this project, said it to me like this:

“Every day I make critical or life and death decisions about complex patients, and I get paid 60% less per hour than dermatologists, who typically see trivial conditions with little intellectual challenge.”

There are lots of ideas embedded in that comment, but the key one is our health system’s failure to appreciate different forms of complexity and risk.

Then on Tuesday, George Lundberg MD weighed in  with a video commentary on MedPage Today supporting this new challenge to the old payment system as well as the RUC’s and CMS’s role in supporting them. He noted that while primary care physicians are invariably nice guys, the old adage that they “finish last” applies here. Engaging a system that is so stacked against patients purchasers and them, will demand that they unify and mobilize, and be willing to play the same hardball that the specialists play.

In the comment section of Dr. Lundberg’s video, the AMA weighed in with a typically corporate response. [Note that they didn’t even get AAFP’s name right, calling it an Association rather than an Academy!]

The AMA is proud to convene the RUC, an expert panel of volunteer physicians, practicing in various specialties including primary care, who make recommendations on how to value the work and resources involved in patient care. The RUC often recommends increases for primary care services. RUC recommendations have resulted in $4 billion in annual increased payments for office and hospital visits – the most common services performed by a primary care physician. In fact, the American Association of Family Physicians recently touted improvements stemming from the work of the RUC to increase values for primary care services. http://www.aafp.org/online/en/home/publications/news/news-now/practice-management/20101201cptcodesrise.html.

This was followed immediately by a comment from a Howard Parness, MD, who identified himself as a retired internist. He said,

“The AMA is in dreamland! It is sad when they start to believe their own “B.S”. They still did not address the problem in structural design of the RUC that Dr Lundberg pointed out.

The sober truth here is that the emperor has no clothes. All primary care physicians and most specialists – or at least those who’ll face the problem directly – know that the current payment system, jiggered continuously for the last 20 years, is desperately out of balance, with results that threaten the larger economy.

The questions now are whether the sides will mobilize, whether non-health care business will step up to support primary care out of enlightened self-interest, and whether the mechanisms of American policy can be moved to act in the common rather than the special interest.

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