A Primary Care Revolt

Richard Reece MD

First published 4/17/11 on MedInnovation Blog

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 recommended 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.

To make a long story short,  94% of the time, CMS signs off on the RUC’s recommendations. Primary care societies are threatening to withdraw from RUC. Furthermore, a law suit may be brought against CMS for being a party to this arrangement, which may be illegal.

For more on what is going on, you may want to visit www.replacetheRUC.com,   a website formed by Brian Klepper, PhD, a health care analyst and Paul Fischer, MD,  a family physician in Augusta, Georgia.

According to Klepper and Fischer, the RUC ought to be replaced. The first step, they say, to remedy this situation is for primary care medical societies to visibly and loudly withdraw from participating in RUC, thereby de-legitimizing the process.

Towards this end,  they recommend:

  1. Making  the public aware of the RUC’s role and urging the primary care societies to stop “enabling” the RUC through their participation.
  1. Recruiting experts who can credibly calculate economic impacts of RUC’s actions, and who can devise alternative payment methodologies.
  1. Demonstrating the unlawfulness of CMS’ (and HCFA’s) two-decades long reliance on  RUC.
  1. Collaborating between primary care and non-health care businesses who pay for employee health benefits.

Klepper and Fischer believe RUC is primarily responsible for unsustainable health costs and performance of unnecessary high-tech specialty-based procedures. You may want to visit their website to understand their reasoning.

Doctor Fischer says four myths have been used to justify pay differentials between primary and specialty care.

1)       The first myth is: what primary care doctors do is easy, when, in fact , it  requires extensive  knowledge to sort through chronic disease complexities and complicating  emotional and societal factors.

2)      The second myth is that it requires less intensive training than other specialties and mid-level practitioners can replace primary care physicians.

3)      The third myth is that all primary care practitioners do is diagnose colds and prescribe antibiotics for upper respiratory infections and drugs for chronic diseases.

4)      The fourth myth, perpetrated by managed care organizations, is that the sole role of primary care physicians is to serve as gatekeepers, as a revolving door to specialists and hospitalists.

According to Klepper and Fischer, the public and even primary care physicians  know little and appreciate less  the role of RUC, a specialist-dominated panel within the AMA.  Yet RUC is  extremely powerful and opaque. Through its longstanding relationship with CMS, RUC and the AMA  have contributed heavily to exploding health costs over the past 20 years.  RUC is why primary care physicians are paid so poorly compared to specialist colleagues and why few medical students, 8% at last count, now choose primary care as a career.  Correct the RUC, Klepper and Fischer maintain,  and you will rid America of much health system waste and expense  than all the cost control measures in the health care reform law combined.

I do not consider specialist procedures to be such a monumental “waste” to the system.  After all, these procedures are much in demand and can be life. life-style. sight, and mobility changing.  Still,  I can see where the revolution and replacement movement may have legs as a potent antidote to high health costs. I can also foresee where hospitals, specialists, the AMA, and CMS will fight tooth and nail to resist changes to the current system. What primary care doctors are asking for is a fair fight, which seems fair to me.

Dick Reece MD is a retired pathologist. He writes regularly about health care on MedInnovation Blog.

2 thoughts on “A Primary Care Revolt

  1. Why not just have primary care withdrawal totally from the ruc and third party system and deal directly with their patients, without the burdensome overhead.
    Costs would come down, docs would have control of their destiny, and med students would once again flock to the specialty.

    Steven Horvitz, D.O.
    Moorestown, NJ

  2. THis is at the root of American Competitiveness, If we want to be global leaders and have a competitive work force this problem (health care costs) has to be addressed. If anyone of us were on the RUQ we would have been doing the same thing jacking the prices up. IT IS NOT SUSTAINABLE!! and anyone sitting on the board must eventually realize this. My patients continue to feel they get value for their money but they have no idea we rate below the top ten in most measures of health care when compared to other countries and we pay out the b—tt for a shoddy pasted together fragmented sysytem; more than any other country. We need to educate the public and expose the system for what it is. The incentives for doing good work need to be changed. We need to do something because our children wont have a carreer to go into worth much and we as older physicians will be going to Europe and India for our long term care.

    Dr Jay Tomeo
    Augusta, GA

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