Facing Uncertainty: Why Primary Care Physicians Must Act Now

Brian Klepper

Over the past four months, the germ of a long overdue primary care uprising has sprouted and begun to flower. When David Kibbe and I first tried to think through how to neutralize the RUC’s terrible influence on American health care, we realized the first steps had to be the primary care community’s refusal to continue “enabling” the RUC – we meant this very much in the clinical sense – through its continued participation and complicity. When the game is rigged against you, there is no benefit in staying at the table.

Primary care societies would visibly and noisily abandon the RUC, with the understanding that quietly walking away would be counterproductive in the extreme. It should be a highly publicized exit, filled with righteous indignation and clarifying for the American public how the RUC’s actions and relationship with CMS have shafted patients, primary care physicians, and the people who pay for health care in America.

This won’t go unchallenged, because virtually everyone else in health care has financially benefited from a system that has stifled primary care’s moderating influence on unnecessary services throughout the continuum while incentivizing more intense interventions. Employers, who foot the bill for half of US health care and its extravagances, are the natural allies here, but as the health care reform process made clear, galvanizing and mobilizing them can be difficult.

Several weeks ago, the New Jersey Academy of Family Physicians took a bold step by being the first state chapter of family physicians to “strongly encourage” its parent, the American Academy of Family Physicians (AAFP), to quit the RUC. Around the country, other state chapters are chewing on whether to follow suit, though so far none have done so.

This matters. In two weeks, the AAFP Board will meet to consider whether to sever its relationship with the RUC. It is a big decision so, presumably, the Board members have their ears to the ground. Hearing little or nothing from the trenches could easily be interpreted as non-support for a monumental step.

It is important to face the uncertainty here. After all, what happens if the AAFP votes to leave and nobody notices? Will they have a place at the table that seeks to replace the current valuation mechanism? What if that replacement approach is worse than the RUC?

These are fair questions. In the real world, the devils you don’t know CAN be worse than the ones you do. It’s fine for people like me to advocate overthrowing the RUC, but in the end, practicing primary care docs will have to live with the results of this action.

At this point, though – to my knowledge, at least – no clear alternative path has been defined if the RUC’s relationship with CMS is destabilized. But several possible reasonable paths have been suggested. For example:

• In his December article about the RUC in the New York Times Economix blog, Princeton health economist Uwe Reinhardt suggested that any medical services valuation panel should include a broader array of health care constituents and experts, like patients, health economists, purchasers and health plan administrators. Dr. Reinhardt’s approach seems obvious, unless of course you’re trying to control the process for a very specific special interest agenda. The RUC Chair, the AMA CEO and 47 medical specialty societies made clear they are intent on doing this in their letters a couple weeks ago to Congress and the health care community.
• Rep. Jim McDermott (D-WA) recently proposed legislation (HR 1256) that would require CMS to hire experts to independently review and evaluate the RUC’s recommendations. This approach seems sensible as well, as a check on the RUC that would hold it to a higher standard and make it far more transparent and accountable.
• Bob Berenson, MD, Senior Fellow at the Urban Institute, a highly respected and thoughtful health care analyst, former Deputy Secretary of the Health Care Finance Administration (HCFA, CMS’ pre-Bush era name), and now Vice Chair of the Medicare Payment Advisory Commission (MedPAC), argues that Congress should fund direct surveys of medical practices and hospitals to determine the resources required for each medical procedure. This would simply bypass the RUC, making it irrelevant.

There are undoubtedly other reasonable approaches as well. But there is one thing that the primary care community can be certain about. If the health care industry or any sectors in it sense the slightest threat to their current revenue streams, they will mobilize their powerful and well-financed DC lobbying machines to protect their interests. That effort could find expression in any of many different forms that are impossible to anticipate.

Still, this outcome is not a foregone conclusion. Because it occupies the front end of care delivery, primary care is the most strategically positioned of all medical specialties. In the past, primary care physicians have not exercised or leveraged their strengths – e.g., ownership of the referral base, the ability to restrict access to obtain financial concessions, or the deep, abiding relationships that most of us – and (because we have coverage) certainly most of us in the middle and upper income classes – have with OUR primary care doctors. If push came to shove, using those kind of assets should certainly be an option. Primary care, American health care and America’s economic prosperity are at stake, after all.

And then there’s the message that would be sent if AAFP actually pulled the trigger and walked away from the RUC with some fanfare. This is an organization representing more than 10 percent of America’s doctors and probably one-quarter of the nation’s annual office visits. Could CMS NOT take heed and invite them to the table? Not likely.

The remarkable upwelling of primary care indignation in the past few weeks has the potential to begin to remake American health care in a way that the tortured, purchased and highly political health care reform process could never do. At least in part, that possibility has emerged because there’s finally been a demand that we stop listening to the contorted defenses of an obviously flawed process, and start looking at what that process has brought us:

• A medical system in which half or more of all expenditures provide zero value, and in which the excesses currently cost us something on the order of $1.4 trillion a year, nearly the equivalent of this year’s national debt.
• A primary care workforce shortage approaching critical status, simply because the income disparity between generalists and proceduralists is too great for medical students to ignore. This translates into reduced management of care appropriateness downstream.
• Compromised quality, as patients are routed to unnecessary and unnecessarily intensive diagnostics and treatments, often for little reason other than money.

Former JAMA and Medscape Editor George Lundberg MD, an icon of America medicine, recently observed to me that, “The whole pitch about the national RESULTS/OUTCOMES of the RUC approach is the final nail…” THIS is the point.

After 20 years of being slowly strangled by the RUC’s relationship with CMS, primary care physicians have an opportunity to stand up and stand together by simply urging their societies to not participate in it anymore. If you are a family doc and you agree, please do three simple things:

• Call your state chapter’s Board and Executive Director and DEMAND that they send a letter in the next week to the AAFP Board, strongly encouraging them to quit the RUC.
• Go here and sign the petition. The AAFP Board wants to know whether there is grassroots support for their action.
• Send this article to your colleagues, so the campaign becomes viral in a way that can benefit the larger effort.

Now is the time to strike. And then we can get the real process started.

Brian Klepper is a health care analyst based in Atlantic Beach, FL.