Paul M. Fischer
First published on 6/15/11 on MedPage Today
A few weeks ago, the Board of the American Academy of Family Physicians (AAFP) announced that, for now, it would continue participating in the Relative Value Scale Update Committee (RUC), the secretive American Medical Association committee that, through a longstanding relationship with the Centers for Medicare and Medicaid Services (CMS), has heavily influenced physician reimbursement.
At nearly the same time, Medicare announced that it will go broke in 2024, a decade sooner than expected and only 13 years away.
During the 20 year reign of the RUC, the average excess in lifetime earnings of specialists compared with primary care physicians has increased from $1.5 million to $3.5 million. Yet, the need for primary care has never been greater or its future foggier.
The organizations that should promote primary care must take some of the blame.
The AMA views itself as the champion for all physicians, but its activities have been central to the trouble in primary care. Its CPT (Current Procedural Terminology) editorial panel authors the language of medical business and has effectively detailed every procedure that physicians can get paid for.
The 400-page CPT book brilliantly articulates the subtle differences in the work of physician proceduralists. By contrast, the few pages devoted to all primary care have resulted in such obtuse and inadequate concepts as a 99214. There are no codes for the numerous coordination of care activities done in primary care, such as completing insurance drug prior approval forms. And no code, no payment.
The AMA is also responsible for the specialist-dominated RUC, which has consistently overvalued procedures while undervaluing primary care and which needs to be replaced.
Over time, the resulting financial incentives have led to a decimation of the primary care workforce and a wide spectrum of overutilized procedures.
Some consider the American College of Physicians (ACP) a primary care organization, but this is more a historical footnote than a present day fact. Only 2% of internal medicine residency graduates now plan to enter primary care. ACP’s large specialty base and smaller primary care membership make it conflicted.
Finally, there is the American Academy of Pediatrics (AAP). While residency graduates continue to have a strong interest in primary care pediatrics, like ACP, many of AAP’s members are sub-specialists rather than general pediatricians.
There was a time when the AMA ideal of a big tent for all physicians was possible, but American medicine’s evolution has made that untenable.
If Medicare cost-cutting uses blunt instruments, as it has in the past, primary care services must be separated from other procedures. A 10% across-the-board physician pay cut might affect a radiologist’s lifestyle, but it would force many primary care practices to close.
Since none of the organizations that should promote primary care have stepped up to lead, it is time for family physicians, general internists, and general pediatricians to form a new organization: let’s call it the American Primary Care Association.
Generalists have more in common with each other than ever before. We need an organization with bold leaders who are willing to acknowledge that the AMA’s big tent has been pulled down.
Paul M. Fischer, MD is a family physician at the Center for Primary Care in Augusta, GA.