The AAFP’s Bold Valuation Initiative

Brian Klepper

This morning, the American Academy of Family Physicians, the largest and “purest” of the major primary care societies – the American College of Physicians (ACP), the American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA) are all heavily influenced by sub-specialists – announced that it has convened a national task force charged with identifying new, better approaches to value primary care services.

This initiative is nationally significant for several reasons. By definition, it challenges the methodology used for nearly two decades by the American Medical Association’s Relative Value Scale Update Committee (AMA RUC), which has drastically under-valued primary care services while over-valuing many specialty services. By taking on this effort, it not only announces that the fruits of the AMA RUC’s labors are unacceptable, but also points out that the methodology the RUC uses to value medical services – this is founded on the Resource-Based Relative Value Scale (RBRVS) “input” taxonomy developed by William Hsaio’s team in the late 1980s – is incomplete and outdated. For example, the RUC’s methodology for calculating value doesn’t consider whether a service produced a worthwhile benefit to the patient or society, whether it was evidence-based or even necessary. More on this in a future article.

Next, the task force is not limited to AAFP members, but includes a wide range of professionals drawn from other primary care medical societies, business, the health plan sector, policy groups and subject matter experts. See the bios here. (I’ve been asked to participate, and will be honored to do so.) In other words, unlike the RUC, this group is more representative of the sectors whose interests it will focus on.

Finally, a representative from CMS, Edith Hambrick MD, will participate as an observer. Dr. Hambrick has been one of CMS’ liaisons with the RUC for many years. But her presence at the task forcle will convey a gravity, along with the impression that CMS is taking this effort seriously.

It is worth noting that the AAFP is still an active participant in the RUC, but has been reassessing their role since January, when David Kibbe MD – David is a family physician, a Senior Advisor to AAFP and my writing partner for several years -and I first called on all primary care societies to quit. About 5 weeks ago, they issued a letter to the RUC containing a series of demands:

• 4 more primary care seats.
• A permanent seat for gerontology.
• Sunsetting of the RUC’s rotating sub-specialty seats.
• New seats for non-physicians, like economists, purchasers and consumers.

These are all reasonable, well-considered requests, especially for a body that has had the most influence over medical services valuation for the past 20 years, and whose recommendations are core to the public interest. Still, acquiescing would be a big leap for the RUC’s leadership. The real question here is whether the AAFP Board will have the will to walk if the RUC rejects their entreaties.

In the meantime, given the influence that reimbursement policy has over the ways medicine is practiced and services are delivered, AAFP’s valuation task force has the potential to be exceedingly and positively disruptive to the current paradigm.