Primary Care in Revolt

Brian Klepper

Last Thursday Anna Wilde Mathews of the Wall Street Journal ran an article detailing the activities surrounding primary care’s gradual awakening and mobilization. With Tom McGinty, Ms. Mathews authored a damning expose on the RUC last October that precipitated our efforts on against CMS’ 20 year reliance on the AMA’s RVS Update Committee (RUC) for valuation of medical services.

There is the lawsuit by six Augusta, GA primary care physicians, spearheaded by Paul Fischer MD. (See his most recent article below). The suit claims that CMS’ and HHS’ longstanding primary relationship with the RUC has rendered that panel a “de facto” federal advisory committee. That would make it subject to the management and reporting rules of the Federal Advisory Committee Act  – transparent proceedings, representative composition, scientifically valid methodologies – that attempt to ensure the public over the special interest. The fact that CMS has never required the RUC to adhere to those rules presumably means that the relationship is out of compliance with the law.

The American Academy of Family Physicians (AAFP), after declining to join the suit, issued a series of demands: more primary care seats, a sunsetting of rotating sub-specialty seats, a dedicated gerontology seat, seats for non-physicians like patients, purchasers and economists. The RUC has until March to respond. If they reject the demands, the question is whether the AAFP Board will vote to walk, as David Kibbe and I urged them to do when we began this campaign last January.

The AAFP has also established a new task force that is charged with developing a more modern approach to valuing primary care services. To my mind, this is an important and strategic effort. It seeks to remove financially conflicted specialists from determining the value of colleagues who hold them accountable. But it also is being conducted in precisely the way the RUC is not – its proceedings are transparent and methodologically rigorous, and its composition includes both physicians and non-physicians (including me). It is important to note that CMS and MedPAC are observers at the task force’s table, the first time attention has been paid to a physician payment advisory body other than the RUC.

The RUC’s response to this unwelcome attention has been awkward. First was a coordinated effort extolling the RUC’s value last April that involved a Kaiser Health News commentary by RUC Chair Barbara Levy, and two letters to Congress, one by AMA Executive Director Michael Maves and the other from 47 medical specialty societies. (The 4 major primary care specialty societies were conspicuously absent.) Since that effort, though, Dr. Levy has repeatedly used a prepared response that, at once, tries to appeal to every American while coming off like something delivered by a Stepford wife. Here’s her quote in the WSJ article:

[The RUC is] an independent panel of physicians from all medical specialties, including primary care, who make recommendations to CMS as all citizens have a right to do.”

Actually, there are problems with both parts of this statement. One is that the RUC only has seats for the largest, most powerful medical specialties. Smaller societies don’t participate (and therefore can’t advocate to CMS for their own interests like the others), and those that do get outsize influence relative to their numbers. For example, there is no representation for the Society of Nuclear Medicine, the Society of General Internal Medicine, the American College of Gastroenterology, or the American College of Allergy, Asthma and Immunology.

Then there’s the part about making “recommendations to CMS as all citizens have a right to do.” Folksy but sleight of hand. CMS has had a special, highly organized most-favored relationship with the RUC that has included lavish meetings attended by CMS staff. How far do you think you’d get if you tried advocating for a physician payment approach outside of the RUC? If medical societies that aren’t seated at the RUC can’t get traction, what chance do you think “any citizen” would have?

The really great thing about this problem is that it is easy to understand. Unlike health care reform, which is Byzantine in its complexity and filled with nuance, CMS’ relationship with the RUC is a straightforward example of “regulatory capture.” A few people sitting in a room, secretly in cahoots with a government agency, have steered immensely excessive funds from the richest country on earth to its largest industry. The relationship has ginned up health care cost so that it is now double that of most other developed nations. That largess has come at the expense of patients, who have been exposed to unnecessary procedures and their risks. It has come from purchasers, who have paid huge sums unnecessarily. And it has compromised primary care physicians, who were unwittingly shortchanged, and then neutralized from their classical role of managing the care process.

Ms. Mathews article provided a comprehensive overview of the players and their antagonisms, which has given the issue visibility and, hopefully, traction. There will undoubtedly be more in-depth coverage now, which is sorely needed.

The most difficult truth to convey is that this one mechanism bears significant responsibility for America’s health care cost crisis, and for health care’s threat to the larger national economy. The more important truth is that it is fixable, though that will require the resolve to beat back the web of special interests that have brought us to this point at such great cost.

By broaching it in the national press, Ms. Mathews and her editors made the topic fodder for national mainstream dialogue. That’s exactly what was needed and it was a great service to us all.