Strengthening Primary Care With a New Professional Congress

Brian Klepper

Posted 10/01/12 on Medscape Connect’s Care & Cost Blog

Three months ago a post on this blog argued that America’s primary care associations, societies and membership groups have splintered into narrowly-focused specialties. Individually and together, they have proved unable to resist decades of assault on primary care by other health care interests. The article concluded that primary care needs a new, more inclusive organization focused on accumulating and leveraging the power required to influence policy in favor of primary care.

The intention was to strengthen rather than displace the 6 different societies – The American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the Society for General Internal Medicine (SGIM), the American Academy of Pediatrics (AAP), the American Osteopathic Association (AOA), the American Geriatrics Society (AGS) – that currently divide primary care’s physician membership and dilute its influence. Instead, a new organization would convene and galvanize primary care physicians in ways that enhance their power. It would also reach out and embrace other primary care groups – e.g., mid-level clinicians and primary care practice organizations – adding heft and resources, and reflecting the fact that primary care is increasingly a team-based endeavor.

We have come to believe that a single organization cannot be serviceable. Feedback on the article suggested that several entities were necessary to achieve a workable design.

Continue reading “Strengthening Primary Care With a New Professional Congress”

The Wrong Battles

Brian Klepper

Posted 9/20/12 on Medscape Connect’s Care and Cost Blog

This week the American Academy of Family Physicians (AAFP) issued a new report describing its vision of primary care’s future. Not surprisingly, the report talks about medical homes, with patient-centered, team-based care.

More surprisingly, though, it makes a point to insist that physicians, not nurse practitioners, should lead primary care practices. The important questions are whether nurse practitioners are qualified to independently practice primary care, and whether they can compensate for the primary care physician shortage. On both counts the AAFP thinks the answer is “no.”

AAFP marshals an important argument to bolster its position. Family physicians have four times as much education and training, accumulating an average of 21,700 hours, while nurse practitioners receive 5,350 hours.

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Primary Care’s Dilemma

Brian Klepper

Posted 9/12/12 on Medscape Connect’s Care and Cost Blog

Early in the new documentary, Escape Fire, which provides detailed portraits of US health care’s craziness, we meet Erin Martin MD, a young primary care physician in The Dalles, OR, who ultimately abandons her practice with low income patients. Time and financial constraints have frustrated her efforts to provide the care she believes is necessary to make a difference in people’s lives. Later, we see her in a business meeting with other primary care physicians in her new practice, reviewing financials. To maintain the practice’s revenues, they’ll need to see more patients, which means shorter patient visits. The defeat is palpable to her, to her colleagues and to the audience.

A few days ago, Rob Lamberts MD, 18 years into his practice, announced on The Health Care Blog that he was dropping out, leaving to go solo in a Direct Primary Care (DPC) practice catering to patients who can pay out-of-pocket rather than through insurance. Dr. Lamberts, a regular and characteristically sunny columnist, is workmanlike but chilly in his explanation.

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Who Will Speak For Physicians and Their Patients?

Brian Klepper

Posted 8/29/12 on Medscape Connect’s Care and Cost Blog

Dr. George Lundberg has an important article on Medpage Today that deserves the thoughtful consideration of every American physician. He argues that the American Medical Association, a successful and representative organization for many decades, more recently “fails on both fronts” to fight for doctors and for the health of the American people. It has become, he says, “unsalvageable.”

In a companion piece earlier this month, he called on all physicians to become lifelong members of the AMA, as a way to gain professional impact and to make the AMA more reflective of American physicians’ concerns. “If you are an American physician and you don’t like what the AMA has done and is doing, if you are not a member, shut your mouth, you have no right to complain.”

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Will the Bubble Burst?

Brian Klepper

Posted 8/19/12 on Medscape Connect’s Care and Cost Blog

My recent 3-hour outpatient prostate biopsy generated nearly $25,000 in charges. My health plan will probably settle for four to five thousand dollars – this is the real market value – but if we were uninsured we’d be on the hook for the whole thing. All in all, a minor diagnostic procedure – nothing cured or treated – for the cost of a pretty nice car.

The capricious insanity of health care pricing is delivered with straight faces by health care professionals and executives to flabbergasted patients and benefits managers. It is the by-product of a system utterly devoid for decades of transparency, accountability or market pressures.

Continue reading “Will the Bubble Burst?”

The Most Important Health Care Group You’ve Never Heard Of

Brian Klepper and Paul Fischer

Posted 8/06/12 on Medscape Connect’s Care and Cost Blog

Excessive health care spending is overwhelming America’s economy, but the subtler truth is that this excess has been largely facilitated by subjugating primary care. A wealth of evidence shows that empowered primary care results in better outcomes at lower cost. Other developed nations have heeded this truth. But US payment policy has undervalued primary care while favoring specialists. The result has been spotty health quality, with costs that are double those in other industrialized countries. How did this happen, and what can we do about it.

American primary care physicians make about half what the average specialist takes home, so only the most idealistic medical students now choose primary care. Over a 30 year career, the average specialist will earn about $3.5 million more. Orthopedic surgeons will make $10 million more. Despite this pay difference, the volume, complexity and risk of primary care work has increased over time. Primary care office visits have, on average, shrunk from 20 minutes to 10 or less, and the next patient could have any disease, presenting in any way.

Continue reading “The Most Important Health Care Group You’ve Never Heard Of”

Why Medical Management Will Re-Emerge

Brian Klepper

Posted 7/31/12 on Medscape Connect’s Care and Cost

Several years ago I had dinner with a woman who had served in the late 1990s as the national Chief Medical Officer of a major health plan. At the time, she said, she had developed a strategic initiative that called for abandoning the plan’s utilization review and medical management efforts, which had produced heartburn and a backlash among both physicians and patients. Instead, the idea was to retrospectively analyze utilization to identify unnecessary care.

This was at the height of anti-managed care fervor. A popular movie at the time, As Good As It Gets, cast Helen Hunt as the mother of a sick kid. When someone mentioned an HMO, Ms. Hunt’s character let fly a flurry of expletives. America’s theater audiences exploded in applause.

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Is Genomic Medicine Clinically Useful Yet?

Brian Klepper

Posted 7/16/12 on Medscape Connect’s Care and Cost

The news of my wife Elaine’s primary peritoneal cancer 27 months ago began a fevered effort to learn all we could about her disease and our options. Peritoneal cancer, which is close in form and behavior to ovarian, is rooted in the abdominal lining. “Gold standard” treatments notwithstanding, the prognosis isn’t good. After a 12-36 month remission in which tumors are inactive, the disease generally returns, and a high percentage of women are gone within 5 years of diagnosis.

Cancer elicits a primal fear that can provoke fantasy and baseless speculation. Cancer patients in remission have told us they are cured. Others, well-meaning, have announced they know someone with “exactly what you have,” and that theirs went away by applying a strict dietary or spiritual discipline.

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Will Anyone Listen When Former CMS Chiefs Call For More Objective Physician Payment?

Brian Klepper

Posted 7/7/12 on Medscape Connect’s Care & Cost

On May 10th, the US Senate Finance Committee, co-chaired by Senators Max Baucus (D-Mont) and Orrin Hatch (R-Utah), convened a remarkable panel of four former Administrators of the Health Care Finance Administration (HCFA) and the Centers for Medicare and Medicaid Services (CMS): Gail Wilensky, Bruce Vladeck, Thomas Scully and Mark McClellen. (See the video here.) Against a backdrop of intensifying budgetary pressures, the roundtable was to provide perspectives on Medicare physician payment, including several controversial issues: the Sustainable Growth Rate (SGR) formula, the Resource-Based Relative Value Scale (RBRVS), and the RVS Update Committee (RUC).

Ironically, the day before, a Maryland Federal District judge dismissed a suit brought against HHS and CMS by six Augusta, GA primary care doctors over CMS’ longstanding relationship with the RUC, based on a procedural technicality and without weighing the substance of the complaint. The physicians challenged CMS’ refusal to require the RUC to adhere to the public interest rules of the Federal Advisory Committee Act (FACA) that typically apply to federal advisory bodies. The suit described the harm that has accrued to primary care physicians, patients and purchasers as a result of the RUC’s highly politicized process. To a large extent, the plaintiffs’ concerns closely reflected those of the former CMS Chiefs.

This was a deeply experienced and dedicated group, all with long government-involved careers. Surprisingly, independent of their divergent political perspectives, there was broad agreement on the direction that physician payment should go. All believe we need to move away from fee-for-service (FFS) reimbursement and toward alternative reimbursement paradigms, like capitation or bundled payments. All agreed that FFS would likely remain present in various forms for many years. There was a general sense that the RBRVS system was built on a series of errors, and that CMS’ relationship with the RUC started off, to use Dr. Wilensky’s term, “innocently enough,” but has become increasingly problematic over time.

Here is Dr. Wilensky’s description of how the CMS-RUC relationship came about.

It [the RUC’s formation and relationship with HCFA] happened innocently enough. Once you had the Relative Value Scale in place you needed to have a way to update relative values and to allow for a change. The AMA, as best we can tell…- sometime after I left to go to the White House, after he -[Bruce Vladeck] was sworn in, there was a lot going on, it was relatively new, in its first year – the AMA approached the Agency about whether it would allow it or like to have the AMA be the convener that would include all physician groups and make some recommendations which initially were very minor adjustments that hardly affected the RBRVS at all. The Agency accepted the offer.

Tom Scully, CMS’ Administrator under George W. Bush, took responsibility for helping facilitate the AMA’s involvement and was perhaps the most passionate that it had been an error.

One of the biggest mistakes we made … is that we took the RUC…back in 1992 and gave it to the AMA. …It’s very, very politicized. I think that was a big mistake…When you go back to restructuring this, you should try to make it less political and more independent.

I’ve watched the RUC for years. It’s incredibly political, and it’s just human nature…the specialists that spend more money and have more time have a bigger impact…So it’s really, it’s all about political representation, and the AMA does a good job, given what they are, but they’re a political body of specialty groups, and they’re just not, in my opinion, objective enough. So when you look at the history of it, CMS is starting to push back more, which is a good thing, I think it would be much better to have an arms-length transaction where the physician groups have a little more of an objective approach to it. And, look, that is the infrastructure of $80 billion of spending. It’s not a small matter. It’s huge.

But perhaps the most striking statement was made by Bruce Vladeck, HCFA Administrator during the Clinton Administration. In speaking about the problems generated by RBRVS (and by inference, the broader issues of SGR and the RUC as well) in the face of severe economic stresses, he called for the leadership and will required to simply do the necessary course correction.

I’m hopeful that some combination of the need to address overall deficit reduction strategies more generally and a different kind of political climate in the relatively near future will create the opportunity for people to say, “We made a mistake in 1997. We created a formula that produces irrational and counterintuitive results, and we’re just going to abolish it and start all over again in terms of some kind of cap on Part B payments. It’s the only way we’re going to get out of this morass.”

In a policy environment less susceptible to influence and more responsive to real world problems, the gravity of consensus on display at this roundtable would justify a call to action. As it was, it validated what many know: that we are rushing headlong down a catastrophic path, steered by forces other than reason and responsibility. The best we can hope for is that someone with authority and courage is listening.

Galvanizing Primary Care’s Power: A Call For A New Society

Brian Klepper

Posted 6/25/12 on Medscape’s Care & Cost Blog

The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.

Paul Starr, The Social Transformation of American Medicine, 1984

How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.

But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.

Continue reading “Galvanizing Primary Care’s Power: A Call For A New Society”

Medicare Physician Payment: The RUC’s Hollow Victory

Brian Klepper

Posted 5/18/12 on The Health Affairs Blog

On May 9th, William Nickerson, Senior Judge in the Southern Maryland Federal District Court, issued a 15 page ruling against the six Augusta, GA primary care physician plaintiffs who challenged HHS’ and CMS’ longstanding relationship with the American Medical Association’s Relative Value Scale Update Committee (RUC). The opinion did not weigh the substance of the case, but instead focused on a procedural provision in which Congress bars the judicial system from considering how the relative value units (RVUs) of medical services are determined. Judge Nickerson wrote:

Accepting as true that RUC plays a major role in the formation of the PFS [Physician Fee Schedule] and also accepting as true that this role unfairly skews the PFS toward certain medical professions and procedures, the Court, nonetheless, finds that Congress has precluded courts from reviewing, not only the final relative values and RVUs, but also the method by which those values and units are generated.

Continue reading “Medicare Physician Payment: The RUC’s Hollow Victory”

Care & Cost Merges Into The Doctor Weighs In

Brian Klepper

When I began Care & Cost in December of 2010, the idea was to aggregate consistently good health care writing, and to moderate the comments to ensure a courteously professional exchange on the site.

It has been a pleasure and even an honor to scour health care blogs of all types early each weekday morning. Wonderfully dedicated and thoughtful colleagues – Merrill Goozner, Kenny Lin, David Harlow, Wendy Lynch, Brad Flansbaum, Bill Bestermann, Jane Sarasohn-Kahn, Paul Levy, Jaan Sidorov, Tom Emerick, Bob Laszewski, Roger Collier, and many more – graciously allowed me to republish their work. The result, I think, has been a cornucopia of high quality insight and knowledge.

Being dedicated to the exercise let me build a faithful readership that included professionals of all political and philosophical persuasions, who vigorously disagreed at times, but always with respect.

Even so, my own schedule has intensified, and maintaining C&C has become more difficult day-to-day. I’m very involved in the development of WeCare TLC, a leading edge onsite clinic and medical management firm. I’ve helped to spearhead the campaign against the current structure of the AMA’s Relative Value Scale Update (RUC) and that organization’s corrosive relationship with CMS. I’m continuing to write, now as a Medscape columnist on Business of Medicine and Primary Care, as well as for other venues. And I’m devoted to the struggle to deal with my wonderful wife Elaine’s peritoneal (ovarian) cancer.

I’ve chosen to fold into The Doctor Weighs In (TDWI) for several reasons. Perhaps most important, it reflects approximately the same sensibility – and possibly a more expansive one – on the kinds of content that a good professional health care magazine should be running. TDWI’s founders and editors are my very close friends Pat Salber, MD MBA and Dov Michaeli, MD PhD, both writers and thinkers whose work I hugely admire. Over the past several months, we’ve often posted the same columns.

So I urge you to head over there and sign up for their morning email. I am deeply grateful and humbled that you chose to spend time with me trying to better understand the many complexities that have made American health care so interesting and vexing.

Thank you for coming. Let’s continue this conversation over at TDWI.

The RUC’s Empty Gesture

Brian Klepper and Paul Fischer

Posted 05/11/2012 on Medscape Business of Medicine

Recently, the leaders of the American College of Physicians (ACP) and the American Geriatrics Society (AGS) lavished praise on the American Medical Association’s Relative Value Scale Update Committee (RUC) for announcing the addition of a rotating primary care seat and a permanent geriatrics seat, and for promising to post vote tallies. Welcoming these maneuvers indicates not only a poor understanding of history but also misguided political and strategic instincts that will continue to harm patients, purchasers, and primary care physicians.

Continue reading “The RUC’s Empty Gesture”

The ACP’s Cognitive Dissonance

Brian Klepper

Relative to their specialist colleagues, primary care physicians have been generally passive about the politics that shape their professional lives, and they have been big losers. It is important for them to consider whether their societies are genuinely acting in their interests. I believe the evidence overwhelmingly reflects poor judgment by the societies that has diminished primary care’s prospects and, more importantly, caused significant harm to patients and purchasers.

Over at the ACP Advocate Blog on Wednesday, ACP Senior Vice President of Governmental Affairs and Public Policy Bob Doherty took me to task for asserting that the American Academy of Family Physicians is the only “pure” primary care society. He’s right, of course, in the sense that the American College of Physicians (ACP), the American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA) have done yeoman’s work in the past few years in promoting the value of primary care. He’s also right, and I stand corrected, on my statement that AAFP is the largest society. The information on Wikipedia shows that ACP has 130,000 members while AAFP has less at around 100,000.

As though any of this matters.

Source: Medscape Physician Lifestyle Report 2012, http://www.medscape.com/sites/public/lifestyle/2012

Continue reading “The ACP’s Cognitive Dissonance”