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”

Moving Beyond Merchant Health Care

Brian Klepper

Published 4/05/12 on MedPage Today

Another luminary-rich panel has been formed to make recommendations about how physician and other healthcare services should be valued and paid for.

The Society for General Internal Medicine launched the National Commission on Physician Payment Reform with funding from prominent healthcare foundations. The 13 commissioners represent a mix of perspectives: a former surgeon/senator, community physicians, academics, two healthcare mega-corporations, a think tank, a state regulator, and a reform-oriented advocacy organization. A group representing large employer purchasers has one seat.

Continue reading “Moving Beyond Merchant Health Care”

The Right Rx for Better Health Care: Rise Up to Challenge the Industry’s Lobbying Power

Brian Klepper and Shannon Brownlee

Published 3/29/12 in the New York Daily News

Obamacare had its days in the Supreme Court this week, and the justices’ decision could have sweeping consequences for the individual mandate provision in the Patient Protection and Affordable Care Act, and maybe even for the fate of the law itself.

Yet whatever the court decides, we will still be stuck with a problem that this contentious law was not likely to solve on its own: an out of control health care industry that threatens the stability of the U.S. economy and the federal government’s ability to deal with our long-term debt.

Continue reading “The Right Rx for Better Health Care: Rise Up to Challenge the Industry’s Lobbying Power”

Adding Seats: The RUC’s Sleight of Hand

Paul Fischer and Brian Klepper

Posted 3/14/12 on The Health Affairs Blog

©2012 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

On February 1, the American Medical Association’s Relat ive Value Scale Update Committee (RUC), Medicare’s primary advisor on physician payment, announced the addition of two seats: a permanent one for geriatrics and a rotating one for primary care. The American Geriatrics Society and the American College of Physicians praised the move as a step forward that will amplify the RUC’s appreciation of their physicians’ contributions.

But the RUC’s maneuvers are a cynical sleight of hand. They attempt to assuage charges of sub-specialty bias while continuing the RUC’s sub-specialty dominance. The additions reduce proceduralists’ share of votes from 27 of 29 (93 percent) to 27 of 31 (87 percent), hardly a power shift. Primary care comprises about 35 percent of US physicians, but cognitive medicine would have only 13 percent of the votes.

Continue reading “Adding Seats: The RUC’s Sleight of Hand”

Trusting Government: A Tale of Two Federal Advisory Groups

David C. Kibbe and Brian Klepper

Posted 2/2/12 on the Health Affairs Blog

©2012 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

Americans increasingly distrust what they perceive as poorly run and conflicted government. Yet rarely can we see far enough inside the federal apparatus to examine what works and what doesn’t, or to inspect how good and bad decisions come to pass. Comparing the behaviors of two influential federal advisory bodies provides valuable lessons about how the mechanisms that drive government decisions can instill or diminish public trust.

Continue reading “Trusting Government: A Tale of Two Federal Advisory Groups”

Can Medical Management Succeed Within A Fee-For-Service Environment?

Brian Klepper

The column immediately below is an important discussion by Douglas Elmendorf, the Director of the CBO – actually it was prepared by Lyle Nelson of CBO’s Health and Human Services Division, but it has Mr. Elmendorf’s imprimatur – which recently released an issue brief concluding that major cost control approaches had not produced savings in Medicare. This of course elicited a cascade of pro/con medical management commentary.

Most important is this sentence near the bottom.

Demonstrations aimed at reducing spending and increasing quality of care face significant challenges in overcoming the incentives inherent in Medicare’s fee-for-service payment system, which rewards providers for delivering more care but does not pay them for coordinating with other providers, and the nation’s decentralized health care delivery system, which does not facilitate communication or coordination among providers.

Continue reading “Can Medical Management Succeed Within A Fee-For-Service Environment?”

Why Only Non-Health Care Business Can Save America From The Health Care Industry

Brian Klepper

The attached PP deck is a presentation I’ve given several times that has received an overwhelmingly positive, if frightened, reception.

It is, perhaps, the most disturbing public argument of my career (which is going some), because it tries to document the health care industry’s “capture” of health care regulatory processes, particularly those that govern payment. The result, as many people understand, is that the health care industry, in its rapaciousness, is effectively driving the larger US economy off a cliff.

Only one group, the non-health care business community, has the heft, influence and motivation to save us, though health care has done a good job dividing and conquering this sector as well, insinuating itself into many of the most powerful institutions (e.g., the Chambers of Commerce). It remains very unclear that the business community can be galvanized/mobilized from its malaise to turn this problem around.

The argument goes like this:

  • The data are clear that the US’ health care economy is absorbing most gains in the larger economy, and driving the US economy toward collapse. For example, nearly all increases in total compensation have been directed at increasing health costs, which in turn flows into the health industry.

Creating Value-Based Incentives for Primary Care

Brian Klepper and David Kibbe

Posted 6/2/11 on The Health Affairs Blog

In a remarkable recent interview, Donald Berwick MD, Administrator of the Centers for Medicare and Medicaid Services (CMS), eloquently described his vision of value-based health care.

Paying for value is an incentive…The underlying idea of improvement is that American health care, historically built in fragments, often cannot achieve for patients what it really wants to achieve…Health delivery system reform refers to really reconfiguring care into much more seamless coordinated-care operations so that people, especially those with chronic illnesses, experience continuity of care over time and space.

Continue reading “Creating Value-Based Incentives for Primary Care”

A Litmus Test for Elected Officials

Brian Klepper and David C. Kibbe

Six months ago, who could have imagined that a large percentage of rank-and-file Americans would support the Occupy Wall Street (OWS) against special interests’ rigging of the American dream? So why not go to the next step? Why not pointedly ask political candidates, “Will you take money from lobbyists?” and “If elected, what will you do to stop special interest influence?”

Most Americans are deeply disturbed by this issue. In a recent Time Magazine poll of people familiar with the OWS protests, 86 percent thought that “Wall Street and its lobbyists have too much influence in Washington.” Gallup found that 68 percent of Americans think corporations should have less political influence.

These trends didn’t just happen. They resulted from special interests’ vigilant attention to legislative possibility, lubricated by the exchange of money for votes. Influence peddling is now so accepted in American politics that the Center for Responsive Politics (CRP) has established a lobbying data base, Open Secrets. But making lobbying contributions transparent hasn’t slowed the torrent of money that re-shapes law and wealth distribution.

Since 1952, the percentage of gross domestic product (GDP) represented by corporate taxes has plummeted from 6.1 to 1.0 percent, while the percentage represented by employment taxes has skyrocketed from 1.8 to 6.3 percent. Meanwhile, a just released Congressional Budget Office study confirmed that the top 1 percent of earners more than doubled their share of the nation’s after tax income over the last 30 years.

CRP’s numbers show that 13,000 lobbyists contributed $3.5 billion in Congress in 2010.  Considering that Congress influences the flow and distribution of a $15 trillion national economy, these investments promote unfair advantages extremely cost-effectively. Politicians from both parties fund their campaigns with the money, shrug off the system’s financial conflicts, and apparently avoid thinking too hard about the consequences.

The intensifying ability of the powerful to buy America’s lawmakers’ votes is the greatest threat to the America that most of us grew up believing in. It is why the rich have gotten much richer, why large, profitable corporations pay no taxes, why health care costs have continued to explode, and why Americans’ social mobility is at an historic low. America has many difficult problems, but lobbying and the way we finance elections are among the deepest, facilitating many others.

Voters can facilitate rapid change by holding their representatives accountable. Asking our political candidates who they think they’re working for would be a simple but powerful way to bring America back into balance.

Brian Klepper, PhD is a health care analyst and the Chief Development Officer for WeCare TLC Onsite Clinic. David C. Kibbe, MD, MBA is Senior Advisor to the American Academy of Family Physicians and an industry advisor on health information technologies.

An Anniversary

Brian Klepper

Last December 1, when I launched Care & Cost, the goal was to develop and maintain a quality daily health care magazine for professionals that would reflect the vastness of health care’s reach and complexity, but that also would adhere to standards for comment, discourse and professional behavior. I saw it as a place to post my own writing, but also to aggregate the many terrific and authoritative health care writers I’ve come to know around the US. I somehow never imagined that it would last a year.

Over time, I’ve come to regularly re-post the columns of about 20 writers, and I occasionally post the work of many more. Each contributor offers a unique perspective, and as a group they all strive to bring fresh insight or clarity to complicated topics. Regular readers have come to expect provocative but clear analyses from Bob Laszewski, Pat Salber, Dov Michaeli, Jane Sarasohn-Kahn, Paul Levy, Kenny Lin, Brad Flansbaum, Wendy Lynch, Merrill Goozner, David Harlow, Jaan Sidorov, Vince Kuraitis, Michael Millenson and many others. I am deeply indebted to these individuals for allowing me to share their consistently superb work with a growing audience of colleagues.

It’s worth noting, as an aside, that most write quite independently of their day jobs. They write for pleasure and out of passion, as though their ruminations on daily events are percolating, and waiting to spill out into reasoned narrative. It is difficult work to consistently produce informed, clear arguments, and they all make it look easy.

I’ve settled into a format that favors three columns a day. When the stars align and a particular topic is in the fore, they may all have different perspectives on the same issue. Other times I’ll try to mix it up. And on weekends, I’ll generally try to offer something lighter or different: maybe a YouTube video on health care or a book review.

Looking back as well as forward, I’ve been surprised but encouraged by the volume, diversity and quality of content that has become available here. In the past year, nearly 800 different posts have appeared on C&C: updates and interpretations about the health care law, discussions about clinical practice, and approaches that employers can use to drive down cost while improving population health status. There’s been the evolving drama of the lawsuit against CMS over its relationship with the AMA RUC brought by 6 brave Augusta, GA primary care doctors. And the evidence-based vascular clinical protocols developed by Bill Bestermann and David Carmouche, and the work of the Consortium for Southeastern Hypertension Control.

I’ve been gratified along the way by the openly collaborative nature of other bloggers. I owe a great debt to my good friend Matthew Holt, whose much more widely read The Health Care Blog remains the content super-site for health care professionals. I was the first regular writer other than Matthew on that blog, and often post there still when I want to be sure to quickly reach the widest possible readership.

The same holds true for the Doctor Weighs In and Health Policy and Marketplace Review. There’s been ongoing support from my close friend and writing partner David Kibbe, and from my wonderful wife and best friend Elaine, who puts up with all these distractions.

There’s no question that we’re all fellow travelers who write and post and read each other’s thoughts because we believe in the positive power of open discourse beyond the mainstream media.

Finally, I’m most appreciative to you, the reader who checks in to see what’s here and maybe comment. Your time is precious and I do my best to ensure that each read has some kernel of truth or substance or delight. To the degree that that’s here more often than not, then I’m succeeding.

Thanks again for stopping by.

Physician Incomes 2009-10

Brian Klepper

This table was published in Practice Link, a physician recruiting magazine, and I calculated the relative value of the offers by specialty, by low, medium and high, and then sorted for the medium. See below for how they turned out.

At current medium offer rates – without considering benefits or production bonuses, the average family doc can expect to earn around $10 million less than an invasive cardiologist or an orthopedic surgeon over the course of a 30 year career.

CMS’ Opportunity: A Lawsuit Offers A Chance To Reform Physician Payment

Brian Klepper and David C. Kibbe

Posted 10/25/11 on the Health Affairs Blog

By mid-November, the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) must respond to the legal complaint filed in a Maryland federal court by six Augusta, Georgia family physicians.

These doctors are not asking for money, but for relief from the negative effects brought about by CMS’ twenty year reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC) for valuing doctors’ work. They are asking CMS to enforce the Federal Advisory Committee Act(FACA), which requires that regulatory agencies shield themselves from undue special interest influence. In the process, they are asking CMS to rethink Medicare’s approach to physician payment, with a mind toward recognizing and valuing primary care’s ability to treat the whole patient within a larger system of care. They are asking CMS to develop payment policy that supports the needs of patients over those of professional groups.

Continue reading “CMS’ Opportunity: A Lawsuit Offers A Chance To Reform Physician Payment”