The RUC (Again): Is there a Light at the End of the Tunnel? A Conversation with Brian Klepper

David Harlow

Posted August 13, 2013 on HealthBlawg

Tunnel of Light TJ Blackwell Flickr CC http://www.flickr.com/photos/tjblackwell/3362987463/

Recently, there were a couple of breathless articles about the RUC (Relative Value Scale Update Committee) published in The Washington Post and The Washington Monthly, reporting as news the state of affairs that has prevailed for years in the realm of re-setting the relative values of physician services annually for purposes of the RBRVS — which is at the heart of the Medicare Physician Fee Schedule (MPFS) and which affects physician reimbursement well beyond Medicare, since the RBRVS is used as a touchstone in determining payment levels under commercial payor agreements as well.

I thought this confluence of publications was a good excuse to call up Brian Klepper, who is an expert critic of the RUC, to discuss the latest stories and talk about the prospects for meaningful reform.

Have a listen to our conversation (about 30 minutes long):

Brian Klepper on RUC HealthBlawg Interview with David Harlow 07262013

Brian Klepper – RUC – HealthBlawg

A transcript is appended to this post.

As detailed in our conversation, the RUC is a committee of the American Medical Association, and it operates behind a veil of secrecy. When it issues its annual update recommendations, CMS generally accepts the recommendation, and promulgates the update as a rule: the annual MPFS rule. The RUC is dominated by specialists, so the system tends to overvalue procedures and to undervalue “cognitive” services, or primary care.

Continue reading “The RUC (Again): Is there a Light at the End of the Tunnel? A Conversation with Brian Klepper” →

Nothing About Me Without Me: Participatory Medicine, Meaningful Use and the American Hospital Association

David Harlow

Posted 5/6/12 on Health Blawg

Meaningful Use Stage 2 regulations were released in March by CMS and ONC. Over the past month or so, I’ve been working with other members of the Society for Participatory Medicine (thank you, all) to prepare comments on these regulations from the patient perspective. Last Friday, we filed two comment letters on the proposed regulations. One letter to the ONC on Meaningful Use Stage 2, and one letter to CMS on Meaningful Use Stage 2. Each letter opens like this:

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Health Insurance Exchange Regulations and the Health Reform Challenge

David Harlow

Posted 3/18/12 on HealthBlawg

The federal Health Insurance Exchange regulations were released in final form last week. (See Timothy Jost’s précis on the Health Affairs blog and HHS presser.)

I had the opportunity to hear Pennsylvania Insurance Commissioner Michael Consedine speak in Philadelphia about his state’s progress towards building an exchange the very next day (I was speaking later on the program). Pennsylvania is one of the 26 states challenging the federal health reform law (and even has a state constitutional amendment afoot that would bar implementation of the individual mandate in PA), but that hasn’t stopped the Keystone State from spending a $1 million planning grant and getting a $33.8 million implementation grant to kick their state health insurance exchange into high gear. (Nothing like playing both sides, eh?)

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Data Breach: How Much Will One Cost You?

David Harlow

Posted 3/06/12 on Health Blawg

MP900440914 The going rate for a compromised medical record seems to be $1000 (well, at least that’s the asking price) as seen in papers filed in the eleven class action lawsuits against Sutter Health following the theft of a desktop computer last fall. The computer contained unencrypted protected health information on about 4.24 million members. The eleven class action suits are likely to be consolidated for ease of handling by the courts.

For an outfit whose most recently reported year-end financials show just under $900 million in income on just over $9 billion in revenue, a $4.24 billion claim certainly qualifies as a big deal. The data breach claims against Sutter Health were filed last year following its self-reporting of the computer theft, and are in the news again due to the potential consolidation.

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Me Too! It’s Not Fair! The Tragedy of the Commons in the Health Care Marketplace

David Harlow

Posted 1/4/12 on HealthBlawg

There are at least two conversations going on in the health care marketplace today, each focused on one of two key questions. One is: How can we achieve the Triple Aim? The other is: Why do they get to do that? (It’s not fair! I want more!)

Until we stop asking the second question, we can’t answer the first question. Why? Because all too often the answer to the second question is the equivalent of: It’s OK, Timmy, I’ll buy you TWO lollipops; pick whichever ones you want.

It’s the tragedy of the commons, transposed to the health care marketplace.

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The 2012 Medicare Physician Fee Schedule is Finalized

David Harlow

Posted 11/7/11 on Health Blawg

CMS issued the final MPFS — the Medicare Physician Fee Schedule for 2012 — this past week. The key feature of the rule, for many folks, is the Sustainable Growth Rate-(SGR)-mandated 27.4% cut in Medicare professional serivces reimbursements. We now get to watch the drama unfold over the next eight weeks, as the MedPAC proposal to replace the SGR is bandied about, and the machinations of the supercommittee tasked with brokering a budget fix either do or do not get us closer to a reasoned approach to doing more with less. The MedPAC idea is to drop the RBRVS conversion factor for specialty care payments 5.9% per year for two years, then hold it steady for 8 years, while keeping the primary care conversion factor flat for 10 years. The net effect: physician payments will “only” double over the next 10 years. (One clever idea squirreled away in the MedPAC report is that savings in the Medicare Shared Savings Plan (ACO) should be measured against a baseline of what Medicare would have spent on the care absent the changes in the proposed SGR fix — i.e., a higher baseline, with greater potential savings. Another 50 clever ideas like this and we’ll be talking about saving some real money.)

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Accountable Care Organization Regulations – The ACO is a Camel, Not a Unicorn

David Harlow

Posted 10/31/11 on HealthBlawg

232323232-fp53393-nu=3238-235-766-232923585737;ot1lsi The final Accountable Care Organization regulations are out, the initial flurry of commentary is out (including my own ACO webinar with simultaneous #ACOchat tweetchat –available for download/replay soon; slides here now: “ACOs, Bundled Payments and the Future of Health Care“), and we can now all catch our collective breath and contemplate the draft vs. final ACO regulation comparisons, the meaning of this new, final set of regulations, guidances and statements from CMS, FTC, DOJ, OIG, and IRS on ACOs and Medicare Shared Savings Programs, and all of the attendant antitrust, antikickback, Stark, and other fraud and abuse matters, and of course tax issues.

So, now that these final regulations are out, and the mythical characteristics of the ACO will soon be dispelled (see under: unicorn), I propose a new animal kingdom metaphor for discussion of Accountable Care Organizations:

The Camel’s Nose is in the Tent.

The definition of a camel, as those of you who tuned into my ACO webinar already know, is a horse designed by a committee. And, given the nature of the legislative and rulemaking processes, that’s exactly what we have before us – a camel.

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CMS Center for Innovation Announces Bundled Payments for Care Improvement Initiative

David Harlow

First posted 8/24/11 on Health Blawg

Many health care provider organizations that have not been overly eager to jump onto the Accountable Care Organization (ACO) bandwagon, citing high startup costs and uncertain returns on investment given the complexity of the program. Well, recently, the CMS Center for Innovation has announced the Bundled Payment for Care Improvement initiative. This initiative incorporates elements of earlier CMS demonstration projects — the gainsharing demos and ACE (acute care episode) bundled payments demonstrations which the HealthBlawger has helped a number of clients around the country qualify for in the past — and builds on the broad authority granted to the CMS Center for Innovation under health reform.

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Modernizing Rural Health Care

David Harlow

First posted 7/27/11 on Health Blawg

The UnitedHealth Center for Health Reform and Modernization released a white paper today on Modernizing Rural Health Care. To quote from the UHG presser,

[The paper] projects an increase of around 5 million newly insured rural residents by 2019 – even as the number of physicians in rural America lags

Quality of care is rated lower in rural areas in 7 out of every 10 health care markets; both physicians and consumers in rural areas more likely to rate quality of care lower than those in urban and suburban markets

Innovations in care delivery – particularly telemedicine and telehealth – can absorb future strain on rural health care systems

The paper inventories the current state of health care for the 50 million Americans living in a rural setting — and it’s not pretty. The question, of course, is why does rural health compare unfavorably to urban health metrics, and what can be done to improve matters?

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Health Insurance Exchange Regs Are Out, And They Make Me Feel Like A Visitor From The Future

David Harlow

First posted 7/12/11 on Health Blawg

Health Insurance Exchange regulations were released by HHS yesterday — in a DC hardware store, for local color and homespun truths — with a go-live date of January 1, 2014, per the Affordable Care Act, and a key interim approval deadline of January 1, 2013, by which date each state needs to demonstrate that it has its act together and are on a glide path to the go-live date. Despite the rancorous opposition to the ACA (consider, for example, the views of the Virginia Attorney General — who is leading a multi-state charge against the individual mandate — expressed at the American Health Lawyers Association Annual Meeting last month, where he was an invited keynote speaker, and later tweeted a tone-deaf assessment of the audience and an unkind skewering of a questioner who didn’t share his perspective), 49 states, D.C. and four territories have accepted health insurance exchange planning grants. Thus, it seems unlikely (for now) that the federales will have to make use of the “Do I have to do everything for you?” clause which would allow HHS to step in and set up an exchange for a state.

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Healthcare Associated Infections: What Is The Message, and What Can We Do About Them?

David Harlow

First posted 7/8/11 on Health Blawg

The good people at GE and JESS3 have come up with an HAI infographic. It’s pretty, and it conveys the horrible information that many of us already know — healthcare associated infections kill about 100,000 people a year, and add $35 billion a year to our collective health care bill (here in the US of A); 5% of hospital inpatients end up with an HAI.

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The Massachusetts Experiment Analyzed: Are We Ready For Global Payment?

David Harlow

First published 6/24/11 on Health Blawg

Massachusetts Attorney General Martha Coakley released her office’s second annual report, An Examination of Health Care Cost Trends and Drivers (PDF; see also press release), which contains a wealth of critical data analysis — and also highlights how little we know about certain things — providing some important context for the discussion of the proposed Part III of Massachusetts health reform, a bill filed by Governor Patrick which would create all-payor ACOs and a system of global payments.

At this late date, few would argue against a move a way from fee-for-service reimbursement for health care, or adding quality metrics to the mix, and tying financial rewards to providers to their performance measured against these metrics. (Consider the Massachusetts Blue Cross Blue Shield ACQ (alternative quality contract) experience.) The AG’s report, however, highlights the wide disparities in payments to providers based on negotiating strength, rather than quality or cost of care (as noted in last year’s AG report; check out the 2009 special commission report, too).

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Don’t Kick a Unicorn When It’s Down

David Harlow

First published 6/3/11 on Health Blawg

There has been a significant outcry against the proposed ACO regs: everything’s wrong and nothing’s right about them, or so some would have us believe. (The comment period is still open, and CMS is still soliciting input; much of the outcry is a form of posturing and negotiation … not that there’s anything wrong with that.)

Today’s “nattering nabobs of negativism” focus on: the estimated price tag for complying with the regulatory requirements (IT and other infrastructure incuded), the slim chance of success by ACOs in righting the wrongs of decades of bloat in the health care system, the premature pledging of allegiance to an idea only partly proven through the PGP demo, the likelihood of failure due to the whole endeavor’s being tied to FFS reimbursement, on the one hand, and due to exposure of ACOs to downside risk, on the other, the unreasonable reliance on dozens and dozens of quality measures . . . and the list goes on. For further detail, see, e.g., David Dranove’s recent post decrying unproven theories baked into the ACO program (with a link to info on the PGP demo’s results, and differing interpretations of those results; check out the lively discussion in the comments to Dranove’s post on The Health Care Blog), Jeff Goldsmith’s opposition to ACOs as conceived in the ACA (and alternative proposal discussed in the linked post), and Mark Browne’s search for a few good quality measures. (This has been a recurring theme for me as well; I would love to find six or eight meta-measures that predict all others; Mark links to the AHA’s comments on the ACO rule, which are worth a read).

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