Monday, February 28, 2011

Common Sense Family Doctor blog: Maybe PSA's time has finally come -- to an end!

I highly recommend reviewing Dr. Kenny Lin's blog post on "Common Sense Family Doctor" regarding PSA testing,
It reviews not only Dr. Lin's experience in helping write the guidelines but the political pressure to "trump" science.
Hopefully, now, the evidence on the non-utility of PSA testing is clear -- but read his piece for the details.

Friday, February 25, 2011

We are moving in the wrong direction: the health care crisis and American hubris


The passion for democracy and liberation from tyranny continues to spread across the Middle East, with major actions (and reactions from dictators) taking place in Bahrain, Yemen, Libya and even Iran. While decades of US foreign policy has focused on supporting these dictators while talking democracy, the people in these countries are looking at the US as a model, not of foreign policy, but of democracy. They may have economic interests, but -- in Libya, for sure, they are willing to die for freedom. Finally, our President, from whom we (and they) had expected great things, is speaking on behalf of freedom.

However, as I wrote last week, things are moving in the wrong direction in the US itself, where right-wing zealots funded by billionaires have taken over not just Congress but the legislatures of many states. Wisconsin is the prime example of an attempt, which may yet be successful, to strip the basic rights of labor unions to organize and fight for their members, a class war thinly veiled by statements of fiscal responsibility negated by the fact that the unions have already agreed to the financial cuts. On NPR’s Morning Edition on Feb 21, 2011 Steve Inskeep,the host interviewing Senate President Scott Fitzgerald, who is carrying the water for Gov. Scott Walker’s bill, could barely contain his irritation as Sen. Fitzgerald kept dodging the questions, reiterating boilerplate talking points rather than answering.

And we are not doing so well. In Empire at the End of Decadence (NY Times, Feb 18, 2011), Charles Blow provides a stunning graphic chart comparing the United States to other countries in the developed world across a variety of areas on which we do, or should, pride ourselves. We don’t come out very well. Among the International Monetary Fund’s (IMF) 33 advanced countries, we are not in the best in any of the 9 areas. We are dead last in prison population per 100,000 (745, more than twice 2nd place Israel’s 325), and tied for worst, with Korea, with 16% of people indicating that they had not enough money for food in the last year. In the only direct health measure, life expectancy at birth, we are, at 78.24 years, ahead of only 5 of the other 32 countries; Slovakia at 75.62, is the lowest, and Taiwan is jus t behind us at 78.15 (the other 3 are Slovenia, Cyprus, and the Czech Republic).

While Republicans rant about individual mandates and repealing “Obamacare”, the health insurance crisis is not over. In the New York Times, Feb 20, 2011, Donna Dubinsky wrote “Money won’t buy you health insurance”. This “co-founder of Palm Computer and Handspring, is the chief executive of a computer software company” describes the difficulty that she had in obtaining insurance on the private market despite being quite well-to-do when neither she nor her husband worked for a large company any more. After being denied coverage at all because of “pre-existing conditions” (“For me, it was a corn on my toe for which my podiatrist had recommended an in-office procedure. My daughter was denied because she takes regular medication for a common teenage issue. My husband was denied because his ophthalmologist had identified a slow-growing cataract,” she finally found a company that would insure them at a high rate with a high deductible, and the rates have continued to rise although they pay (because of the deductible) most of the bills themselves.

The point is not that she is in tough straits. I am sure Ms. Dubinsky would agree that there are a lot of people who we should have a lot more sympathy for than her; people who are homeless and jobless and hungry, and millions more who are on the verge of becoming so. And yet there are many who continue to see the uninsured as “other”, the “them”, rather than the “me and my neighbors”, despite the fact that many of their neighbors, and relative, and friends, must be in this boat. Ms. Dubinsky’s article points out, if there were any more evidence needed, that insurance companies are greedy and absolutely not to be trusted with the health care of the American people. The Affordable Care Act, (ACA) mandates individuals to purchase health insurance, ostensibly the objection of the Republican right (who are presumably either well insured or healthy and optimists), which was the only way the insurance companies would buy in: they basically said “We can only allow no underwriting (denying insurance to people they assess as too high a risk) this if you make everyone buy insurance.”

Should you even think for a moment that for-profit insurance companies are anything but self-serving, it is worth looking at Jacob S. Hacker and Carl DeTorres’ scorecard, The Health of Reform (NY Times, Feb 17.2011). They grade the ACA in Rollout, Reaction, and Results and give the overall program so far a “B”. The reaction of the insurance companies gets a “C”: “Eager to have millions of new private customers, the big private plans and their lobby are against repeal. Still, they spent tens of millions of dollars supporting the anti-reform candidates in the elections and are fighting key consumer protections and cost controls”.

Paul Krugman is generally a supporter of the ACA health plan, believing that it actually will be a major step to addressing our fiscal problems. “What would a serious approach to our fiscal problems involve? I can summarize it in seven words: health care, health care, health care, revenue. “He continues (Willie Sutton Wept, NY Times, Feb 18, 2011),
What would a serious approach to our fiscal problems involve? I can summarize it in seven words: health care, health care, health care, revenue….What would real action on health look like? Well, it might include things like giving an independent commission the power to ensure that Medicare only pays for procedures with real medical value; rewarding health care providers for delivering quality care rather than simply paying a fixed sum for every procedure; limiting the tax deductibility of private insurance plans; and so on. And what do these things have in common? They’re all in last year’s health reform bill. That’s why I say that Mr. Obama gets too little credit. He has done more to rein in long-run deficits than any previous president. And if his opponents were serious about those deficits, they’d be backing his actions and calling for more; instead, they’ve been screaming about death panels.”
So, while the President’s plan might be criticized for being a giveaway to insurance companies, the right is attacking it for all the things it actually does well!

Dubinsky ends her article “If members of Congress feel so strongly about undoing this important legislation, perhaps we should stop providing them with health insurance. Let’s credit their pay for the amount that has been paid by the taxpayers, and let them try to buy health insurance in the individual market. My bet is that they all would be denied. Health insurance reform might suddenly not seem to them like such a bad idea.”

Maybe, but some folks have no shame. It is not a bad idea, it is, as Krugman demonstrates, a pretty good idea from an economic as well as health standpoint. And Blow may be right when he says that, rather than confront the realities of developing a population with the health and education to compete in a global economy, too many people “…would prefer to continue to bathe in platitudes about America’s greatness, to view our eroding empire through the gauzy vapors of past grandeur.”

That is not a conceit that we can afford.


Saturday, February 19, 2011

The challenge of expanded Medicaid and the dearth of primary care physicians

The shortage – current and future – of primary care physicians in the US has been a recurrent theme on both this blog and many other venues in journals and the blogosphere. In addition, several posts relating to the Affordable Care Act (ACA) have noted the difficulty Massachusetts has had since it implemented an individual mandate, with many more people covered and not enough primary care doctors to see them (Solving Medicare costs and the budget deficit: primary care, cost-effectiveness, and universal health coverage, Jan 5, 2011; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?, Apr 12, 2010). Apparently, there are a lot of states that will be in worse shape than Massachusetts, according to a study by Leighton Ku and colleagues in the New England Journal of Medicine.

In The States' Next Challenge — Securing Primary Care for Expanded Medicaid Populations (NEJM 10Feb2011;364(6):493-5) the authors look at the expansion of Medicaid mandated in ACA, to 133% of poverty for nonelderly adults by 2014, and note that this expansion will be far greater for states that currently have the most restrictive eligibility for Medicaid than those that have the most generous (e.g., Massachusetts). They note that this will require far more primary care doctors, and observe that many of these same states have the greatest deficit in primary care capacity. Using a creative approach, they create a “Medicaid expansion index” to identify how much a state’s Medicaid population will grow as well as a “primary care capacity index”. They standardized them so 100 was the average, and combined them to get a relative assessment of each state’s “challenge”; over 100 is worse than average, under is better. The scores ranged from 212.6 (Oklahoma) to 15.2 (Massachusetts, in fact!). Unsurprisingly, the states that face the greatest challenges are mostly in the South and Midwest, like Oklahoma, while the other states with low scores tend to be in the Northeast. Some of this is, as Ku notes, a primary care physician deficit in those states with high scores, while and much of it is a result of the fact that these high-score states have such limited current eligibility for their current Medicaid programs that they will have the largest number of newly-insured people.

The authors acknowledge that the “Access to care is determined in local service areas, not at the state level. Access problems could be more severe in rural or inner-city areas than in suburban communities, for example.” No doubt they will be; as many posts on this blog (e.g., Primary Care and Rural Areas, Apr 28, 2010) have noted, distribution of providers (not only physicians but nurse practitioners and other “midlevels”) is not even close to adequate, both for primary and subspecialty care. There are too few providers in the inner-city, but in rural areas the situation is worse -- 20% of Americans live in these areas, but well under 10% of doctors practice there. Only family physicians distribute in proportion to the population, but 20% of family physicians is not anywhere near 20% of doctors. Other primary care specialties, such as pediatrics, are very concentrated in urban areas (Primary Care, Pediatrics, and Physician Distribution, May 21, 2009).

Ku,, express some guarded optimism, suggesting that expanded insurance coverage will support more primary care doctors – but note that the expansion also doesn’t begin until 2014. Given the long time frame to create physicians in any specialty, this will at best leave us with several years of shortages. And, at the current rate, “at best” is unlikely. The authors emphasize the need for training more primary care doctors, especially in the most “challenged” states, but really make no suggestions that are likely to have a significant impact, citing such things as expanded scope for “midlevels” (does not address distribution) and expectation that increased funding for Federally-Qualified Health Centers (FQHCs).

In the very next article in the same issue of the NEJM, Stephen R. Smith does make some suggestions for change that would likely produce more primary care doctors. In A Recipe for Medical Schools to Produce Primary Care Physicians[1], he starts with the admissions process, suggesting that admissions be MCAT (Medical College Admissions Test) “blind”, meaning that above a pre-defined minimum score, MCAT scores will not be considered (so that a student with a very high score is considered “more desirable” than one with just a high score). He emphasizes the need to select students “…who express a desire to serve underserved populations, who demonstrate altruism, and who are committed to social responsibility” because “they are more likely to go into primary care”. (However,expressing interest is not the same as actually having interest. See the experience of Pennsylvania’s Commonwealth Medical College. [2]) He suggests that the curriculum be based on a “patient-centered learning approach” with continuity follow-up of actual patients and teaching of “basic science” in the context of these actual patients. He urges that the entire curriculum be built around the competencies needed for a primary care physician, that students be taught in inter-professional teams, and that community-based settings be used for training.

These are all good ideas. They are consonant with recommendations I have made (of course, this makes them good :)!). While they do not look at “output variables” (mainly income/reimbursement), they do address the two areas over which medical schools have the greatest control – the students they admit (“input variables”) and the curriculum (the “process”). The suggestions that Smith makes have all been tried, and they all work to a significant degree to increase the number and percent of primary care doctors. At the University of Kansas, for example, we do have essentially “MCAT-blind” admissions, and look for the characteristics he suggests, among others, believing that such personal characteristics as caring, altruism, and communication skills are not only important for primary care, but for all physicians. The problem is absolutely not that we don’t know what works; we do. The problem is that we have, nationally, lacked the commitment to implement these strategies on a large enough scale to have a sufficient impact on the supply of physicians.

There are two big issues, though. Obviously, the first is that “output variables” – mainly the enormous differential in expected physician income – are not addressed. This is critical. As long as reimbursement policies by Medicare (see Outing the RUC: Medicare reimbursement and Primary Care”, Feb 2, 2011) and other insurers dramatically favor subspecialists and especially proceduralists, there will not be enough primary care doctors. Indeed, the other “problem” medical students often identify with primary care – less than appealing “lifestyle” (read: “too much work”) is related to this; if you make a lot more per hour, you have to work fewer hours.

The other big issue is that Smith addresses his suggestions to the many new allopathic (“MD”) medical schools being currently created. He notes that these are (mostly, although not all) designed to increase production of primary care physicians (although, as noted in the footnote about the Commonwealth Medical College, even those may have trouble getting students who are actually interested in primary care), and he is correct that adopting his suggestions, among others, is more likely to keep them on that path. However, this is too simple; it forgives existing medical schools from fulfilling this responsibility, and they absolutely should not be so forgiven. This is particularly true for the most “elite” schools, many of them private and in the Northeast and very “selective” (indeed “selectivity” – the percent of applicants that you turn down – is a criterion for high rank by US News and World Report). Such schools are also the ones with the highest amounts of National Institutes of Health (NIH) research support, and pride themselves on producing researchers. Different schools, the refrain goes, have different mission; we produce “physician scientists”, somebody else should produce the primary care doctors (hey, like those “new schools!”).

The problem is twofold. First, these schools produce a lot of physicians, and they need to produce the kind of physicians that the community needs. Second, these schools set the standard for what most other schools want to be like – to be highly ranked by US News and get lots of NIH money. The last big expansion of medical schools, in the early 1970s, was also supposed to produce primary care doctors, but many or most of them immediately abandoned that mission and began trying to be like Harvard or Johns Hopkins. What needs to happen is that Harvard and Johns Hopkins need to look more like the University of Kansas, and produce a much higher percent of community-serving primary care doctors. In fact, so does the Warren Alpert School of Medicine at Brown University, where Dr. Smith works.

So, in case I haven’t been clear, two things need to happen:
1. Current physician reimbursement formulas need to be abandoned, and Medicare needs to adopt a reimbursement scheme that will result in primary care physicians having at least 70% of the income of subspecialists. Where Medicare leads, private insurers will follow.
2. All medical schools must adopt admissions policies that de-emphasize high exam scores and emphasize desirable personal characteristics, and lead to much greater diversity of students by socioeconomic status, geographic origins, and race/ethnicity. They need a curriculum that reinforces these skills, problem solving, independent learning, and communication. The elite private schools should take the lead; where they lead others will follow.

When? What should be the timeline? Immediately. Right now. No delays. Both should have been done yesterday.

[1] Smith SR, “A Recipe for Medical Schools to Produce Primary Care Physicians”, NEJM 10Feb2011;364(6):496-7 (online available only to subscribers)
[2] The Commonwealth Medical College in Scranton, Pennsylvania selected its students based on an expressed interest in primary care, but found that in their first class, on a pre-matriculation survey (before they even started school!) only 23% still said they wanted to be primary care doctors! (Tracy & Smego, “Discordance of Self-reported Career Goals of First-year Medical Students During Admission Interviews and Prematriculation Orientation”, Family Medicine, Jul-Aug 2010.

Sunday, February 13, 2011

Freedom abroad, health at home: experiments in preventive health care

First, we must celebrate the victory of the people of Egypt in ousting the 30-year dictator Hosni Mubarak, and we revel in the democratic character of both this peaceful revolution and that in Tunisia last month. We hope that all of the dreams and aspirations of the masses of people involved are realized – freedom of speech, freedom for women and minorities, freedom from hunger. Thinking and reading about it brings tears of joy and admiration for these brave people. It is truly inspiring and encouraging to see this part of the world moving in the right direction. I feel that it may be wrong to have a post that dilutes this excitement with discussion of other topics, but take comfort in the fact that the papers, magazines, and blogosphere are talking about little else.

Unfortunately, at the same time it is sobering to think about how much, in the US, we are moving in the wrong direction (see Bob Herbert, “When democracy weakens”, NY Times, Feb 12, 2011). Politicians elected, with money coming from the wealthiest corporations and individuals, on the platform of promising to create jobs, do nothing of the kind (see Robert Reich, “The recession isn’t over until the jobs come back”, Kansas City Star, Feb 12, 2011. At the federal level, to the extent Congress is doing anything, it is giving money away to the richest and taking away from poor and working people. State legislatures are also focused on eliminating support for poor people, as well as oppressing immigrants and banning gay marriage – or any rights for gay people (see Charles Blow, “Repeal, restrict, and repress”, NY Times, Feb 12, 2011). And, of course, on further restricting abortion rights. Indeed, there are those in Congress who wish to eliminate Title X funding for contraception. Given that contraception is the most effective way to decrease the abortion rate, this seems bizarre, but only if you are into “reality-based” policy making.

Where is the good news in our country? We all know that there are lots of good people out there, doing lots of good things. In health care, much of the positive news is people pitching in, volunteering to try to fill the holes left by a health care system that does not, despite the Affordable Care Act (ACA), provide care for much of our population. One example is the JayDoc Clinic, an operation entirely run by students from the University of Kansas School of Medicine, featured in the Feb 12 Kansas City Star (“Student run JayDoc clinic serves the uninsured”). Great work, and a great article, but one result is going to be more people who are in need hearing about it, and further overwhelming the clinic. The JayDoc, like so many “safety net” clinics, is a “finger in the dike”, struggling to survive in providing basic care while billions are spent on what Don Berwick, currently head of the Center for Medicare and Medicaid Services (CMS) and his colleague Brent James at the Institute for Healthcare Improvement (IHI) call “rescue care”.

Meeting the basic health care needs of the really-needy is not only right and compassionate, but is likely to cost less (in dollars and pain) if it prevents serious illness later. Since this does not seem to be a focus of government, which is busy cutting taxes on billionaires like David and Charles Koch and cutting access to contraception, some progressive and thoughtful parts of the private sector have been creating models across the country. Many of these are detailed by surgeon and writer Atul Gawande in his article “The hot spotters: can we lower medical costs by giving the neediest patients better care?” (New Yorker, Jan 24, 2011).

Gawande examines several cities where efforts have been made to identify the sickest, neediest, and highest-cost-users of health care, and intervene to try to reverse or ameliorate the causes. Some of them, like the lead story of the program in Camden, NJ, are the result of hard and extended volunteer work, by Dr. Jeffrey Brenner and friends. Others, such as in Atlantic City, result from partnerships between existing institutions (in this case, a hospital and a union). None are the result of wise governmental leadership investing in these programs to reap a benefit of greater health and lower cost. In Red, Blue, and Purple: The Math of Health Care Spending, Oct 20, 2009, I discussed the implications of the fact that most people use little health care, and a small percent use most of it. Managed care in the late 1990s failed in part because it put major hurdles in the way of receiving health care for the large proportion of the population whose health care use accounted for a small percent of health care spending in any case.

The programs described by Gawande do the opposite; they identify the actual people who account for most of the health costs in these communities and provide services and support to help those people. In Camden, for example, 1% of the population – 1000 people – accounted for 30% of its costs. 900 people in two buildings (a nursing home and a low-income housing project) accounted for more than 4000 hospital visits and $200,000,000 in health care bills over a 6 ½ year period. And, as Gawande points out, Camden is not unique. There is no money for this from the public sector or insurance industry because it is being spent (in addition to insurance company profit and administrative waste) on “rescue care” for people with conditions that advanced so far because they never received sufficient preventive and primary care.

Public funds are also not being spent (indeed, as noted above, they are being cut) to support the myriad other “determinants of health”, social, economic, cultural and linguistic that are necessary for them to take advantage of preventive and primary care, to have the capability (Capability: understanding why people may not adopt healthful behaviors, Sep 24, 2010) of improving their health. Planning to achieve reductions in health care costs by “solutions” such as increasing copayments and deductibles so that people have “more skin in the game” are based on belief but not on facts. Gawande cites the experiences of benefit manager Verisk Health, which showed that such obstacles caused people to use less of all kinds of care – including primary and preventive care – until they finally got so acutely ill that needed to come to an emergency room, get admitted, go into an intensive care unit, so that costs in fact went up. One man “…had badly worsening heart disease and diabetes, and medical bills over 2 years in excess of $80,000. The man, dealing with higher co-payments on a fixed income, had cut back to filling only half his medication prescriptions for his high cholesterol and diabetes. He made few doctor visits. He avoided the ER – until a heart attack necessitated emergency surgery and left him disabled with chronic heart failure. The higher co-payments had backfired…” This outcome has been known for a long time; the RAND health insurance experiment in the 1970s and published in the New England Journal of Medicine in 1983[1] (see also: Joseph P. Newhouse, "Free for all?: lessons from the RAND Health Insurance Experiment", RAND 1993) showed that the opposite strategy – elimination of co-payments and deductibles -- resulted in higher utilization of health care; of both that which might be seen as “unnecessary” (colds) and that which was clearly necessary. And it saved money.

The interventions that have had success in Camden and other places were not “one size fits all”. Different people had different issues that required different interventions. Some were about poverty, some were about substance abuse or mental illness, some were about cultural misunderstandings or about language, and on and on. Interventions required more from nurse case managers for some people, social workers for others, physicians and nurse practitioners for others, and “health coaches” or promotoras for others. A lot of the latter; people who were familiar with the needs of the high-utilizer patients, who spoke their language, lived in their communities, and were often willing to “talk like [my] mother” to them.

And it is not always successful. But it is successful enough, far more successful than just pouring dollars into rescue care, that it needs to move beyond the limits that volunteers and a few forward-thinking institutions are constrained by. It needs to recognize the critical nature of teams, of integrating preventive and primary health care with basic social (and sometimes legal) services, with meeting core needs for food, housing and transportation that are all too often not even considered by policy makers. Funding is key; depending on volunteers in such efforts as these, or the JayDoc student–run free clinic will never come close to being a solution.

About Dr. Brenner’s program in Camden, Dr. Gawande writes “It remains unclear how the program will make ends meet”. In fact, these sorts of programs need to become the mainstream of health care and service delivery, and need to become the priority of federal, state, and local government.

[1] Brook RH, et. Al., “Does Free Care Improve Adults' Health? — Results from a Randomized Controlled Trial”,N Engl J Med 1983; 309:1426-1434.

Wednesday, February 9, 2011

Education in Medicine: The characteristics of future physicians

Education in Medicine: The characteristics of future physicians: "In my blog from 2/4/11 'Why do we put so much import on the MCAT?', I discussed some of the negative characteristics that can be associated ..."

Tuesday, February 8, 2011

Saturday, February 5, 2011

AMA response to "Outing the RUC"

In general, I do not post comments regarding "Comments" posted to my blog. I appreciate them, would encourage you to post them and will reply personally if asked and given an email address, but the nature of a blog does not really encourage dialogue among readers. This is because once you have read a post, you are unlikely to come back and check to see if there are any "comments" posted that you might wish to comment further on.

I am making an exception in this case to call attention to the comment from the American Medical Association.
They indicate that "The entire premise of this column is false." They note that "The RUC often recommends increases for primary care services; RUC recommendations have resulted in $4 billion in annual increased payments for office and hospital visits – the most common services performed by a primary care physician." I note that this is not entirely responsive; while the "office and hospital visits" are the most common services provided by primary care physicians, they are also provided by many subspecialists, and we don't know what % has gone to PCPs vs. subspecialists, nor do they indicate what % of Medicare physician payments $4billion is. The sources of my information are cited; also the data in the graphic showing that the ratio of subspecialists to PCPs is INCREASING, not DECREASING, is the important point. Indeed, the graphic here, from the recently-released 20th report of the Council on Graduate Medical Education (COGME) shows that this definitely affects entry into primary care.
Please add your comments if you wish.

Wednesday, February 2, 2011

Outing the RUC: Medicare reimbursement and Primary Care

Along with many others, I have written extensively about the need for more primary care physicians in the US. I have also addressed the various disincentives that exist for medical students to enter primary care specialties, such as family medicine, rather than narrower subspecialties or procedural specialties. One of these is the lower income earned by doctors in primary care; this is felt by many to be one of the major issues in specialty selection, and is increasing in importance as students graduate from medical school with larger and larger debt burdens, often exceeding $200,000. A study by the Robert Graham Center of the American Academy of Family Physicians (AAFP), “Income disparities shape medical student choice”, finds that the difference in income between primary care on subspecialists has been increasing since 1981, and that by now there is a difference of $3.5 million in the lifetime income of the average subspecialist (not even the most highly paid) and the average primary care physician.

So why is there such great variation in the reimbursement of different specialists? It is not on hours worked; many studies have taken this into account and found that on an hourly basis there is a great variation. The Wall St. Journal’s Anna Wilde Matthews and Tom McGinty, in “Physician panel prescribes the fees paid by Medicare”, describe a study done for the Medicare Payment Advisory Commission, MedPAC, that found a wide-range in per-hour reimbursement, from $101 for primary care physicians to $161 for surgeons to $193 for radiologists and $214 for dermatologists. It is not on the basis of length of training; all physicians go to medical school and the training, for example, for surgeons is considerably longer than that for dermatologists. Is it how hard the work is? After all, not everything is brain surgery. Well, to an extent, but there is considerable latitude in how “hard” is valued. What about “necessary to the health of a person” or “necessary to the health of the population”? Hardly. Let’s discuss this some more.

First, it is important to understand that the reimbursement paid to physicians by Medicare is essentially the basis for payment from all payers; contracts and reimbursements are almost always based upon multiples of what Medicare pays. Depending upon the size of the physician group negotiating with an insurance company, the particular multiplier may be greater or smaller, but Medicare reimbursement is the yardstick. Medicare payment itself is based on a formula that is primarily based upon the work that a certain activity involves, with several smaller modifications (regional variation, malpractice cost, etc.). This formula is described by health economist Uwe Reinhardt in his December 10, 2010 Economix blog for the NY Times, “The little-known decision makers for Medicare physicians fees”. Based on complex (or not) scenarios constructed for this purpose, the amount of “work” involved in over 7,000 “procedures” (for this purpose, “procedure” includes things like office visits of varying length and complexity) are assigned relative value; indeed they are assigned “relative value units” (RVUs).

But over time things change. A surgical procedure that might have taken a long time and required a hospital stay may now be done quickly in an outpatient setting. Counseling and managing several complex diseases in a primary care setting may take a lot more work and time. So the relative values may change, and reimbursement could go up or down for any of these “procedures”.

Except that, in order to keep Medicare spending from spiraling even more out of control than it has, the total number of RVUs has to stay constant. So when the number of RVUs (specifically, work-RVUs, or wRVUs) for one procedure goes up, those for others have to go down. Enter the RUC.

Several recent articles, included the Matthews and McGinty and the Reinhardt pieces cited above, have addressed the role played American Medical Association’s (AMA) Relative Value Scale Update Committee, or RUC, an organization most physicians, not to mention most other Americans, have never heard of. This group of appointed doctors makes recommendations to the Center for Medicare and Medicaid Services (CMS) about the relative amount that Medicare should pay for different physician activities. While not required to do so, CMS takes the recommendations of the RUC more than 95% of the time. While about half the services provided by physicians are in primary care, primary care doctors, according to an article in the New England Journal of Medicine by Washington state Congressman and physician Jim McDermott, “Harnessing our opportunity to make primary care sustainable”, only 6% to 13% of the 29 physicians on the RUC are in primary care. While they are supposed to be unbiased toward their own specialties, this does not seem to be what happens. Psychologically, even when they are trying to be fair, they know more about what they do and how “hard” it is than they do about what others do. Concretely, it may be easier to measure the work involved in “1 colonoscopy” or “1 gall bladder surgery” or “reading one chest x-ray” than the complex variation in primary care visits. In any case, the record demonstrates that RVU assignment, and thus reimbursement, has continued to go up for specialist procedures and thus down for primary care.

So we have a bunch of physicians, appointed essentially by their specialty societies, making recommendations on how much physicians should get paid, and a bunch of specialists deciding how to value what they do compared to what others do (certainly a conflict of interest, as defined by Howard Brody and discussed by me in The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010), and a tremendous dominance of non-primary care over primary care physicians among this group. Why should we be surprised that we get the results that we get?

More important, for the health of the American people, the decisions made about reimbursement drive what procedures are done and what activities physicians pursue. Since reimbursement is based on “work”, not “benefit” – to the individual or certainly to the population – we get the bizarre mix of health care services that we have. Writing in Kaiser Health News, Brian Klepper and David C. Kibbe, in an article titled “Quit the RUC”, note this:

“But there is a more insidious and destructive issue at hand. The perverse incentives that are embedded in fee-for-service physician payments influence care decisions and are a principal driver of the health system's immense excesses. Encouraged by the RUC, sometimes unnecessary specialty procedures may appear more valuable and appropriate than primary care services. The system pays more for invasive approaches, so conservative treatment choices that are lower cost and lower risk to the patient may be passed over, especially near the end of life. The resulting waste, half or more of all health care dollars, has fueled a cost explosion that has led the industry and the larger economy to the brink of instability.”

Different solutions have been proposed. Klepper and Kibbe suggest that the primary care professional groups drop out of participation in the RUC altogether (“Quit the RUC”). Reinhardt feels that there is value in getting advice from this independent group, but that CMS should be much more cautious about taking its recommendations. McDermott agrees, or suggests that at least the number of RUC members be adjusted or increased to include a much larger percentage of primary care physicians.

One or more of these solutions needs to occur. Most importantly, the solution needs to look at overall benefit when assigning reimbursement value. I considered titling this piece “Wreck the RUC” (alliterative and less offensive than the other obvious, rhyming, option). If we are interested in improving the health of the American people, we need more primary care doctors, and we need to address all the open and hidden factors that are in place to work against such change. The RUC is a good place to start.

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