A new organization for primary care

Recently, the Board of the American Academy of Family Physicians (AAFP) announced that, for now, it would continue participating in the Relative Value Scale Update Committee (RUC), the secretive American Medical Association committee that, through a longstanding relationship with the Centers for Medicare and Medicaid Services (CMS), has heavily influenced physician reimbursement.

At nearly the same time, Medicare announced that it will go broke in 2024, a decade sooner than expected and only 13 years away.

During the 20 year reign of the RUC, the average excess in lifetime earnings of specialists compared with primary care physicians has increased from $1.5 million to $3.5 million. Yet, the need for primary care has never been greater or its future foggier.

The organizations that should promote primary care must take some of the blame.

The AMA views itself as the champion for all physicians, but its activities have been central to the trouble in primary care. Its CPT (Current Procedural Terminology) editorial panel authors the language of medical business and has effectively detailed every procedure that physicians can get paid for.

The 400-page CPT book brilliantly articulates the subtle differences in the work of physician proceduralists. By contrast, the few pages devoted to all primary care have resulted in such obtuse and inadequate concepts as a 99214. There are no codes for the numerous coordination of care activities done in primary care, such as completing insurance drug prior approval forms. And no code, no payment.

The AMA is also responsible for the specialist-dominated RUC, which has consistently overvalued procedures while undervaluing primary care and which needs to be replaced.

Over time, the resulting financial incentives have led to a decimation of the primary care workforce and a wide spectrum of overutilized procedures.

Some consider the American College of Physicians (ACP) a primary care organization, but this is more a historical footnote than a present day fact. Only 2% of internal medicine residency graduates now plan to enter primary care. ACP’s large specialty base and smaller primary care membership make it conflicted.

Finally, there is the American Academy of Pediatrics (AAP). While residency graduates continue to have a strong interest in primary care pediatrics, like ACP, many of AAP’s members are sub-specialists rather than general pediatricians.

There was a time when the AMA ideal of a big tent for all physicians was possible, but American medicine’s evolution has made that untenable.

If Medicare cost-cutting uses blunt instruments, as it has in the past, primary care services must be separated from other procedures. A 10% across-the-board physician pay cut might affect a radiologist’s lifestyle, but it would force many primary care practices to close.

Since none of the organizations that should promote primary care have stepped up to lead, it is time for family physicians, general internists, and general pediatricians to form a new organization: let’s call it the American Primary Care Association.

Generalists have more in common with each other than ever before. We need an organization with bold leaders who are willing to acknowledge that the AMA’s big tent has been pulled down.

Paul Fischer is a family physician who practices at the Center for Primary Care.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.

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  • jsmithfan

    Where do I sign up and pay dues? As a general internist, I understand the inherent conflict within ACP and know that they can never really represent me. What I don’t understand is the AAFP leadership. Continuing to participate in the RUC and extolling the PCMH model after the disastrous TransforMED national demonstration project is asinine! Maybe the real world practicing FPs will jump ship from the AAFP and join in as well.

    • Fam Med Doc

      Dear jsmithfan,
      I agree w you & therefore am not a member of the AAFP. And why would I? That organization is lead by a bunch of spineless leaders with the subsequent decline of our reinbusement. Family Medicine & our brother & sister internists doing primary care are not supported by the rest of medicine in society. But speaking of which, nor is society as a whole supportive of primary care. Oh, they love our work but are more than happy to pay us peanuts. And this will not change, Obamacare or not, until primary care docs fight back. The AAFP could start by ceasing to support membership in the RUC & leading Family Medicine out of RUC’s stranglehold on our necks.

      But that won’t happen. I love my Family Medicine docs dearly & respect our work in the communities immensely but we are a bunch of namby pamby wimps which will continue to accept peanuts.

      • Primary Care Internist

        i agree with you. same is true for internists – as a group we are a bunch of wimps who take abuses from insurance companies, hospitals, patients, and other doctors without any regard for our own individual or collective self-esteem.

        in my previous primary affiliated hospital in suburban NY, a small 300-bed community hospital without a teaching program, internists rotated on-call responsibilities, absorbing the unassigned generally medicaid or “self-pay” patient admitted thru the ER, and keeping them on our service and responsibility and liability until discharge. This meant that, even if only on call once a week, you are essentially seeing patients for free every day in the hospital, patients that you couldn’t realistically use to build your private outpatient practice.

        Did the ENTs or surgeons or cardiologists or OB/GYNs do this for free? No, of course not. They demanded, and got, from the hospital payment for on-call whether they came into the hospital or not. An ENT i sublet office space to regularly got checks from the hospital for this, even though he was in his 70s and never ever set foot in the hospital.

        When i suggested to my other internist colleagues to collectively refuse to do on-call until we are paid too, this was met with a “gosh, we can’t do that” mentality.

        I don’t know how this is not discrimination. Seems to me that we should be paid AT LEAST as much as the specialists who don’t have to come in. The hospital gets subsidized by the gov’t for taking on patients that they know they won’t get paid for directly, then passes none of this onto us suckers.

        Needless to say, i dropped my admitting privileges and i hear the hospital is looking at hiring hospitalists, as they are having trouble filling out the call schedule. And their execs are still making high 6- and 7-figures.

        • Fam Med Doc

          When i suggested to my other internist colleagues to collectively refuse to do on-call until we are paid too, this was met with a “gosh, we can’t do that” mentality.

          Yup, that summarizes our stupidity quite well. Well said. And yeah, I stopped taking call too from the ER when I saw how much free work I was doing. Doesn’t matter. There are plenty of my colleagues who are willing to work for free.

          The best way the AAFP could advocate for our specialty is to urge it’s members to stop taking free call & cancel their Medicaid contracts due to crummy reinbursement (full disclosure- I don’t have a Medicaid contract cuz i would go BK if I did). Oh, and stop paticipating in the RUC.

          But let’s be honest: it ain’t happening.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    While I do applaud this effort to give primary care a voice in reimbursement reform, I do believe that there are much quicker and easier fixes that can be accomplished within the current system and could serve as a stopgap for grander changes.

    This is where I see the main point of entry:
    “There are no codes for the numerous coordination of care activities done in primary care, such as completing insurance drug prior approval forms. And no code, no payment.”

    As I recently wrote,
    http://thehealthcareblog.com/blog/2011/06/07/coordinating-care-coordination/
    adding CPT codes for specific care coordination activities should be a very simple thing to do. Getting the RUC, AMA, AAFP and CMS to back these changes (which do not adversely affect sub-specialists), should be much easier than an all out war, particularly since there is consensus regarding the need to raise primary care reimbursement.
    Sometimes, taking the pragmatic road (at least short term) will yield better results, although in a less spectacular fashion.

    • pcp

      I don’t think the problem is lack of CPT codes. There are already CPT codes for phone calls, team conferences, etc., but neither CMS nor the commercial carriers pay for them. Adding more CPT codes that are grotesquely underpaid (to the point of not covering overhead) or not paid at all won’t get us anywhere.

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        The current CPTs are way too cumbersome and restrictive to be useful, and although some payers will pay for them (I remember seeing a Texas Medicaid manual somewhere), it is very hard to get all the authorizations needed in place.

        You will have to somehow separate care coordination from the regular E&M because not all physicians coordinate care. My preference would be to have several levels of complexity (and expertise) that can be tagged to each office visit as needed and worth an extra $20 and $100 (or something like that) per visit – no special rules of how many per year or what particular circumstances.

        The alternative, as in the latest $42 million CMS demonstration project for FQHCs, is $6 per head per month. Probably enough to pay for automated phone reminders and/or postage stamps.
        You could of course just double the E&Ms across the board for primary care and call it a day.

        • pcp

          “You could of course just double the E&Ms across the board for primary care and call it a day.”

          That seems to be the quickest and most efficient way of dealing with the problem, so we’ll never see it! I’d pay for it by eliminating the “facility fees” that reward large organizations for being inefficient.

  • http://petereliasmd.com pheski

    Sign me up. I have already let the AAFP and their associated foundation for fundraising that they will receive neither $ nor support from me until the support me – which means leaving the RUC.

    Peter Elias

  • ray

    Very surprising or maybe not surprising that most physicians are unaware of this secretive RUC board and how powerful they are and how they decide the reimbursements. Probably more than 80% of docs have no clue how these are set up.
    Why is the process do opaque despite recent uproar about them?

  • solo fp

    Even with the RUC and value units for each CPT code, the difficulty is that 10 insurance companies will pay 10 different fees. My level 3 visits range from $39.95 to $75 for in network plans. Medicare is at $70, and 80% of the plans are at least 20-40% below Medicare fees. A way to fix primary care is to require a minimum payment for each office visit code.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      That’s a terrific idea!
      Should probably be the Medicare fee.

  • DRJEBJ

    The AAFP is failing us. I would join a primary care organization that promotes throwing government, insurance and big pharma out of our relationship with patients.
    Trying to get paid for filling out forms and talking to reveiwers on the phone is not the way to go. More bureacracy and additional codes? I don’t think so. Lower your prices and drop the insurance companies out of the loop.

  • jsequoia

    I’d join this new organization for sure. Those of us advocating for change always seem to feel like our representatives are spineless. I think people are afraid of change. This new organization needs a bottom up structure that allows for participation of young physicians and fire-bellies.

    We should also include the preventive health docs as good primary care is a lot of preventive care.

    My two cents. Let’s get the ball rolling.

    Jacqueline Sequoia MD MPH

  • American Medical Assn

    Dr. Fischer is incorrect: The CPT codes do describe coordination of care services including telephone calls, care plan oversight and team conferences, and the RUC has recommended values for these codes. The Medicare program has elected not to pay for these valuable services.

    The RUC is far from secretive – more than 300 attendees participate in typical RUC meetings. The March report from MedPAC noted that Medicare payments for primary care services have increased 20 percent since 2006 due in part to recommendations made by the RUC.

    As the nation’s largest physician organization, the AMA is dedicated to representing and supporting all physicians and medical students, regardless of specialty or practice type, throughout the stages of their career. The AMA helps all physicians in their everyday practice through educational resources and tools to handle interactions with health insurers, legal expertise, assistance evaluating and adopting health IT, and advocacy. One example of this is strong opposition to across-the-board cuts to Medicare, such as the failed Medicare physician payment formula known as SGR, which poses a threat to all physician practices and compromise patients’ access to care. The AMA has successfully staved off SGR cuts, which are currently the largest threat to primary care physicians, and is dedicated to ending the dangerous cycle of looming cuts and short term fixes.

    • Leo Holm MD

      So the AMA developed codes that no one will pay for. Why bother? Primary Care docs continue to get buried under uncompensated duties. Most doctors do not palpate the increases you mention. Perhaps the AMA means well, but it’s efforts do not translate into reality for the average Family Medicine doc.

    • Rebecca Coelius

      The AMA can provide all the lip service to primary care that it wants, but there are two simple truths that you cannot deny:

      1. The RUC has had a greater impact on payment for services rendered than any other individual actor.

      2. Payments to primary care physicians have increased at a fraction of specialists, and this income disparity is one of the #1 reasons given by medical students for not considering primary care, continuing to worsen a shortage already at emergency levels. The general opinion held can best be stated in a quote I saw recently on SDN, the major medical student online forum: ” Any med student considering primary care needs a head CT, STAT “.

      Now I am one of those primary care bound medical students, but some days I understand where my colleagues are coming from.

  • Doc99

    The sound you are hearing is that of Howard Beale’s window’s opening.

  • Anonymous

    Dear Doctors,

    In the UK there is a strong Association of GP and they belong to the Royal College of General Practioners. Thsi has a strong say in the pay, work timings and services Family Doctors/GPs provide. Should we not copy their system that has proven to work and will give us a strong voice in the American Health Care System?

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