Should family physicians leave the RUC?

Last June the American Academy of Family Physicians (AAFP) sent a letter to the AMA’s Relative Value Scale Update Committee (RUC) demanding specific changes to the ways that the RUC conducts its business. Primary care has been severely compromised by the RUC’s recommendations, and there was an implicit threat that the nation’s largest medical society would withdraw if the demands were ignored.

I co-authored a Kaiser Health News article in January 2011 calling on AAFP and other primary care societies to quit the RUC. The campaign was given real teeth when six Augusta, GA primary care physicians filed suit last June in a Maryland federal court against the US Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS). The complaint charges that those agencies have refused to require the RUC to adhere to the stringent requirements of the Federal Advisory Committee Act, which ensures that policy is formulated in the public rather than the special interest.

In early March, after the RUC rejected the AAFP’s demands, that society’s leadership caved. Then, in a letter to its members, AAFP President Glen Stream, MD argued that the best course is to remain tied to the group whose recommendations to CMS have, by AAFP’s own admission, devastated primary care over the past two decades.

AAFP’s leadership’s decision to remain in the RUC is seriously misguided. It’s isn’t just about its members, but about everyone harmed by CMS’ reliance on the RUC. It is certainly bad for primary care but, far more importantly, it is very bad for patients and for purchasers.

AAFP’s leaders and members should clearly understand that, after this period of deep consideration, their society’s active participation renders them party to and complicit with the RUC’s actions, including those that create incentives for unnecessary services, those that inhibit primary care’s moderating influence on specialty care, and those that undermine the development of an adequate supply of next-generation primary care physicians.

AAFP’s continued participation makes it partially accountable for patients who are exposed to the physical risk associated with unnecessary procedures, and for the excess cost borne by health care purchasers. The society can argue that it is not culpable, but to everyone outside the RUC who understands the impacts of its maneuvering, the AAFP now owns the RUC’s actions.

This didn’t need to happen. In his defense of the decision, Dr. Stream flatly states that “Withdrawing the AAFP from the RUC would not delegitimize the RUC,” as though this should be taken at face value. Really? AAFP counts more than 100,000 members, one-seventh of the US physician population handling perhaps one-third of all physician visits. Wouldn’t a highly orchestrated and publicized exit have impact or raise questions? If not, then AAFP is admitting that it really is impotent in public policy.

Dr. Stream notes that “None of the other primary care physician organizations were interested in leaving the RUC,” as though that’s a surprise. The American College of Physicians, the American Osteopathic Association and American Academy of Pediatrics are dominated by sub-specialists, and so have been content with the RUC’s approaches. The only question this raises is why, from a strategic perspective, the AAFP hasn’t seized the opportunity to embrace, consolidate and leverage the broader primary care’s community true strength, which would significantly enhance its policy position.

As America’s only pure primary care society, AAFP may indeed stand alone in the health care industry. Primary care’s empowerment would diminish revenues resulting from inappropriate services throughout the care continuum, so nearly every other health care group favors the paradigm that has dominated for the past two decades.

But the non-health care business community is larger and more powerful than health care, has carried a tremendous excess health care cost burden, and has every reason to stand with primary care. The National Business Group on Health was an active participant on the AAFP’s Primary Care Services Task Force. They and other business groups would undoubtedly respond to a request to rally, if asked.

Finally, Dr. Stream claims, “Important strategic political partnerships outside the RUC could have been damaged if we withdrew, and that could have harmed the Academy’s advocacy efforts.” This undoubtedly was the clincher, but it is questionable whether it makes sense to depend on allies whose collaboration requires the acceptance of egregious terms.

For 20 years, AAFP has been at the RUC’s table, and the lot of family physicians has eroded dramatically. The decision to stay means continuing with the same behavior and expecting a different result.

But it is worse than that. The AAFPs now moves forward with a group it has publicly acknowledged actively works against the interests of patients, purchasers and primary care physicians. It is very difficult to justify that.

Brian Klepper is Chief Development Officer of WeCare TLC and blogs at Care and Cost.

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  • Peter Elias

    The AAFP should leave the RUC. Or family physicians should leave the AAFP.

    Full. Stop.

    Peter Elias, MD

  • http://twitter.com/#!/CloseCall_MD Close Call

    Spot on.  Time to leave the RUC.  How much worse can it get?

  • Anonymous

    Knowing very little about the overall issue, the points Dr. Stream makes seem reasonable to me.  1/7th is a significant number, sure, and it would make headlines (well, it wouldn’t exactly make the front page of the New York Times); but de-legitimize the entire system?  I just don’t see that.  It might even be viewed by some to de-legitimize the AAFP.  Looking at the issue from the outside, I would view that as being a radical move, one not even supported by the majority of primary care providers.  There are good arguments for primary care rallying its forces against the RUC, but at the moment, the AAFP would stand alone.  On the fringe.  My question is the following; if the view of AAFP against the RUC is so right, and so just, and with primary care being as disgruntled as it is, why is it so hard to get everyone on your side?

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

    I am having a little trouble with the last statement. Are we saying that with the exception of FPs, all other doctors in the country are actively working “against the interests of patients”?

    Looking in from the outside as well, it seems to me that there is a concentrated effort to disempower all physicians – from the push to herd them all into employment in large institutions, to the push to dumb down and further specialize medical training, to the push to have mid-levels provide most care, and yes, even the push to control all clinical actions via technology regulations.
    I don’t quite see whose interests are served by fueling this dogfight over something that is presented as a zero sum game, although it is not.

    Yes, primary care should be paid a lot more than it is paid today, but if you look at how primary care is being redefined by policy, I would say that there are much bigger problems on the horizon other than the RUC. And physicians in other specialties must understand that primary care is just the canary in the mine; everything else will follow suit as “purchasers” take over the management of medical care. Do you think these new landlords will concern themselves with “interests of patients”?

    I think physicians need to get over all these petty differences and stand united in confronting the proposed destruction of medicine. It is in their best interest to do so, and it is in the best interest of their patients.

  • Glen Stream, M.D., M.B.I.

    In the interest of transparency, here is my message to AAFP members in its
    entirety.

    – Glen Stream, M.D., M.B.I.

    President’s
    Message

    We’re Changing Our Approach to the RUC

    AAFP Will Work Within the RUC and
    Directly With CMS

    By Glen Stream, M.D., M.B.I.

    Posted: 3/16/2012, 3:40
    p.m. – I recently had an office visit with one of my longtime
    patients, a 67-year-old, developmentally disabled man who we will call
    “Mike.” Mike is extremely personable and fairly independent, despite
    his limitations, and he rarely complains, which is remarkable considering that
    he also has a long list of chronic conditions:

    * diabetes,* hypertension,* hyperlipidemia,* chronic kidney disease;* cystectomy for bladder cancer; and* emphysema.

    Mike had come to see me for a
    follow-up appointment related to his chronic conditions. On top of those
    issues, however, he also had an acute cough that required an X-ray, and he was
    dealing with an acute psychosocial stress because his sister — his primary
    caregiver — had passed away recently.

    Mike’s scheduled 15-minute appointment stretched to 40 minutes, and his
    multiple health issues presented me with a dilemma that family physicians face
    every day. When dealing with evaluation and management (E/M) codes, we are only
    allowed to bill for four diagnoses, despite the fact that our patients –
    unlike, say, a dermatology patient who presents with a single problem — often
    have more than four issues they need managed.

    Evaluation and management codes, such as 99213 and 99214, are limited by
    Medicare billing rules. More importantly, they fail to reflect the complexity
    of our patients’ conditions, the effect one of those conditions might have on
    another, and the intensity of the services we routinely provide. It’s one of
    many factors that have left primary care physicians undervalued, underpaid and
    extremely frustrated.

    On March 12, the AAFP sent recommendations from its Primary Care Valuation Task
    Force to CMS, asking the agency to adopt a series of short-term strategies to
    improve primary care payment. During development of the recommendations, CMS
    had an observer in the room, and during a recent meeting with CMS Acting
    Administrator Marilyn Tavenner, B.S.N., M.H.A., she indicated she was eager to
    receive and consider our recommendations.

    The recommendations, which were developed by the Primary Care Valuation Task
    Force during the past seven months and approved by the AAFP Board during a
    recent meeting in Washington, include

    * new CPT codes — specifically for primary care — for
    E/M services,* valuation of these codes that reflects the intensity
    and complexity of primary care,* enhanced payment options for primary care physicians
    that are based on three definitional functions of primary care, and* payment for telephone and online E/M services.

    CPT codes typically are created by a
    CPT committee convened by the AMA. The AMA/Specialty Society Relative Value
    Scale Update Committee (RUC), which has historically undervalued primary care
    services, then makes recommendations to CMS regarding how individual CPT codes
    should be valued. By sending our task force’s recommendations on primary care
    payment directly to CMS, we sidestep the flawed RUC process.

    This is appropriate because we are asking CMS for short-term improvements for
    primary care payments to be included in the 2013 Medicare physician fee
    schedule, which is under development now. Going through the AMA’s process would
    not reflect the urgency this situation requires.

    Participants in the RUC process, including the AAFP, have been informed that if
    they participate in the RUC they are obligated to not go around it. However, we
    have informed the RUC and the AMA that we are advocating directly to CMS, and
    we will do what is necessary to improve payment for primary care services.

    So where does this leave us with the RUC? The AAFP Board decided this month to
    remain involved in the RUC — for now — but that participation will be subject
    to ongoing review.

    Last June, the AAFP sent a letter to the RUC, calling on the committee to make
    changes in its structure, process and procedures to more fairly represent and
    value primary care. Specifically, we asked the RUC to

    * add four primary care seats to the RUC, with one each
    from the AAFP, the American Academy of Pediatrics, the American College of
    Physicians and the American Osteopathic Association;* create three new seats to represent outside entities,
    such as consumers, employers, health systems and health plans;* add a seat to represent the specialty of geriatrics;* eliminate the three current rotating subspecialty seats
    when the current representatives’ terms expire; and* implement full voting transparency.

    The RUC’s response was inadequate.
    It agreed to add one seat for geriatrics and one rotating primary care seat.
    The RUC did not add seats for public members, and it did not eliminate rotating
    subspecialty seats. The committee made only minimal improvements in voting
    transparency.

    So why did the Academy elect to stay in? It wasn’t because we’re satisfied with
    the RUC’s past work or its response to our requests — we’re not. The RUC has
    been devastating to primary care.

    However, the Board made the difficult decision to stay in because of the belief
    that it is the best strategy to achieve our ultimate goal of better payment for
    family physicians. We will continue to work within the RUC to reform its
    processes while also working outside the RUC. We’re staying engaged, and we
    will continue to advocate changes that benefit family medicine.

    I realize this is an issue many of you are passionate about. Last year,
    multiple resolutions advocating leaving the RUC were introduced at the Congress
    of Delegates. There also is a group of primary care physicians involved in an
    ongoing lawsuit against CMS based on its relationship with the RUC. The
    decision to stay at the table within the RUC was not made lightly.

    Multiple factors played a role in the decision.

    * Important strategic political partnerships outside the
    RUC could have been damaged if we withdrew, and that could have harmed the
    Academy’s advocacy efforts.* If we withdrew, we would have gone alone. None of the
    other primary care physician organizations were interested in leaving the
    RUC.* Withdrawing the AAFP from the RUC would not
    delegitimize the RUC, which would continue to fill its family medicine and
    primary care seats while claiming that it has improved its representation
    for primary care through the new seats it is adding. We would, however, lose
    our chance to have a relationship with those representatives and to hear
    an insider voice on what happens on the RUC.*We cannot depend on the current level of support we now
    have from the administration and CMS. If things change after the November
    elections, we run the risk of losing our voice entirely if we’re off the
    RUC, and CMS, under a different administration, does not see our
    importance the same way.* Withdrawing or not withdrawing has no impact on our
    moving forward with task force recommendations to CMS. We are doing the
    same things now that we would be doing if we had withdrawn.

    Had the AAFP elected at this point
    to withdraw from the RUC, this dramatic statement may have gotten some fleeting
    media attention. But our strategic goal is to improve payment to family
    physicians, and that goal is best achieved by the dual approach of continuing
    to work within the RUC and directly with CMS.

     

    4
    Comments

    Brian
    Crownover

    3/22/2012 7:02 AM

    Appreciate the rationale
    explanation.  Please continue outside track.

    William
    Bodenheimer

    3/22/2012 7:34 AM

    Thank you for the above concise
    explanation.  It makes me feel better that you continue to work our
    situation both within and without the RUC.

    Wilson
    Moscoso-Donoso

    3/22/2012 12:11 PM

    Unfortunately, the decision of the
    AAFP board to stay on the RUC just reinforces the perception that family
    medicine can’t stand on its own feet. We are dependent on the good will of
    other specialties for our training, we need approval from other specialties
    to get privileges at hospitals and finally our payments are dependent on the
    RUC, where we have minimal representation. This is not a very good situation
    to be in.

    Thomas
    Allen

    3/23/2012 2:40 PM

    This explanation makes sense, especially with the added bit of
    rebellion!  Now, another dimension to the problem.  Insurance companies
    (Anthem as an example) pay a lower percentage of Medicare to primary
    care than to other specialists for the same CPT codes!  I thought the
    original goal of RBRVS was to level the playing field, but regardless of
    the RUC, etc. we get undervalued at other levels and in other ways.   

     

  • http://twitter.com/livewellthy Stewart Segal

    Working within the system has gotten us to where we are now; barely surviving.  Our leadership continues to hold onto the idea that by accepting the RUC under protest, they will ultimately succeed in changing it.  What they will accomplish is the mass exodus of their members.  It’s time to stand up and walk out.

  • Brian Klepper

    Several responses. Let’s start with my friend and colleague Margalit.
    No, of course I don’t mean to imply that all doctors are waging a war against patients. But most specialty societies that represent them and participate in the RUC actively advocate for higher reimbursement for the procedures they do, and that translates to incentives and over-utilization, which is well documented. See Paul Fischer’s MD article - 
    http://careandcost.com/2011/08/16/why-medical-specialists-should-want-to-end-the-reign-of-the-ruc/  – for a lucid explanation of the problem.Westeasterly, the AAFP’s exit from the RUC would not “de-ligitimize the entire system” but, with the right allies (e.g., large purchasing coalitions, like the National Business Group on Health and the National Business Coalition on Health) and the right publicity, would make the problem far better understood by rank-and-file Americans, who are very aware that their health care costs are crazy.

    The deeper point here is that the AAFP is not, in my opinion, very adept at the finer points of either negotiation or strategy, and their members and constituents have suffered as a result. Until they begin using the leverage they have at their command, they’ll continue to be out-maneuvered and bested by specialists, galvanized through the AMA. 

  • KevinMd100

    Read, “How the AMA Killed the Family Doctor” in “The Battle Over Health Care: What Obama’s Reform Means for America’s Future (Rowman & Littlefield, April 2012).  

    Health care reform built a house without a first floor — namely primary care.  http://www.battleoverhealthcare.org

  • pmfischer

    Dr Stream talked tough at the AAFP annual meeting about standing up to the AMA and leaving the RUC if the AAFP demands were not met.  His decision to stay in the RUC is gutless and foolish.  It shows that the AAFP leadership is more concerned about their political friends and careers than the public’s health or the organization’s members.  With bold action, the AAFP could have very easily become the leader of a second RUC that focused soley on primary care payment. Instead, Stream has clutched failure out of the jaws of success.  Even the AAFP’s role on the RUC is compormised by this embarassing decision and politicl misstep.  paul fischer md

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

     Oh, Brian. I think you just hit the nail squarely on its head.  The AAFP MUST become more adept at those finer points. I happen to think that the best venue is from inside, but this is not too terribly important.

    The AAFP, in my opinion, needs to impress upon the “industry” that their members are the only means by which health care costs can be contained while quality is at the very least maintained, and as such deserve extra consideration above and beyond the mundane mechanics of the RUC. I think Dr. Stream is on the right path, but I also think that a major public campaign is needed to get the public on their side.

    Americans will support their family doctors because these are the doctors that in most cases advocate for patients. This is the link that needs to be made, and perhaps it is not politically correct to say this, but the comprehensivist family doctor is all that stands between decent, personalized health care for all, and complete deterioration to a two tier system of excellent care for the few and a third world country model for the many.
    So instead of fighting the specialties, the AAFP should take its case to the public, not asking for more money, but asking for empowerment to continue caring and advocating for patients. The money will follow.

  • buzzkillersmith

    Abandon the RUC or continue to watch medical students abandon family medicine. Not that that will happen.  The AAFP’s honchos would lose out on a lot of interesting lunch meetings. Who’d want to risk that?

  • katerinahurd

    Can you help me understand the ambivalent relationship between the family practioner and the specialist.  Just by reviewing the members that comprise the RU committee, the number of specialist dominates any PCP.  How does this justify a PCP referal to a specialist?

  • http://twitter.com/redbirds12 John Key

    Doctors like to doctor–and not get involved in business, medical politics, and the like–and look where it’s gotten us!  Time to leave any medical organization that “sells us down the river”.  The idea of staying in to effect a change won’t work.  Time is short and the water rises.