Why the Accuracy In Medicare Physician Payment Act should pass

With the recent release of two mainstream exposes, one in the Washington Post and another in the Washington Monthly, the American Medical Association’s (AMA) medical procedure valuation franchise, the Relative Value Scale Update Committee (RUC), has been exposed to the light of public scrutiny. “Special Deal,” Haley Sweetland Edwards’ piece in the Monthly, provides by far the more detailed and lucid explanation of the mechanics of the RUC’s arrangement with the Centers for Medicare and Medicaid Services (CMS). (It is also wittier. “The RUC, like that third Margarita, seemed like a good idea at the time.”)

For its part, the Post contributed valuable new information by calculating the difference between the time Medicare currently credits a physician for certain procedures and actual time spent. Many readers undoubtedly were shocked to learn that, while the RUC’s time valuations are often way off, in some cases physicians are paid for more than 24 hours of procedures in a single day. It is nice work if somebody else is paying for it.

Two days after the Post ran its RUC article on the front page, it reported that the AMA is already visiting Congress in force, presumably to protect its role defining the value of medical services for Medicare. The question now is whether Congress will take steps to remedy the situation.

It won’t be easy. In January of this year, a federal appeals court upheld a lower court ruling, rejecting a legal challenge by six Augusta, GA primary care physicians to CMS’ longstanding reliance on the RUC to determine the relative value of medical procedures. The core of the physicians’ argument was that the RUC is a “de facto” federal advisory committee and therefore subject to the common interest rules associated with the Federal Advisory Committee Act (FACA). FACA requires, for example, that a panel’s composition , say of medical specialists, reflects their distribution in the real world. It also requires that applied scientific methods are credible and that proceedings are conducted transparently.

The RUC has flouted these principles, and operated opaquely. The RUC’s Chair, the AMA’s CEO and 47 medical specialty societies have also publicly dismissed the idea that other stakeholders in the cost process — e.g., patients, purchasers (like health plan representatives) or health care economists — should participate in valuation activities. Their stated view is that only physicians can understand what the rest of us should pay for care.

The court’s ruling effectively meant that the RUC’s position is all but unaccountable and unshakeable. So now we are down to the nub. Only Congress can alter the RUC’s status by requiring it a follow FACA’s rules.

A bill introduced last month by Rep. Jim McDermott’s (D-WA) would require just that, providing an important first step toward fiscal responsibility in American health care. The Accuracy in Medicare Physician Payment Act (HR 2545) would bring the RUC under FACA’s transparency rules, and provide Medicare with external expertise, including from non-physicians, to objectively evaluate the RUC’s recommendations. Passage would be a clear statement by Congress that it seeks an end to special interest favors that have driven egregious levels of health care waste for decades.

Rep. McDermott, a physician himself, has taken a bold position here, but it remains to be seen whether his colleagues will stand by him. No doubt the RUC’s recent negative press has exerted some pressure on Congress to meaningfully address a serious problem for the American people. Getting a bill passed, though, will require overcoming the intense resolve from medical specialty societies and the corporations that support them to maintain their very lucrative status quo.

Brian Klepper is chief development officer, WeCare TLC, and blogs at Care and CostPaul Fischer is a family physician.

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  • openyourmind

    “Their stated view is that only physicians can understand what the rest of us should pay for care.”
    There are lots of healthcare folks who know and understand how the system works. We can use them too. Physicians are just one part of he healthcare umbrella. We can get more disciplines involved and increase accountability. It will happen.

    • drgn

      this is a serious political problem not a matter of who is competent to understand the system..

      • openyourmind

        Okay. There are still all kinds of healthcare professionals who need to be involved. I don’t care who they are – that has nothing to do with politics. But I understand what you are saying. I know physicians use “politics” to stay in control. As a patient, I don’t like it. I want other voices involved. And that is happening.

        • drgn

          Sadly, I don’t see non-specialist MD’s or any other credible voices being given the power to change this very entrenched system. I have been following this for awhile and it seems pretty hopeless.

          Or let’s put it this way. I think it is about as likely as banks paying back all the homeowners they foreclosured.

        • rbthe4th2

          They not only use it that way but to blacklist to keep people in line. People have said they are afraid to complain BECAUSE of what docs will do to them.

  • drgn

    Unfortunately, immediately after the RUC articles broke in the WashPost, WashMonthly and Time, Modern Healthcare reported that the AMA deployed an army of lobbyists to defend their policy position with Congress. I wish there was a way to out lobby them but at the present moment it sucks to be in primary care.

    • drgn

      What would Tinsley Randolph Harrison say – The founding editor of Harrison’s Principles of Internal Medicine?. Or William Osler? No doubt rolling over in their graves.

  • American_Medical_Association

    The AMA convenes a group of volunteer physicians to provide input to CMS’ decision-makers on the resources required to care for Medicare patients. By tapping into the front-line knowledge of this expert physician panel, Medicare gains credible insights into the complexities of patient care at no cost to taxpayers.

    While everyone is free to respond to the government’s call for public feedback on the Medicare program, the AMA panel applies an evidence-based approach for making objective recommendations that have long garnered the praise of government officials from both sides of the aisle.

    The AMA ensures transparency of the panel’s recommendations by making data and rationale publicly available and CMS has a seat at the table during panel discussions. And while the panel submits recommendations to CMS for consideration each year, the agency is not obligated to accept them.

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

      It all depends on how you define “cost to taxpayers”, doesn’t it?

    • drgn

      “The Lady Doth Protest too much as Shakespeare would say.

      You are doing an excellent job of lobbying. And here is yet another fine example. Why look this is yet another example here on KevinMD. Why you have found my post within an hour. Good job. You might want to change your wording since you seem to have the exact same post on all these blogs.

      • buzzkillerjsmith

        AMA boilerplate is par for the course.

        The RUC is rotten to the core, as is the AMA of course. All of us know this. It is interesting that the mainstream media are now paying some attention. When Obamacare hits big time, we can expect more stories on this stuff.

        I urge readers here to read the Post and Monthly articles, especially the latter. It actually gave me a few chuckles in addition to the info. Interesting how the inventor of the RBRVS knew 20 years ago that it had been captured by the AMA and thus turned into a gigantic scam.

        Back in buzzkill mode, I say nothing will change for the better. I have embraced the despair.

        • drgn

          I agree the monthly article was spot on. I also hope something changes but I’m rather skeptical myself.

    • LesCarter

      This response makes it sound like you, AMA, are reasonable enough to feel the proposed law would pose no problem. Is the post by Klepper and Fischer mistaken about your stance? What’s mentioned about applying FACA rules to the RUC wouldn’t pose a real problem. So you can lobby your way out, or maybe you could implement some changes that pre-empt the proposed law.

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