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Wednesday, November 21, 2007

The pathophysiology of primary care dwindels

There are two recently published sources of important information regarding a major cause of the primary care exodus. One is in JAMA ( JAMA,November 21, 2007) Vol.298,no.19, pg 2308, " The Unintended consequences of Resourced-Based Relative Value Scale reimbursement", Goodson, J.D.) and unfortunately as important as this is, you need a subscription to read it. The other source is free and we can thank The Happy Hospitalist for his insight.

The major cause is decreasing take home pay. This plus increasing third party requirements and mandates and the threat of malpractice and the perceived greener pastures of the non primary care branches of medicine add up to the perfect storm.

And the cause of the decreasing take home pay is the system of CMS payment fee schedule. What follows is a description of how the price controls on physician's fees are implemented. In 1992 the RBRVS was put into place allegedly to mitigate the payment gap between procedure type docs and those who just see patients. Over the past 15 years it seems to have had just the opposite effect.

These price controls seems to have disproportionately impacted the income of the primary care sector. Until recently I was not ware of the role the AMA and a group known as the RUC played in this story. The AMA web site give a rather sterile and uninteresting rendition of who and what the RUC is. It is a group that gives advice to CMS about the details of the price controls.According to the JAMA commentary, their "advice" is put into motion about 80 % of the time by CMS. The committee is disproportionately represented by surgical and other non-primary care physicians. Of the 30 members, 27 have no term limits and the meeting are not made public.The proceedings are said to be proprietary (the AMA owns the CPT (current Procedures and Terminology to which the RVU ( Relative Value Unit) systems is linked.)

"All animals are equal but some animals are more equal that others."

So the story seems to be that the "remedy" set up in 1992 to make more equitable the payments from CMS to procedure and non procedure physicians has been largely controlled by a group of physicians who do procedures and the gap between the two broad groups has now so widened that there is now much scurrying to leave a sinking ship.

To summarize and embellish. There are wage controls on physicians fees. These are implemented by CMS with advice and consent from a procedurist dominated, AMA sanctioned group, the RUC. The third party payers follow suit. Wage controls lead to shortages (of primary care docs who are disproportionately impacted ),poorer quality and increased waiting times. Every year the AMA goes to Congress to plead, beg and weakly threaten them to not cut the overall CMS funding by as much as proposed. This dysfunction "system" is not going to correct itself.

I make no claim to the "answer". One approach that resonates in my libertarian consciousness is that made by the American Association of Physicians and Surgeons. The following is copied from their website. It is basically an escape route away from the wage controls and favors individual choice over the current command and control arrangement.

H.R. 580 Seniors”Health Care Freedom Act of 2005, and
Say “NO” to Government Cookbook Medicine
“We oppose the various bills playing with the Sustainable Growth Rates (SGR), such as HR 3617, HR 2356, HR 1162 and S. 1574. Instead of changing the SGR, we support H.R. 580, the Seniors’ Health Care Freedom Act of 2005” that would allow the use of private contracts under the Medicare program. This is a win for patients, doctors and taxpayers as well.
“Our survey shows that 63% of doctors would be more willing to treat Medicare patients if unrestricted private contracts were allowed. Patients could pay doctors more than Medicare allows if they think the service is worth it. It would be up to the patient.”

I know ,the chances of something like that passing have to be slim to none and as Dan Rather was fond of saying, "slim just left town."Still it is good to dream of the day when physicians could join the other professions (lawyers,accountants, dentists, veterinarians,etc) who do not go to Congress every year to beg for crumbs.


Anonymous said...

i am not sure i follow the logic. the rvu's for procedures have declined over time while the rvu for clinic visits have increased. the differential is righting itself, if in fact that is the desired goal, despite the makeup of the group.
i certainly agree that the starting point favored procedurists. but the system will in fact accomplish the goal of reducing the income differential if it is allowed to continue.
so they can still claim they did it right. it just took 20 years

james gaulte said...

The differential between the relative "haves", ie procedurists and "have nots",ie non-procedurists may have decreased a bit.But,the take home fees for the non-procedurists has reached a real critical point at which
primary care docs are drooping out of the game and the proposed further CMS cuts may cause still more to retire early or do something other than primary care if they can.

The Happy Hospitalist said...

retired doc, thanks for the mention. It's nice to know someone is reading!

james gault hits the nail on the head.
Go to my blog. I graphed out my interpretation of the economics of the situation And if you don't have JAMA you can read any one of my many blog entrys over the last month to get a sense on exactly what JAMA said.

anonymous, the "narrowing of the gap" has been peanuts. It is a facade without meaningful change over the last 15 years.

But make no mistake, the RVU system is allowed to continue will kill off ALL of medicine, primary care and specialty care, by way of its constant attempts to place price limits. Prospective students will avoid medicine all together. Just follow my graph trend lines out another 15 years in your mind and you'll see what I mean.

So instead of more fairly equalizing reimbursment, RVU has alienated all physcians.


The only way, I see it to bring WIN-WIN back into the system is for doctor and patient to create the contract, to set the price based on market forces and let doctors compete with each other based on price and quality.

How many unhappy cosmetic surgeons or LASIK eye surgeons do you know about. And how many of their patients are unhappy.


Roy M. Poses MD said...

The details of how the RUC worked, and how it worked to the detriment of primary care, appeared in the Annals of Internal Medicine early this year. See: Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. The link is: http://www.annals.org/cgi/content/full/146/4/301

I first blogged about the RUC in March on Health Care Renewal (http://hcrenewal.blogspot.com) here:

I blogged again in May after another article appeared in the New England Journal of Medicine that explained some of the problems with the RBRVS system: Newhouse JP. Medicare spending on physicians - no easy fix in sight. N Engl J Med 2007; 356: 1883-1884. The link is here:http://content.nejm.org/cgi/content/full/356/18/1883
My blog post is here: http://hcrenewal.blogspot.com/2007/05/more-on-disparities-between.html

It seems very clear that 1) Medicare controls physician reimbursement for Medicare patients, and indirectly strongly influences all physician reimbursement, since managed care organizations and insurers tend to just go along. 2) The Medicare reimbursement rates in turn are heavily influenced by the RUC. CMS does not seem to get any other input on updating the RBRVS system. 3) The RUC is dominated by sub-specialist proceduralists. 4) The RUC seems to make no effort to get input from physicians in the trenches. As best as I can tell, the actual membership of the RUC is not published, although it is possible to figure who most of the members are.

This appears to be a terrible, unfair system, and the RUC appears to be one of the missing links that explain why US health care is such a mess.

james gaulte said...

Thanks you for your comments and a reminder about your blogs on this topic earlier this year.This reference gives a much more comprehensive explanation than I did.(http://hcrenewal.blogspot.com/2007/
I find it amazing how little is known and perhaps knowable about the RUC,seems like an organization that Agent Fox Mulder would be up against.

Anonymous said...

I agree with much of what's being said here regarding the damage done over the last 20 years by the RBRVS, I'm surprised there hasn't been more discussion of the 2007 CMS RVU changes.

Level 3 and Level 4 office based evaluation and management codes, in addition to the common inpatient evaluation codes, had substantial increases for 2007. Twenty to thirty percent increases actually. Yes, cuts elsewhere buffered some of that increase, but it still ended up, relative to procedural codes, being a not-insignificant step in the right direction.

Unfortunately, physicians aren't aware of the details of many of these increases and aren't pushing as hard as they should be for changes within their groups. Additionally, the private payors haven't seemed to follow suit, maybe due to existing contracts that need to expire, or maybe just due to lack of negotiating power and will on behalf of physician groups. (or both) Whatever the case, I think we should be emphasizing follow through on the important changes that have been made by the RUC and CMS regarding the RVU updates.

The system, for once, took a step in the right direction. Let's make sure the intended changes happen and keep the pressure on.

Anonymous said...

This link may be of interest: