(and How to Fix It) · •Question: Why would companies create these relationships unless there was a reasonable expectation that they would pay off? •Directly counter to FACA requirements

Brian Klepper, PhD CMS & The AMACMS & The AMA’’s RUCs RUC Page 1

The National The National Medical Home SummitMedical Home Summit

CMS & The AMACMS & The AMA’’s RUCs RUC

Brian Klepper, PhDBrian Klepper, PhD

How Primary Care How Primary Care Became the Job Became the Job

Nobody Wanted Nobody Wanted (and How to Fix It)(and How to Fix It)



• 31 physicians ‐

27 specialists & 4 PCPs

• CMS’

sole advisors on medical services valuation since 1992

• CMS has historically accepted 90+% of recommendations

• Commercial health plans typically follow Medicare’s payment lead

• Immense financial impact

• Not officially a Federal Advisory Committee.(FAC). Legal precedent that it is a “de facto FAC.”

The Relative Value Scale Update Committee (RUC)The Relative Value Scale Update Committee (RUC)



Specialist DominatedSpecialist Dominated

•Until March, PCPs comprised only 7% of panelists. PCPs are about 35% of US docs.

•Many specialties not represented –

including (incredibly!), until recently, Geriatrics.

•Chair Barbara Levy MD insists its an “expert rather than a representative panel.”

(WSJ)

•Directly counter to FACA requirements.

NonNon‐‐Representative Composition Representative Composition



Effectively A Lobbying OrganizationEffectively A Lobbying Organization

•Dr. Levy: “The work of the RUC benefits the entire Medicare

system and is done at no cost to taxpayers.”

–

i.e., AltruismAltruism

•Dr. Levy: “We assume that everyone is inflating everything when

they come in. They are wanting to fight for the best possible

values for their specialties.”

–

i.e., Lobbyingi.e., Lobbying

•Dr. Neil Brooks (FP): “If radiology presented a new set of codes that had to do with imaging procedures, there was a feeling that

some people would go along with that if radiology would go along

with other things.”

–

i.e., Horse Tradingi.e., Horse Trading

NonNon‐‐Representative Composition Representative Composition



SecretiveSecretive

Opaque ProceedingsOpaque Proceedings

•Proceedings are to develop recommendations that will determine the allocation of Medicare dollars.

•Attendance at RUC Meetings by the Chair’s invitation only.

•Attendees must sign a non‐disclosure agreement.




SelfSelf‐‐Interest Parading As ScienceInterest Parading As Science

Suspect MethodologiesSuspect Methodologies

•Self‐Selected Samples. Societies notify their members to participate in the surveys.

•Members know their responses will drive valuations and reimbursement levels.

•The RUC has accepted as few as 30 responses to drive valuation recommendations.




Panelists Have Financial Ties To Companies That Panelists Have Financial Ties To Companies That Could Benefit From RUC Decisions*Could Benefit From RUC Decisions*

•Dr. Levy: “The RUC has a strict conflict of interest policy for both those presenting to the RUC and for members. RUC members would recuse

themselves from discussion or voting on any issue related to a potential

conflict.”

•Proceedings closed to the public. We’ll have to take her word for it.

•Question: Why would companies create these relationships unless

there was a reasonable expectation that they would pay off?

•Directly counter to FACA requirements.•

*Poses, “Conflicts of Interest Affecting Members of the RUC,”Health Care Renewal, 4/26/11

Financially ConflictedFinancially Conflicted

http://hcrenewal.blogspot.com/2011/04/rucing-about-conflicts-of-interest.html



Real World Impacts of RUC InfluenceReal World Impacts of RUC Influence

1.

Over‐values specialty services while under‐valuing PC

2.

Inhibits PC’s moderating influence and accountability function over specialty services.

3.

Creates systemic incentives to perform more services, and more expensive services. (Specialists “practicing

to the codes.”)

4.

Payment disparities between PC and specialties. Crisis‐level PC shortage now.



Pt. Volumes Pt. Volumes ––

Primary vs. Specialty CarePrimary vs. Specialty Care

• Typical 2012 established primary care office visit duration = 7.5‐12 min. 30 years ago, it was 20‐25

• PCPs paid by visit, so may refer time‐consuming problems

• Most specialists profit from procedures

• Result: huge increases in specialty visits, outpt diagnostics, procedures



Payment DisparitiesPayment Disparities

Compare Primary Care Office Visit (99214) and Cataract Compare Primary Care Office Visit (99214) and Cataract Extraction with IntraExtraction with Intra‐‐Ocular Lens ImplantOcular Lens Implant

• 99214 – 25 Minutes and 3 Different Problems. Could be anything.

Palette is all medical knowledge. Medicare pays $111.36

• Cataract Extraction & Intra‐Ocular Lens Implant – 15 minutes.

Restores sight! 50 year old, low risk, repetitive procedure. Medicare

pays $836.36.

•• Hourly rate of Ophthalmologist pay is 12.5x PCP pay.Hourly rate of Ophthalmologist pay is 12.5x PCP pay.

• PCP’s job is arguably more complex/challenging.

Klepper & Kibbe, Rethinking the Value of Medical Services,

Health Affairs Blog, 8/1/11.

http://healthaffairs.org/blog/2011/08/01/rethinking-the-value-of-medical-services/







The average family The average family doc can expect to doc can expect to

earn about $10 earn about $10 million less over a million less over a

career than an career than an invasive cardiologist invasive cardiologist

or an orthopedic or an orthopedic surgeonsurgeon.



OECD Data, 2009, From the Incidental Economist, 10/22/10

http://www.google.com/imgres?hl=en&sa=X&biw=1024&bih=485&tbm=isch&prmd=imvns&tbnid=9WWqevsPmlc_RM:&imgrefurl=http://theincidentaleconomist.com/wordpress/how-do-we-rate-the-quality-of-the-us-health-care-system-%E2%80%93-infrastructure/&docid=Ifn7YJOTw



OECD Data, 2009, From the Incidental Economist, 10/22/10

Med Students Are Being Driven Away From Med Students Are Being Driven Away From PCPC

http://www.google.com/imgres?hl=en&sa=X&biw=1024&bih=485&tbm=isch&prmd=imvns&tbnid=9WWqevsPmlc_RM:&imgrefurl=http://theincidentaleconomist.com/wordpress/how-do-we-rate-the-quality-of-the-us-health-care-system-%E2%80%93-infrastructure/&docid=Ifn7YJOTw



Corrodes Medical ProfessionalismCorrodes Medical Professionalism

• Lucrative procedures encourage specialiststo “practice to the codes.”

• Physicians who own advanced imagers order them up to 6x more than those who don’t

• Stents are no more effective than “optimal drug therapy”

and lifestyle changes, and they

introduce significant risk/cost. Medicare spends $1.6 billion annually on drug‐eluting stents.

• Endless examples.



Procedural VolumesProcedural Volumes

Medicare spends a fortune each year on procedures that have no proven benefit and

should not be covered.

When a procedure…is not supported by evidence, …taxpayers should have no

obligation to pay for it.

Rita Redberg, MDEditor, Annals of Internal Medicine“Squandering Medicare’s Money”

NY Times, 5/25/11



Winners & LosersWinners & Losers

• Winners• Nearly Everyone in the Health Industry

(Except Primary Care)

• Losers• Patients –

Unnecessary Care and Risk of Harm

• Purchasers

(Employers, Taxpayers, Individuals) – Immense Unnecessary Cost

• Primary Care Physicians



The Law SuitThe Law Suit

• In August, 6 Augusta, GA PCPs filed suit in Maryland Federal

Court Against HHS & CMS.

• The suit challenges CMS’ longstanding reliance on the

RUC without requiring adherence to FACA.

• The case will probably go to trial and, possibly, because of

the stakes, to the Supreme Court.

• This is expensive. The docs are paying the legal

fees themselves.



Comparison with a Federal Advisory CommitteeComparison with a Federal Advisory Committee

Health Information Technology Health Information Technology Policy Committee (for ONC)Policy Committee (for ONC)

•Comprised of Volunteers

•Proceedings publicly available

•Methodologies sound

•Members must declare conflicts

Relative Value Scale Update Relative Value Scale Update Committee (for CMS)Committee (for CMS)

• Comprised of Volunteers

• Proceedings closed to public

• Methodologies highly suspect

• Conflict practices unknown

Kibbe & Klepper: “Trusting Govt: A Tale of Two Advisory Groups,”Health Affairs Blog, 2/2/12.

http://healthaffairs.org/blog/2012/02/02/trusting-government-a-tale-of-two-federal-advisory-groups/



Fighting The RUCFighting The RUC

•• Educate. Educate. Physicians, Purchasers and Patients need to understand the impact of the RUC on cost/quality. Feel free to

snag our stuff and write about it in your local newspaper.

•• Presentations.Presentations.

This is a great topic for Rotary and Chamber breakfasts. Watch the local manufacturer’s blood boil. Business Business

has every reason to support this!has every reason to support this!

•• Demand That The Primary Care Societies Quit the RUC. Demand That The Primary Care Societies Quit the RUC. They’re either conflicted by specialists or in thrall to the AMA.

If they don’t walk, you should.

•• Financial Support.Financial Support.

Help the Augusta docs fight this on your behalf.



The Reforms We NeedThe Reforms We Need

• CMS Should Sever Relationship With RUC.

• Replacement by a FAC, comprised of physicians, physicians, purchasers, patients, &

health economists

• Immediate recalibration of most frequent costly over‐

and under‐valued codes

• Better yet: scrap RBRVS and FFS for a value‐ based payment methodology



Brian R. Brian R. KlepperKlepper, PhD, PhD

is

a health care analyst and commentator. He is

Chief Development Officer for

WeCare

TLC, LLC, an

onsite primary care clinic and medical management firm based in Longwood, FL, and Managing Principal

of

Healthcare Performance Inc.,

a consulting practice based in Atlantic Beach, FL.

An active author and speaker, Dr. Klepper

has provided health care commentary to

CBS Evening News,

the Wall Street Journal, the New York Times, and

the Washington Post. He has published articles on

Kaiser Health News,

Medscape, Healthleaders, The New England Journal of Medicine, Modern

Healthcare, Business Insurance

and newspapers nationally.

In December 2010, he founded and now edits

Care & Cost, an online professional health care magazine.

He is a regular contributor to

the Health Affairs Blog

and other expert health care blogs. With his wife,

he also maintains Elaine’s Journey, which details their struggle against Peritoneal (Ovarian) Cancer.

Brian serves on the American Academy of Family Physicians’

Primary Care Services Valuation Task Force,

and is a reviewer for Health Affairs

and The Journal of Ambulatory Care Management. He serves on the

Board of

the Consortium for Southeast Hypertension Control (COSEHC), dedicated to translational

medicine for vascular disease.

He

is an Advisor to

the Lundberg Institute, the Patient‐Centered Primary

Care Collaborative, which advocates for medical homes,

and

the Center for Value Health Innovation,

which helps business identify and implement approaches proven to

improve quality while reducing cost.

In January 2011, with David Kibbe

MD, he began a campaign,

Replace the RUC!, that focuses on the

most important driver of inappropriate health care cost. That effort has resulted in a lawsuit by six

Augusta, GA primary care physicians against the US Centers for Medicare and Medicaid Services (CMS)

over its longstanding inappropriate relationship with the AMA’s Relative Value Scale Update Committee

(RUC).

Contact Brian at 904.395.5530 (o), 904.343.2921 (c), [email protected].

http://www.wecaretlc.com/

http://www.careandcost.com/

http://healthaffairs.org/blog/

http://www.elainewaples.blogspot.com/

http://www.aafp.org/online/en/home/publications/news/news-now/practice-professional-issues/20110720pcvaluetaskforce.html

http://www.healthaffairs.org/

http://journals.lww.com/ambulatorycaremanagement/pages/default.aspx

http://www.cosehc.org/

http://www.lundberginstitute.org/

http://www.pcpcc.net/leadership

http://www.pcpcc.net/leadership

http://www.vbhealth.org/

http://www.medpedia.com/users/68

http://www.replacetheruc.org/

mailto:[email protected]

Documents

(and How to Fix It) · •Question: Why would companies create these relationships unless there was a reasonable expectation that they would pay off? •Directly counter to FACA requirements