Wednesday, May 25, 2011

CMS stifles primary care. Washington sleeps.

Brian Klepper and Paul Fischer take aim at the approach used by CMS to set rates for the various medical specialties. Thanks to ePatient Dave for leading me to this and for reminding me that this was a topic I covered last October, based on a report in the Wall Street Journal and insights from several of the doctors at my hospital. In short, a secret, unaccountable panel makes recommendations to CMS that favor proceduralists over cognitive specialists. These recommendations then get translated into the actual rates paid to the different types of doctors.

In their article on the Health Affairs Blog, Klepper and Fischer note:

We have focused on rallying the primary care and business communities to pressure CMS for change, and are contemplating a legal challenge. But the obvious question is why these steps are necessary. Why doesn’t CMS address the problem directly? Why does it continue to nurture the relationship?

So, while CMS is busy trying to revise impractical ACO regulations and also persists in avoiding pressure on its delegated agency, The Joint Commission, to make public the best practices of hospitals that pay funds to be accredited, it fails to act on this poor process and the resultant skewing of rates. And not a word about this from elsewhere in the Administration or the Congressional leadership.


Anonymous said...

For those who do not follow the arcana of Washington, it is important to distinguish this board, the Relative Value scale Update Committe, from the new board mandated by the Health Care Act and lately in the news, namely the Independent Payment Advisory Board.

The former one which you address, Paul, is a problem. The latter one, which addresses the question of how much Medicare should pay for things, is to be independent of Congress - which is causing the Republicans to try to kill it. Personally, I think this latter Board is a good idea.

On the Relative Value committee, I am not sure that CMS has the authority to get rid of it. One has to be careful with assuming where power lies in Washington.

nonlocal MD

Paul Levy said...

CMS has lots of authority to change the way it does business. It has to decide to want to.

Keith said...

The answer undoubtedly is that money speaks. Specialists who make much better incomes than primary care, have stacked the deck, and have much more disposable resources to effectively lobby congress to maintain the status quo.

Some years ago, CMS tried to change the situation by comissioning a study to look at the actual overhead costs of running a practice in the assortment of medical specialties. They outsourced the project to a private company who was unable to obtain the information because they met nothing but roadblocks from the specialty societies, and the project was abandoned. Since specialists largely spend the bulk of their time in hospitals, the cost and maintanence of an office is a much lower expense than outpatient endeavors, but hitorically, the piece of the RBRVS that takes into account physician overhead has been markedly overvalued for specialists. CMS simply let the project die rather than confront those who obstructed this study to determine if these overhead costs were correct.

Powerful interest continue to have a firm grip on the legislatiive process and will thwart change whenever it can. Hospitals, specialists, medical device companies, and pharmacuetical companies all make up a huge part of our economy withdovetailing interests, and all will be quite happy to have things stay the way they are.

clsmt said...

Until the AMA (the doctor's lobbying body) asks for this reform, it isn't going to happen. Since the members that fund the AMA best are specialists, I wouldn't hold your breath.

jonmcrawford said...

clsmt, disagree, if the American Academy of Family Physicians really pulled out, it would be a huge statement that others would take notice of.