Friday, July 13, 2012

Klepper makes the payment case clear

This is a very important article by Brian Klepper on Medscape.  It is entitled: "Will Anyone Listen When Former CMS Chiefs Call For More Objective Physician Payment?"  Pay particular attention to the parts about the committee that establishes the relative rates paid by Medicare to different kinds of specialists, a formula that affects virtually all private insurance companies as well.

There was a general sense that the RBRVS system was built on a series of errors, and that CMS' relationship with the RUC started off, to use Dr. Wilensky's term, "innocently enough," but has become increasingly problematic over time.

Tom Scully, CMS' Administrator under George W. Bush, took responsibility for helping facilitate the AMA's involvement and was perhaps the most passionate that it had been an error.

One of the biggest mistakes we made ... is that we took the RUC...back in 1992 and gave it to the AMA. ...It's very, very politicized. I think that was a big mistake...When you go back to restructuring this, you should try to make it less political and more independent.

I've watched the RUC for years. It's incredibly political, and it's just human nature...the specialists that spend more money and have more time have a bigger impact...So it's really, it's all about political representation, and the AMA does a good job, given what they are, but they're a political body of specialty groups, and they're just not, in my opinion, objective enough. So when you look at the history of it, CMS is starting to push back more, which is a good thing, I think it would be much better to have an arms-length transaction where the physician groups have a little more of an objective approach to it. And, look, that is the infrastructure of $80 billion of spending. It's not a small matter. It's huge.

But perhaps the most striking statement was made by Bruce Vladeck, HCFA Administrator during the Clinton Administration. In speaking about the problems generated by RBRVS (and by inference, the broader issues of SGR and the RUC as well) in the face of severe economic stresses, he called for the leadership and will required to simply do the necessary course correction.

I'm hopeful that some combination of the need to address overall deficit reduction strategies more generally and a different kind of political climate in the relatively near future will create the opportunity for people to say, "We made a mistake in 1997. We created a formula that produces irrational and counterintuitive results, and we're just going to abolish it and start all over again in terms of some kind of cap on Part B payments. It's the only way we're going to get out of this morass."

In a policy environment less susceptible to influence and more responsive to real world problems, the gravity of consensus on display at this roundtable would justify a call to action. As it was, it validated what many know: that we are rushing headlong down a catastrophic path, steered by forces other than reason and responsibility. The best we can hope for is that someone with authority and courage is listening.


Barry Carol said...

Since Medicare spending is growing more slowly than expected for the third year in a row, perhaps CMS could at least take responsibility for primary care reimbursement away from the RUC and just pay the PCP’s more. It probably wouldn’t be all that expensive in the scheme of things and there is a good chance that the primary care docs, if they had more time to spend with patients as a result of being paid more, they might reduce the need for referrals to high priced specialists. While clearly not as good a solution as finding a more objective way to determine reimbursement rates for all physicians, it could be a viable alternative in the short run given the political realities surrounding the issue.

PMC said...

Am delighted to see the RUC getting the attention that it deserves.

Absolutely incredible to me that the mainstream media hasn't taken this on given the importance.

Am delighted to see that the debate is starting and hope things escalate from here.

e-Patient Dave said...

The link to Brian's article on Medscape seems not to work, but based on the headline I think I found a copy on THCB.

For posterity I'll add what you know: this comes up because Washington Monthly finally brought a more public spotlight onto the issue, with Special Deal:
The shadowy cartel of doctors that controls Medicare.