"Trouble Coming Every Day" as Discussed by our Fellow Health Care Skeptics

With apologies to the late Frank Zappa... even though we are going through the dog days of summer, the parade of health care troubles in the news is never ending, so I thought I would recap some of the more interesting issues discussed by some of my fellow health care skeptic bloggers.

We have discussed the ongoing decline of primary care. On DB's Medical Rants, Dr Robert Centor takes on the topic: "The system has, without consciously meaning to, held primary care in contempt." The result is a "quiet rebellion: of primary doctors.

We have discussed whether the currently fashionable idea of "accountable care organizations" (ACOs) might turn out to be a cover for health care oligopolies. See what Paul Levy, CEO of the Beth Israel/ Deaconess Medical Center said about them in his blog, Running a Hospital.

We frequently talk about the manipulation or suppression of clinical research studies by those with vested interests in the results pointing in a particular direction. On the Hooked: Ethics, Medicine and Pharma blog, Dr Howard Brody wondered why the FDA will not even reveal the identities of the clinical researchers who did the studies on which it based its decision to approve the Infuse bone growth enhancement device.

Prof Carl Elliott has done an outstanding job investigating commercially funded and implemented clinical research. Dr Brody reviewed his new book, White Coat, Black Hat.  In the Carlat Psychiatry Blog, Dr Daniel Carlat reviewed Prof Elliott's new article in Mother Jones on how a pharmaceutical company sponsored drug trial went badly awry.

We asked whether the former CEO of a for-profit hospital chain who resigned after the company paid a > $1.7 billion penalty to settle charges of fraud would be a proper candidate to be governor of Florida. After Rick Scott won the Florida Republican primary, Maggie Maher, writing in the Health Beat blog, took on Scott's dubious past as prologue to a worrisome future.

Well I'm about to get sick
From watchin' my TV
Been checkin' out the news
Until my eyeballs fail to see
I mean to say that every day
Is just another rotten mess
And when it's gonna change, my friend
Is anybody's guess

So I'm watchin' and I'm waitin'
Hopin' for the best
Even think I'll go to prayin'
Every time I hear 'em sayin'
That there's no way to delay
That trouble comin' every day
No way to delay
That trouble comin' every day
- Frank Zappa

Harvard Cut Money for Primary Care "Step-Child"

This story, about cuts in the funding for Harvard Medical School's minimal program in primary care, has received little attention in the US. I was alerted to an article about it in the Harvard Crimson by a news article in the British Medical Journal that was picked up by Medscape.

Here are the main points, from the Crimson article,

Harvard Medical School has suspended funding for its Primary Care Division as part of a broader departmental restructuring effort, prompting students and faculty to circulate a petition calling on HMS Dean Jeffrey S. Flier to reaffirm the School's commitment to primary care education.

According to Nancy J. Tarbell, dean for academic and clinical affairs at HMS, the School had provided roughly $200,000 in funding each year to the Division. She said that the Division, which has not been disbanded but whose structure and administration is being reviewed, will remain affiliated with HMS. The Division has always been funded exclusively by the Medical School, according to HMS spokesman David J. Cameron.

'The reorganization of this division is really a narrow administrative issue,' said HMS Dean of Medical Education Jules L. Dienstag. 'It has nothing to do with the commitment of HMS to primary care, which is unchanged, undiluted, and undiminished.'

Nevertheless, as of Thursday afternoon, over 450 individuals had signed the online petition, including students, residents, faculty, and physicians from HMS and its affiliated hospitals. The petition calls for the School's administration to present a detailed plan of action for expanding institutional support despite the budget cut, expand loan forgiveness initiatives that financially enable students to pursue primary care specialties, support efforts to strengthen primary care in a reformed national health care system, and solicit and implement proposals from the HMS community to improve primary care education.

The Division was previously part of the HMS-HPHC jointly administered Department of Ambulatory Care and Prevention (DACP), which Tarbell said was recently restructured and renamed as the Department of Population Medicine and placed solely under HPHC's administrative purview in order to better reflect its core research and teaching activities.

Tarbell, who seemed unclear about what actual services were provided by the Division, said that the HMS administration is conducting a 'comprehensive review' of the its programs and that the Division has historically been 'relatively small.'

'When you look at [HMS's primary care initiatives] as a whole, at the big picture, you can't make the argument that funding has decreased for primary care training at HMS,' Tarbell said, adding that the school is expanding its funding this year for a required third-year medical clerkship from $600,000 to $800,000.

But despite administrators' reassurances that primary care education remains a top priority at the Medical School, some students and faculty maintain that the cut sends a negative message about the School's priorities, which they say have traditionally centered on specialty medicine and research. And the petition expressed concern about the future of outreach activities previously coordinated by the Division, including a Primary Care Mentorship Program, if funding or a Divisional home were to be eliminated.

'Primary care, from the perspective of the Medical School, was sort of a stepchild [in the past], and not much was done to provide students with information about primary care careers or to connect them with role models in primary care,' said Susan Edgman-Levitan, executive director at The John D. Stoeckle Center for Primary Care Innovation.

'Harvard's goal has always been to create leaders in medicine, with regards to basic science and new developing fields. Primary care has never really been a major emphasis, although I think on a global basis, Harvard has put a major emphasis on reaching out to the rest of the world,' said Martin P. Solomon, an assistant clinical professor of medicine at the Brigham. 'People like Jim Kim and Paul Farmer are all very important and have had an enormous impact on primary care worldwide, but in our own backyard, Harvard has had very little impact. [Primary care] is not ... glamorous....'

Indicating where the medical school's priorities lie, during the month in which the cuts were announced, Dean Flier took the time to open, and thereby endorse the meeting of ACRE (the Association of Clinical Researchers and Educators). The grandiosely named group promotes unrestricted financial relationships among medical academics and health care corporations, and dismisses those concerned with the effects of these relationships (see our posts here and here).

It is true that the cuts in primary care occurred at a time of general belt-tightening, due to the sudden decline in the value of Harvard University's endowment. However, as reported in a muck-raking article in Vanity Fair by Nina Munk, even the reduced endowment is still the largest of any university in the US.

Furthermore, primary care generated relatively small costs to the university. However, as reported by Vanity Fair, the current financial crisis was generated on the University's tremendous building binge during the years the endowment seemed like it would grow forever:

... the university is facing the onerous financial consequences of over-building. Consider this: Over the 20-year period from 1980 to 2000, Harvard University added nearly 3.2 million square feet of new space to its campus. But that’s nothing compared with the extravagance that followed. So far this decade, from 2000 through 2008, Harvard has added another 6.2 million square feet of new space, roughly equal to the total number of square feet occupied by the Pentagon. All across campus, one after another, new academic buildings have shot up. The price of these optimistic new projects: a breathtaking $4.3 billion.

The University also rewarded the managers of the endowment with pay sufficient to make them very rich.

By the early 2000s, Harvard’s top moneymen were making as much as $30 million to $40 million a year. Finally, in 2003, seven members of Harvard’s class of 1969 wrote a strong letter of protest to the university’s president, Larry Summers. They spoke out loudly, publicly, informing any member of the media who would listen that compensation at Harvard Management Company was 'obscene.'

At other American universities, where investing money for the institution is regarded as a kind of public service, Harvard’s swagger raised deep suspicion. 'Harvard became a bunch of mercenaries,' the chief investment officer of another big private university told me.

Most of these managers decamped, taking the money with them, before the endowment value crashed.

By 2005, Jack Meyer had had enough. After 15 years at Harvard Management Company, frustrated by the circular fights about compensation, and sick of justifying himself to Summers and Rubin, he walked out and started his own giant hedge fund. Shamelessly, he took many of Harvard Management Company’s best people with him, about 30 portfolio managers and traders, along with the chief risk officer, chief operating officer, and chief technology officer. Harvard’s trading floor was decimated.

No one in the current or past Harvard leadership has yet been held accountable for the overspending that seemed predicated on the absurd (at least in retrospect) assumption that the endowment would continue to grow indefinitely.

At some point in the last five years, the men and women who run Harvard convinced themselves that the endowment would grow at double-digit rates forever. If Harvard were a publicly traded company, those people would have been fired by now.

Because of the case of the Harvard endowment, the US Internal Revenue service is reportedly investigating how university endowments were run (e.g., see Reuters).

But meanwhile, primary care, already a step-child, was cut.

The case of primary care at Harvard shows how the leadership of academia, and academic medicine in particular, has become entranced by the glamorous, the glitzy, the high-tech, and the prospects of wealth to be made by their pursuit, while neglecting the core academic and health care missions that are the reasons for the existence of universities and medical schools.

No wonder US health care is in a crisis. Those who want meaningful health care reform should find a way to push academic medicine to uphold its mission rather than enrich and glamorize its leaders, and to allow health care professionals to reaffirm their professionalism (regardless of past interpretations of US anti-trust law to the contrary).

ADDENDUM (5 August, 2009) - see more comments on Harvard's failed governance here on the ACTA Blog.

A Window on the Unworkable Settings in Which Physicians Practice

The Annals of Internal Medicine just published an important problem that helps explain why our health care crisis is so intractable. (Linzer M, Manwell LB, Williams ES, Bobula JA, Brown RL, Varkey AB et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med 2009; 151: 28-36. Link here.)

The article arose from the MEMO (Minimizing Error, Maximizing Outcome) study. The study included an initial cross-sectional survey and then longitudinal follow-up of 422 physicians, roughly equal numbers of family practitioners and general internists, in 119 different ambulatory settings in New York City, NY, Chicago, IL, Milwaukee, WI, Madison WI, and smaller towns in WI. The surveys asked physicians about their work-flow and time pressure, the pace of their practice (from calm to chaotic), their ability to control their own work activities, and five aspects of organizational culture (emphasis on quality, emphasis on information and communication, trust, cohesiveness, and alignment of values between physicians and leaders.)

The results showed how bad the practice environment in primary care/ generalist practice has become. Some important points were:

- More than half of the physicians (53.1%) said they needed more time to do physical examinations, and nearly half (47.6%) for follow-up visits.
- Almost half (48.1%) described the pace of their offices as chaotic.
- Substantial majorities of physicians thought their workplaces' organizational cultures were deficient, if not hostile.
- Only 23.7% thought there was a high emphasis on quality.
- Only 28.2% thought there was a high emphasis on communication and information.
- Only 30.6% thought there was a great amount of trust.
- Only 33.9% thought there was high work place cohesiveness
- Only 14.2% thought there was great alignment between the values of leadership and physicians.

So, to summarize, many physicians thought they did not have enough time to take care of each individual patient. Most thought their workplaces were nowhere near calm, and nearly half thought they were chaotic. Few thought that their workplaces emphasized quality or communication and information, or inspired trust or cohesiveness. Very few thought that their leaders' values were aligned with their professional values.

This blog has focused on problems with the leadership and governance of health care organizations. We have discussed leadership that is:
–Autocratic, or “imperial”
–Insulated
–Uninformed about health care context, indifferent to health care values
–Incompetent
–Self-interested
–Conflicted
–Corrupt
We have shown that the governance of health care organizations may be:
- Unrepresentative
- Unaccountable
- Opaque
- Not Subject to Ethical Standards
and that such governance facilitates and enables bad leadership.

I submit that the study by Linzer et al suggests how bad leadership can make the settings in which physicians practice unworkable. It may be that some of the time pressure that physicians face is due to the perverse incentives built into their pay schedules (e.g., see this post), and bureaucratic demands of insurers and government agencies. A fast paced and demanding environment is one thing, however, and a chaotic envirnoment is another. What else would explain chaotic work environments other than bad organizational leadership? Futhermore, how could well lead organizations ignore quality, and fail to inspire trust and cohesiveness? How could good leaders inspire four-fifths of the physicians to say the leaders of their organizations did not value what they value?

This article strongly suggests that we cannot fix the health care crisis simply by changing financing mechanisms or money flows. We can only improve health care by improving the leadership and governance of health care organizations, and by rethinking the size and scope of health care organizations. The most crucial part of health care is what goes on between individual health care professionals and individual patients. Yet our system is composed of endlessly enlarging bureaucracies run by self-interested, often clueless, and sometimes dishonest, if not criminal leaders. This must change, unless we want this crisis to get much, much worse.

The RUCkus Continues: Former Medicare Administrator Calls the "RUC Process" "Incredibly Flawed," and the AMA Chair Says He's "Inaccurate"

We have posted frequently about the role of the RBRVS Update Committee (RUC) in fixing the rates at which Medicare pays physicians. These payment rates have been much more generous for procedures than for "cognitive" services, (that is, services including interviewing and examining patients, making diagnoses, forecasting prognoses, recommending tests or treatments, and counseling patients.) Several authors have suggested that how the RUC fixes payment rates is a major cause of the decline of primary care. (See our previous posts on this here, here, here, here, here, here, and here and important articles by Bodenheimer et al,[1] and Goodson.[2])

An Interview with a former Medicare administrator

Health Affairs just published an interview(3) with Kerry Weems, a recent administrator of the US Center for Medicare and Medicaid Services (CMS) under the Bush administration, who had some remarkable criticism for the RUC.

Iglehart: The last question I wanted to ask you relates to the Specialty Society Relative Value Scale Update Committee [RUC] of the American Medical Association. The AMA formed the RUC to act as an expert panel in developing relative value recommendations to CMS. The twenty-nine-member committee essentially determines, through the relative values it establishes for the codes that form the basis of Medicare payments, how much doctors will earn from providing services to beneficiaries. In recent years the RUC has come under criticism based on the view that its specialty- dominated composition undervalues primary care services and, in some instances, overvalues specialty services. I have two questions, Kerry, regarding the RUC. You have been in government for twenty-six years; have you ever heard of an administration that has seriously questioned the RUC process, and whether CMS ought to somehow internalize it or delegate it to another body?

Weems: I think there is a general consensus that the RUC has contributed to the poor state of primary care in the United States. In many ways the supposition behind the RUC process, behind the whole relative value scale, is incredibly flawed. It's an input measurement system, so it asks, What's the cost of my inputs, and that's how I'm going to price my outputs. It has no relationship to perhaps the market value of what you might buy. So because it's highly procedure based, it's prejudiced against just standard primary care evaluation and management [E&M] visits, because in an E&M visit it's hard to document what happens in the same way that it is when you remove a mole, or perform some other procedure.

So the process itself is flawed. I don't think that we can make a change without a statutory change giving us the ability to do that. But it's something that is drastically needed. You know, it's funny that we talk about better coordination of care and creating the medical home. Well, the place where this can occur is in an E&M visit, which has been highly undervalued by the RUC.

Iglehart: You say that the RUC process is seriously flawed and needs to be overhauled. Was there ever any discussion during the eight years of the George W. Bush administration about doing that?

Weems: There were a number of discussions, but it's a hard nut to crack. Those discussions never ripened to the point where we could say we've got something better.

Iglehart: But you'd anticipate under the Obama administration that those discussions will continue?

Weems: Sure. And, you know, you can even see the early attempts at trying to crack that. Representative [Pete] Stark [D-CA] introduced last year the so-called CHAMP [Children's Health and Medicare Protection Act] bill, in which he proposed to develop a new payment approach that would have provided more money to primary care physicians. He split it up into several different categories. This probably wasn't the right approach, but again, he was trying to work through the problem, trying to provide more money for primary care. His heart was in the right place.

There are a number of important points here.

First, a former CMS administrator charged that the RUC has a substantial role in the decline of primary care in the US. Such charges have been made by well-reputed academics who have analyzed the role of the RUC from the outside. But as we have said before, aspects of what the RUC does are obscure, especially because the proceedings of RUC meetings are not made public. But now someone more directly involved has made the same charges.

Second, a former CMS administrator has called the "RUC process ... incredibly flawed." Even the second Bush administration felt these flaws were sufficient to have "a number of discussions," but found "it's a hard nut to crack." Hence he said that although there is something fundamentally wrong with the "RUC process," the government could not easily fix it.

Yet RUC leadership has repeatedly said that the RUC is merely a private advisory committee which gives recommendations to CMS using its rights to free speech and to petition the government. (Note also that above, Inglehart first said that the RUC was formed as "an expert panel" to make "recommendations." But then he said the committee "determines ... how much doctors will earn.") If the RUC is simply an advisory committee, and CMS did not like the advice the RUC was giving, why couldn't CMS leaders simply ignore the RUC?

Weems' remarks do not make sense if the RUC is merely an outside private group providing advice. But they do make sense if the RUC is acting like a government agency.

So this interview once again raises the question: why does CMS rely exclusively on the RUC to update the RBRVS system, apparently making the RUC de facto a government agency, yet without any accountability to CMS, or the government at large?

A response by the Chair of the Board of the AMA

Within days of this interview, Dr Rebecca Patchin, the Chair of the Board of Trustees of the American Medical Association (AMA), wrote a response to the Weems interview. (Amazingly, the response appeared as a blog post on the Health Affairs Blog.)

First, she implied that a former CMS administrator did not know what he was talking about when it came to the RUC.

In the interview, inaccurate statements were made about the role of the AMA/Specialty Society RVS Update Committee (RUC), which advises CMS regarding the relative levels of reimbursement for different medical procedures performed by physicians.

Now I feel like I am in good company. The leaders of the RUC have charged that I made inaccurate statements about the RUC as well (see post here).

However, Dr Patchin failed to identify any particular statements by Kerry Weems or his interviewer as inaccurate, much less provide any evidence to that effect. Note that while the RUC leaders also charged me with making inaccurate statements, they did not specify any particular statements as inaccurate, much less produce evidence in support of their contentions.

Next, Dr Patchin wrote:

Every time the RUC has been asked to review payments for E&M (evaluation and management) codes, the RUC has sent CMS recommendations that would lead to higher payments.

This may be so, but it ignores an important issue. While the RUC may have made some recommendations to increase payments for cognitive services, it has made many more recommendations to increase payments for procedural services. Furthermore, while payments for individual procedures went up, and the volume of procedures also went up, the global budget for physicians' services, called the Sustainable Growth Rate (SGR), resulted in across the board cuts. Since raises for procedures were larger and more frequent than raises for cognitive services, the net effect was that payments for procedures increased relative to cognitive services.

Even more important, it begs that question: what has the RUC done at times when no one asked it "to review payments for E&M ... codes?" After all, the RUC leadership has argued again and again that it is only a private advisory committee (and see below for another such argument). As such, it should be able to choose how often it deals with payments for cognitive services. It should not have to wait to be asked to review them. So why wasn't the RUC reviewing these payments more frequently?

Then, Dr Patchin reiterated:

To clarify: The RUC makes recommendations to CMS, and then CMS makes its payment decisions.

and again,

Bottom line: the RUC makes recommendations, CMS makes payment decisions.

This, once more, begs the questions. Why didn't the RUC make more recommendations to improve payments for cognitive services? Why doesn't CMS get recommendations about payments to physicians from sources other than the RUC? Why doesn't CMS make the process for setting physicians' payments, and updating and revising the RBRVS system more broad-based and transparent? Why did the administrator of CMS feel unable to change or ignore the "RUC process?"

I don't have the capacity to find out the answers to these questions. Answering them might take some investigative reporting, or even a Congressional investigation. Given that physicians' payments are key incentives driving the health care system, and that payments favoring procedures are likely to be a major cause for rising volume and costs of procedures, which, in turn, is likely to be a major reason our health care system is so expensive, why do we know so little about how these payment rates are set?

References

1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. Link here.
2. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. Link here.
3. Iglehart JK. Doing more with less: a conversation with Kerry Weems. Health Aff 2009; http://content.healthaffairs.org/cgi/content/full/hlthaff.28.4.w688/DC1

No Such RUC - The New England Journal Takes on the Primary Care Crisis, Sort Of

The vast amounts spent globally on health care do not seem to translate into access for many patients, quality care, and improved outcomes. The US, in particular, spends huge amounts, now more than $2 trillion a year, without getting universal access, or superb quality and outcomes. While we spend all this money, the primary care and generalist practitioners on the front lines of care are paid less and less, are increasingly embattled and disgruntled, and their numbers are rapidly thinning.

Although these problems are huge, there is not much clear discussion of them.

Thus, it was encouraging to see the vaunted New England Journal of Medicine, the premier US journal of medicine, take up the issue of the "future of primary care." A few weeks ago, the journal published a series of commentaries on the issue,(1-6) and the transcript of a round table discussion among their authors.(7) It was touted as the views of experts on "the crisis in U.S. primary care."

Unfortunately, although the series acknowledged some surface characteristics of the US health care system that have lead to this crisis, it did not delve further into its causes.

On the surface, a major cause of the crisis is that payments to primary care physicians are so limited that we are driving them out of business, while we pay lavishly for new, high-technology, often risky and invasive procedures.

However, understanding how and why this happens requires dissecting layer after layer of complex details. Doing so can be frustrating, if not eye glazing, and this may be one reason why the discussion of this pivotal issue has been so limited.

The first layer of complexity was implicitly acknowledged, but not discussed in the NEJM series. Bear with me through it.

The First Layer of Causation: Low Payments for Face-to-Face Visits, Rising Overhead

Physicians are paid for each encounter with a patient. Their pay only covers what they do in the presence of the patient, and not other efforts on patients' behalf, e.g., communicating with patients when they are not in the office, communicating with other professionals, paperwork required by insurance companies, etc, etc. Furthermore, pay for office visits is available only in a very small number of categories, and the pay for more complex visits is not commensurate with the increase in time and effort that they require, so that physicians who spend a lot of time trying to deal with complex problems will not be paid commensurate with their work. Pay for office visits has not increased as fast as inflation, and certainly not as fast as the expenses of running physicians' offices, i.e., office overhead, has increased. Thus, to try to maintain income, and to support increasingly complex office operations and overhead, primary care physicians must limit the time they spend with any one patient.

The result is the 15 minute visit for nearly all patients. But it is ridiculous to try to manage complex problems in 15 minute visits. Furthermore, primary care physicians spend hours of unpaid time doing paperwork, communications, etc.

The NEJM special articles dealt briefly with the contrast between how primary care physicians and proceduralists are paid, and the adverse effects of the 15-minute visit. The series coordinator, Dr Thomas Lee, noted that "procedure-oriented specialties offer higher potential incomes."(1) Dr Allan H Goroll decried the "current volume-driven, fee-for-service approaches," the "piecework payment system that perpetuates our 'hamster-wheel' environment."(4) Dr Thomas Bodenheimer asserted that primary care physicians are"overstressed by large patient panels." He blamed this on "the over-burdened 15-minute clinician visit."(3) He mentioned the 15-minute visit three other times in his commentary. In the round table discussion that accompanied the articles, he protested, "it's the tyranny of the 15-minute visit. If you come in to your practice in the morning and you see that you have 12 to 15 15-minute visits in the morning and another 12 to 15 15-minute visits in the afternoon, and you know you can't do it all in 15 minutes...."(7) Finally, in the round table discussion that accompanied the series, Dr Katherine Treadway offered the longest and most impassioned discussion, first explaining the problem,

Since I’ve been in practice a long time and I have an elderly, sick population, that for every hour of face-to-face time, I have another hour, at least, of time that I spend that’s unreimbursed. So, if I’m there for 13 hours, I’m getting paid for about 6 of the hours I’m spending.

and

The RVU system is ...designed for specialty care and single problems. There is nothing in the RVU system that allows you to take into account the fact that you’ve just seen somebody with congestive heart failure, hypertension, hyperlipidemia, coronary disease, renal insufficiency, and diabetes.

Why Are Payments Low for Face-to-Face Visits?

However, none of the commentaries addressed how we got to this pass, or, to continue the analogy above, none dissected the next layer. At best, they seemed to imply that this came about due to the forces of nature or an act of God. For example, in the round table discussion, Dr Lee said,

And I want to go to the payment system next. But do you think — I mean, which comes first, the chicken or the egg? Is it in the water and in the culture, in the educational values? And then the payment system may just reinforce that? Or is it the other way around, the payment system’s where it begins and that’s why it’s in the water?

To which Prof Barabara Starfield could only reply,

Unfortunately, it’s the chicken and the egg cycle. It doesn’t start in any one place.

The Role of the RUC

Actually, one can find the next layer of explanations in one place. The current bizarrely distorted manner in which physicians are paid was the act of people, a few people operating largely in the shadows.

The US Medicare system determines what it pays physicians using the Resource Based Relative Value System (RBRVS). This system determines the pay for every kind of medical encounter according to a complex formula that is supposed to account for physicians' time and effort, physicians' practice expense, and the cost of malpractice insurance. The components of physicians' effort assessed are, in turn, technical skill and physical effort; the required mental effort and judgment; and stress due to the potential risk to the patient.

To keep the system, which was started in 1990, current, requires addition of new kinds of encounters, which means encounters involving new kinds of procedures, and updating of the estimates of various components, including physicians' time and effort. To do so, the Center for Medicare and Medicaid Services (CMS) relies almost exclusively on the advice of the RBRVS Update Committee (RUC). The RUC is a private committee of the AMA, touted as an "expert panel" that takes advantage of the organization's First Amendment rights to petition the government. Membership on the RUC is allotted to represent specialty societies, so that the vast majority of the members represent specialties that do procedures and focus on expensive, high-technology tests and treatments. However, the identities of RUC members are secret, as are the proceedings of the group.

This opaque and unaccountable process has resulted in increases outstripping inflation in fees paid for procedures, while fees paid for "cognitive"medicine, i.e., for primary care, and for services that involve diagnosis, management of acute and chronic disease, counseling, coordination of care, etc, but not procedures, have lagged inflation. The effects of the RUC have been amplified by the unexplained tendency of commercial managed care and health insurance to track the RBRVS system when making their own payments to physicians.

For further details about the RUC, see these posts on Health Care Renewal (here, here, here, and here) and important articles by Bodenheimer et al,(8) and Goodson.(9)

The Unanswered Questions

Understanding this layer of the process raises some major questions, whose answers could help dissect the next layers.

• How did the government come to fix the payments physicians receive? Government price-fixing has not been popular in the US, yet this has caused no outcry.
• Why is the process by which they are fixed allowed to be so opaque and unaccountable? Why are there no public hearings on the updates, and why is there no input from practicing physicians or organizations other than the RUC?
• How did the RUC become de facto in charge of this process?
• Why does the AMA keep the membership on the RUC secret, and give no input into the RUC process to its general membership?
• Why is the RUC membership so dominated by procedural specialists? Why were primary care physicians, who made up at least a sizable minority of physicians when the update process was started, not represented according to their numbers?
• Why has there been so little discussion of the RUC and its responsibility for an extremely expensive health care system dominated by high-technology, expensive, risky and invasive procedures?

Of course, since the NEJM series failed to address the role of the RUC in the collapse of primary care, it could not raise, much less begin to answer such questions. The series mentioned the RUC only once, and virtually parenthetically, (by Dr Gorroll, who noted, "the current system "relies on the Relative Value Scale Update Committee [RUC] of the American Medical Association to set values for primary care services, despite the committee's marked overweighting in favor of procedural specialties...."[4]) Despite having written a key article explaining the role of the RUC,(8) Dr Bodenheimer was apparently only asked to write about practice innovations that could somehow compensate for continuing limits on the length of primary care visits.(3) It appears that it remains politically incorrect to question the RUC.

However, failing to understand, or even address the causes of the collapse of primary care will make it all the more difficult to find a way to revive it.

"Those who cannot remember the past are condemned to repeat it." attributed to George Santayana

References

1. Lee TH. The future of primary care: the need for reinvention. N Engl J Med 2008; 359: 2085-2086. Link here.
2. Treadway K. The future of primary care: sustaining relationships. N Engl J Med 2008; 359: 2086, 2088. Link here.
3. Bodenheimer T. The future of primary care: transforming practice. N Engl J Med 2008; 359: 2086, 2089. Link here.
4. Goroll AH. The future of primary care: reforming physician payment. N Engl J Med 2008; 359: 2087, 2090. Link here.
5. Starfield B. The future of primary care: refocusing the system. N Engl J Med 2008; 359: 2087, 2091. Link here.
6. Roland M. The future of primary care: lessons from the U.K. N Engl J Med 2008; 359: 2087, 2092. Link here.
7. Lee TH, Treadway K, Bodenheimer T, Starfield B, Goroll A. The future of primary care: perspective roundtable: redesigning primary care. Link here.
8. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. Link here.
9. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. Link here.

"An Impending Hurricane of Outrage" About the RUC?

We have posted a number of times, (most recently here, and see links to earlier posts) about the RBRVS Update Committee's (RUC) responsibility for Medicare's relatively poor payments for primary care and other "cognitive" physicians' services, compared to procedures. This imbalance has rippled through all of US health care, affecting how private insurers and managed care organizations reimburse physicians, and generally how the US systems favors procedures over talking, examining, thinking, diagnosing, prognosticating, deciding, and prescribing and super-specialization over generalism and primary care.

The RUC ostensibly is just an advocacy group sponsored by the American Medical Association, yet it seems to be the only source of outside input about physicians' reimbursement used by the US Center for Medicare and Medicaid Services (CMS). Given this influence, it is dismaying that it is secretive, unrepresentative, and unaccountable. Neither its membership nor proceedings are public. It is dominated by proceduralists and sub-specialists. It is unaccountable to US physicians, much less the general public.

We therefore recently commented skeptically about how CMS put the RUC in charge of setting physicians' payments for the patient-centered medical home (PCMH). The PCMH seems to be a newly fashionable concept for reviving primary care. It turns out a lot of other medical and health care bloggers were equally skeptical. In this post on the e-CareManagement Blog, Vince Kuraitis describes physician bloggers as "spewing venom" at the idea of the RUC determining how the PCMH might work. He linked to five blogs other than Health Care Renewal (and the Happy Hospitalist, to whom we linked in the post above), and then noted "you can add me to the list." His final question was, " Are these reactions just a few lone bloggers, or the first whispers of the impending hurricane of outrage? I suspect the latter."

Payments for the Patient-Centered Medical Home Mired in the RUC

We have posted a number of times, (most recently here, and see links to earlier posts) about the RBRVS Update Committee's (RUC) responsibility for Medicare's relatively poor reimbursement of primary care and other "cognitive" physicians' services compared to procedures. This imbalance has rippled through all of US health care, affecting how private insurers and managed care organizations reimburse physicians, and generally how the US systems favors procedures over talking, examining, thinking, diagnosing, prognosticating, deciding, and prescribing and super-specialization over generalism and primary care.

The RUC ostensibly is just an advocacy group sponsored by the American Medical Association, yet it seems to be the only source of outside input about physicians' reimbursement used by the US Center for Medicare and Medicaid Services (CMS). Given this influence, it is dismaying that it is secretive, unrepresentative, and unaccountable. Neither its membership nor proceedings are public. It is dominated by proceduralists and sub-specialists. It is unaccountable to US physicians, much less the general public.

CMS in its wisdom also put the RUC in charge of figuring out how physicians' practices participating in trials of the patient-centered medical home (PCMH) would be paid. The PCMH has gotten a lot of buzz lately. It purports to be the modern way to characterize a well-functioning primary care practice. Various powers that be that now want to support primary care seem only interested in supporting such care that fits the PCMH model. Yet putting the RUC, which seems to be the single most important cause of the decline of primary care, in charge of payment for this new version of primary care, appears to be a great case of putting the fox in charge of the hen-house. On the Retired Doc's Thoughts blog, Dr James Gaulte first pointed this out.

The RUC just released its report on how physicians providing medical homes ought to be paid. Now, on the Happy Hospitalist blog, this post dissected how the RUC came up with its recommendations, in all their mind-numbing detail. That blog summarized the results as "punching primary care in the face," and furthermore,

The payment rates that are recommended are insulting and downright degrading. Do they think nobody is paying attention? These people have no business trying to create public policy.

Unless I'm completely off base in my interpretation, if I was an outpatient doc, I would run faster than Forest Gump from this proposed financial disaster.

This is a reminder of what can go wrong with a "single-payer health care system," which is what Medicare is. When the government sets what physicians are paid, which is what happens in Medicare, (and de facto happens for our entire health care system, as private insurance companies and managed care organizations seem to slavishly follow the CMS' lead as engineered by the RUC), the government ought to provide a rational, transparent, accountable method of doing so. The current RUC based system is the opposite, irrational, opaque, and unaccountable. If we don't fix it, we can kiss primary care goodbye, with all the negative consequences that would entail. And further woe unto us if the calls for health care reform lead to "Medicare for all," with the RUC based system intact.

What Influences Advocacy for "Doctor Nurses?"

We have posted many times on the external forces battering primary care physicians (family physicians, general internists, and general pediatricians) in the US. Whenever new fervor for cost cutting arises, the tendency seems to be to call them in as the usual suspects. Thus, primary care doctors have seen their reimbursement lag inflation (see our post here and a post from DB's Medical Rants here), while they are subject to an ever increasing bureaucratic burden aimed at decreasing their supposedly wasteful and overly expensive practices. No wonder fewer and fewer physicians are going into primary care, and more are leaving. They can make much more with less hassle and a "better lifestyle" in other specialties, especially those based on procedures. Yet it is hard to see how our health care system can work with ever fewer, and ultimately no primary care doctors. Health care systems in other countries, which may produce results as good as or better than the US, are much more focused on and supportive of primary care. When no American has his or her own personal physician, who will be able to diagnose their less than obvious problems? Who will be able to manage their inter-related chronic diseases?

Instead of making primary care practice a more workable proposition, however, the current fad is to find other ways to do primary care that do not really involve primary care doctors. For example, an article in the Wall Street Journal addressed the idea of making nurse practitioners get doctorates (but not medical degrees, heaven forfend).

As the shortage of primary-care physicians mounts, the nursing profession is offering a possible solution: the 'doctor nurse.'

More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. The two-year programs, including a one-year residency, create a "hybrid practitioner" with more skills, knowledge and training than a nurse practitioner with a master's degree, says Mary Mundinger, dean of New York's Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings.

One wonders how much nurses will learn from this two year program which might be the shortest doctoral program ever proposed. Primary care physicians, of course, take four years (two mainly classroom, two mainly clinical) to get their degree, and then spend three or more years in post-graduate house-staff clinical training.

Nonetheless, Mundinger seems to imply all that extra training does no good.

A study led by Columbia's Dr. Mundinger and published in the Journal of the American Medical Association in 2000 showed comparable patient outcomes in patients randomly assigned to nurse practitioners and primary-care physicians.

Mundinger partially bases her advocacy of the "Doctor Nurse" on the assumption that nothing can or will be done to make it more possible for doctors to practice effectively in the primary care arena.

Dr. Mundinger, of Columbia, says the primary aim of the DNP is not to usurp the role of the physician, but to deal with the fact that there simply won't be enough of them to care for patients with increasingly complex care needs. As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

In addition to training in diagnostic and treatment skills, doctors of nursing practice can have hospital admitting privileges, coordinate care among specialists, help patients with preventive care, evaluate their social and family situations, and manage complex illnesses such as diabetes and heart disease, says Dr. Mundinger, who has been leading the effort behind the National Board of Medical Examiners' planned certification exam.

Note Dr Mundinger's acceptance (the use of the word "fact" above) that the decline of primary care physicians is inevitable. How well two years of training beyond the bachelors degree will prepare these advanced practice nurses to do what used to be done by doctors with at least seven years of training neither Dr Munginger or the article addressed.

In my humble opinion, the solution of our health care problems will not be the "delivery" of "primary care" by people with substantially less training than primary care physicians. The blog DB's Medical Rants has been thoughtfully addressing some of the misconceptions that may underlie this bad idea. One, which DB attributed to "suits" who control but do not really understand health care, is that primary care is basically simple, limited to care of minor acute illnesses and routine prevention based on guidelines. This ignores all the complexity and ambiguity and uncertainty that taking care of the whole patient entails. (See in particular the idea that primary care doctors must deal with the concept of the "long tail.") Primary care really involves dealing with less than obvious, often obscure diagnoses, coordinating management of complex and interrelated chronic illnesses, whose prognoses and response to therapy are difficult to predict, and dealing with intricate biopsychosocial issues. It may be harder and harder for primary care doctors to do these tasks, given that they are not paid to do many of their components, and they are besieged by conflicting and often nonsensical bureaucratic demands. But "doctor nurses" with much less training will find them even harder.

So why does this bad idea continue to gain traction? It may be that the influences behind its advocacy are not as straightforward as they seem. Let us revisit the WSJ article above, and particularly the advocacy of "doctor nurses" by Mary Mundinger.

That name should, in fact, sound familiar to Health Care Renewal readers. While Dr Mundinger is the Dean of the School of Nursing of Columbia University, she has some part-time gigs. In particular, she is on the board of directors of UnitedHealth Group , the large for-profit managed care organization and health insurer. As a director, she is supposed to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.] For that loyalty, by 2007 she had received (per the company's 2007 proxy) rights to acquire 345,930 shares of UnitedHealth, and in 2006 was paid $73,750 in cash and stock options valued at $412,575. That level of compensation might inspire some loyalty.

Presumably, it is in the interest of UnitedHealth to hold down what it pays for primary care. In fact, the company, like most other managed care organizations and health insurers, has gone along with the physician payment scheme used by Medicare, and de facto controlled by the shadowy RBRVS Update Committee, which has minimized payments to primary care, but paid for procedures much more lavishly (see post here). Thus Dr Mundinger's advocacy for primary care furnished by "doctor nurses," who would be less well trained and paid than primary care doctors, might serve UnitedHealth Group's interests.

But Dr Mundinger's loyalties seem even more complex than that. She has been known as a particular supporter of the former CEO of UnitedHealth, Dr William McGuire. A 2006 Pulitzer Prize winning article in the Wall Street Journal quoted her thus, "We're so lucky to have Bill. He's brilliant."

In fact, we posted often (see these posts here, here, and here from 2006 with links backward) about the hugely lavish compensation afforded to the Dr McGuire, and how this remuneration stood in stark contrast to the stated mission of UnitedHealth Group:

UnitedHealth Group is a diversified health and well-being company dedicated to making the health care system work better. The company directs its resources into designing products, providing services and applying technologies that:
- Improve access to health and well-being services;
- Simplify the health care experience;
- Promote quality; and,
- Make health care more affordable.

Controversy has swirled over the timing of huge stock option grants given to Dr McGuire (see post here), leading to his resignation in October, 2006 (see post here). More recently, McGuire agreed to pay back some of those options, although that would reportedly leave him with more than $800 million worth of options (see post here).

Dr Mundinger's support of McGuire lead two advisory firms, Institutional Shareholder Services (ISS) Inc. and Proxy Governance Inc, to suggest that institutional investors not vote for Mundinger in the 2006 election for UnitedHealth board members (see post here.) Thus, she seems better known for her personal loyalty to the CEO whom she was supposed to supervise than her unyielding loyalty to UnitedHealth Group's stockholders.

To make things even more complex, Mundinger also is a member of the boards of directors of Gentiva Health Services, and Cell Therapeutics Inc. Gentiva Health Services provides home care services. Cell Therapeutics Inc is a biotechnology company that develops cancer treatments. Per its 2008 proxy statement, Dr Mundinger received $127,531 in total compensation from Gentiva Health Services in 2007, and has received options to purchase 10,090 shares of its stock. Per its 2007 proxy statement, Dr Mundinger received $92,865 in total compensation from Cell Therapeutics Inc in 2006, and has received options to purchase 23,750 shares of its stock. Thus she has reason to have unyielding loyalty to the stockholders of these two companies. However, these companies' interests, to maximize profits from home care services, and to maximize profits from cancer treatments, conflict with the interests of the UnitedHealth Group to minimize what it spends paying for these services and treatments.

So trying to figure out the influences behind Dr Mundinger's prominent advocacy of "doctor nurses" is well nigh impossible. Dr Mundinger has an amazingly complex set of conflicts of interest. So where do her interests lie? - Improving clinical care and promoting clinical science and teaching (the academic mission of her nursing school)? Increasing UnitedHealth Group's profits by decreasing its payments for health care? Increasing Gentiva Health Services' profits by increasing the payments it gets for home health services? Increasing Cell Therapeutics Inc's profits by increasing what it gets paid for cancer therapies?

And that is, as we have said before, the curse of conflicts of interest in health care. Conflicts lead to confused thought, speech, and action. One cannot tell what interests lie behind the speech and actions of the conflicted. So health care policy advocacy by the conflicted, rather than leading to better health care for all, just leaves us in a fog of doubt and confusion.

But financial ties to various industries, regardless of the conflicts they produce, fuel the imperial pretensions of their academic health care institutions' leadership (see post here). So the universities and their leaders will not give up their conflicts without quite a fight. But the confusion about clinical care, about research, about health policy that swirls out of the ever more pervasive web of conflicts in health care means it's time for that fight to start.