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PCPs sue medicare over reimbursement disparity PCP vs subspecialist

Discussion in 'Family Medicine' started by tony montana, Aug 20, 2011.

  1. tony montana

    tony montana Dr. G-Spot
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    The battle against the American Medical Association (AMA)-led process that favors higher payments to specialists at the expense of primary care physicians (PCPs) is quickly escalating into a war, with the filing of a lawsuit in federal court by six Georgia PCPs.

    The lawsuit, filed in U.S. District Court in Maryland, maintains that the Centers for Medicare and Medicaid Services (CMS) and its parent agency, the U.S. Department of Health and Human Services (HHS), are in violation of federal law because they rely too much on the AMA’s Specialty Society Relative Value Update Committee (RUC) to set values for Medicare payments.

    “CMS has failed to realize that 20 years of AMA RUC control over the physician fee schedule has resulted in a process that is irrational, arbitrary, and absolutely destined to lead to the continued devastation of primary care,” the lawsuit states.

    The RUC was created in 1991 to make recommendations to CMS on the physician work component of the relative value units used to determine Medicare payments to doctors. The lawsuit, filed by physicians associated with the Center for Primary Care, a medical practice near Augusta, Georgia, claims that the RUC is an “unchartered and unofficial Federal Advisory Committee,” and thus is operating in violation of several laws, including the Patient Protection and Affordable Care Act passed last year.

    In the past, the AMA has maintained that the committee is just an independent group exercising its First Amendment right to petition the federal government.

    Plaintiffs point out that only two of the 26 voting members of the RUC represent primary care, yet the federal agencies “have relied and continue to rely upon the AMA RUC to make critical national policy determinations with regard to physician payment for primary care. This reliance continues despite 20 years of the AMA RUC’s failures to adequately address the disparity between payments and reimbursements to primary care physicians as opposed to specialist physicians.”

    U.S. Rep. Jim McDermott (D-WA), a physician who introduced legislation to require CMS to consider input from neutral third-party analysts in addition to the RUC when setting reimbursement rates, said the lawsuit “brings to light another important point—that reliance on the RUC is not only bad policy, it may also be a violation of federal law.”

    McDermott said that because of “distorted” Medicare reimbursement rates created by the RUC, “too many medical school students are choosing to become specialists because CMS pays specialists much more than primary care doctors,” which has exacerbated PCPs.

    In June, the American Academy of Family Physician (AAFP) sent a letter to RUV chairwoman Barbara Levy, MD, insisting that changes be made to the committee’s makeup so that its determinations would be fairer to primary care. Those changes included adding four more primary care seats to the committee.

    AAFP asked for a decision on those changes by next March, and, in July, formed the Primary Care Valuation Task Force to explore more appropriate ways to value evaluation and management (or E/M) services, the most common services provided by PCPs



    http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=736049&sk=19c7c2c13a03f808a03916f2fb024213
     
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  3. RPW

    RPW
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    I'm loving the AAFP right now! They're pissed and actually trying to do something about it!

    I wonder if the hotshots at CMS even knew we were mad?
     
  4. senseiturtle

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    +1


    I'm glad that the AMA is being exposed for what it is.


    As a student, I refused to join the AMA. Got a membership card a few weeks later. Actively quit 3 times. They continue to just sign me back up for the next year.

    Started residency, declined to join. Got a letter saying my "membership transferred successfully," with a new membership card. Quit again.


    They claim to represent "us." Yet, less than 20% of all practicing physicians are involved with the AMA. I'd imagine that over half overtly despise the positions that the corporation has taken. If it weren't for owning ICD-9 and charging exorbitant fees for insurance and medicare to use it, I'd bet the group would crumble.
     
  5. bronx43

    bronx43 Word.
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    I'm glad SOMEONE is actually trying to do something about this, even though I highly doubt something will actually come out of this.
    However, this is nothing more than trying to get a bigger share of the pie (not that there's anything wrong with that). Are PCP services undervalued? Are specialists overvalued? Who knows... whatever number they come up with is arbitrary anyways, given the lack of any semblance of a free market. It's just a pity primary care was ever in such a position.
     
  6. RPW

    RPW
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    I think it's an image problem.

    The general public(at least in my area) seems to view an fp as someone who did a year of internship and then went to work in a clinic.

    The problem comes from the grandfathering in of the gp's a couple of decades ago. Now... do I think it was wrong to make all of the oldschool gp's bc in fm? No. It was absolutely the right thing to do at the time.

    However I do feel that it has left us with a certain public preception that in no way correlates to our actual level of education and training.
     
  7. Sneezing

    Sneezing Even Bears do it!
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    If I were a judge I would through this out.
    -Physicians don't have to accept CMS patients. They can opt out or simply not sign up in the first place.
    -A medical student choses to pursue certain specialites. No one is coercing them into not applying to family medicine.
    -Family medicine residencies fill... even if it isn't 99% American grads like general surgery or Rad Onc. Saying people aren't going into primary care is a red herring argument.

    *Quit taking CMS, drop the low balling insurance panels and take cash. Doing so will put the problem back in the hands of CMS, and as they scratching their heads wondering where everyone went state your intentions for more representation and higher piece of the pie. The greatest bargaining chip for any employee (which is what physicians are making themselve by suckling from the government hog) is the ability to quit and walk away.

    This law suit just stinks of entitlement that is no different than the rest of society is exhibiting. Pick up your professional boots put them on and walk away.
     
  8. Blue Dog

    Blue Dog Fides et ratio.
    Physician Gold Donor SDN Advisor Classifieds Approved 10+ Year Member

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    The issue isn't limited to Medicare patients, as every commercial payer bases their fee schedule on Medicare. As for "walking away," a direct-payment practice is not as easy to establish or successfully operate as you seem to think it is, nor is it the ideal option for every doctor or every patient.
     
  9. bronx43

    bronx43 Word.
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    This isn't practical in the real world, nor does it make sense from any theoretical standpoint, either. As many attendings here will attest, cash practices are difficult to set up and only profitable in certain areas with the perfect clientele mix. The idea that a substantial portion of PCPs can do this and make more money is simply stuff of fairy tales.
    As far as the philosphical/theoretical perspective, you realize your argument works for ANY specialty - thus negating the system entirely. The system is set up so the number of providers perfectly (or almost perfectly) saturates the demand. Surgeons can "feel" slighted about their reimbursement for a cholecystectomy, and take cash only. So can cardiologists for caths, or anesthesiologists for anesthesia. If that is the case, why even have Medicare? So unless the federally appointed judge wants the demise of a large, publicly supported entitlement program, then he will not agree with your assessment.
     
  10. Obnoxious Dad

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    Doctors have always been free to walk away from medicare recipients. The question is whether the panel which sets fees has conformed with the law. Furthermore it has to be asked if the fees for primary care services have been set at such an unreasonably low level that patients can find physicians.

    It's probably true that almost all family practice residency spots fill. However, if you look at the fill rates in the match for 2006-2010, the match rate was only about 90%. This is somewhat low compared to many other specialties.
     
  11. Blue Dog

    Blue Dog Fides et ratio.
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    That's what was implied, however.

     
  12. bronx43

    bronx43 Word.
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    He meant cash only in his post. Either way, private insurers usually set their reimbursement at a percentage to Medicare, so you get short ended as long as Medicare rates remain stagnant.
     
  13. Sneezing

    Sneezing Even Bears do it!
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    However you mix it up it can work. Stop taking CMS and sign on specific panels. Charge your professional rates and if need be balance bill. Or simply do cash only. Yes, I say simply intentionally.

    Yes, any physician can chose to do this. However, most hospitals still list themselves as CMS excepting/billing facilities and most physicians still take it because it is still profitable. This point is tipping and soon physicians will be the first to drop it and secondarily will be facilities.

    Retainer practices can exist for as little as ~$100 dollars a month per patient. People pay more for their cell phones and cell plans. People spend almost that much for cable. A pair of designer jeans cost that much. Medical care is affordable especially on the primary care side of the equation and as long as people are stuck in their rigid boxes of thought we will continue to fly this plane into Mount Bureaucracy.
     
  14. bronx43

    bronx43 Word.
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    Again, this does NOT work on a macro scale. The idea that you can forgo $5-6 billion a year payed to family medicine from Medicare and expect to make MORE money as a whole is just ridiculous. The Medicare population in general does not have the disposable income to pay even $100 a month for primary care services.
    But, even if it was financially feasible, the government would never allow this. If physicians as a whole begin to shun Medicare patients, expect swift legislation to require taking Medicare or seeing Medicare patients to retain licensure (or something along those lines.) There will be no additional funding coming your way.
     
  15. Richie Truxillo

    Richie Truxillo Your Scut Monkey Mentor
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    Thanks for posting this, can't wait to see how this works out.


    I, too, never joined the AMA and never plan on it unless agendas change to include everyone. The amount of marketing spam they send to my house and practice is mind blowing though. They could have given me a free year membership for the postage they have paid on mailings by now. :smuggrin:

    Also, Blue Dog is right, concierge or retainer practices are difficult to setup and are very location/economy dependent.

    Have a good day at work fellas.
    -Rich
     

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