Fixing America's Health Care Reimbursement System

First published 3/3/11 on Kaiser Health News

A tempest is brewing in physician circles over how doctors are paid. But calming it will require more than just the action of physicians. It will demand the attention and influence of businesses and patient advocates who, outside the health industrial complex, bear the brunt of the nation's skyrocketing health care costs.

Much responsibility for America's inequitable health care payment system and its cost crisis is embedded in the informal but symbiotic relationship between the Centers for Medicare and Medicaid Services and the American Medical Association's Relative Value System Update Committee -- also known as the RUC. For two decades, the RUC, a specialist-dominated panel, has encouraged national health care reimbursement policy that financially undervalues the challenges associated with primary care's management of complicated patients, while favoring often unnecessarily complex, costly and excessive medical services. For its part, CMS has provided mostly rubber-stamp acceptance of the RUC's recommendations. If America's primary care societies noisily left the RUC, they would de-legitimize the panel's role in driving the American health system's immense waste and pave the way for a more fair and enlightened approach to reimbursement.

Replace the RUC

A few weeks ago, my writing partner David C. Kibbe and I ran an article on Kaiser Health News called “Quit the RUC!“ that has caused some turmoil within the physician community, particularly in DC.

First, it noted that the RUC, the informal specialist-dominated AMA panel, has made recommendations for 20 years about the value of medical procedures within the highly arcane and jiggered Resource-Based Relative Value Scale (RBRVS). As the Wall Street Journal recently reported, CMS (and its predecessor, HCFA) has accepted some 90 percent of its recommendations, apparently almost without question. It shouldn’t surprise anyone that the vast majority of recommendations involve payment increases to specialists that have come at the expense of primary care.

The Politics of Scarcity

Larry Arrington and Brian Klepper

First published 2/11/11 on Kaiser Health News

Medicaid, along with debt and shortfalls in public pension funds, is driving state and local governments toward budgetary disasters. The ways we cope with this fiscal crisis will test our political system and our national character. Political expediencies could further compromise the lives of the sick and the disadvantaged, and risk unnecessary human suffering and social turmoil.

Quit the RUC

BRIAN KLEPPER and DAVID C. KIBBE


First published 1/20/11 on Kaiser Health News

Recently, a Wall Street Journal expose and a New York Times column by Princeton economist Uwe Reinhardt detailed how vast health care resources are steered by the American Medical Association’s Relative Value Scale Update Committee -- or RUC, a secretive, 29 person, specialist-dominated panel. Since 1991, the RUC has been the main, if unofficial, adviser on Medicare physician reimbursement – how specific procedures should be valued - to what is now called the Centers for Medicare & Medicaid Services. Many Medicaid and commercial health plans follow Medicare’s lead on payment, so the RUC’s influence is sweeping.

The Year of Reform

BRIAN KLEPPER

Originally published 12/23/10 on iPractice.

“The search for static security — in the law and elsewhere — is misguided. The fact is security can only be achieved through constant change, adapting old ideas that have outlived their usefulness to current facts.”

William Osler, MD, 1849-1919

Even as the healthcare reform process hit snags, it had a sense of inevitability. For decades, anyone with even a modest understanding of how the current system worked could only conclude that it was too costly, delivered too little value, was fragmented in ways that often thwart quality and safety, and was an inordinate burden on the rest of the economy. It was, in a word, unsustainable.

So the question was not whether change would come or not, but what forms it would take. And, of course, against this backdrop was the nagging worry, at least for doctors, that it would mean a further erosion of position: more intrusion and less say.

Perhaps it isn’t the practice of medicine, per se, that has become so challenging, but the environment of practice. The system can be complex, adversarial, and bureaucratic, wringing away the pleasure of caring well for patients.

Unfreezing the Health IT Market

DAVID C. KIBBE AND BRIAN KLEPPER

Originally published 1/12/11 on Health Affairs Blog

Washington Post columnist Ezra Klein recently described the Obama administration’s consistent efforts to improve troubled private markets:

Isolate the eight key economic decisions of the Obama presidency: The intervention in the financial sector, the intervention in the auto sector, the intervention in the housing sector, the stimulus package, the health-care bill, financial regulation, and the tax deal…Where there was a market that they considered functional-but-frozen, they worked to unfreeze it.

Why Everyone Should Experience the Holocaust Exhibition

January 07, 11

First published in the Florida Times Union

An extraordinary traveling exhibition and lecture series from the US Holocaust Museum, Deadly Medicine: Creating the Master Race, is in my community now. The presentations describes the events leading up to the arrest of Jews and other minorities in Nazi Europe in the 1930s and 1940s, and then the depraved acts – medical experiments and genocide – that were carried out in the name of “cleansing.” There can be a tendency among Jews, like me, to focus on our own victimization, but there is a larger message and opportunity here.

It would be a mistake to think that this exhibition is only about Jews or Germans. Rather, it is about a deep sickness that all societies – even the most enlightened – can fall prey to. In recent years alone, we’ve seen horrific mass murders in Nigeria, Bosnia, Cambodia, Uganda, Armenia, Rwanda, Sudan, Congo and throughout South America, always as more stable nations stood by and watched.

There are patterns that typically occur before and after these disasters. The persecuting groups organize in ways that make them more powerful and effective. They portray the people they hate as threats, inferior, less worthy, unfeeling and sub-human. As atrocities become known, they orchestrate messages that deny any wrongdoing and deflect blame back onto their victims.