Medicare, not AMA, should set values ​​for primary care payment

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Hidden inside a new federal report on the future of primary care poses a challenge for an influential group that has criticized its approach to valuing U.S. doctors ’pay for having been biased toward specialists.

The Centers for Medicare & Medicaid Services (CMS) should independently assess physician services, given the limitations of the existing Medical Association’s Relative Value Scale (RUC) Committee, according to a new report of the National Academies of Science, Engineering, and Medicine (NASEM).

He report“Implementing High-Quality Primary Care: Rebuilding the Health Care Base,” published on May 4, also recommends raising the profile of primary care in the eyes of policymakers and the public.

With regard to the assessment of services, the authors of the report say that it will not be possible to review the current composition of the RUC to completely overcome what they consider to be its shortcomings. Currently, the RUC plays an excessive role in distributing the funds that Medicare, the country’s largest health care buyer, spends on physician services, according to the report. CMS has had to rely too heavily on the findings of the RUC, which “has moved away from science-based estimates toward stakeholder input,” the report says.

There is no regulatory or institutional block that prevents CMS from assessing medical services independently of the RUC, according to the report. Creating this knowledge base within CMS would help move Medicare payments toward a system that does more to fix payments on patient outcomes, according to the report.

“In fact, it’s hard to imagine that it could do so in the absence of an independent rating mechanism inside or outside the agency, such as the Medicare Payments Advisory Commission,” the report’s authors write.

Creating this capacity would require “a relatively modest level of resources and staff” and would not prevent the RUC from continuing to make recommendations to the CMS on physician remuneration, according to the report.

Person-centered, relationship-oriented care

The recommendation related to the need for CMS to develop new knowledge on Medicare compensation for clinicians was a specific recommendation included in the powerful report.

Primary care should be promoted as a “common good,” the report stresses. He argues for making efforts to allow more Americans to establish a partnership with a primary care physician, which the authors describe as the cornerstone for improving outcomes in the United States.

“Everyone in the country needs to have easy access to high-quality, person-centered, relationship-oriented primary care that meets the needs of the community,” Christopher Koller said at a news conference Tuesday. ‘report. Koller is chairman of the Milbank Memorial Fund, a gifted foundation, and is a member of the committee that drafted the report.

The comprehensive report also offers many suggestions for raising the profile of primary care within federal policy-making circles. These include a call for the creation of a Primary Care Research Office at the National Institutes of Health and a recommendation that the Department of Health and Human Services establish a Primary Care Secretariat Council.

The report also says that CMS should continue with the policies established during the COVID-19 pandemic that would allow greater use of telehealth and virtual visits.

At the press conference, Koller advocated a dramatic change in the way primary care advocates seek funding for their camp.

Too often attempts are made to justify spending money on primary care, as doing so would lead to future savings in health care costs. Studies have not supported these claims, which remain more relevant arguments for expanding access to primary care, he said.

“We think it’s an unreasonable request” to demand savings, Koller said.

Instead, advocates for primary care should argue that the ability of the field to increase life and preserve health is worth the investment, he said.

Challenge to the AMA RUC

Many of the report’s recommendations focus on ways to increase the pay of primary care specialists.

It calls on CMS to move from the fee-for-service (FFS) payment model to hybrid models, which could be part FFS and partially capitalized. This approach would reward physicians with better outcomes and grant payment per patient rather than per visit or procedure, which would make them the default payment method over time. The CMS should aim to increase physicians ’payment rates for primary care services by 50%, identify expensive health care services, and reduce their rates to achieve this.

A key component of efforts to increase primary care pay would be to change Medicare’s approach to reimbursing different specialties, according to the report.

Over the years, the RUC has leaned toward targeting higher pay for specialists who perform the procedures, in part because of the composition of this group, the report says.

“These shortcomings in the RUC process are getting worse over time because changes in the Medicare quota schedule have to be budget-neutral. As a result, primary care services in general and assessment and management [E/M] specifically, codes have been passively devalued in the PFS [physical fee schedule] as their relative prices fall as a result of rising other service prices (including new technologies). “

Primary care and other medical fields that focus on managing complex conditions gained at least a partial victory last year when CMS chose to stick to its plans for a revision of E / M codes. of Medicare. The I / O review reflected the changes made through the WADA RUC. The group responded to long-standing criticism of wage disparities.

Finished the objections of many specialized groups that focus on procedures, such as surgeries, CMS finalized a pay rule for 2021 aimed at raising primary care pay while compensatory cuts were made in other fields.

But Congress took steps to delay some of those changes, said Bob Phillips, MD, co-chair of the NASEM committee that wrote the report. Therefore, it is not clear at this time the importance that the I / O review will demonstrate in resolving wage disparity claims between primary care and procedural-focused specialties.

“There is an embedded tragedy there and, like the rest of the RUC community, they believe they have solved our problem … The eagerness to reopen talks on how to redistribute resources to primary care may not be there,” he said. Phillips, who is also director of the Center for Professionalism and Value in Health Care at the American Board of Family Medicine.

This could leave primary care without resources and “anemic in its ability to improve health and health equity,” Phillips said. Medscape Medical News.

Primary care receives less than 5% of the money spent on health care, but provides more than a third of all health visits. Increasing compensation for primary care is critical to maintaining the workforce in this field of medicine, he said. Many clinicians who could stay in the field change careers to increase their income.

“They’re not just doctors. They’re professional doctors and nurses and medical assistants,” Phillips said. “Evidence shows that participants in these areas choose other careers because they have loans. They have children who want to go through college. They have houses to buy and the difference in income potential and risk of The burnout is such a message powerful for them not to enter the field and some to leave. “

Sean Cavanaugh, former director of the CMS Medicare Center in the Obama administration, reviewed the NASEM report at the request of Medscape. In an interview, he recalled how CMS officials would try to counteract the imbalances in the payment of doctors introduced by the RUC.

He credits CMS for starting to raise wages for primary care through the E / M review. Like Phillips, he says more work is needed. He hopes there will be a drift toward the distribution of money from the Medicare doctor’s rate schedule with a bias toward specialties that focus on procedures.

“I don’t think we can leave that at the RUC. We need a fundamentally different process,” said Cavanugh, now policy director and commercial director of Aledade, a company that helps independent physicians participate in responsible care organizations.

When asked about the new report’s recommendation to move away from the current RUC-based system, the American Medical Association said in a statement, “The RUC process is credible and transparent and is based on an approach based on the evidence to make fair and objective recommendations that the government may consider when establishing Medicare payment policies.For decades, the RUC has offered recommendations that led to this improving the payment of primary care, as the significant increase in payment for recently implemented office visits “.

However, in an interview with Medscape Medical News, George M. Abraham, MD, president of the American College of Physicians, emphasized support for the CMS to more directly assess the value of medical services.

There is widespread agreement in health policy circles about the need for better coordinated health care and a reduction in the provision of fragmented and often costly services. Having a more “neutral” entity like CMS reviewing cost data would likely produce better results, Abraham said. CMS could still consult with RUC, but the interaction of medical services and the larger goal of coordinated patient care would also be considered.

“CMS could examine its overall priorities and drive the final decision in terms of how to prioritize resources,” Abraham said. He noted that Medicare has a fund of funds to pay doctors.

“The cake is the same size. It’s how the slices are cut,” Abraham said. “CMS is probably in the best position to decide, because CMS sees how resources are currently spent and what all the expenses CMS pays are.”

ACP was one of the funders of the NSEM investigation that led to the report. Other sponsors were the Pediatric Academic Association, the Agency for Health Research and Quality, the Alliance for Academic Internal Medicine, the American Academy of Family Physicians, the American Academy of Pediatrics, the Board. American Society of Pediatrics, the American Society of Geriatrics, the Blue Shield of California, the Commonwealth Fund, Family Medicine for America’s Health, the Administration of Health Resources and Services, the New York State Health Foundation, the Patient-Cented Outcomes Research Institute, the Samueli Foundation, the Society of General Internal Medicine and the Department of Veterans Affairs.

Kerry Dooley Young is a freelance journalist based in Washington, DC. He previously covered health policy and the federal budget for the convening of the Quarterly Congress / QC and the pharmaceutical industry and Bloomberg’s Food and Drug Administration. Follow her on Twitter at @kdooleyyoung.

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