Obamacare Lawsuit

Once again, I apologize to the folks who did not wish to receive these blogs and read my ranting. I did make a conscientious effort to delete all the names on the “no call list.”  Also, this topic is not meant to undermine my esteemed and deserving colleagues but is an important topic of National debate that will sweep across the States once the Federal Court renders a decision.

Six family physicians in Georgia have accused the Medicare program, in a federal lawsuit filed two weeks ago in US District Court in Maryland, of illegally relying on a committee (RUC) of the American Medical Association (AMA), which they hold responsible for paltry reimbursement rates for primary care physicians and inflated ones for proceduralists and sub-specialists.

This the latest sign of a long-standing rift between primary care doctors and specialists over Medicare compensation. This difference has been a major cause of difficulty with access to primary care physicians across the Nation.  If Obama Care becomes a reality the access to the proposed “free” preventative services would worsen as the number of new PCP’s opting out or being produced will continue to decline unless this disparity is narrowed urgently.

A recent legislation proposed by Rep. Jim McDermott, MD (D-WA) would require the Medicare and Medicaid Services (CMS) to hire independent analysts to identify overpaid and underpaid services in addition to “listening” to the AMA (RUC) committee's advice.

AMA historically represents more sub-specialists than primary care physicians and has been the proponent of RBRVS and its flawed RVS (relative value scale) that led to wide disparity in the reimbursement for cognitive services typically provided by Internal Medicine doctors and family Practice doctors.

Designed to cover all specialties, including the primary care specialties, the committee is supposed to work with the complicated formula. It has 29 members, 23 of whom are appointed by National Medical Societies. Twenty-six of the 29 have voting rights.

Illegal Advisory Committee? 

This will be decided by the lawsuit filed by the 6 FP doctors in Evans, Georgia. This committee (RUC) is being blamed for contributing to the inequality leading to Medicare underpaying primary care physicians and overpaying the specialists

The suit alleges that:

1. Committee membership is "highly biased" toward procedural specialties and only 2 seats of the 29 total truly represent primary care.
2. Committee’s recommendations are based on practice data collected by medical societies using a survey method that experts describe as inherently biased, arbitrary and capricious.
3. The committee functions for all intents and purposes as a federal advisory committee, yet it does not obey laws requiring such committees to field a balanced membership and conduct public meetings. (For its part, the AMA states on its web site that RUC is not an advisory committee to CMS but an independent group "exercising its First Amendment right to petition the federal government," and final payment decisions rest with the CMS.)

All of these circumstances combine to tilt the scale in favor of specialty care and devastate primary care in the process. Medical students are choosing more lucrative specialties (less hours more rewards), leaving primary care shorthanded. Those who do toil in that field are hard pressed to meet the needs of their current patients, leave alone the millions of new patients to be added in the future as a result of proposed changes in the healthcare reform.

For two decades now, this panel has been dominated by specialists who undervalue the essential, complex diagnostic and cognitive skills of primary care physicians, while often favoring costly procedural services.  The result of this is clear — there is a shortage of PCP’s and the patients are not getting the basic services they need. The medical costs are increasingly driven higher by costly and risky procedures, some with questionable benefit…. as determined by evidence based medicine.

The whole issue of RBRVS and RVS and the committee is bizarre and self-serving.  The two medical societies representing primary care physicians — the American Academy of Family Physicians and the Society of General Internal Medicine — have endorsed the proposed McDermott legislation, whereas a consortium of 47 societies, mostly in the specialty realm, have lined up against it. This opposition group includes the American College of Surgeons, the American College of Cardiology, the American College of Obstetricians and Gynecologists, the American College of Radiology, and the to my surprise American Osteopathic Association (AOA).  As of recent years AOA has been producing more sub-specialists than any other group and it encourages its members to “gain respect” by joining the sub-specialty ranks of medicine.  The reason being primarily the financial support these institutes need…., prospective medical students had looked at schools of Osteopathy only second to the traditional allopathic medical schools.

Missing from the list is the giant American College of Physicians (ACP), presumably representing internists. Not surprisingly ACP has long lost its muscle in representing its ranks in the political arena, unlike other colleges that successfully lobby on their members behalf.

Rep. McDermott cites another fact, “however — since RUC's debut, the income gap between primary care physicians and their specialist colleagues has widened from 61% to 89%”.

This disparity needs to be narrowed and needs to be narrowed soon and…. before our species becomes outmoded….. like the Dinosaurian phenomenon!

Harbir Makin, MD
Internal Medicine, Anchorage Alaska