Medicare SGR Replacement Bill: "An Unwarranted Role of Medical Specialty Boards"

From Merrill Goozner at Modern Healthcare Magazine:

"The law not only scraps the sustainable growth-rate formula for physician payment, it consolidates the diverse programs for rewarding or penalizing physicians. The CMS no longer will calculate separate payments for reporting quality measures, improving performance or meeting meaningful-use standards.

Instead, the CMS will substitute a composite MIPS score for each physician participating in the Medicare program. When measured against clinical peers, a physician's score could result in the agency rewarding or penalizing him or her up to 5% of annual revenue starting in 2020. That rises to 9% of revenue for 2022 and beyond.

While the program is designed to be revenue-neutral, it allocates $500 million for rewards, just in case a majority of physicians turn out to be like the kids at Lake Wobegon and achieve universally high composite scores.

The overall score will be based on how well participating physicians perform in four separate categories: quality measures (30% of the total); resource use (30%); achieving meaningful use (25%); and clinical practice-improvement initiatives (15%). Each component will be determined by agency rulemaking and stakeholder input.

But some stakeholders are being given a greater say in the process (others are invited to participate, of course). The law, for instance, asks “eligible professional organizations” to recommend quality measures for use in the program. It defines eligible professional organizations as “nationally recognized specialty boards of certification.”

It also says physicians can achieve the maximum score on the clinical practice-improvement component by being part of a certified medical home or “comparable specialty practice.” The law gives “eligible professional organizations” the ability to make that determination. The bill also mentions “practice assessments related to maintaining certification” as one way to achieve a maximum clinical practice-improvement score.

The special role given physician specialty boards in the SGR replacement bill heightens the stakes in the recent controversy swirling around the costly and complicated recertification process at the American Board of Internal Medicine, one of the largest boards in the nation. A rival group is seeking to substitute continuing medical education credits for recertification test-taking, which the ABIM and patient and consumer advocacy groups oppose.

The flare-up has brought some of the more unsavory and unscientific aspects of the self-regulating physician recertification process to light. A recent New England Journal of Medicine perspective by ABIM critic Dr. Paul Teirstein of the Scripps Clinic noted that the latest studies have shown no relationship between physician recertification and performance on quality measures—the very task given to certification boards in the SGR replacement bill.

Teirstein also accused the ABIM of being “a private, self-appointed certifying organization” that charges exorbitant fees “unfettered by competition” for its products and tests.

The certification boards aren't major powerhouses on the Washington lobbying scene. Last year, for instance, the ABIM spent only $160,000 on the lobbying firm of Mehlman Castagnetti Rosen Bingel & Thomas, according to Senate lobbying records. But that firm's chief healthcare lobbyist, Dean Rosen, once served as an adviser to then-Senate Majority Leader Bill Frist (R-Tenn.), and apparently still has good connections with the staffers who drafted the language of the SGR replacement bill.

As we editorialized here two weeks ago, a permanent end to SGR is the right thing to do. And creating MIPS to replace multiple rewards programs will lessen the administrative burden on physicians and physician practices, and incentivize them to move toward value-based care payment models.

But other stakeholders will need to remain vigilant to ensure that self-interested physician specialty boards don't play an outsized role in setting the parameters of the program—especially when it comes to determining what constitutes quality and clinical-practice improvement."

This is horrible. Our government is about to authorize the use corrupt and completely unaccountable certifying organizations to serve as a metric with which to determine the "value" of health care for our patients and remuneration for working physicians nationwide. In fact, the certifying organizations the bill authorizes are being sued in federal court for possible anti-trust violations. How embarrassing would our U.S. Senators look in the eyes of seniors everywhere if that suit is found in favor of the plaintiffs?  The whole Medicare SGR Replacement Bill, H.R. 2, would fall apart.  Are our U.S. Senators really ready to put their political careers on the line for one flawed bill? (Note the senators who were lobbied were never privy to this pending lawsuit.)

(To think that the policy divisions of our sub-specialty medical societies are also complicit in this scheme is even more appalling.)

Is this what our patients need? Are we, the front line working physicians, going to allow the self-serving money trail of government grants to determine what constitutes quality care for our patients and "value" for  our health care system?

All physicians AND their patients need to stop and pick up the phone Monday morning. Call BOTH your Senators and flood the switch boards. Tell them to vote "NO" on the Medicare SGR Replacement Bill (H.R. 2).

Unless, of course, you think $2.3 million dollar condominiums with chauffeur-driven BMW 7-series town cars is how our nation should define health care "value" in the years ahead for our Medicare patients.

-Wes

Addendum: Here's even more lobbying to CMS that pushed for ABMS "board certification" to be the only board used for CMS's Physician Compare website in Sept 2014.

Reviewing The Regulators

In 1990 the American Board of Medical Specialties (ABMS) and the American Board of Internal Medicine (ABIM) changed their requirements for physician board certification from a voluntary life-long designation and educational process to a time-limited designation lasting 10 years.  This decision to require repeated testing, the public was told, was based on data from a single highly flawed retrospective literature review that suggested physician competence deteriorates over time.  Despite this, over the ensuing years hospitals and insurance companies increasingly require physicians to be board certified for credentialing or billing purposes.  And as a result of changing the life-long designation of board certification to a temporary one, physicians were left with little choice but to pay for and participate in the ABMS/ABIM MOC program to practice their trade.

In 2005, the ABMS modified their re-certification requirements and created a program called "Maintenance of Certification" (MOC).  This program required completion of "Practice Improvement Modules" in addition to the completion of certain knowledge-base testing modules before a physician could sit for their secure re-certifying examination.  This decision to include "Practice Improvement Modules" was a unilateral one by the ABMS and its subsidiaries and was never scientifically challenged or validated by the independent physician community.

This year, the requirements for MOC changed again when all US physicians were now required to pay for and participate in the ABMS/ABIM MOC process every two years, in addition to re-taking their certifying examination every 10 years.  Because of the added cost and time requirements with the most recent change to the ABMS/ABIM  MOC process, physicians began questioning the MOC program's legitimacy as a means of assuring physician quality verses the ABIM's bottom line.  An online petition was signed by over 18,850 physicians asking to "recall the changes to MOC and to institute a simple pathway consisting of a recertification test every ten years."   In his response to this petition and to support the credibility of the MOC process, the President and CEO of the ABIM referred to the research conducted by the ABIM leadership and staff:

"There is a good deal of research demonstrating the value of MOC: from the validity of the examination, to the importance of independent assessments – clinicians are not good at evaluating their own weaknesses. All of this research drives and informs our program requirements and product development."  

Review of the ABIM’s "research" topics showed they cover a wide range of important clinical care issues including trust, teamwork, ethics, obligations of the Hippocratic Oath, characteristics of internal medicine physicians and their practices, teaching, staffing patterns, electronic health records, clinical skills, and the structure of medical homes. But closer inspection of much of this work shows it was not research, but rather opinion and editorial.  Much of the "research" resides behind expensive online paywalls free to the academic community, but expensive for the non-academic physician and public to review.  Given these realities, before casting aspersions on physicians' ability to evaluate their own weaknesses, it appears a review of the ABIM's "research" in regard to its clinical legitimacy is in order.

In 2014, the Center for Medicare and Medicaid Services (CMS) published the entire database of $77 billion dollars of payments made to US health care providers in 2012.  The data are easily reviewed using a website created by the Wall Street Journal.  In an effort to establish the credibility of the ABIM leadership and staff's journal publications as it pertains to the various aspects of medical practice they claim to actively monitor, each author published in the 2014 collection of journal articles published on the ABIM website was cross-referenced with their CMS 2012 Medicare provider payment data.

Methods

 The ABIM publishes journal articles authored by ABIM staff and leadership for the years 2000-2014 on its website.  The 31 articles published so far in 2014 were randomly selected for review. Each author of each paper was then compared to their 2012 Medicare payment data.  If the payment data for a particular author were non-zero, then the total number of inpatient and outpatient new and existing patient encounters were totaled to determine the total 2012 annual Medicare patient care encounters seen by the author.  Procedure counts were not added to this total of encounters, since the intent here was to "even the playing field" between "proceduralists" and hospital- or office-based clinicians in terms of the number of patient contact episodes they had each year.  In the event more than one physician author's first and last names were identical, the source article was reviewed to assure the proper physician data was obtained based on their city, state, or academic institution.

Authors designated as employees of ABIM, those with acknowledged conflicts of interest or those with non-academic or policy affiliations were also recorded. The average, median and standard deviation of 2012 Medicare payments and patient encounters were then calculated.

As a point of reference, the author of this blog post received a total of $163,184.55 in Medicare payments representing 529 patient encounters (298+75+13 established outpatient visits, 31 outpatient new visits, 82+14 initial hospital/inpatient care and 16 subsequent hospital care visits) according to the 2012 Medicare database. This number of encounters represented 1.5 days of outpatient clinic visits per week in 2012 (personal data) as well as inpatient patient care encounters payments received from Medicare patients. This encounter volume represented 42% of this author’s total number of clinical encounters billed in 2012 (personal data).

 Results

Thirty-one articles published by the ABIM staff and leadership in 2014 (so far) represented work by 150 authors.  Of the 31 articles published on the ABIM's website to date for 2014, ten of them (33%) were published solely by ABIM employees or leadership. Only 80 of the 150 authors held an MD degree.  The authors were a heterogeneous mix of US and non-US physicians, one veterinarian, nurses, students, statisticians, researchers, representatives from National Board of Medical Examiners, Center for Medicare and Medicaid Services, the Urban League, the Foundation for Advancement of International Medical Education and Research, Mathematica Policy Research, Inc., the National Collaborative for Improving Primary Care Through Industrial and Systems Engineering, the VA medical system, staff members of the American Board of Internal Medicine Foundation, and others from Consumer Reports Health.

Clinical Involvement

Of  physicians with an MD degree, the average 2012 Medicare payment amount was $18,196.97 ± $68,220.55 (median $0). Only thirty-seven of the 80 physician authors (46%) had Medicare payments paid to them in 2012.  Three authors had payments exceeding $100,000 in 2012 while the vast majority (30 of the 37) received under $25,000. This average payment amount corresponded to an average of 131 ± 308 patient encounters (median 0) for the entire year 2012.

If all of the authors were included in the analysis, the average 2012 Medicare payment was $9705.05 ± $50,502.95. The median Medicare payment to the authors published in 2014 to date was $0. The average number of patient encounters per year in 2014 was 70 ± 234. The median number of patient encounters in 2012 by the authors published to date was 0.

The entire spreadsheet (pdf) of the 2012 Medicare payment and encounter data by each author that published with ABIM leadership and staff in 2014 can be reviewed here.

 Discussion

This study is the first to cross-reference a portion of ABIM publishing authors to the 2012 Medicare provider payment database. While Medicare payment data might not represent the full workload of today's clinical physicians, it is the most complete database of US physician clinical work performed on patients in the United States published to date.

The ABMS/ABIM's Maintenance of Certification program has been criticized by many working physicians as onerous, expensive, time-consuming and a poor reflection of physician quality. In his response to physician concerns over the MOC process, the President and CEO of the ABIM stated:

"ABIM's mission is to enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills and attitudes essential for excellent patient care."

Dramatic changes to the health care landscape have occurred over the past five years.  If the mission of the ABIM is to truly certify internists who with “skills and attitudes essential for excellent patient care," we are left to question the legitimacy of recommendations made by physicians who no longer care for patients in today’s health care arena. The ABIM seems content with making recommendations to physicians while being woefully inxperienced about the challenges that face internists today.   In fact, the data presented in their work confirms that physician quality is being regulated by an unqualified body.

While some might argue that regimented study and time-consuming non-clinical data acquisitions are required to assure physician quality, it remains quite possible that such a dishonest and lopsided approach will backfire as physicians refuse to participate in this process or retire early from medicine just as more patients are entering our health care system. Burdening clinical physicians with unrealistic and unproven demands for non-clinical tasks detracts from needed patient care.  Recall that only three of the physicians included in the author list of ABIM's 2014 publications received over $100,000 of Medicare payments while 30 of 37 physicians in the published articles in 2014 received less than $25,000.   Might the recommendations and data that the ABIM is making available to hospital groups and insurance organizations be seriously flawed?

Even a cursory review of the background of the authors of several published works of the ABIM staff and leadership reviewed suggests a troubling narrative. For instance, one article included with the ABIM's 2014 list of journal articles is entitled "Internists' attitudes about assessing and maintaining clinical competence" (J General Int Med 2014; 29(4):608-614).  While this title might seem reassuring to the public that the ABIM is serious about their mission, their credibility becomes suspect when closer inspection of the background of the authors revealed only one of the six authors had any clinical encounters in 2012 and another author was a veterinarian. In another article entitled "Time to trust: longitudinal integrated clerkships and entrustable professional activities," (Academic Medicine, 89(2), pp 201-4) none of the authors received payments for patient care in 2012 and the authors acknowledge the ideas presented were provided by two political "think tanks."  Should these be the people we entrust to develop clerkship ideals and "entrustable professional activities" (whatever that is) for our future physicians?

We should note that despite fourteen years of articles on the ABIM's website, none of the ABIM’s "research" has ever evaluated any negative consequence of their MOC program.  Rather, these ABIM papers "drives and informs" additional unsubstantiated "program development" like a public relations firm. Without independent assessment of their practices, it remains completely possible that the MOC process causes more harm than benefit to actual patient care delivery as a result.

The Medicare payment data of ABIM authors also begs the question, how are the ABIM physicians and legislators spending their time?  It is apparent that most physician members of the ABIM are not involved in clinical care.  Given the conflicts of interest mentioned in the various citations, physician quality assurance is not the ABIM's priority.  Perhaps the physician members of the ABIM would have more credibility advising struggling doctor-employees on beefing up their curriculum vitae, earning consulting fees, perfecting public relations skills, and creating multiple income streams since their annual revenue take with their MOC program implementation went from $46,131,129 in 2010 to $55,625,925 in 2012 (Data from the 2011 and 2013 IRS Form 990 published on guidestar.org/).  Given these data, it is appears that the ABIM is more concerned about padding their resume to (1) create and air of legitimacy, (2) serve a political agenda, and (3) to provide a smoke screen for the high salaries of their board members.

Clearly, busy front-line full-time practicing physicians do not have the time for creating publishing mills or for scientifically meaningless survey collection.  Patients want capable practicing physician availability, not survey collectors. Assuring physician quality should not be about creating and funding a political action committee subservient to a political agenda, but rather understanding the challenges physicians face in their workplace and knowledge base and working collaboratively to offer continuous professional improvement.

Limitations

There are several limitations to this study.  First, because the CMS Medicare payment database does not capture work performed on patients under the age of 65, the database does not accurately reflect the total clinical work load a physician performs each year.  Physicians who do not accept Medicare for payment would not appear on this database.  However, since older patients commonly access our health care system more frequently as they age, it would be expected that internists writing policy for health care delivery would participate in the Medicare government program.  Second, the 2012 Medicare payment data reviewed does not correlate to the year the articles were published in the literature.  However, one would expect that experienced physicians who changed the testing requirements for MOC in 2014 would have recent direct patient care experience to appreciate the many factors that impact physicians today.  Finally, reviewing only one year's literature published on the ABIM's website might have introduced sampling bias.  Still, the sampling of the most recent year offers the advantage of reviewing articles that might affect upcoming policy decisions.

Conclusions

Physicians are not above proving their competence and establishing quality standards, especially if those standards are scientifically sound and transparent.  The legitimacy of the MOC process to assure physician quality should be called into question based on a careful literature review of the many conflicts exposed by this review and the limited recent clinical experience of those that contribute to their evidence base.  Citing numerous publications to legitimize the MOC program creates the illusion that this process of insuring quality care and has been vetted by actual scientific data.  Nothing could be further from the truth.

-Wes

A Case of Fraud

He was a slender-framed man, mid- to late-sixties, with a kind of ridden-hard-put-away-wet complexion.  It was clear the years had not always been good to him, but being the kind soul that he was, he had plenty of friends.  It was a beautiful summer day to spend with friends for a barbecue, but he arrived feeling puzzled why he collapsed at home earlier in the day.

He stopped at the keg and poured himself a beer in a red solo cup, and as he approached his friends with a smile, he did it again, this time which such gusto that his beer went flying and the thud he made when he hit the ground made everyone gasp.  He laid motionless for a moment face down on the ground while his friends rushed to his aid.  An ambulance was summoned as others rolled him over onto his back.  He began to move - slowly at first - then more purposefully.  As sirens approached, he asked his friends, "What just happened?'

A bit later, he arrived in the Emergency Room, awake, alert, pleasant, and seemed - on the surface at least - fine.  His vital signs were normal - perfect, in fact.  About the only things immediately noticeable was his thin frame, his coffee-stained teeth, and a clump of grass in his hair that the nurse kindly removed.  He was placed in the gurney, an IV was started, blood was drawn, and EKG was performed as a few "hellos" and "what happeneds" were exchanged, then off to the CT scanner he went to rule out an intracranial process.  It was normal and his EKG showed a first-degree AV block and incomplete left bundle branch block without evidence of acute injury or prior heart attack.

He returned from the CT scanner and was examined a bit more closely.  A loud, blowing, holosystolic murmur was heard by the medical student.  In fact, it was loud enough to create a "thrill" - a palpable vibration on the thin man's chest.  The medical student seemed pleased with himself, then ordered his first echo which revealed a relatively weak heart with a few chamber walls that didn't move so well, and a very leaky heart valve.  He was admitted, placed on telemetry, and seen by a cardiology consultant.  Closer inspection of the echo revealed a dilated left ventricle with a posterior wall motion defect and a central jet of mitral regurgitation large enough to fill the left atrium with a mosaic of color that extended to the pulmonary veins.  It was clear he'd need surgery, so a diagnostic catheterization was performed.  It showed three-vessel coronary artery disease and confirmed severe mitral regurgitation.  His medications were adjusted and surgery consulted.  A date for surgery was arranged at the neighboring hospital the following week and all seemed well.

But he had different plans.

As he settled down for dinner, he felt suddenly flushed, lightheaded, and broke out in a sweat.  With that, the telemetry alarm sounded and soon the room was full of people, crash carts, and hysteria.  His dinner table was shoved aside and he was laid flat as his chest was made bare.  He didn't know what all the excitement was about, but heard the words "He's fibrillating!" and then felt the cool metal discs covered with cold goo applied to his chest.  "What are you do...?" and with that, he felt his chest and arms jerk violently just before he passed out.  "Shit, he's still fibrillating!" someone shouted.  So they charged again and shocked him, this time to sinus rhythm.  The anesthesiologists who had arrived on the scene of the arrest took no chances: he was intubated and expeditiously transferred to the ICU.

Upon arrival to the ICU, the patient was clearly recovering well and quickly extubated the next day.  Beta blockers were administered additional anti-anginal and anticoagulants given.    Once stabilized, he was transferred to the surgical hospital and underwent urgent bypass surgery with mitral valve replacement.  At the time, the surgeon could see considerable endocardial scar.

His recovery was uncomplicated, but four days after his surgery, he still required external pacing.  Cardiac electrophysiology was consulted to consider an ICD placement, given his history of sinus node dysfunction, cardiac arrest, diminished LV function, and the visible presence of endocardial scar during surgery.

The electrophysiologist reviewed the case and noted that the patient's original in-house arrhythmia at the time of his "arrest" was actually an organized, rapid ventricular tachycardia that was then shocked into ventricular fibrillation by an asynchronous defibrillation attempt.  An echocardiogram performed post-operatively showed a very low EF of 23%, but a good repair of his valve and he appeared to be progressing quite nicely in his cardiac rehabilitation.  Still, it was felt he was at high risk for another arrhythmic event, so a wearable defibrillator as ordered as they waited out his conduction system a bit longer to see if it would recover function.   It never did.

So 10 days later after the sinus node failed to recover, the electrophysiologist had a choice: implant a pacemaker, or implant a defibrillator?   It shouldn't be a difficult decision in this case, should it?

But the electrophysiologist knew he'd be committing fraud if he implanted a defibrillator and billed Medicare for the device and procedure.  That's because Medicare's 2005 National Coverage Decision requires doctors to wait 90 days and then "reassessing" the patient's heart function later before implanting a defibrillator once the heart is revascularized surgically.

But he wondered about the extra risk of infection created by two surgeries (one for a pacemaker and one later to upgrade the device to an implantable defibrillator) instead of one.   He wondered if anyone ever considered the frequent venous occlusions that preclude later upgrade of pacemakers to defibrillators via the same side as the original pacemaker implant.   Even if he implanted a defibrillator lead at the same time he implanted the original pacemaker, wouldn't he be committing fraud if a more expensive defibrillator lead were billed to Medicare instead of a pacemaker lead?   And what about the added cost, inconvenience, and poor compliance rates of patients issued wearable defibrillators as they wait out the 90-day waiting period for an ICD?  Finally, what are the ethics of asking his patient to sign a form that obligates the patient to pay for his defibrillator if Medicare fails to do so when the actual costs involved to implant a defibrillator are closely held institutional secrets?

So he wrote his note.  He documented his rationale thoroughly.

Then proceeded to commit fraud.

-Wes

Refs: 

Fogel RI, et al. The Ultimate Dilemma: The Disconnect Between the Guidelines, the Appropriate Use Criteria, and Reimbursement Coverage Decisions JACC, 2013;() doi:10.1016/j.jacc.2013.07.016.

Dr. Wes: When the Feds Come Knocking

When Health Care is Promoted As "Free"

Health expenditures in the United States neared $2.6 trillion in 2010, over ten times the $256 billion spent in 1980. The rate of growth in recent years has slowed relative to the late 1990s and early 2000s, but is still expected to grow faster than national income over the foreseeable future.

So imagine my surprise when I saw this Medicare commercial last night that stated preventative health care services provided by Medicare were "free:"



CMS also uses the word "free" in the description of the new health care law's provisions on their Youtube channel:

"For those with Medicare, the health care law offers most preventive health care services for free."

Describing health care services as "free" dissociates people the cost reality of providing these services. It perpetuates the myth that we can have health care services without having to pay for them. Further, calling services "free" devalues the expertise and cost of facilities and regulatory oversight required to support such services.

Of course, public policy experts who promote these deceptive advertising techniques argue that these ads are justified because they encourage people to participate in preventative health services, thereby saving costs.  But where are the data that these ads really work?    Scientists know the realities of indeterminate, false positive and false negative testing of any screening test.  We know the huge costs of additional testing that occurs in such in instance.   Given our overriding health care cost concerns, should we not insist on proof of the cost-effectiveness of such a large-scale, national approach to preventive medicine services rather blithely assuming it works?

After all, the reality of health care today is that it is anything but "free."

-Wes

When the Feds Come Knocking

Slightly over a year ago, the Department of Justice (DOJ) launched an investigation of a large number of institutions regarding concerns that implantable cardiac defibrillator (ICD) procedures were performed for reasons outside of the criteria set forth in Medicare’s National Coverage Decision (NCD).  This investigation occurred just after Al-Khatib and others published a report January 4, 2011 in JAMA that suggested as many as 22.5% of implantable defibrillators implanted for primary prevention of sudden death were not evidence-based.  While the physician community took issue with the Al-Khatib paper, the media firestorm it generated paired with the announcement to the Heart Rhythm Society physician community that a federal investigation was underway, had a chilling effect on ICD implantation nationwide.  Drs. Jonathan S.Steinberg and Suneet Mittal report on their experience with DOJ investigators under this heavy regulatory oversight in today’s Journal of the American College of Cardiology.

Steinberg and Mittal's diplomatic account carefully describes the challenges of retrospective audits performed by lawyers from the Department of Justice and those of their targeted health care facilities. The DOJ identified 229 cases as potentially inappropriate cases based on Medicare code criteria.  (This represented 8.7% of the de novo non-resynchronization ICD implants done for primary prevention at their institutions). After determining that some of these targeted cases were actually for secondary prevention or other coding transgressions, the authors could medically justify all but thirty-four (15%)  (or a very low 1.5% of all ICD’s implanted for primary prevention of sudden death) at their institution.  As has been the case in most reports, the majority of outside NCD-directed ICD implants occurred because of timing violations—too close to the diagnosis of heart failure, heart attack and coronary intervention. These timing constraints constitute the primary issue before implanting doctors: their professional society guidelines do not -- in all cases -- recognize similar timing restrictions.

It is surprising that we are not told what sanctions, if any, were levied against their respective institutions.   Perhaps the authors felt this important detail was unimportant to disclose or perhaps they were prohibited from doing so.  Perhaps their penalty is still being determined: after all, nothing drives behavior like fear.  To this end, we found the authors' compliments of the government's legal team unusual to report in a scientific manuscript, as if the they were suffering from Stockholm Syndrome.

We should acknowledge that the authors have added much needed clarity to the gray area of decision-making surrounding ICD implantation. Their explanations of timing violations highlight problems with coding, confusion around incidental PCI intervention in patients with dilated cardiomyopathy, and demonstrate the overlap decisions that must be made when bradycardia and tachycardia functions might be required for our patients.  This kind of clinically-relevant nuance was lacking in the impugnable Al-Khatib JAMA piece.

We can only speculate the large cost of the legal fees and man-hours devoted to this review process.  We will never know how many patients died during, or now after, the course of this investigation because they were not offered ICDs because ICDs can only be offered to patients who meet Medicare’s rigid, outdated, and still-to-be-updated National Coverage Decision for implantable defibrillators.   But perhaps this is the price of regulation that America is willing to pay in return for cost savings.  Perhaps we should not be concerned that professional guidelines for care delivery should be second fiddle to government mandates for ICD implantation.

With this latest report, a new era for medical practice is now upon us – one where priorities of low cost care and high quantity of care determined by non-medical personnel supersede the highest quality of medical care to our patients.   For regulators, it is easy to be a Monday-morning armchair quarterback evaluating health care delivery.  It is far harder, however, to decide prospectively who is likely to die (or not) when they sit before you with a newly-diagnosed cardiomyopathy and ejection fraction of 12%. 

When government and legal officials who carry no responsibility for the long-term well-being of our patients have the authority to retrospectively impugn and penalize doctors (and their health care facilities) based merely on retrospective reviews of billing codes and outdated payment mandates, they risk irrevocable harm to patients who might qualify for devices according to updated professional guidelines.  Doctors everywhere should stand up collectively to disown the practice of using NCD mandates, rather than updated professional guidelines, to determine appropriate care for patients.

After all, our patients are depending on us.

Westby G. Fisher, MD
Director, Cardiac Electrophysiology
NorthShore University Health System and
Clinical Associate Professor of Medicine
Pritzker School of Medicine, University of Chicago
Evanston, IL

John Mandrola, MD
Cardiac Electrophysiologist
Baptist Medical Associates
Louisville, KY

Addendum 27 Mar 2012: Link to Steinberg/Mittal article finally added.

Addendum 14 Sep 2012: Update on the DOJ Decision

References:

Jonathan S. Steinberg and Suneet Mittal. "The Federal Audit of Implantable Cardioverter-Defibrillator Implants: Lessons Learned." J Am Coll Cardiol. April 3, 2012, 59 (14) 1270-4. doi: 10.1016/j.jacc.2011.12.026

Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. J Am Coll Cardiol. May 27, 2008;51(21):e1-62.

Al-Khatib S, Hellkamp A, Curtis J, et al. Non–Evidence-Based ICD Implantations in the United States JAMA. 2011;305(1):43-49. doi: 10.1001/jama.2010.1915

Note: This post also appears on Dr. John Mandrola's blog: http://www.drjohnm.org/

Bucking the Established

"Out with the old, in with the new!"
Who's your doctor? Do you have one?

If you have one, you aren't that interesting to them any longer because you're "established." This is not the fault of your doctor, but because of government rules for paying doctors: "new patient" visits pay better than "established patient" visits. "New patients" have a much better chance of needing new procedures, so they are even more special. Add to that the fact that more and more patients are going to need to become part of the "system" soon, and "new patients" quickly achieve the health care value trifecta.

Sorry. Those are the rules.

The higher payments made by insurers and government agencies for new patients was meant to offset the longer amount of time and cognitive challenges of dealing with a new patient that enters the doctors office. There is no question that there is more work to do when a new patient enters a medical facility: entering demographic data on a computer, actually taking a set of vital signs, performing a careful history and physical. But thanks to the explosion of ancillary health care assistants, imaging studies, the availability of the internet, and a constant push to do more in less time, doctors work differently today than they once did. Much of the data gathering is accomplished before the patient enters the office, imaging studies and baseline testing often occurs before a patient is even seen (remember those tests "required" for "quality" care?). Furthermore, because limitations for the frequency of testing has been imposed by government regulators, health care systems leap at the opportunity to "direct" doctors to order tests the moment the test might be needed. As such, "new patients" become particularly valuable to health care systems compared to "established" ones.

But are established patients really that tarnished? Should a doctor's time with them be valued any less than the time spent with a new patient? Is there value in that continuity of care? Or are we just creating a incentivized human funnel to our health care system that favors new patients over those with whom we might develop relationships? Is the doctor-patient relationship at risk as a result?

Absolutely.

Just as it was intended.

-Wes

Our Polite New World of Rationing

To ensure rational and responsible dissemination of this new
technology (transcatheter aortic valve replacement [TAVR]), government,
industry and medicine will need to work in harmony.”

- David R. Holmes, Jr., MD, FACC
President, American College of Cardiology
Today, Edwards Lifesciences’ will request pre-market approval of its SAPIEN Transcatheter Heart Valve from the FDA's Circulatory Systems Devices Panel of the Medical Devices Advisory Committee. And for the first time, the groundwork for our complicated new era of health care rationing will be exposed.

To win an expensive technology on behalf of patients these days, there will have be "harmony" between doctors and their professional organizations and government regulators. If not, patients lose.

At issue is a transformative technology - another milestone forwarding medical innovation on behalf of some of our oldest and sickest patients: those with critical aortic stenosis who are too sick to undergo open heart surgery. Aortic stenosis tends to be a disease of the elderly that carries at least a 2-year 50% mortality when accompanied by a weakened heart muscle. Yet thanks to the wonders of careful engineering and some daring researchers that paired their expertise and lessons learned from a variety of disciples (cardiothoracic and peripheral vascular surgery, cardiology, and even cardiac electrophysiology), technigues and technology have combined to offer a percutaneous option for aortic valve replacement.

Everyone involved in this research (and even those who have watched from afar) knows this therapy works. Most believe in the long run, it will prove to be a safer option than open heart surgery in these patients.

But that's about where the harmony ends.

The new valve is expensive and so is the procedure to implant it. Although rumor, the valve itself might cost $20,000 US. Medicare (the insurer of the elderly) pays only 80% of the costs, typically, and has an arcane coding system that pays more for the code for aortic valve "replacement" than it does for aortic valve "insertion." (For goodness sakes, doctors, stop calling it TAVI and stick with TAVR, okay?!?) Will hospitals and insurers be able to afford a run on these devices? And what about Medicare that's already struggling with a huge unfunded liability?

And then there's the whole issue that doctors can't be trusted to do what's right for their patients anymore. They are uniformly greedy, at least in the eyes of the media and the regulators. They care about themselves more than their patients and thanks to a few unscrupulous doctors (and the fee-for-service system in which they work) ample evidence exists to contribute to this perception handsomely. Marcus Welby, MD: rest in peace.

But doctors still hold sway with their patients. For regulators, this is the biggest problem. Doctors, you see, get to stare directly into the eyes of the patients (and their families) as they discuss their principle problem: their narrowed aortic valve. We have to explain the options for treatment available: (1) doing nothing (and what will happen), (2) having open heart surgery (and what will happen), or (3) inserting replacing their valve in a minimally-invasive fashion (and what will happen).

Guess which option the patient is most likely to choose?

The fear with this new technology unleashed on the public, of course, is that the implant rate will reach a fever pitch as hospitals, ever hungry for the latest technology to tout, splash their cardiologists faces over billboards and national TV promoting TAVI TAVR. Doctors, too, driven by productivity quotas, are eager to increase their caseload so they can send their kids to college. The discord with the desires of government regulators is obvious.

But if you really want to see all hell break loose, splash the images of a frail minority patient that was denied the option to receive a percutaneous valve on the basis of their age that turns to the media to expose their story.

Katie bar the door.

So we must be polite. We must demonstrate harmony. We must have databases. We must have panels of doctors and regulators and professional bodies assembled that sing Kum-By-Yah by their campfire is a great display of good will and uniform conviction to diffuse responsibility.

After all, rationing's a bitch.

-Wes

Health Care's Dangerous Politics

"An election is coming. Universal peace is declared, and the foxes have a sincere interest in prolonging the lives of the poultry."

~George Eliot, Felix Holt, Chapter 5

* * *
This morning, the chickens learned from two former independent public trustees for Medicare and Social Security what the foxes in our political hierarchy were up to with their recent budget forecasts for Medicare :

... the program's long-term deficit may be roughly three times what the trustees projected.

. . .

In addition, for the third consecutive year there were no independent Medicare trustees to issue a separate statement. Without them, the Obama administration was able to put forward an unjustifiably positive outlook for the Medicare program and the impact of the health care legislation. If public trustees had been in place, they could have helped ensure that a more realistic view was presented in the report, possibly including a reasonable best estimate along the lines set out in the chief actuary’s alternative.

Politician's fudging the numbers?

Say it ain't so!

But don't worry. It's only America's health care we're taking about. The new entitlement programs will be better. Much better.

Really.

. . .

What's that?

Why don't you trust me?

-Wes

Medicare's Escher-Like Budget Logic

Everyone knows the doctor cuts will never happen:

"I’m not willing to do that by punishing hard-working physicians or the millions of Americans who count on Medicare. That’s just wrong."

- President Obama 12 Jun 2010

... except when they must happen to make the Medicare budget work.

Oh, and rest assured we can continue to cut costs in Medicare without affecting the quality of care provided.

-Wes

DOJ Takes Aim at Doctors

... as conspirators:

This case is a watershed for two reasons:

First, until now the Federal Trade Commission, not the Justice Department, has taken the lead in prosecuting physicians. Since 2000, the FTC has brought about three dozen cases against physicians (all but one of which settled without any trial). But the FTC only has civil and administrative jurisdiction; the Antitrust Division has civil and criminal jurisdiction. The Sherman Act makes no distinction between civil and criminal “price fixing,” so in a case like this, it’s entirely a matter of prosecutorial discretion whether to charge the doctors with a civil or criminal offense.

Based on the descriptions in the Antitrust Division’s press release, there’s certainly no reason they couldn’t have prosecuted the doctors criminally and insisted upon prison sentences — and there’s little doubt such threats were made or implied to obtain the physicians’ agreement to the proposed “settlement.”

The second reason this is a landmark case is that the Justice Department has unambiguously stated that refusal to accept government price controls is a form of illegal “price fixing.” (Emphasis mine)

The FTC has hinted at this when it’s said physicians must accept Medicare-based reimbursement schedules from insurance companies. But the DOJ has gone the final step and said, “Government prices are market prices,” in the form of the Idaho Industrial Commission’s fee schedule. The IIC administers the state’s worker compensation system and is composed of three commissioners appointed by the governor. This isn’t a quasi-private or semi-private entity. It’s a purely government operation.

What’s more, the Antitrust Division has linked a refusal to accept government price controls with a refusal to accept a “private” insurance company’s contract offer. This lives little doubt that antitrust regulators consider insurance party contracts the equivalent of government price controls — and physicians and patients have no choice but to accept them.

Read the whole thing to understand the implications of this settlement. Given the 21% cut to Medicare payments that occurred today (but CMS is 'holding claims' for ten days to allow for another stop-gap measure to be implemented), ask yourself two questions: (1) "Where was the AMA?" and (2) Are you ready to be a government employee?"

-Wes

A Letter to Congress: Let Us Help You

Dear Congress:

I wanted to write you to tell you how proud I am of you. You’ve worked so hard on health care reform and focusing on what matters to Americans. Your beautifully conducted Health Care Summit, live before the C-SPAN cameras (finally) was a welcomed site. I have such a better grasp of the issues now. Thank you. You folks are awesome.

I did notice that both sides seem to be entrenched over what to do going forward – at least on camera. Everyone wants everyone to have insurance, but that thorny issue of costs keeps raising its head. Dog gone it. There always seems to be something to serve as a spoiler when real discussions take place in this health care reform debate.

But take heart. There is a way to fix all of the problems encountered with health care reform and I think you know what that the answer is: cut the doctor’s Medicare payments, already only 80% of costs, by another 21%.

We, your ever-ready and willing sycophants think that’s a great idea.

Knowing that we can be “team players” that are willing to take a leading role in health care reform will finally cement our image as omni-beneficent. People will finally be able to see through the media stories (transcript) that aired the day before the Health Care Summit about doctors as sexual predators. (video here). As Rahm Emmanuel said, “"You never want a serious crisis to go to waste. And what I mean by that is an opportunity to do things you think you could not do before." We as physicians are happy to do our part to counter these "systemic" problems with doctors. Thank you.

Now just so you know, we might have to make some eentsy–teensy–weentsy adjustments to how we do things, but it’s all be good. Really. Don’t worry. We’re innovators and entrepreneurs after all. We’ll figure out a way to curb inflation. We’ll lower the costs of staffing and equipment. And we’ll even single-handedly take ourselves off your payroll to lighten your load.

And it will all be good.

I mean, what could go wrong?

-Wes

Another Medicare Billing Blunder

Yes folks, doctors' Medicare payments are in the best of hands:

If your heart skipped a beat when you saw that January’s Correct Coding Initiative (CCI) edits bundled catheter ablations with electrophysiology (EP) studies, you weren’t alone.

Good news: CMS has decided to delete the edits retroactively because their addition was a mistake, according to the Heart Rhythm Society (HRS).

Snag: The deletion won’t happen until April 1.

Interesting that Uncle Sam can charge interest to you if you don't pay your taxes on time, but we can't charge Uncle Sam interest when we don't receive our payments on time.

-Wes

Doctor Paycut Suit Score: HHS 1, ACC 0

It's hard to bring a suit against lawyers. As case in point, from ModernHealthCare.com:

A U.S. District Court judge in Fort Lauderdale, Fla., has denied the American College of Cardiology's request for a preliminary injunction to block a scheduled Medicare reimbursement cut for cardiology services.

The ACC, its Florida chapter and other cardiology organizations filed a lawsuit against HHS Secretary Kathleen Sebelius on Dec. 28, seeking to stop the pay cut on the grounds that is based on the “erroneous and flawed” Physician Practice Information Survey. The ACC said Medicare payment cuts for 37,000 cardiologists are being based on the practice expenses of 55 doctors.

In addition to denying the injunction, Judge William Dimitrouleas denied a request for expedited discovery and canceled a scheduled hearing.

“We are deeply disappointed in the judge's decision not to hear our case on the preliminary injunction based on his opinion that the federal courts do not have jurisdiction to review Medicare physician payment determinations,” ACC CEO Jack Lewin said in a news release.

And from the ACC Advocate newsletter:

Basically, the judge refused to hear our case on jurisdictional grounds, finding that statutory language governing the Medicare program precludes judicial review of the relative value units and the methods for determining the RVUs in the Medicare fee schedule.

Interesting. So it seems that federal courts don't have jurisdiction over a federal program like Medicare's labyrinthine processes. Then who does?

(Maybe a sympathetic lawyer out there could explain this ruling to us not so legally inclined.)

-Wes

The Rule of Twenties

Heard from a local independent gerontologist tonight who does not accept Medicare or other insurance payments in our state:

"When it comes to geriatrics, it's the rule of twenties:

20 problems
20 medications
20-minute phone calls
20 minutes to take their clothes off
20 minutes to put their clothes back on.

With the initial physical exam, three follow-up visits, and one EKG that Medicare pays for, I would receive only $360 in total. I pay $40,000 per year in malpractice, yet have never had a judgement against me. Think how may patients I'd have to see to cover just that expense. (editor's answer: 111)

You wonder why I am not a Medicare provider? I'd never survive at that their payment rate. And Blue Cross? They're no better and often pay less.

Funny thing is, Medicare was only too happy to have me opt out, because to them, I'm no longer part of their problem."

And the reason every primary care doctor's not doing this???...

-Wes

Which Is It: Self-Referral or Gainsharing?

A series of fines have been levied in New Jersey for various fraudulent practices that might have a chilling impact on the way hospital systems do business:

The doctors -- Ravindra Patel of Scotch Plains, Jasjit Walia of Edison and Rakesh Sahni of Rumson -- agreed to pay a combined $960,000, representing twice the annual salaries they received from the University of Medicine and Dentistry of New Jersey, according to Ralph J. Marra, acting U.S. attorney for New Jersey.

Lawyers for the cardiologists were unavailable for comment last night.

Federal law prohibits doctors from accepting payments in exchange for referring patients. Beginning in 1996, authorities say University Hospital began trying to increase the number of cardiac procedures it performed by offering salaries to doctors in private practices in exchange for referrals.

A criminal inquiry into the program began after a federal monitor -- former U.S. Attorney Herbert J. Stern -- charged many of the doctors were given no-show faculty jobs. Most had few if any research credentials, and few actually taught, authorities said.

Many hospital systems pay non-employed specialist physicians from the surrounding community as "directors" of various specialty departments. In the case of cardiologists or gastroenterologists, one such role might be as "Director of the Catheterization Laboratory" or "Director of the GI Laboratory." Such directors reportedly play a role in assuring proper staffing, scheduling, or as training resources for nurses or technicians. But if no work actually occurs by the contracted physician in kind, then the government can move in. It appears this was the case in New Jersey.

But an even more perplexing problem is posed if there are competing groups vying for the services of one lucrative hospital laboratory, these same "directors" may be perceived as skewing the availability of lab time toward their groups, creating a source of friction for their competition. The defense of such a case can get very expensive for a hospital system.

But just when it appears doctors are starting to get the message about such arrangements, comes a new form of legal kickback: "gain-sharing." Gosh, I don't know why all of this is confusing, do you?

Could this be part of the government's upcoming strategy to save "$500 billion" in Medicare fraud costs? If so, it appears figuring out what is legal and what's not will continue to be next to impossible for physicians, and when there's a need for cash, well, it appears the side with the larger bankroll will win.

But if there's one takeaway from all of this: doctors and hospitals might want to carefully scruitinize their current consulting/employment arrangements.

After all, the government's a little short of cash right now.

-Wes

Medicine's New Car Pricing

One of the most distasteful moments in life is walking in to a car dealership and knowing that the prices on the vehicles mean nothing relative to the purchase price you must "negotiate."

Once you decide on a car (and your heart's set on it), you are immediately ushered to a nice desk and a polite salesman types on a computer, adds a few numbers to a spreadsheet, lets the speadsheet add in a little extras sales tax and numerous "fees," and then swivels the monitor your way to show you what the real cost of ownership. You smile politely, knowing he's padded the amount with his commission and dealer mark-up, then start negotiating.

At first the dealer is appauled that you would do such a thing. You threaten to leave. Magically a few thousand dollars disappears. You're still not impressed. He asks if you have a trade-in. You say, "No." He offers you dealer financing. You decline and offer cash. He gets his manager. His manager, looking like "Slick Willy," turns up the heat. They walk away. They return and remove a few hundred more. You know other dealerships can do it cheaper. They say best of luck. You walk out, thoroughly pissed. The salesman runs out to the parking lot and offers a final price two thousand cheaper. You stop, and wonder, "who the hell are these guys?" and drive off.

Such is the case with health care pricing, too.

The only problem is, of course, that you're dealing with your health at a very vulnerable moment in life. "List price" in medicine means nothing any longer. Whether your insured or uninsured, the prices that appear initially on your bill mean nothing. You must haggle.

Insured folks have agreed to let most of the haggling be done for them by the insurer, since the prices insurers pay for health care are pre-negotiated with hospital systems beforehand. You, in accepting a particular policy plan, get to "pick" your deductible and co-pay amounts, knowing full well that the negotiators are taking their piece. But that's the price the War Lords of health care system have exacted on the common man in the name of "transparency."

Noninsured folks have it much tougher. They get the list price sent to them after their care and get to feel the impending doom of realizing they've bought a Mercedes when they could only afford a Hyundai. So they make an appointment with the financial assistance office at the hospital. The nice lady there determines your ability to pay. If your "lucky" enough to be unemployed and have little income, you might get a flat 35% off. If not, no worries, an easy payment plan will be arranged. Never mind the bills will continue for years. Never mind that you have to have another operation and another admission in three months.

But even worse are to poor saps who have insurance and come from out of state, or those with tons of cash and don't want the world to know about their illness. They pay full fee. That's how the game goes. And that's why hospitals inflate their prices: "there's money in the thar' hills!" That extra money pays for lots of little extras at hospitals.

To be fair, hospitals aren't the only ones to blame. Like a co-dependent spouse of an alcoholic, the payment system that only pays only 80% of costs and leaves the rest to be paid by secondary insurers or the patient (as Medicare does) further enables this dysfunctionality. The lack of price transparency for our entire health care system is staggering. No wonder no one knows what things really cost in health care and no wonder ANY attempt to estimate costs always underestimates reality (poor CBO).

And so, when we see survey's from the New York Times finding that there are high fees in medicine, I can only say, "Duh!"

Welcome to the world of obfuscation and new car pricing.

Real reform would require no-haggle CarMax pricing but none of the current proposals require this.

If they did, then maybe we'd get somewhere in the health care debate.

-Wes

Lessons from a Wheelchair

Thanks to Medicare, a $348-dollar wheelchair costs taxpayers $1200.

Here's why.

-Wes

Implications of Cutting Cardiologists' Payments

It's been interesting to hear my cardiology colleagues in the community discuss what the proposed CMS cuts might mean for their patients and the implications for therapy access for patients requiring cardiovascular services.

In one local group, 40% of the cardiologists are over age 55. Now imagine cutting their practice income between 11 and 42% this year, with the potential for additional cuts yearly afterward. Recall that payments collected must first pay for office overhead: staff, collection personnel, lease payments, rent or mortgage, taxes, etc. These expenses do not go down annually. Cardiologists' take-home pay will be the item ultimately affected by these cuts. If a cardiologist makes, say, an average of $350,000 and one assumes a 50% overhead cost for his practice before the cuts, then $175,000 must first go to support his overhead. If income to the cardiologist's office is reduced 20% (on average) in 2010, then of the total $525,000 that was collected last year will translate to only $420,000. Since the practice expenses remain (at best) constant, the cardiologist's salary will be $245,000. ($350,000-$105,000 = $245,000).

Most internists and primary care doctors are quietly smiling right now. "Serves 'em right!" they snicker under their breath.

But if we consider this threat, is there an incentive to order fewer tests to offset their losses as they struggle to pay their kid's college educations?

No.

Further, recall the fact those "rich" cardiologists do not finish their training until age 30, on average, and that about a third of them are over age 55. We have to wonder if many will opt for early retirement instead of tolerating the bureaucratic hassles and salary cuts. After all, the nice thing about an MD degree is there are plenty of other options besides clinical care.

Alternately, in exchange for the dramatic salary reductions, they might demand a better life-style with better hours. If so, 90-minute door-to-balloon times might not be so easy to come by for hospitals. ER's might not find cardiologists quite so available, too, since the added 8% added to E&M codes won't offset the economic losses enough to warrant this extra workload. Hospitals' quality ratings will likely fall as they fail to meet their benchmarks and Medicare payments will dwindle to them, too.

While these cuts might help the Medicare budget very slightly and look good to policy pundits who have never had to go to a hospital at 2AM for an acute MI (heart attack), it's an entirely different thing in real life. Regretably, it's often the patients that lose.

Is this the price our system is willing to pay?

Perhaps. These cuts are certainly on the table. (Warning: pdf, 1277 pages).

But one thing's for sure, with these cuts will come consequences. Given the fact that cardiovascular problems are one of the most common ailments in man and a large number of cardiologists are approaching retirement age, these are going to be every tough times for doctors, hospitals and patients alike.

Is this who should be affected most by our current reform plans?

I wonder.

-Wes

Medicare's Mythical Cost Savings

Meghan McArtle makes some interesting observations in the Atlantic Monthly:

Monopolies, government or private, are risk averse, slow to innovate, and generally run things for the benefit of themselves rather than their customers. Hamstringing them with regulations can limit measurable outcomes, like excess profit-taking, but not unmeasurable ones, like the people who might have been cured by a drug the system didn't invent. And the political system introduces its own problems. As Robert Heinlein pointed out years ago, systems that have only positive feedback loops tend to fail catastrophically.

My critics will want me to explain why, then, Europe can do it cheaper. The answer is threefold. First, most European nations have better governance than we do--the American political system is a Public Choice disaster. Second, they pay people less money in a way that's hard to replicate here (and even if it wasn't, would be a one time savings that wouldn't check the rate of growth). Third, we're still driving quite a bit of product innovation. Our messy, organic, wasteful, unfair, irrational system allows experimentation, and they cherry pick the best results. If we stopped doing this, their system would stop looking so good.

The back and forth in the comments section are equally enlightening.

-Wes

Biasing the Argument Against Specialists

In an article originally published in the Washington Post on 20 Jun 2009 and republished in the Chicago Tribune today, the national shortage of primary care physicians is highlighted and serves as a significant problem for health care reform efforts underway. The systematic devaluation of primary care relative to "procedural-based" medicine is again addressed:

The disparity results from Medicare-driven compensation that pays more to doctors who do procedures than to those who diagnose illness and dispense prescriptions. In 2005, for example, Medicare paid $89.64 for a half-hour visit to a primary-care doctor in Chicago, according to a Government Accountability Office report. It paid $422.90 to a gastroenterologist who spent about the same amount of time performing a colonoscopy in a private office. The colonoscopy, specialists point out, requires more equipment, specialized skills and higher malpractice premiums.

But, as mentioned previously, we should realize that Congress made attempts to correct this disparity though "fudge factors" to the RVU payment formula before:

In 1993, Congress declared a redistribution of funds from proceduralists to primary care physicians. Initially there were 2 conversion factors—1 for medicine and 1 for surgery. The conversion factor, ie, the multiple of the RVU for payment, had the added advantage of demonstrating where costs were increasing. The 2 conversion factors demonstrated conclusively that surgeons did not increase their utilization when reimbursement decreased (because, for example, patients have only 1 gallbladder, and the indications for its removal remain constant). Other specialties increased their utilization, a process that continues to this day. In a refining effort to shift money to primary care, a third and separate conversion factor was developed in 1995. By 1997, it was clear that separate conversion factors were not controlling utilization of primary care and medicine services, causing these 2 conversion factors to decrease. The 3 separate conversion factors were eliminated in 1998, resulting in a decrease for surgery and an increase for medicine and primary care. In addition, more surgeons' practice expense reimbursements are included under the indirect category, now reimbursed at 35% of cost; internists and primary care physicians have a higher percentage included as direct expenses, which are reimbursed at 66%.

But few mention these facts. Further, when payment differentials are cited between primary care and specialists (whom have been conveniently reduced to "proceduralists"), the 90-day global period (the surgery and all care related to the procedure for 90-days afterward) is rarely, if ever, mentioned in the discussion. Follow-up visits, dressing changes, wound checks, and management of complications - all conveniently ignored pre-paid for three months.

Without a clear understanding of all of the issues related to physician compensation and the problems with government's prior attempts at meddling with the system to correct the disparity between primary care physicians and specialists, we should understand that simply cutting specialists' fees in favor of primary care physicians might lead to not only additional primary care shortages, but an even more acute shortage of specialists as well.

-Wes