AMA’s Influence on the Relative Value Payment Scale Attacked in Court, Congress; Accountable Care Organization CEO calls integrative medicine a financial asset in Obamacare model;
Patient-Centered Medical Home leaders Zunin and Trompeter see exceptional opportunities for integrative teams; Integrative medicine loses a friend in a high place as Berwick gets “pink slip” from Republicans
Under a two-decade old relationship, a panel dominated by tertiary-care-based specialty societies of the American Medical Association has met behind closed doors to set fee structures which, over 90% of the time, guide reimbursement policies of the US government. AMA’s Relative Value Scale Update Committee, known as the RUC, is a 29-member panel of representatives from MD medical specialties. RUC determines the relative value of specific medical services then makes recommendations to the Center for Medicare and Medicaid Services (CMS). CMS typically rubber stamps these over 90% of the time. Now a group of primary care physicians based in Atlanta, Georgia is suing the US government to end the practice and make the advisory group a US panel that will operate with transparency.
The suit is supported by Congressman Jim McDermott (D-WA). McDermott, a psychiatrist, has independently introduced legislation that, while it would not strip the RUC away from the AMA, would create more balance in its membership and openness in its processes. McDermott told Medpage that he supports efforts, whether judicial or legislative that seek to limit the influence of high-end specialties on rate-setting at the Centers for Medicare and Medicaid Services. On March 30, McDermott posted on his website that “for two decades now, this panel has been dominated by specialists who undervalue the essential and complex work of primary care providers and cognitive specialists, while often favoring unnecessarily complex, costly and excessive specialty medical services,” said McDermott in a statement posted on his website in March 2011. The American Academy of Family Physicians supports the McDermott legislative, which is entitled the Medicare Physician Payment Transparency and Assessment Act of 2011 (H.R. 1256).
The Atlanta doctors argue in their August 5, 2011 posting on their webpage, that the relationship between the RUC and CMS “creates systemic incentives to provide unnecessary and unnecessarily complex services.” They add that “it is not unreasonable to argue that this single relationship is the core driver of runaway healthcare costs, threatening the stability of American healthcare economy and the larger U.S. economy.” The doctors are also collecting donations for the lawsuit through the site.
Comment: I agree that the power of the specialists as expressed through RUC is a huge barrier to change. Any honest SWAT analysis, or treatment plan, would identify the RUC diversion of resource and target a plan to remove this obstacle to cure. Good for these Atlanta doctors and for McDermott. Each of the integrative practice fields should file amicus briefs, in they haven’t already.
“For the first time ever, the payment will change toward keeping people healthy … For the first time in 100 years it will be our job at Allina to keep the village healthy.” So spoke Ken Paulus, CEO of Minnesota’s huge Allina Hospitals & Clinics at the November 10, 2011 Integrative Medicine in Action event hosted by the Bravewell Collaborative. This shift, Paulus believes, will be “the point of inflection” for integrative medicine. He is quoted in this Huffington Post article:
“When I first heard of integrative medicine, I saw you as an expense. But [as payment in Accountable Care Organization (ACO) structures] kicks in that supports keeping people healthy, you will be an asset. Integrative medicine will be an asset.”
Paulus did not describe the exact details of how ACOs will support this shift. Instead he referenced the story of Chinese barefoot doctors who were only paid by communities if the people in their charge were kept healthy. Paulus positioned integrative approaches as aides in such health creation.
Comment: I had the opportunity to hear Paulus’ comments and felt a certain giddiness that may only be explained as the promised resolution of unrequited desire for economic alignment for integrative medicine. Capitalism in US medicine tends toward the big margins of what might be called SUV medicine: inpatient services, patented drugs and high-tech machines. Paulus suggested that the ACOs established by the Obama-Pelosi reform are creating a context for developing what some of us 10 years ago dubbed “a thriving industry of health creation.” This provoked a re-publication of the Design Principles for Healthcare Renewal for which this phrase was crafted as part of Principle #9.
In preparation with integrative pediatrician Larry Rosen, MD for a February 11, 2012 presentation on ACOs, PCMHs and integrative medicine at the Integrative Healthcare Symposium, I recently interviewed two integrative health leaders with emerging patient-centered medical homes (PCMHs). The topic: How do they see they see the potential fit with integrative health approaches? Tom Trompeter, MHA, is CEO of Healthpoint, a network of 10 federally-qualified health centers in the Seattle-area. For 15 years, these centers have integrated services of naturopathic physicians, licensed acupuncturists and massage therapists with their PhD psychologists, nutritionists, dentists and MD/RN staff. Trompeter speaks of the PCMH, which he prefers to call a “health home,” as a “break from the paradigm of a physician owning a patient.” Similarly: “It’s not about the billable visit.” The concept of patient ownership shifts, in Trompeter’s view: “My patient needs to transition to our patient.” He believes this opens the door to teams and “the team approach opens the door for diversity” of providers and services. The Trompeter interview is here.
Integrative physician Ira Zunin, MD, MPH, MBA is the founder of the 40 practitioner Manakai O Malama center in Honolulu. Zunin’s clinic was approached by leaders of the local delivery system to merge his center with the area hospital and payers through linked electronic medical records (EMR). Zunin describes significant immediate value via increase in referrals that the EMR created for his acupuncturists, massage therapists and naturopathic doctor. He underscores Trompeter’s point on payment: “In the PCMH, payment plays into our hand. You have unassigned dollars that aren’t directly connected to a provider or a procedure or a code. You can use the dollars from an integrative perspective.” In this Integrator interview, Zunin speak also to the significant challenges. Yet his overall view is positive: “The PCMH model is supposed to help the whole person, in his or her community. We’ve always been looking at everything with a bigger tool set, with a focus on health. We’re oriented to this model. We’re oriented to teams.”
Comment: Since these interviews, I found myself listening to a local practitioner bemoaning the awkward fit of the insurance coding dance for a whole person practice that is relationship-based, time-intensive and individualized. I was pleased to say: You might check in with the leaders of the local ACO movement to see if you can get paid to keep people healthy. Their may be light at the end of integrative medicine’s economic tunnel.
Comment: Healthcare writer Joe Nocera caught up with Donald Berwick, MD within a week of Berwick’s exit from his recess appointment as administrator of the Centers for Medicare and Medicaid Services (CMS). In his December 5, 2011 New York Times op-ed piece (Berwick’s Pink Slip) Nocera writes: “Dr. Berwick, I’m here to tell you, was the most qualified person in the country to run Medicare at this critical juncture, and the fact that he is no longer in the job is the country’s loss.” I agree. The fact that Berwick once spoke favorably about the British health system model that costs half as much as that in the US and produces better outcomes sealed his fate before his Republican executioners. Berwick’s extension of evidence-based medicine to evidence-based policy-making is apparently as palatable to medical business-as-usual as is the science behind global warming for Big Oil. The waste-trough of US medicine, estimated by leaders at the Institute of Medicine to be at 50% of the $2.6-trillion spent annually, seems to have only produced compelling evidence of a donor base, not scientific base, for the Republicans who pushed him out.
Meantime, when Berwick stepped down, integrative medicine lost a friend in a high place. As noted here, Berwick’s positive perspective on integrative medicine is on record. He was a keynoter at the February 2009 IOM Summit on Integrative Medicine and the Health of the Public. Berwick elucidated his “Basic Principles for Integrative Medicine.” They are worth restating here on his exit.
- Place the patient at the center.
- Individualize care.
- Welcome family and loved ones.
- Maximize healing influences within care.
- Maximize healing influences outside of care.
- Rely on sophisticated, disciplined evidence.
- Use all relevant capacities – waste nothing.
- Connect helping influences with each other.
This is a pretty darned good list to hang on the mirror as a daily reminder for those in the field of integrative health. Now, let’s see what Berwick, the founder of the Institute for Healthcare Improvement (IHI) will be up to next.