Brian Klepper and David Bibbe have an interesting piece on The Health Care Blog about a legal challenge to the American Medical Association’s RVS Update Committee.

I’ve commented on criticism of the RUC before.

As a brief refresher however the RUC is a committee made up largely of representatives from the members of the American Board of Medical Specialties. The RUC makes recommendations on how much Medicare’s fee schedule, known as the Relative Value Resource Based System, should pay for any given physician service. To be a little clearer, it spells out how much each physician activity should be worth as compared to other physician activities. For instance, how much should a doctor get paid for a craniotomy as compared to a primary care office visit.

In theory this isn’t new money; the RUC doesn’t recommend that the RVRBS pay a certain amount to physicians for certain activities but merely just recommend comparatively how much each physician activity should be worth.

“You should pay physicians ten times as much for a lithotripsy as for a pap smear.” I just made that up right now, but you get the idea hopefully. They’re just recommending how to divide up the Medicare pie.

The RVRBS was created by Medicare and came into play in 1991. Part of the reasons behind it being to close the income gap between primary care physicians and specialists. However, in the past two decades that gap has actually grown. This has become the source of chagrin from many sides, as demonstrated by Drs. Klepper and Bibbe’s piece.

The role of the RUC in failing to close the primary care – specialist income gap is a constant criticism of it. Major criticisms include the fact the majority of its members represent specialists, the secrecy under which it works and the fact that it’s recommendations are by and large accepted and implemented by CMS.

These criticisms are fair enough and I won’t go into a full fledged defense of the RUC. However I do have two concerns with attacks on the RUC:

First, it appears that the compensation between all procedures and E/M services such as office visits has actually narrowed per unit since the deployment of the RVRBS. See former RUC chairman Dr. William Rich’s letter in the Annals and pre-RVRBS commentary data on physician reimbursement here and here and elsewhere.

Second, this seems to imply and, at least cursory there appears evidence, that the growth in the primary care – specialist gap is largely based on volume and not the RVUs themselves.

If true that seems to excuse, not in full, but certainly in part the RUC. To be sure it appears fair to criticize that the RUC has not fully accounted for the time involved in each RVU for which they make recommendations. The RVUs are obviously supposed to account for the fact a colonscopy can be done in 20 minutes while a level 4 office visit takes substantially more time. However, there appears to be a much larger issue in physician reimbursement, well beyond the scope of the RUC. Perhaps attention is better focused on broader reform than RUC criticism.

Anyway go read the article at The Health Care Blog. It is thought provoking, as always when Dr. Klepper and others discuss the RUC.

New physicians, known as interns, entering residency, which is the training physicians go through after medical school, can no longer take overnight call in the hospital without supervision from a more advanced resident or from a faculty physician. In addition they cannot work more than 16 hours straight. This as of July 1st.

For me this means a situation in which I’m taking essentially the same amount of overnight call as I did last year but, if the interns were part of the overnight call pool I’d be taking substantially less. Let this stand as my disclosure for this post.

The rules for interns are part of new regulations on resident physician work hours from the Accreditation Council for Graduate Medical Education.

For the past decade, the move to limit resident working hours has been a constant debate and struggle. I’ve written about it in the past here and here. Part of the situation is that it has become accepted that longer duty hours, less sleep for resident physicians, who are intimately involved with patient care at teaching facilities, leads to iatrogenic harm and worse patient care.

In moves to improve patient care and, in no small measure, to stem any public outcry and to make sure that resident duty hour regulation remains part of medicine’s self govern mandate the rules on resident work hours have become subsequently more restrictive through three iterations.

The problem is however that no matter how intuitive it may seem that limiting the amount of time resident physicians can work should mean they’re more rested should mean fewer mistakes when treating patients, it turns out that the evidence for such was highly circumstantial when resident work hours were first implemented and has not been borne out since the implementation.

It’s true that there are witnessed attentional mistakes in medicine that lead to patient harm. And it’s true that there is evidence from studies outside of medicine, and our own everyday anecdotal experience, that fatigue worsens attentional mistakes.

A very small 2004 study in the New England Journal of Medicine, 24 interns partook, randomized but did not blind the schedules of these physicians-in-training to a traditional schedule with 30 hour call shifts, where the residents routinely but not always worked over 80 hours a week, and to a float system where the residents worked 16 hour shifts and did not work over 80 hours a week. The interns working more and working longer shifts, made more errors.

But since implementation of resident physician work hour restrictions almost no change in patient’s harmed by errors or in patient outcomes has been seen. This from multiple large retrospective studies looking at data from millions of patient visits to teaching hospitals.

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Much has been made of the lack of tertiarization (I’ll pretend that is a word) in American health care. The U.S. has a proportion of specialists to primary care physicians greater than any other western nation. Just over a third of U.S. physicians practice primary care.

Ratios of primary care physicians to specialists that more strongly favor primary care have, in the past [doc], to be strongly associated with lower mortality, higher compliance with health care and other positive outcomes.

But flipping through a Dartmouth Health Atlas project shows even amongst this long tenent there is a lack of consensus,

Rates of leg amputation, a serious complication of diabetes and peripheral vascular disease, also had no relationship with having at least one annual visit with a primary care clinician. And patients’ risk of leg amputation varied dramatically depending upon where they lived – there was a tenfold difference in the rate of leg amputation, ranging from 0.33 per 1,000 beneficiaries in Provo, Utah to 3.29 per 1,000 in McAllen, Texas.

The report also found that having an annual primary care visit did not keep patients out of the hospital for ambulatory care-sensitive conditions such as diabetes and congestive heart failure. There was a more than fourfold difference in the rate of ambulatory care-sensitive discharges among Medicare beneficiaries, ranging from 30.7 per 1,000 in Honolulu to 135.0 per 1,000 in Monroe, La.

It’s a complex issue for sure and certainly the sum of evidence seems to support benefits for more primary care physicians (even at the expense of specialists) but I thought the write up on the Dartmouth Atlas data was interesting.

There’s a minor scandal being carried on at the major teaching hospital of UT Southwestern’s medical school and the public hospital for Dallas, Parkland. The Dallas Morning News is reporting that up to recently UT Southwestern was paying medical students to work in the psychiatric emergency room at Parkland during their off time.

What exactly they were being paid to do is in some dispute according to the article but there’s major contention over paying medical students for any sort of clinical care. If they were interacting with students, documenting clinical care in notes or essentially doing anything but delivery food trays to them, there is likely a serious problem with paying medical students, who are not yet clinicians, for any sort of patient interaction. And so there is minor drama.

I don’t know the truth about what medical students were doing, but I will agree wholeheartedly that the way medical education is organized now in the United States, there is something unethical about paying physicians to play clinicians.

In an op-ed appearing in the New York Times on May 29th, Drs. Bach and Kocher lay out a plan for making primary care more attractive to medical students. They propose the following,

Under today’s system, all medical students have to pay for their training, whether they plan to become pediatricians or neurosurgeons. They are then paid salaries during the crucial years of internship and residency that turn them into competent doctors. If they decide to extend their years of training to become specialists, they receive a stipend during those years, too.

But under our plan, medical school tuition, which averages $38,000 per year, would be waived. Doctors choosing training in primary care, whether they plan to go on later to specialize or not, would continue to receive the stipends they receive today. But those who want to get specialty training would have to forgo much or all of their stipends, $50,000 on average. Because there are nearly as many doctors enrolled in specialty training in the United States (about 66,000) as there are students in United States medical schools (about 67,000), the forgone stipends would cover all the tuition costs.

It’s novel and I think worth discussion.

But sitting in a specialty poised to be burdened the most under such a plan I have some reservations. Neurosurgeons have perhaps the longest training of any specialty. The majority of neurosurgical residencies are 7 years and with fellowship training the burden for future neurosurgeons could be upward of $450,000 under the current proposal at $50,000 a year.

There are a number of other specialties as well, where the average income falls well short of the median cited in the op-ed. In a specific example, neurosurgeons who go on to do 1-2 years of fellowship in pediatric neurosurgery take a significant pay cut as compared to those neurosurgeons who go into practice straight out of residency and treat adults. Or consider the infectious disease specialty where the average income is hardly more than that of a primary care physician but require extra fellowship years. The point is that while the average income for a primary care physician is has a shorter distribution and is more homogemous, there is great variability in income for specialists. The proposal is likely to drive medical students and graduating residents, now forgoing primary care, out of certain specialties including infectious disease, physical medicine and rehabilitation and many pediatric surgical specialties to name a few.

My second contention is that, for the most lucrative specialties, I’m not sure the incentive will be enough. Let us consider the numbers given in the op-ed concerning the median specialty and primary care incomes. They cite $325,000 and $190,000 respectively. It may not be totally realistic but will serve my point if we have a pediatric neurosurgeon earning the former and a primary care physician earning the latter.

Let’s say the pediatric neurosurgeon takes 8 years of training and owes $400,000 at the end. The primary care physician does 3 years of training and owes nothing. Assuming some level of government guarantee of the loans used by the pediatric neurosurgeon and he or she is paying them off over 15 years at a 6.8% rate.

Over a 20 year period (from the time the primary care physician enters practice after completing his or her free training to the time the pediatric neurosurgeon is finished paying his or her loans) the gross numbers stack up like this:

Primary Care Physician 20 Year Earnings
20 years x 190,000 = 3,800,000

Pediatric Neurosurgeon 15 Year Earnings
Remember the specialist will be in training for five years while the primary care physician is out earning.

15 years x 325,000 = 4,875,000 – 640,000 loan payments = 4,235,000

On the sum there is still incentive for medical students and residents to choose a high paying specialty.

Finally, I’ve discussed this before, but self reported surveys continue to show that medical student’s decisions concerning primary care are only partly related to future earning potential and other factors are more important. This plan doesn’t address the appearance problems that primary care suffers and the expectations of health care in this country which, in addition to the comparatively low earning potential, make primary care unattractive to American medical students.

I am A strong proponent of strengthening primary care. The reality is we need to normalize primary care and specialist reimbursement and dramatically reduce the number of specialist training positions in order to force a more tertiary health care system more in line with the rest of the western world.

I have serious doubts making medical school free will significantly bolster the future of primary care.

Don’t let anyone but this blog’s readership know, but, I admire Donald Berwick.

The director of the Center for Medicare & Medicaid Services has dedicated the majority of his adult life to studying and improving the delivery of health care. And he stepped up to one of the highest platforms within health care policy knowing the challenges to acceptance he faced. Not that I would dare that he considred such when Obama asked him to take the position. Still, to only small surprise his well versed and verbalized opinions on what health care could be have hampered his service to the Obama administration.

Several people who work with Dr. Berwick at the Medicare agency said they were disappointed that the White House had not done more to promote him. “Everybody here admires Don and the work he’s done, but he is not going to be confirmed,” a supporter said. “That’s inevitable. The Republicans will block him. There’s not a lot of optimism that the White House can do anything about it.”

Berwick, a pediatrician by training, has made an internationally recognized career of his focus on optimizing the delivery of health care and he has, at times, been frank about what such would entail,

“Any health care funding plan that is just, equitable, civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional.”

Although many have this particular Dr. Betwick quote it is hard for anyone, looking at the actual data, to refute such a claim. Or Berwick’s many chides that improving health care will entail a more visible and transparent rationing of such. And rationing, publicized rationing, will be the death of meaningful health care reform at present.

Not that Donald Berwick doesn’t have his supporters, but his detractors in Congress will be the end of his tenure at the head of the CMS under a recess appointment from President Obama.

[H]is past record of controversial statements, and general lack of experience managing an organization as large and complex as CMS should disqualify him being confirmed as the CMS Administrator.

I don’t agree with many of Dr. Berwick’s opinions. Not on their merits mind you but on their implications.

And that’s a troubling position from which to argue with someone. The position that I concede your points but I disagree with you nonetheless. Of course, that has been my long held position. Essentially I concede that if you desire to improve the health of this country, by most population based metrics, then reforming the delivery of care to make access more affordable is important. And to improve access will require a better planned (not that our current system is planned at all) rationing of health care; a more visible rationing.

But challenging Dr. Berwick on his credentials is something else.

Managerial skill is something he has proven not only at the IHI but throughout his professional career. And I’m not sure a career government professional is someone we desire, on that merit alone, to head the CMS as the Senate Republican letter to President Obama implies.

Dr. Berwick’s tenure will have been too short, no matter my opinion of his ideas for Medicare, Medicaid and health care in general. 17 months at the helm may be long in the life of a CMS director,

This is a substantial period of time and long enough to have set a tone at CMS and to have recruited key second and third-tier administrators to work on important pieces of the Affordable Care Act. Berwick has already jump-started the Center for Medicare and Medicaid Innovation, the best hope health reformers have for finding smart ways to cut health care spending. Under Berwick’s tenure, the federal regulation of private insurance was also brought under the CMS mantle, a power consolidation that could have long-range implications.

But arguably shorter than the respect he deserved, no matter your politics.

Medicaid is a matched grant program, wherein the federal government matches money spent by the states, to provide a funding source for healthcare the economically disadvantaged. Medicaid, as can be imagined, has been pushed by the Great Recession.

From 2007 to 2009, Medicaid enrollment accelerated as a result of the recession. During economic downturns, people lose jobs and incomes decline making more individuals eligible for Medicaid at existing eligibility levels. Access to Medicaid coverage remained stable over this period due to protections put in place under ARRA. Increases in enrollment stemming from the recession were the primary drivers of increased spending on Medicaid over this period. Looking over the last decade, Medicaid spending per enrollee has increased more slowly than growth in national health expenditures per capita and growth in private health insurance premiums. Despite the program’s success in holding down per capita cost growth, states are grappling with immediate budget issues related to the economic downturn and related state budget constraints coupled with the expiration of the enhanced federal Medicaid matching funds from the ARRA on June 30, 2011.

Given the level of cost-containment that has already taken place, additional reductions in Medicaid spending growth over time will depend on…broader efforts to reduce health spending across all payers

Enrollment has gone up while state revenues and budgets have been squeezed. In 2010-2011 the federal government increased the funds given to the states, effectively shouldering a greater burden of the Medicaid budget. But that extra money was a one year deal and is set to expire.

And so states, faced with budget deficits in large part attributable to Medicaid (for instance: Wisconsin’s shortfall over the next two years is made up in half by Medicaid costs) continue to struggle. And state lawmakers have been very prominent in vocalizing their displeasure with the situation. One of the problems is some of the restrictions on reducing Medicaid eligibility, basically striking some people from the rolls, that the Affordable Care Act places. Basically,

But what really makes this Medicaid fight different from ones that have come before is the impact of the health overhaul passed last year, which calls for a huge expansion of Medicaid in 2014 to low-income childless adults.

States won’t actually be on the hook for most of those costs; all but 10 percent will be paid by the federal government.

But between now and 2014, in order to get that federal money, governors basically can’t cut back on most Medicaid eligibility. That makes a lot of them, well, not very happy.

“I really believe that the federal government, with their maintenance of effort, have really tied our hands and not given us the flexibility to do what we do,” said Iowa’s Branstad. “I don’t mind being held accountable [but] I’d like to be able to set our own eligibility requirements.”

This part of the Affordable Care Act, and other provisions related to Medicaid funding, has actually been challenged in federal court along with the more media grabbing assertion that the individual mandate oversteps Congress’ authority. However the mixed success opponents, including the state Attorney Generals, have had within the judicial system, it is of note that no court has sided with the plantiffs when it comes to the requirement that the states maintain current Medicaid rolls if they want to be eligible for future federal Medicaid dollars come 2014.

And so state Governors have gone politiking,

Haley Barbour doesn’t have many nice things to say about Medicaid these days.

He says he’s frustrated with “people [who] pull up at the pharmacy window in a BMW and say they can’t afford their co-payment.”

And, he says, “Forgive me if I think people who work two or three jobs to pay for health care for their families shouldn’t be forced to pay for health care for people who can work, but choose not to.”

Some more fringe state lawmakers have even talked about opting out of Medicaid all together,

The Heritage Foundation, a conservative research organization, estimates Texas could save $60 billion from 2013 to 2019 by opting out of Medicaid and the Children’s Health Insurance Program, dropping coverage for acute care but continuing to finance long-term care services. The Texas Health and Human Services Commission, which has 3.6 million children, people with disabilities and impoverished Texans enrolled in Medicaid and CHIP, will release its own study on the effect of ending the state’s participation in the federal match program at some point between now and January.

Although that is, for all the talk, extremely unlikely,

“I can’t imagine Mississippi opting out,” [Barbour] said at a hearing on Capitol Hill Tuesday. “We’re a poor state, and it’s an important program. We want to run it better for taxpayers and beneficiaries. … I am not an opt-out advocate and I’m just being forthright about that.”

Medicaid is feeling the squeeze from the Great Recession. It will continue chugging along, but the promise of an expanded Medicaid helping to provide insurance to more than half the people theorized to be covered under the Affordable Care Act, well that might be too much to ask,

Obama’s new budget calls for spending $279 billion on Medicaid and the Children’s Health Insurance Program, down from $285.4 billion this year. In plain language, this means stripped-down health care coverage for the poor and bigger burdens for the states.

In a terrible scene in Arizona Representative Gabrielle Gifford and others were shot as she held a meeting with her constituents outside a supermarket. At least six are dead. My prayers are with everyone involved in this, their families and loved ones.

Even as at least one of the suspected perpetrators has been identified and theories on motive swirl and the unfortunate game of politics is already playing out, the major attention has been on how Rep. Giffords is doing.

Rep. Giffords suffered, per reports, a single gunshot wound to the head with both an entrance and an exit. From eye witness accounts with a posterior entrance wound.

In the same press conference it is commented that the bullet transversed just one hemisphere. She underwent neurosurgery, although the exact nature of such isn’t clear. Post operatively she was following commands.

Of course, no one but her physicians right now know exactly what is going on but missile wounds to the brain are tough things. There is some optimism but I’m afraid we should probably be more cautious than some of the vibes coming from the media.

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I recently talked about what changes came into effect on the New Year under the Affordable Care Act. One of the tangential things I didn’t comment on was an executive Medicare regulation running parallel to congressional efforts which came into effect January 1st and promised to pay providers for any time spent discussing end of life issues with patients.

The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves.

Section 1233 of the bill passed by the House in November 2009 – but not included in the final legislation – allowed Medicare to pay for consultations about advance care planning every five years. In contrast, the new rule allows annual discussions as part of the wellness visit.

The proposal for Medicare coverage of advance care planning was omitted from the final health care bill because of the uproar over unsubstantiated claims that it would encourage euthanasia.

The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Critics decried the new rule as taking control away from patients and devaluing life and setting up death panels.

There is…something at least vaguely disturbing about a government incentivizing doctors to [discuss end of life issues] as part of an expansive regulatory program that has, as one of its primary goals, cost reduction.

At least the linked to criticism at Hot Air,

There is nothing wrong with patients planning for contingencies through advance directives. There is also nothing wrong with doctors discussing those options with patients ahead of those decisions. As the spouse of a patient who has faced life-threatening circumstances on more than one occasion, I certainly understand why these conversations need to take place before the pressures of acute circumstances come into play. This new regulatory effort at least puts the conversation where it belongs, in routine wellness visits, rather than as a five-year set conversation. It also appears to make this a voluntary conversation (at least for now), one the patient can decline without any repercussions.

I couldn’t agree more but I would argue that there should be reimbursement for it at anytime, anywhere.

Too bad, as bowing to political pressure, the Obama administration soon backed off of the regulation this week.

Lacking a pallative care team there may be no one outside my team, the neurosurgery service, who sees as much end of life issues. Neurotrauma, aneurysmal bleeds, primary central nervous system cancer, bad things. And the choices family have to make in the heat of the moment are gut wrenching and painful and full of angst.

Patients and their physicians need to have conversations with families present concerning end of life issues well before anything happens. The young and the old need to have the conversation. In some ER with a loved one with a massive subdural on Coumadin, with me, is not the place to have the conversation for the first time.

The best way to promote people discussing end of life issues with their physicians is to pay physicians for such discussions. Too bad the political establishment on the right has a problem with that.

Healthcare is a limited commodity. It’s limitations are defined by the numbers of professionals supplying it and their physical limitations on the number of patients they’re able to treat, on availability of biomedical equipment and technology, on availability of physical space to safely provide medical care and, underlying all of these, on the funding for such.

And so, not everyone can get all care they need or want.

And, it is true, no system will even be able to supply such. There will always be limitations. And there will always be some rationing.

The argument from many proponents of reform has long been that at present we covertly ration healthcare and we do it haphazardly and so reform that makes rationing more transparent and planned is actually a positive. Essentially the argument is that, everyone is scared of rationing in health care reform but what many don’t realize is that such is already occurring and we should embrace making rationing more rational with health care reform.

It is an argument made recently by ration as a verb,

to supply, apportion, or distribute as rations (often fol. by out ): to ration out food to an army.

to supply or provide with rations: to ration an army with food.

to restrict the consumption of (a commodity, food, etc.): to ration meat during war.

It’s a verb, it’s an action. It implies planning and action. Not the haphazardness that defines who currently does and doesn’t get certain care within the American health care “system.”

The Economix piece quotes former CMS head Dr. Mark McClellan later,

“Just because there isn’t some government agency specifically telling you which treatments you can have based on cost-effectiveness,” as Dr. Mark McClellan, head of Medicare in the Bush administration, has said, “that doesn’t mean you aren’t getting some treatments.”

And I agree but it’s important to keep our terminology straight, at least to opponents of rationing and health care reform as defined currently by things like the Affordable Care Act. In that quote above I would claim only the former represents rationing and not the latter.

And the end results are not the same.

Rationing, the centralized distribution of health care resources is vague but for many proponents of current national health care reform efforts essentially it means the most bang for the most people for the buck. An egalitarianistic vision of health care.

However, down the slippery slope, it promises to leave peripheral exotic patients on the sideline and to limit freedom of choice.

By some quantitative quality measures health care, over the whole population, may be better. But in rational rationing these are the physicians you can see, these are the procedures you’re entitled to no matter the nature of your specific disease or your personal means. It could potentially stifle innovation in health care and certainly will limit choice.

Currently your economics and your social status influence the care you receive and they choices you have. In a rationed system, as envisioned by many proponents of current health care reform, the care you receive and the choice you have are influenced by some centralized entity who determines such. The latter is certainly more rational and has the potential to improve some measurements of health in this country but it holds the potential to inherently redefine the notion of choice within your means, of freedom upon which (and I don’t mean to be hyperbolic here) the American dream has been based. Or at least the mythos that is the American dream.