Report of the Council of Subspecialty Societies (CSS) of the American College of Physicians (ACP) 12 September 2011, Washington D.C.
The ACP responded to the CMS initiative for the Relative Value Scale Update Committee (RUC) to review all 94 evaluation and management (E/M) codes with the following recommendations. CMS was requested to work with the medical community to develop E/M codes that appropriately describe services. The current medical service valuation system does not include metrics of critical physician work that occur outside of face-to-face contact with the patient. A review would not be effective in compensating physicians for rendering comprehensive care and chronic disease management or alleviating the shortage of primary care physicians. A proposal to eliminate the 5 year review would result in smaller and more frequent survey sets and would increase the time commitments of volunteer physician advisors while expending increased specialty society resources
The American Academy of Family Practice (AAFP) has requested that the RUC to add four additional primary care seats for the ACP, AAFP, the American Academy of Pediatrics, and the American Osteopathic Association while eliminating two rotating internal medicine subspecialty seats, while adding three ‘external’ seats for consumers, health plans, and health systems and a seat for geriatrics. The ACP is supportive of the addition of additional primary care seats on the RUC while retaining the subspecialty seats on a permanent basis.
A number of committees have been established to provide recommendations for physician payment reform. The American Medical Association (AMA), American College of Surgeons (ACS) and the ACP have initiated the Physician Payment and Delivery Reform Leadership Group whose mission is to provide a forum for physicians and their representative organizations to use evidence-based approaches to support the development of new payment and delivery systems that meet patient and population needs; provide opportunities for physician participation across specialties, practice types, and community settings; and provide a sound and sustainable economic foundation for physician practices.
The AAFP Task Force on Primary Care Valuation is charged with reviewing and making recommendations to the AAFP Board for an alternative methodology to value primary care services provided by family and other primary care physicians. Workgroups will define primary care, develop a separate primary care conversion factor, establish a new primary care code family, and consider comprehensive payment reform for comprehensive care.
A RUC/CPT committee, established in response to the 2012 Physician Fee Schedule proposed rule, will consider alternative ways of valuing E/M codes. The Brookings Institution Research Project has the mission of identifying clinical informed solutions for policymakers that will enhance reimbursement in primary care, research models which can promote integration of primary care and specialty services and develop score-able solutions for MedPAC, CBO etc..
Recognition programs for the Patient Centered Medical Home continue to be developed by several organizations. The most prominent and most commonly acknowledged by health plans is the National Committee for Quality Assurance (NCQA).
As of September 2011 NCQA has recognized 2710 practices, inclusive of 13,000+ physicians. Multiple health plans are paying rewards for recognition. More than 50% of specialists serve as primary care practitioners (NEJM 2010;362:1555-58, 29 April 2010).
Drug shortages have increased three-fold (212%) since 2005. These are primarily sterile injectibles including: anti-infectives; anti-neoplastics; and anesthetics. According to the Food and Drug Administration (FDA) the primary reason for the shortages is product quality control An additional factor, that is seldom acknowledged, is the “gray market in pharmaceuticals” where opportunistic companies have achieved exclusive manufacturing rights that has resulted in increased costs to distributors and hospitals up to 4000%
The Budget Control Act of 2011 requires that Congress enact more than $2 trillion in deficit reduction over the next 10 years, enforced by caps The Joint Select Committee on Deficit Reduction, also identified as the “super committee” is tasked with presenting their report and legislative language by 23 November 2011 with enactment by 23 December 2011. No filibuster or amendments will be permitted If legislation is not passed the process of “sequestration” will be implemented with a 2% reduction in defense(50%) and non-defense discretionary and mandatory(50%) spending Exempted programs include military retirement, social security, Medicaid, unemployment insurance, low income programs and others.
Between 1999 and 2009, health care spending has almost doubled from $1.3 trillion to $2.5 trillion, representing 17.6 % of the gross domestic product. Options for deficit reduction as advised by the Congressional Budget Office (CBO) include addition of the Public Plan to Health Exchanges, limit malpractice torts, conversion of Medicaid to block grants, reduce the federal Medicaid match, raise Medicare eligibility to age 67, and consolidate and reduce Graduate Medical Education (GME) payments. Other recommendations from the CBO: require manufacturers to pay a minimum rebate on Medicare Part D drugs for low-income beneficiaries; reduce Medicare rates across the board in high spending areas, increase the Medicare Part B premium from 25 to 35% of program costs, combine Medicare Part A and B deductible, limit Medi-gap coverage, reduce NIH funding, accelerate excise tax on high cost plans, increase the tax on alcoholic beverages, tax high fructose beverages, increase Part A payroll tax, and repeal the individual insurance mandate. Bob Doherty, the Senior Vice President, Governmental Affairs and Public Policy of the ACP, believes that the most vulnerable recommendation for medicine are the GME payments.
Respectfully submitted,
Joseph W. Sokolowski Jr. M.D.
ATS representative to the ACP, CSS
