Tag Archives: AMA

Criticism of the AMA’s RUC Grows

Tom Scully, the outspoken former head of Medicare, recently said that one of the biggest mistakes policymakers made when redesigning the physician payment system in the early 1990s was giving the American Medical Association control over the Relative Value Scale Update Committee or the RUC.

The RUC, which is as controversial as it is unknown, is a 29-member panel that makes recommendations on how to value of thousands of physician services under Medicare. While Medicare officials are under no obligation to accept the panel’s decisions, most of the time that’s exactly what they do.

Courtesy Wikimedia Commons/ Public Domain.

Mr. Scully told members of the Senate Finance Committee that the current RUC structure, as run by the AMA, isn’t objective enough. There’s a lot on the line since the RUC’s decisions impact about $80 billion in Medicare spending each year, he said. As lawmakers consider how to reform the physician payment system, he urged them to also think about ways to make the RUC less political and more independent.

The comments in the Senate hearing room were just a sampling of the criticism that the AMA and the RUC have received recently. Over the past year or so, the RUC has been under near constant attack from a small group of primary care physicians who are suing the Centers for Medicare and Medicaid Services with the goal of getting the agency to dump the RUC. Their contention is that the RUC is biased toward subspecialists and that the panel’s recommendations have contributed to a significant gap between primary care and specialty pay.

The AMA has continued to support the RUC process, arguing that a group of physicians is best positioned to determine the value of medical services and that the panel has often championed payment increases for primary care services.

— Mary Ellen Schneider

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OSHA Denial Roils Resident Work-Hour Reformists

Reaction has been mixed to the Occupational Safety and Health Administration’s recent decision to deny a second petition from the Public Citizen Health Research Group and other groups to have OSHA, rather than the Accreditation Council for Graduate Medical Education, regulate resident/fellow work hours.

The American Medical Association, which had worked to keep ACGME at the helm, applauded OSHA’s decision in a recent statement .

“The ACGME is the appropriate body to regulate and monitor resident duty hours, as it is optimally suited to oversee resident and fellow physician duty hours on behalf of both the profession and the public,” AMA president Dr. Peter Carmel said. “We are pleased that OSHA agrees.”

In denying the petition, OSHA officials wrote that resident duty hour standards are “best addressed within the context of resident training and education,” and that new duty hour standards and enforcement mechanisms that took effect in July 2011 “provide an opportunity for ACGME to take meaningful steps to protect the health of resident physicians within the context of their overall residency experience.”

OSHA officials also noted that federal whistleblowers provisions protect residents and interns who voice concerns related to extended work hours.

Public Citizen fired back in a letter to OSHA that the Obama administration was rehashing “the same discredited Bush-era arguments of nine years ago when our first petition was rejected on almost identical grounds.”

The group went on to say that “OSHA has, once again, opted out of its legal obligation to protect residents from excessive work hours, deferring instead to a largely unaccountable private entity, the ACGME.”

Currently, when a resident reports work-hour violations, they risk retaliation from colleagues and put their training programs at risk for probation and even loss of accreditation, Sonia Lazreg, health justice fellow with the American Medical Student Association, said in an interview.

After the 2003 work rules were implemented, more than 80% of residents reported that their programs were in violation when they could report anonymously to an external body, she said. During the same period, ACGME resident survey reporting suggested that only 3% of programs were in violation.

“Only when we have external enforcement, beyond the ACGME, will we see true implementation of duty hours,” she added.

The AMSA co-petitioned OSHA based on what Lazreg described as overwhelming evidence that current schedules cause an increase in mood disorders, motor vehicle accidents, pregnancy complications and needle-stick injuries among residents. As the federal body tasked with ensuring employee safety and health, she said OSHA has a responsibility to intervene when evidence so strongly points to worker harm.

“OSHA’s denial translates into continued employee risk, injury and death,” Lazreg said.

With so much on the line, it’s unlikely that either side will give ground on this contentious issue any time soon. Notably, OSHA said it had received 15 letters in support of OSHA regulating resident hours and 26 letters in opposition.

 Where do you fit it? Let us know.

By Patrice Wendling

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Pushing the Supercommittee: The Policy & Practice Podcast

The AMA launched a multi-million dollar ad campaign to push for an SGR fix now. Courtesy AMA

As the Joint Select Committee on Deficit Reduction, or the Supercommittee, works behind closed doors to find more than a trillion dollars in debt reductions, the American Medical Association is pulling out all the stops to get a permanent fix to the Sustainable Growth Rate Formula on the agenda. Whether the committee chooses to address the SGR issue, they have until Nov. 23 to get their recommendations out.

Meanwhile, the Obama administration has awarded nearly $300 million in scholarships and loan repayment to physicians willing to spend two to four years working in rural communities. The initiative is aimed at boosting the physician workforce shortage in under-served areas.

For more on that, take a listen this week’s Policy & Practice Podcast.


Stop in next week to hear more about the legal wranglings of the Affordable Care Act and physician pay concerns.

– Frances Correa (@FMCReporting)

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Examining the IPAB: The Policy & Practice Podcast

The Independent Payment Advisory Board, the new panel that will be charged with reducing the growth in Medicare spending, was the focus of intense debate on Capitol Hill last week. In the July 18 edition of the Policy & Practice podcast, we have all the details on the two House hearings held on the panel and why physicians are worried about its impact.

The Independent Payment Advisory Board (IPAB) was created under the Affordable Care Act to help keep Medicare spending under control. But most physician groups are calling on Congress to scrap the board or substantially change how it operates. Opponents, who include the American Medical Association, say that if the IPAB goes forward, physicians would be subject to two levels of cuts: one from the IPAB and one from Medicare’s Sustainable Growth Rate (SGR) formula. Physicians are already facing a nearly 30% Medicare fee cut next year from the SGR unless Congress steps in.

HHS Secretary Kathleen Sebelius tours Frager’s Hardware Store in Washington, D.C., before an event to announce new rules on health insurance exchanges. HHS photo by Chris Smith.

This week’s Policy & Practice podcast also has news on the new federal regulations for how states can set up health insurance exchanges. Those exchanges, which aim to make it easier for Americans to buy insurance, are slated to be up and running by 2014. And check out the podcast for the latest on the debt ceiling negotiations and how Medicare could be affected.

Take a listen and share your thoughts:


Check back with us next week for more on the debt ceiling legislation and the Institute of Medicine’s recommendations on what preventive services health plans should cover for women.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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A Chance at an SGR Fix?: The Policy & Practice Podcast

There’s a lot at stake in the negotiations over raising the nation’s debt limit, from the impact on the global economy to the potential elimination of Medicare’s Sustainable Growth Rate (SGR) formula. That’s right, the much-despised SGR, which is used in determining physician payments under Medicare, has even made its way into the talks about increasing the debt ceiling.

House Speaker John Boehner (left) and Senate Majority Leader Harry Reid (right) met with the President on July 10 to discuss the debt limit. Official White House Photo by Samantha Appleton.

As the president and congressional leaders go into overdrive, holding daily meetings on ways to trim the deficit, the medical establishment is pushing hard for lawmakers to stop the cycle of threatened physician pay cuts followed by last-minute legislative Band-Aids. The American Medical Association, along with more than 100 state and medical specialty societies, recently sent a letter to lawmakers warning that the cost of an SGR fix will only go up. Right now, they estimate the 10-year cost of replacing the SGR is nearly $300 billion, but that figure could rise to more than $500 billion in just a few years, they wrote. The debt ceiling legislation provides “the best—and perhaps only—opportunity to ensure stability in Medicare payments, ensure continued beneficiary access to care, and address the SGR deficit in a fiscally responsible manner,” the organizations wrote in their letter.

Get the full scoop on the SGR in this week’s Policy and Practice Podcast.

Take a listen and share your thoughts:


And stayed tuned next week for all the details on new regulations on state-based health insurance exchanges.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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Rolling Out Health Reform: The Policy & Practice Podcast

Many of the hallmarks of the Affordable Care Act, such as state-based health exchanges to purchase insurance, won’t go into effect until 2014. But, in the meantime, officials at the Department of Health and Human Services are plenty busy rolling out other provisions of the law, making adjustments to some of the law’s programs, and just promoting what they’ve done so far.

Recently, HHS officials announced that they would stop granting exemptions that allow limited-benefit health plans to keep in place low annual coverage limits that are at odds with the Affordable Care Act. HHS has been granting waivers to these so-called “mini-med” plans in an effort to keep the products affordable for consumers. But no more. Starting on Sept. 23, HHS will no longer accept waiver applications or extension requests from these plans. And, in 2014, all health plans will be barred from placing annual limits on coverage under the health reform law.

HHS has also been busy promoting the availability of free preventive services for Medicare beneficiaries. Starting at the beginning of this year, Medicare beneficiaries were eligible to receive recommended preventives services ranging from mammograms to smoking cessation counseling with no copays or deductibles under Medicare Part B.

Photo courtesy National Cancer Institute.

But seniors haven’t flocked to take advantage of the services. Only about one in six Medicare beneficiaries has accessed the free services, according to a government report. So HHS is launching a public outreach campaign that includes radio and TV ads. The government is also reaching out to physicians, asking them to discuss the preventive services with patients.

For more on the implementation of the Affordable Care Act, plus a recap of the American Medical Association’s House of Delegates meeting, check out this week’s edition of the Policy & Practice podcast.

Take a listen and share your thoughts:


The Policy & Practice podcast is taking a break next week, but check back on July 11for all the latest developments in health reform.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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Video of the Week: AMA Backs Individual Mandate

The American Medical Association’s House of Delegates voted 326-125 to support the premise that all Americans should be required to buy health insurance if they can afford to do so.

Our reporter Alicia Ault was there to catch AMA President Cecil Wilson’s discussion of the organization’s position on health insurance.

You can read more about the American Medical Association’s House of Delegates activities at Internal Medicine News.

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AMA House Ends on Sour Note: The Policy & Practice Podcast

The American Medical Association’s House of Delegates meeting wrapped up on Tuesday afternoon, a day ahead of schedule. The delegates touched on a wide range of issues over the four days at the Hyatt Regency in Chicago.  None was more hotly debated than whether the AMA should back the so-called individual mandate that’s a central tenet of the Affordable Care Act.

AMA delegates at work. By Alicia Ault

While much time and energy was devoted to that topic, delegates also discussed many public health, practice management and payment issues.  The nation’s obesity epidemic was addressed in many resolutions.  Pediatricians and medical students pushed for having the AMA take a strong stand on fast food, competitive eating, and physical education.

The annual meeting generally showcases the diversity of opinions among the nation’s physicians and among the various medical specialties that make up the House of Delegates. In the end, the policies that are adopted are supposed to reflect some kind of consensus forged out of those many voices.

But perhaps more than any year in the past, it was clear as the meeting ended that the AMA is struggling to maintain a consensus.  Many state delegations complained of declining membership, which they said was directly related to dissatisfaction with how the AMA was representing them.

Take a listen to our final wrap-up podcast on the meeting proceedings.


And tell us whether you think the AMA continues to represent your voice in medicine.

— Alicia Ault (on Twitter @aliciaault)

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A Sales Pitch for ACOs

There’s been a lot of criticism of the accountable care organization (ACO) concept lately, or more precisely, the federal government’s proposal to share Medicare savings with qualifying ACOs starting next year.

That proposed regulation, which was released at the end of March, outlined how qualifying ACOs could earn additional payments if they could save the Medicare program money. But there were plenty of caveats. The Centers for Medicare and Medicaid Services proposed that ACOs meet a certain threshold of savings before they could get any money back. And the rule also set rigorous standards for quality of care, requiring ACOs to meet 65 quality measures.

Since the rule came out, many physicians’ groups have criticized the proposal, saying that it made it too difficult for physicians to get involved. The steep up-front investment in technology, workflow redesign, and staffing, coupled with the uncertainty of achieving savings, would be too much for many practices, they argued. And even officials at the Cleveland Clinic, a health system that many viewed as a prime candidate for being a successful ACO, have said they see major problems with the Medicare plan for ACOs as it stands today.

Dr. Don Berwick. Photo by Laurie Swope.

Earlier this week, Dr. Don Berwick, the CMS administrator, defended the direction his agency is headed with ACOs. In a speech to participants at an ACO learning session sponsored by CMS in Minneapolis, Dr. Berwick said ACOs are one big step toward building a different, better health care system that promises to improve care for individuals and the population as a whole, all while lowing cost. But he admitted that it was a “very, very difficult step.”

There will be growing pains for everyone in the health care industry as they move forward with ACOs, he said. For instance, physicians, nurses, and other health care providers will have to learn to work together in teams to care for patients with chronic illnesses. Physicians working in the operating room and in the intensive care unit will need to truly embrace checklists. And everyone will have to grow used to their electronic health records and disease registries. Prevention, he said, must become an “obsession.”

And beyond those cultural changes, there are many other obstacles. There’s stranded capital, Dr. Berwick said, and a workforce that is underinvested in primary care and not well suited to supporting continuity of care. There are immature metrics to measure what goes on in an ACO and limited capacity to use the metrics that do exist, he said. Plus, there’s the problem that most of the money paid out by Medicare and private insurance is for the volume of care delivered, not the quality of care received.

But those aren’t reasons to shy away from ACOs or other fundamental reforms of the health care system, Dr. Berwick said. To help overcome some of the obstacles to the success of ACOs, CMS’s Innovation Center is holding learning programs like the one in Minneapolis. They are also experimenting with the idea of advancing funds to promising ACOs that lack start-up money. And they are working to get better data out of the Medicare system. “We intend to help,” Dr. Berwick said.

How many ACOs are likely to emerge next year when the program begins? Dr. Berwick said he doesn’t know, but he’s hopeful that officials at CMS can craft a final rule that will attract many organizations. He urged physicians, hospitals, and others to consider taking a leap of faith, despite the risks. “I ask you to think again about what you risk if, while the world shifts around you, you choose to stand still.”

So does Dr. Berwick make a convincing case for ACOs and the government’s shared savings program? Let us know what you think.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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Fixing the SGR: The Policy & Practice Podcast

Doctors know that the Medicare physician payment system is broken. Lawmakers know it. Maybe even some patients know it, too.

The problem is how to fix it so that it doesn’t bust the federal budget. And if lawmakers choose to replace the Sustainable Growth Rate (SGR) formula, which is currently used to determine physician payments under Medicare, they will face another challenge: choosing a new formula that won’t create the same problems in a few years.

Medicare payments could fall off a cliff if Congress doesn't act this year. Image via Wikimedia from User Urban.

The Medicare Payment Advisory Commission, which advises Congress on all things Medicare, has come out with a new report that outlines several alternatives to the SGR. In its report, MedPAC tells lawmakers that by replacing the SGR with a structure that doesn’t have scheduled payment cuts to doctors, they would have the chance to adopt other payment changes that could save the system money.

For example, in exchange for across-the-board pay increases to physicians, Medicare officials could reduce payments for specific services that are overpriced, they wrote. Or they could shift payments away from procedures and toward services that promote care coordination and population health.

Get all the details on the SGR, Medicaid reform options, and the 2012 GOP presidential field in this week’s Policy & Practice podcast.

Take a listen:


And check back throughout the week for all the policy news out of the American Medical Association’s House of Delegates meeting.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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