Tag Archives: American Medical Association

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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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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Filed under Family Medicine, Geriatric Medicine, Health Policy, health reform, IMNG, Obstetrics and Gynecology, Physician Reimbursement, Podcast, Practice Trends

A New Face at the AMA

The American Medical Association has selected a new leader. The group has hired Dr. James Madara, the former CEO of the University of Chicago Medical Center, to be the new executive vice president and chief executive officer at the AMA.

At a press conference to announce the appointment, Dr. Madara, 60, said he is enthusiastic about taking on the post. And he immediately got to work defending the relevancy of the organization he will head starting July 1. The debate surrounding the Affordable Care Act and the subsequent uncertainty about the health care system highlights the importance of having the AMA act as a strong advocate for physicians and patients, he said. “I think this is a very unique time in American medicine where a physician voice is needed critically.”

Dr. James Madara. Photo courtesy of the AMA.

Dr. Madara has no shortage of experience. He is an academic pathologist and an expert on epithelial cell biology and gastrointestinal disease. He has also been a leader at major academic medical centers, including Emory University and the University of Chicago. Before taking on the role of CEO at the University of Chicago Medical Center, he was the longest-serving dean at the university’s Pritzker School of Medicine. Recently, he served as a senior advisor at Leavitt Partners, a health care consulting firm founded by Michael O. Leavitt, the former governor of Utah and Secretary of Health and Human Services under President George W. Bush.

Dr. Madara will have his hands full managing the AMA, which has garnered a lot of attention over the apparent divide within its ranks on health reform. But Dr. Madara is no stranger to controversy. As the CEO at the University of Chicago Medical Center, he spearheaded a program known as the Urban Health Initiative. It is a program aimed at connecting residents of Chicago’s South Side with preventive care from local physicians and hospitals. But critics accused the university of trying to unload poor, uninsured patients at other facilities.

Dr. Madara said his experience with the Urban Health Initiative taught him people are uncomfortable with change but that you can’t let that discomfort stifle innovation. We will follow Dr. Madara’s tenure to see what changes he brings to the AMA.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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Drug Makers Go High-Tech to Prevent Opioid Abuse

Daytona 500 practice run (U.S. Air Force photo by Larry McTighe via Wikimedia Commons)

In the heart of Appalachia, there have long been doughty renegades who prefer not to pay taxes on their whiskey (also known as moonshine or a potential substance of abuse). These ingenious individuals have continually come up with imaginative ways to distill and distribute their products, while evading law enforcement (also known as revenuers). In fact, one of America’s favorite pastime — NASCAR — was born of the need of moonshiners to outrun the revenuers.

These days though, the game is being played the other way around.  Drugmakers, with encouragement from the government, are coming up with some pretty cool ways to prevent the abuse and misuse of opioids and other prescription drugs, which have become another of American’s favorite pastimes. In 2009, 16 million Americans age 12 and older had taken a prescription pain reliever, tranquilizer, stimulant, or sedative for nonmedical purposes at least once in the year prior to being surveyed, according to the National Survey on Drug Use and Health.

Dr. Lynn Webster discussed some innovative technologies to prevent opioid misuse at the annual meeting of the American Academy of Pain Medicine. So what’s on the horizon?

Approved in 2010, Exalgo is an extended-release formulation of hydromorphone that is indicated for once-daily administration for the management of moderate-to-severe pain in opioid-tolerant patients requiring continuous, around-the-clock opioid analgesia for an extended period of time. The drug uses a new technology – osmotic-controlled release oral delivery system (OROS) — which uses osmosis to attract water in the body to the inside of the capsule to trigger release of hydromorphone. It takes about 6 hours for the drug to release effective levels of hydromorphone and 4-5 days of use to reach a steady state of the drug in the body, said Dr. Webster.

Oxycontin abuse (courtesy of 51fifty via Wikimedia Commons)

Acurox is an oral immediate-release oxycodone tablet with a proposed indication for the relief of moderate to severe pain. Acurox uses another new technology, this one designed to deter misuse and abuse by intentional swallowing of excess quantities of tablets, intravenous injection of dissolved tablets, and nasal snorting of crushed tablets.

Collegium Pharmaceutical is developing an extended-release opioid formulation using DETERx technology to thwart abuse. Crushing or chewing prior to ingestion is a commonly used method of abusing oxycodone. Company studies have demonstrated that the plasma profile for the new DETERx formulation pill, when chewed, was bioequivalent to the taking the pill whole and as intended. This suggests that attempting to breakdown the sustained-release microspheres by chewing would not result in a meaningful increase in plasma level.
“It’s an abuse-resistant formulation, in that [potential abusers]can’t extract more than is intended for drug delivery,” said Dr. Webster.

Perhaps the most interesting and impressive technology is being developed by PharmacoFore. According to the company, the delivery system’s developer, the novel Bio-Activated Molecular Delivery (Bio-MD) technology effectively deters prescription drug abuse at a molecular level. “This technology does not involve the reformulation of existing opioid drugs in physical matrices that are easily circumvented by simple extraction methods. Our opioid Bio-MD systems are “activated” to release clinically effective opioid drugs only when exposed to the correct physiologic conditions (i.e., ingested).”

The system uses a mechanism “that locks in the amount of release of an opioid from a moiety, which is attached to a molecule … it can be any opioid … it’s an inert compound until it’s activated to be released,” said Dr. Webster. Essentially, the opioid molecule is attached to this delivery compound, which is “kind of like a clock. The intrinsic trypsin in our GI tract will activate that clock, which will cause a process to begin … and it will allow that drug to be released.” The “clock” compound determines how much time it will take for the active compound to be released and can be attached to any opioid. “It’s very early on though,” cautioned Dr. Webster. This molecular delivery system is in phase I trials.

Moonshine still in Knox County, Tennessee photographed by TVA in 1936 (courtesy of Wikimedia Commons)

Still, if the drug companies are able to get these technologies approved, we could see a drop in prescription drug abuse. It remains to be seen if there will be a corresponding increase in moonshine.

Kerri Wachter

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