The graph and the accompanying Washington Post article  by Peter Whoriskey and colleagues shows the implications of overvaluing some medical procedures. The article compares how many procedures are performed  with the number of services a physician would normally be expected to provide in a day. To be sure there’s an expectation that the clinic patient population varies, and that physician skill, and physician familiarity might shift an individual’s mean time upwards or downwards. However, assuming the data used to estimate times  for the purposes of calculating times is representative, the survey times should be close to  the average times in clinics.  TheMedicare Payment Advisory Commission, the Congressional agency charged with reviewing Medicare payments, has suggested the underlying data could be improved.
I’m currently working on a book on this intriguing and complex process. An article I wrote with colleagues last year in Health Affairs showed that Medicare accepts 90 percent of the American Medical Association’s Relative Value Update Committee (RUC) recommendations. The RUC provides estimates of the times for physician services, based on surveys of physicians. That rate of acceptance is falling as Medicare’s feet are increasingly held to the fire by greater publicity and interest by Congress.
If the numbers are based on the time it takes to do the whole procedure from the patient’s point of view, this result is obvious. In most practices, an RN, PA, or whoever (or groups of same) will do all the prep for a procedure up to the point (incision or whatever) that legally has to be done by the physician. Then, on the way out, same thing: closing and cleanup all done by lower-paid personnel. It’s a great example of specialization and the marketplace at work. Oh, yeah, it’s kinda rotten for the patient unless the procedure doesn’t actually require any explanation or interaction.
This issue has a lot of moving parts. It’s more complex than “wily contractor rips off the inept government again.”
1. The AMA certainly has a conflict of interest in recommending RVS rates while benefiting from increases.
2. The AMA staffs the RVS Update Committee (RUC) and supposedly pays ~$8 million annually for its rate setting analyses. If the Feds did the work (albeit with less conflict-of-interest), then they would have to pay for it. To do it well and universally would cost more. The RUC necessarily focuses on RVS items “needing” increases. The government taking on this responsibility invites charges of bloated bureaucracy, button-sorting expenditure during sequester, etc. Conversely, delegating this responsibility to an interested party may be “penny wise …”
3. The annual RUC recommendations have a minor effect compared to the AMA’s ownership of the CPT coding system. No code, then no bill; and vice versa. CMS doesn’t have to accept RUC recommendations, but the AMA’s decisions on CPT are binding. The Feds have two non-voting (?) members on the CPT Committee. Also, everyone then has to pay the AMA to use the CPT codes.
4. Statutorily, Medicare supposedly offsets the RVS net increases (“code creep”) with decreases in the Standardized Amount (paid for RVS weight 1.0000). However, Congress has delayed this adjustment year-by-year since 1990.
5. The RUC annual recommendations conceal considerable conflict over resources between primary care practitioners versus specialists, different types of specialists, and physicians versus midlevel practitioners, etc. Conflicts over USMG versus FMG, urban versus rural, geography, salaried versus independent practice, etc. have indirect interests.
6. The RVS equates to the “flat rate manual” for car repairs. Mechanics charge the number of hours recommended by the manual, not their actual hours. An experienced mechanic should be able to “beat the book” consistently. However, the manual protects the consumer by providing a charge ceiling over the less efficient or unlucky mechanic.
http://www.cartalk.com/content/about-flat-rate-book-business-has-anyone-ever-seen-it
Thus, you may want an operator who does the procedure so often that the work goes efficiently (10 colonoscopies per day) versus the operator less familiar with the instruments. A well designed system for moving the patients through the operational bottlenecks may help.
7. The Medicare Physician Fee Schedule explicitly considers years-of-education in the reimbursement formula. So, specialists have inherently higher prices.
“The Medicare Physician Fee Schedule explicitly considers years-of-education in the reimbursement formula. So, specialists have inherently higher prices.”
In standard bureaucracies, initial qualifications have greatest effect on starting salary. But the advantage erodes over time. CEOs with PhDs don’t SFIK get paid (even) more. It’s not clear why 60-year-old specialists should be paid more than GPs because they studied 2 years longer in their youth.
I don’t quite understand the chart. For example, look at the busiest ophthamologist. That doctor is criticized for doing 41 procedure hours in one day. But that day was a Thursday, and the average procedure hours for the other five days (no data for Sunday) were five on Tuesday and zero the rest of the days.
I’m not sure what this means, but could part of it be that the data reflects the day bills are issued, rather than the days procedures are actually performed? The article is also unclear as to what is being averaged. In the example, did the doctor bill for an average of 41 hours per Thursday?
So…how many colonoscopies CAN one physician do in a day?
Unlike commenter byomtov, I saw no charts in the linked article.
Clean up on aisle 420! Bearded gentleman in a suit doubled over mumbling “It’s the Kush Doctors all over again!!!!”
“Ophthalmologist David Shoemaker is among the busiest doctors in Florida, performing 3,594 cataract surgeries and similar procedures last year.”
Now, now, that’s only half as many scripts as Colorado’s busiest doctor.
Medical practice? No. Just a human [re]assembly line.
Ah, yes, but he’s so well-paid that he only has to perform surgeries two days a week. Apparently cataract surgery pays better than medical marijuana physical exams (who knew?), and takes roughly the same amount of time.
His workload of 30 to 40 surgeries per day on Mondays and Tuesdays amounts to 30-plus-hour workdays if AMA time estimates are correct. Yet he works about 10-1/2 hours those days.
If he performed surgeries five days a week instead of two that 3,594 number extrapolates to 8,985 per year (about 36 per day using the standard 50 5-day weeks per year assumption — right in line with the number cited above).
Shhh! We’d better keep it down. We wouldn’t want Dr. Kleiman to overhear us. The mere thought of a doctor performing 8,400 physicals per year has been known to cause him stomach ailments. We don’t want his fragile condition to deteriorate to the point where he finds himself seeking a kush-doctor for relief. That could set up a vicious positive-feedback cycle that might actually make his condition worse, undermining our secret evil plot to use mmj as a gateway to re-legalization for all adults.
So where are the malpractice lawsuits? 17 years that California has had their medicinal cannabis patient protection law and I haven’t been able to find even a single malpractice law suit filed against a doctor that has recommended cannabis. It’s not like California doesn’t have a thriving population of ambulance chasers.
The Washington Post did a remarkable disservice to readers as they attempted to report on an AMA committee’s role in providing cost information to the Centers for Medicare and Medicaid Services.
In recent years, the committee has taken the initiative to identify overvalued medical services to help drive cost reduction. To date, they reviewed about 1,300 potentially misvalued services and recommended reductions to 500 previously overvalued services, redistributing $2.5 billion to primary care and other services. The committee is currently reviewing gastrointestinal services, including colonoscopy procedures. That review will be complete next year. But let’s not forget that the Medicare physician payment system is ultimately budget-neutral. There is no financial impact if the government accepts a recommendation for increasing a medical service value because any increase is automatically offset by decreasing values assigned to all other services. It also should be noted that the annual growth in Medicare physician services has been at a historical low for each of the last three years – less than 1 percent.
The AMA ensures transparency of the process, making the data and rationale for each committee recommendation publicly available and CMS representatives attend all RUC meetings. And while the committee submits recommendations to CMS for consideration each year, the agency is not obligated to accept them. The general public is also able to comment on individual procedures, and processes are in place to ensure that input from all stakeholders is considered by CMS.
Medicare provides health care coverage for millions Americans, and it is unfortunate the reporter chose to play fast and loose with the facts. Learn more by visiting: http://www.ama-assn.org/ama/pub/news/news/2013/2013-07-22-washington-post-ruc-fact-sheet.page
Mr Whoriskey and his colleague deserve an award. But it probably won’t come from the AMA.
Nice post thanks to share this all information here…