Doctors Sue HHS, CMS Over 'Secretive' Payment Committee

Six primary care physicians from Georgia have filed a lawsuit against the federal government, claiming that a committee of volunteer physician-advisors that recommends reimbursement rates for Medicare procedures and services is secretive and skewed toward medical specialists.

The physicians, all from the Center for Primary Care in Evans, GA complain that for nearly 20 years the Department of Health and Human Services and the Centers for Medicare and Medicaid Services have relied on the "specialist-dominated" Relative Value Scale Update Committee (RUC) for reimbursement advice.

The 74-page suit, filed this week in U.S. District Court in Maryland, claims that the RUC violates the Federal Advisory Committee Act's requirements for representation, transparency, and methodological rigor. As a result, the Center for Primary Care physicians claim, the RUC "has systematically overvalued many specialty procedures while undervaluing primary care." The plaintiffs want a federal judge to suspend the RUC process until HHS and CMS comply with FACA rules.

One of the plaintiffs, Paul Fischer, MD, told HealthLeaders Media that the timing of the suit is "very fortuitous," as Congress grapples for ways to contain Medicare costs.   

"We are going to win this. The law is pretty clear and the facts are pretty clear. We will win on a legal basis," Fischer says. "But the second thing is Medicare is too expensive and so broken and the government doesn't have too many things it can do. This gives the government a tool."

Fischer says the existing payment structure that RUC has dominated is a huge driver of healthcare costs. "We have too many specialists doing too many unnecessary procedures and the price that we pay doctors has been fixed by this secret little committee of the AMA. That is illegal," he says. "Let's come up with a better way of pricing physician services more in line with the value they provide to the society."

The suit notes that CMS has historically accepted more than 90% of RUC recommendations. The resulting higher income for specialists has discouraged medical students from primary care and exacerbated the nation's shortage of generalist physicians, the plaintiffs contend. 

Barbara Levy, MD, chair of the RUC, issued a statement that acknowledged the lawsuit but did not talk about the specific allegations. "The RUC is an independent panel of physicians from all medical specialties, including primary care, who make recommendations to CMS as all citizens have a right to do. These volunteers provide physicians' voice and expertise to Medicare decision-makers through their recommendations," Levy said.

Fischer says his group tried to go through traditional channels to have their grievances heard but that they were ignored by the AMA and the American Academy of Family Physicians. "The first thing we did was go to them almost a year ago to support this effort. But AAFP sits on the RUC. They are part of the problem. When they were unwilling to do anything I decided to go it alone," Fischer says.

Attempts to speak with AAFP leaders on Wednesday afternoon were not successful, but the AAFP has created a task force to increase efforts to add cognitive value to the relative value unit physician fee formula. And the group is calling for the RVU formula to be revised.

Fischer says he and his colleagues are forced to address the issue in a lawsuit because nobody else has taken it up. "Family medicine and primary care are in a crisis in this country and nobody's been willing to fix it. The government hasn't tried to fix it. The medical schools haven't tried to fix it. The specialists are off doing procedures and making a lot of money," he says.

"My daughter is a resident in family medicine and I am doing this at the end of my career to make things better for her as she becomes a family doctor." Fischer says the practice has spent about $100,000 in legal fees. "It's money coming from seeing patients one at a time in the office," he says.

The plaintiffs have set up a Web site to solicit donations from primary care physicians, patients and other sympathizers. "Some people call it David and Goliath. One guy in the office called it Don Quixote," Fischer says. "Pick your metaphor."

See Also:
 AAFP Calls For Revisions to RVU Formula