St. John's Mercy Hospital has made public its sweeping plans to build a new hospital in Joplin, MO as the centerpiece of a nearly $950 million rebuilding plan for the city's tornado-ravaged healthcare infrastructure.
"We are making this commitment because it's the right thing to do for Joplin," Lynn Britton, president/CEO of Mercy which includes 28 hospitals and more than 200 outpatient facilities in a seven-state area, said in a media release. "The May 22 tornado devastated our community here in Joplin and destroyed our hospital, but we've promised all along we would rebuild. We plan to break ground January 2012 and open the new hospital, as well as a secondary northeast campus, in 2014."
The new 327-bed hospital will be built about three miles from the destroyed St. John's Hospital. The new hospital will include medical, surgical, critical care, women's/children's (labor, delivery, recovery and postpartum rooms), behavioral health and rehab, with planned expansion up to 424 beds as needed.
Within one week of the tornado, which claimed 150 lives, Mercy had made operational a 60-bed MASH-like field hospital. Now the tent hospital is transitioning to a "hard-sided modular facility" and plans are underway to open a component hospital in the spring of 2012 that will allow St. John's Mercy to regain its Level II Trauma Center designation.
The federal government on Wednesday unveiled proposed rules to help consumers better understand their health insurance benefits and costs, and search for the most appropriate coverage.
"We are telling insurance companies that they need to be more transparent about the benefits they offer, what they are spending premium dollars on, and justifications for any proposed rate increases," Centers for Medicare and Medicaid Services Administrator Donald Berwick, MD, said in a Wednesday afternoon media teleconference. "This is all grounded in the idea that the more informed the patient is, the better decisions he or she can make."
Berwick acknowledged that insurance benefits and cost information confuses many consumers. "Many times people will make decisions on coverage and not understand what it means for them until they get sick or until their care is denied or until they face high out-of-pocket costs," he said.
The Summary of Benefits and Coverage proposed rules would give consumers access to two forms to help them evaluate their health insurance choices, including: a summary of benefits and coverage; and a uniform glossary explaining terms such as "deductible" and "co-pay."
If the proposed rules are adopted, health plans would be required to provide the forms to shoppers and enrollees upon request and before coverage is purchased. The forms are scheduled to be available sometime in 2012 for the more than 180 million health insurance consumers with private health insurance coverage.
America's Health Insurance Plans raised concerns that the proposed rule would create an expensive burden that insurers would pass along to their customers. "The benefits of providing a new summary of coverage document must be balanced against the increased administrative burden and higher costs to consumers and employers," AHIP press secretary Robert Zirkelbach said in a media release.
"For example, since most large employers customize the benefit packages they provide to their employees, some health plans could be required to create tens of thousands of different versions of this new document—which would add administrative costs without meaningfully helping employees."
AHIP also wants the federal government to push back the implementation date "to give health plans sufficient time to make the operational and administrative changes needed to create these new documents. We will be submitting detailed comments and look forward to working with regulators to mitigate potential unintended consequences of this new requirement," Zirkelbach said.
Lynn Quincy, a senior health policy analyst with the Consumers Union, sat in on the teleconference with Berwick and said the proposed rules would provide consumers with a single, standard method of understanding health plan features, similar to standard disclosures for mortgage terms or credit cards.
Quincy said the nonprofit Consumers Union has heard "hundreds of stories of consumers who purchased a health plan they didn't understand."
"In the most unfortunate cases the consumer suffered a severe illness and was unpleasantly surprised when he or she learned they didn't have the coverage they thought they had purchased," Quincy said.
"Our own studies have revealed that shopping for health insurance is a task that consumers dread. In part, they told us it's because they find current healthcare documents too difficult to understand. There is no doubt that consumers need much better health insurance disclosures."
Physician groups across the country operated at a significant loss in 2010, thanks largely to dwindling Medicare reimbursements. At the same time physician compensation increased by an average of 2.4%, according to the American Medical Group Association's 2011 Medical Group Compensation and Financial Survey.
"The trends are pretty much continuing and have been consistent over the last six years of so. The operating margins are getting smaller and the pay increases are getting smaller as well," Tom Flatt, director of communications and publications at AMGA, told HealthLeaders Media.
The survey of 239 medical groups -- 55% of which had more than 100 physicians -- found that operating margins are getting thinner. In 2010, only physician groups in the Western region of the nation were nearing break-even (-$27 per physician).
All other regions were operating at a loss: the Eastern region averaged a loss of $1,597 per physician; the Southern region averaged a loss of $1,870; and the Northern region continued to experience significant losses (-$10,669 per physician in 2010, compared to -9,943 per physician in 2009).
Flatt says that many of the physician groups were able to offset Medicare reimbursement cuts through ancillary services like pharmacy and imaging. But concerns about cuts to reimbursements remain.
"We are hearing from our own groups who are anticipating significant cuts in Medicare that they are really worried about it. They are operating at such a small margin now that this will have a tremendous impact on access for patients," Flatt says. "They're really feeling like they are on the edge of a cliff and without some sort of revenue, it's really going to impact patient care."
Indeed, a Merritt Hawkins’ survey released in June showed that most job openings for physicians are in hospitals, while demand for private practice physicians is on the wane.
The compensation portion of the survey found that 69% of the specialties experienced increases in compensation in 2010, with the overall average increase around 2.4%. In 2009, 76% experienced an average increase around 3.8%.
The primary care specialties saw about a 2.6% increase in 2010, while other medical specialties averaged an increase of 2.4% and surgical specialties averaged around 3.8%. Primary care and surgical specialties saw about a 3.8% increase in 2009, while other medical specialties saw 2.4%.
The survey results show that during 2010, the specialties experiencing the largest increases in compensation were allergy (6.38%), emergency medicine (6.37%), and hospitalist/internal medicine (6.29%).
Flatt says the compensation packages are being driven "primarily" by supply and demand.
"We've seen this trend in the past decade or so, that certain spikes in the salaries of certain specialties, maybe because the specialty hasn't seen a large pay raise in a long time and demand has suddenly become greater because less people are going into that field, or because of the demand for certain specialties," he says. "Allergies is one of those that we've seen just take off."
Hospitals that invest in pressure-redistribution foam mattresses in the emergency department could save money in the long run by reducing the burden of pressure ulcers among elderly patients, according to a study in Annals of Emergency Medicine.
A claims-based study conducted by Millman, Inc. on behalf of the Society of Actuaries found that in 2008, pressure ulcers cost an estimated $10,288 per error and $3.858 billion total. Pressure ulcers—the most frequent type of expensive error—were most often preventable, the authors wrote.
Ba' Pham of The University of Toronto, the study’s lead author, told HealthLeaders Media that installing pressure-redistribution mattresses won’t solve the bed sore problem, “but it helps.”
“It’s just a fact that people don’t make the link between the risk of a hard surface to bed sores,” he said. “They’re not paying attention to the problems. Obviously changing the mattress is not the full solution, but it is probably contributing to reducing the burden.”
Every year, approximately 6.2 million hospital admissions through EDs involve elderly patients at risk of developing pressure ulcers. Studies have found that approximately 6% of patients admitted through the emergency department acquired pressure ulcers within 48 hours of admission.
CMS will not reimburse hospitals for the cost of treating hospital-acquired pressure ulcers, which it considers a “never event.”
Pham’s research studied the cost-effectiveness of pressure-redistribution foam mattresses on ED stretchers and beds for early prevention of pressure ulcers in elderly admitted emergency department patients. They found that early prevention was 82% likely to be cost-effective.
The National Association of Insurance Commissioners is urging the federal government to avoid creating regulatory loopholes for health insurance exchanges that could give multistate plans significant advantages over their smaller, in-state competitors.
"Insurance Commissioners and the NAIC have serious concerns about the potential for market disruption and adverse selection, and the resulting negative impact on consumers and health insurance markets which would arise if Multi-State Plans are allowed to operate under different rules than their competitors," NAIC leaders said in a letter to Cheryl D. Allen, contracting officer for the U.S. Office of Personnel Management.
Starting in 2014, OPM will be responsible for contracting with at least two health plans that will be sold on every state's HIX as "multistate plans." NAIC said in its letter that language in the law could inadvertently create two sets of rules – one for larger multistate plans, one for everyone else."
The letter was signed by NAIC President and Iowa Insurance Commissioner Susan Voss, and co-signed by the NAIC President-elect, Vice President and Secretary-Treasurer. NAIC was responding to OPM's request for information as they draft guidelines for multi-state plans.
The commissioners warned that separate rules could threaten plan solvency and lead to market segmentation, consumer confusion and a loss of consumer protections. "We urge OPM to require Multi-State Plans to be subject to all fees and assessments levied by state Exchanges in order to finance their operating expenses," the letter said. "Allowing larger insurers a free-ride at the expense of smaller competitors would damage competition and could endanger the viability of Exchanges."
NAIC also raised concerns that a second provision, written to ensure a level playing field, could in fact upend state consumer protection laws if the multistate plans are exempted from state regulation. "Healthcare delivery system varies greatly from one state to another and within a state, and these variations give rise to different consumer protection issues," the letter said.
"Exempting Multi-State Plans from the additional consumer protections a state has put in place will confuse consumers, leave some consumers with less protection than others and result in an unlevel playing field that could give the largest insurers additional competitive advantages in the marketplace, thereby undermining the goal of the PPACA to create more competition in health insurance markets and strengthen consumer protection."
If OPM exempts a plan from applicable state regulation, by extension it also exempts all other plans – both in and out of an Exchange - from those same regulations, leaving a regulatory vacuum, NAIC said.
Hospital-acquired infections are back in the news of late, not that they ever really go away.
Recently, the federal government told Parkland Memorial Hospital in Dallas to come up with a correction plan for a litany of safety issues that include infection control. If the feds aren't happy with the action plan, Parkland's Medicare payments could be in jeopardy.
Also, Infection Control Today reports on Chicago hospitals' battle with an outbreak of the bacterium Clostridium difficile. According to ICT, an investigation suggests that patients transferred from one hospital to another have helped to spread a strain of the bacterium.
Daily media reports remind us that the threat of HAI demands constant diligence, even while another wave of layoffs at hospitals across the nation. This time, Medicaid is identified as the primary culprit, although other issues like lower admissions, reductions in Medicare reimbursements, and a general uncertainty about the nation's economic future, have been cited.
Whatever the reasons for the layoffs, hospital executives making the difficult cuts stress that patient care will not be compromised. They assure the public that as best they could they preserved nurses and other critical bedside staff. If the cuts are coming from environmental services – maids, janitors, and other cleaning staff – it seems only logical that hospitals are exposing themselves to a greater risk of HAI.
"It is a reason for concern. If a hospital decides to make those cuts in environmental services staff that will make it much more challenging to keep rooms clean," says Ann Marie Pettis, RN, BSN, director of Infection Prevention for the University of Rochester Medical Center, and a senior advisor with the Association for Professionals in Infection Control and Epidemiology.
"It is already a challenge given the fact that throughput is such an issue – the quicker they can turn the room over for the next patient. There is pressure on environmental services to do that. If you start cutting their staffing it is just going to exponentially add to that challenge for them," Pettis says.
Pettis says that for years hospitals have downplayed the role of environmental services in controlling HAI.
"Historically I don't think the respect and attention have been paid to the importance of environmental services," she says. "For many years we were fairly convinced that hand hygiene was the main thing we had to worry about and maybe the environment was something we didn't need to focus on."
Pettis mentions that leadership attitude has changed with new studies linking the prevalence of HAIs to environment. "The research has shown us that it is more than a single-prong approach. We need clean hands, clean patients and a clean environment. I see it as a three pronged approached to preventing infections," she says. "None of those three things are necessarily more or less important than the others."
There is also the uncomfortable issue of respect for environmental services staff. Whether consciously or not, some people in healthcare either look down upon cleaning staff, or don't bother looking at all. Cleaning staff might be first targets for layoff cuts because they occupy the bottom step of a hospital hierarchy and many of them haven't built seniority.
"They have not gotten their due," Pettis says. "The workers are typically some of the lowest paid workers in the organization, and there is turnover because of that."
This is where HR can help, primarily by lifting the profile of cleaning staff with other hospital employees. "Building that bridge between administration and infection preventionists and environmental services is key," Pettis says.
A little recognition for a job well done is an inexpensive way to build staff loyalty. Most of all, the recognition has to be coupled with training to build competence and efficiency and professional pride. "There is a constant need for training. Not just training but observing to ensure the training has been effective," Pettis says.
The C-suite may need some training, too. "We're trying to make admitting and the C-suite understand that you cannot put pressure on environmental services to take short cuts because we all understand how important through put is but you can't shortchange the cleaning process."
If your senior leadership needs more convincing about the importance of a quality cleaning crew, you can point out that starting in 2012, HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) will include a query on hospital cleanliness.
"Of the questions on the survey for patients is 'How would you rate the cleanliness of your room when you were hospitalized?' And by the way, you don't get partial credit for this. The patients have to say 100% of the time it was good or your hospital gets dinged," Pettis says. "It helps explain why a lot of C-suites are paying so much attention to this."
The Department of Justice had a busy week prosecuting Medicare fraud from coast to coast. Here's a rundown of some of the more notable, high-profile arrests and convictions.
LA Pastors Convicted in $14.2M Medicare DME Fraud
Two pastors of a now-defunct Los Angeles church and an accomplice have been convicted of conspiracy and fraud counts in connection with a $14.2 million Medicare fraud scheme involving durable medical equipment, the Departments of Justice and Health and Human Services said.
After a two-week trial in federal court in Los Angeles, a jury found Christopher Iruke, 60; his wife, Connie Ikpoh, 49; and Aura Marroquin, 30, guilty of multiple charges. Iruke, Ikpoh, and Marroquin billed Medicare for power wheelchairs, orthotics and other DME that were not medically necessary or never provided. The couple recruited parishioners from their now-defunct Arms of Grace Christian Center to help perpetrate the scheme, prosecutors said.
Philadelphia Physician, Pharmacist Indicted in Drug Fraud Case
A 498-count indictment was unsealed this week charging 53 defendants, including a Montgomery County physician and a Northeast Philadelphia pharmacist, in a multi-million dollar drug conspiracy involving phony prescriptions, phony patients, and an alleged drug trafficking organization, federal prosecutors said. The indictment was announced by United States Attorney Zane.
In addition to charges of drug possession and drug distribution, the indictment contains 240 counts of healthcare fraud.
Named in the indictment and arrested were Norman Werther, MD, of Horsham, pharmacist Ihsanullah "Sean" Maaf, of Northeast Pharmacy in Philadelphia, and alleged drug trafficker William Stukes, of Philadelphia. According to the indictment, Stukes and his alleged drug trafficking organization recruited large numbers of pseudo patients and took them to Werther's medical office for fake examinations.
These "patients" paid an office visit fee, usually $150, to the office staff and Werther would write prescriptions for oxycodone-based drugs without there being a medical need. The "patients" were driven to various pharmacies to have their prescriptions filled, including Northeast Pharmacy where Maaf would fill the prescription.
The drugs were then turned over to Stukes or his drivers. Stukes and his organization would allegedly sell the narcotics to numerous drug dealers, who are also named in the indictment, who would also then resell the drugs on the street.
CA Clinic, MD, to Pay $7.5M To Settle Fraud Case
An Orange County, CA physician and the clinic he operated will pay the federal government $7.5 million to settle whistleblower Medicare fraud civil claims related to billings for cancer treatments, the Department of Justice has announced.
Glen Justice, MD, an oncologist from Corona del Mar, CA, and the CEO of Pacific Coast Hematology, was sentenced last month to 18 months in prison after he pleaded guilty to submitting bills to Medicare for injectable cancer medications that were never administered to patients, DOJ said.
Federal prosecutors announced a settlement last week in the civil case against Justice, 66, which arose from a whistleblower lawsuit brought forward by former employees at the medical group.
The civil lawsuit essentially reiterates the allegations brought forward in the criminal trial.
The fraud, which prosecutors say began in 2003 and continued until late 2009, was brought by whistleblowers Dora Figueroa and Francisca Pages, who both worked for Justice at Pacific Coast Hematology, The women could receive up to 25% of the settlement, as part of the whistleblower statute.
MD Oncologist Pleads Guilty to Purchasing Misbranded Drugs
Isabella Martire, MD, age 52, of Laurel, MD, an oncologist in solo practice, has pleaded guilty to introducing a misbranded drug into interstate commerce.
According to Martire's plea agreement, in 2010, federal law enforcement investigators began investigating a pharmaceutical wholesaler based in England concerning allegations that the company was importing into the United States prescription drugs approved and labeled for use only outside the United States. Further investigation revealed that Martire purchased nearly $200,000 of misbranded prescription drugs from the company in 2010.
Martire used the misbranded drugs to treat her cancer patients. She sought reimbursement from Medicare, Medicaid, TRICARE, federal employee health benefit plans and private health insurers for reimbursement of the cost of those drugs. The cost savings Martire realized by purchasing the misbranded drugs was at least $790,600 in 2010.
Martire faces a maximum penalty of one year in prison followed by a year of supervised release when she is sentenced on Oct. 17, prosecutors said.
Miami Home Health RN Gets 10 Years for Fraud
Armando Santos, RN, of Miami, was sentenced last week to a statutory minimum of 10 years in prison following his conviction by a federal jury in May on several counts related to healthcare fraud, federal prosecutors said.
Santos, 46, was employed by a Miami-Dade based home healthcare agency called Ideal Home Health, and was paid to provide care for Medicare beneficiaries that were homebound, diabetic, insulin dependent, and so ill that they were unable to inject themselves with insulin.
Evidence at trial showed that at least two of the Medicare beneficiaries that the defendant claimed to be injecting with insulin twice daily, seven days per week, were neither in need of insulin nor homebound.
The owners of Ideal Home Health, Elizabeth Acosta Sanz and Luis Alejandro Sanz, both of Miami, were recently arrested and face related healthcare fraud and conspiracy charges.
Miami Woman Is 10th Person Arrested in $27M Healthcare Fraud Conspiracy
Elizabet Lombera, 39, of Miami Lakes, FL was indicted August 10 by a federal grand jury in Miami of conspiracy and fraud charges for her alleged role in a scheme to scam more than $27 million from Medicare. The indictment Lombera and her co-conspirators installed nominee presidents to hide her control of five durable medical equipment companies in Miami that submitted fraudulent claims to Medicare.
Collectively, the five companies submitted approximately $27,383,328 in fraudulent claims to Medicare and received $12,438,952 in reimbursements. The indictment alleges that Lombera used the money for personal gain, including paying for a trip to Japan. Six of Lombera's co-conspirators have already been sentenced for their roles in this conspiracy.
A lawsuit filed this week by six Georgia physicians illustrates the growing resentment and anger that primary care providers have with what they say is a secretive Medicare reimbursement process that is skewed towards specialists, says Roland Goertz, MD, president of the American Academy of Family Physicians.
"For a group of physicians to resort to legal action should give you an indication of how frustrated primary care physicians are," Goertz told HealthLeaders Media. "Their feeling is that the system over the last 20 years has not appropriately rewarded them for the care they provide. Nor has it appropriately positioned them for their importance in this system."
In a lawsuit filed this week in U.S. District Court in Maryland, the Georgia 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.
AAFP declined to join the suit, Goertz says, because the physician organization wants to change the way RUC does business without going to court. "We are taking a different tack at this point, sending a very direct letter to RUC itself and meetings with CMS to see if there is an alternative. One of the problems with shutting things down is what alternative would be used for payment?" he says.
The RUC now has 29 total members, 23 of whom come from medical specialty societies. Of the 23 physician-members, three are rotating seats and two of the three rotating seats are reserved for internal medicine sub-specialties The remaining six seats include the chair of the RUC, a representative of the AMA, a representative of the CPT-editorial panel, a rep of the AOA, a rep from the healthcare professionals advisory (non-physician provider), and a rep from the practice expense review committee.
Goertz says, the AAFP has asked RUC to:
? Create more seats for general internal medicine, general pediatric medicine, and general family medicine;
? Add three new seats for external representatives, such as employers, health plans, and consumers ("We believe the presence of three external seats on the board would provide a more transparent process with good input from those that the decisions impact");
? Create a permanent seat for geriatric medicine, which is now one of the rotating seats;
? Eliminate the existing rotating specialty seats as the current representatives on the board term out;
? Improve transparency on all votes.
Under the existing structure, Goertz says, primary care physicians are underrepresented and have little power. "There are a total of 29 votes at any given time and only three that you can identify as primary care representatives. One of the reasons for our request for the four new seats is that to pass anything at RUC requires a two-thirds vote. There is no ability to challenge a two-thirds vote when you only have three primary care votes."
The lack of transparency with the RUC process is particularly troubling, he says. "That is one of our requests for them -- that they make the process more transparent to the public because the public -- particularly the Medicare recipient -- is impacted significantly by the decisions that are made," he says.
Goertz says AAFP wants a decision on its demands by next March, "which would give the RUC group two meetings to consider our requests. In the interim we have created a task force made of the best minds we could put together from the physician payment world to develop a more-appropriate payment methodology for paying particularly primary care physicians."
Even though AAFP is not joining the Georgia physicians' suit Goertz says many of their complaints are legitimate. "Regardless of who you are, when you sit on a committee you represent your own interests no matter how the process may be set up to not reflect that," he says. "The proof is in how the payment process has separated primary care physicians from non-primary care physicians, particularly over the last 20 years since RUC has been in place."
Peninsula Regional Medical Center will pay the federal government $1.8 million to settle claims that officials at the Salisbury, MD hospital knew about, but failed to act on, unnecessary cardiac stent procedures performed by a cardiologist, the Department of Justice has announced.
The cardiologist, John R. McLean, MD, was convicted of fraud last month after federal prosecutors showed that he inserted unnecessary cardiac stents into more than 100 patients as part of a scheme to defraud government and private insurers of more than $700,000.
The settlement this week with PRMC resolves allegations that senior medical staff at PRMC failed to act on complaints of staff in the cardiac catheterization laboratory about the medically unnecessary procedures that McLean was performing, DOJ said in a media release.
PRMC also agreed to repay money it received from federal health benefit programs between April 24, 2003 and Dec. 4, 2006 for medically unnecessary stents performed by McLean.
The hospital entered into a Corporate Integrity Agreement with the Department of Health and Human Services, Office of Inspector General, which requires PRMC to ensure accurate billing. The CIA also requires the hospital to appoint physician executives to oversee medical staff quality-of-care matters, DOJ said.
McLean, 59, could receive up to 35 years in prison when he is sentenced on November 10. Prosecutors want to recover $711,583 that they believe McLean garnered in the scheme, but U.S. District Judge William D. Quarles, Jr. will determine the exact amount of forfeiture at the sentencing.
Evidence presented at the two-week trial showed that from at least 2003 to May 2007 McLean performed cardiac catheterizations and implanted unnecessary cardiac stents in more than 100 patients at the hospital, prosecutors said.
McLean, federal prosecutors added, falsely recorded in the patients' medical records the existence or extent of coronary artery blockage to justify the stents and the claims to health insurers, including Medicare and Medicaid.
In a statement released Wednesday, PRMC said: "Although Dr. McLean was convicted in federal court in July of criminal charges, Peninsula Regional Medical Center has never been the focus of any criminal investigation or faced any criminal action related to his stenting practices."
PRMC referred to McLean as an "independent medical practitioner who "resigned his medical privileges in March 2007, shortly after questions arose about his stenting practices."
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."
