An attack on the medical establishment buried in an 1,800-page regulation

Boston Globe

5 days ago

Medicare officials have been loath to change it because it has spared them from needing their own staff and budget to make such pricing decisions, along with the unpleasant politics of adjudicating conflicts between competing groups of physicians.
But a change buried inside a 1,803-page proposed regulation published last Monday suggests the Trump administration would like to move away from this longstanding system. If finalized, it could begin overturning a process that has entrenched pay advantages for certain kinds of doctors.
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'We're modernizing Medicare by correcting outdated assumptions in how physician services are valued,' said Chris Klomp, a deputy administrator of the Centers for Medicare and Medicaid Services, in an email.
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Robert F. Kennedy Jr., the secretary of health and human services, has emphasized that medicine should focus more on primary care and prevention, and less on the treatment of advanced diseases. He has also crusaded against 'corporate medicine,' and has specifically criticized the American Medical Association. Stat News reported in November that Kennedy was considering policies to disempower the AMA committee.
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Dr. Bobby Mukkamala, the AMA's president, was highly critical of the proposed change.
'The American Medical Association believes that proposals to exclude or limit the input of expert practicing physicians and health care professionals in the development of Medicare payment policy would ultimately harm patients and represents a radical departure from the time-tested CMS decision-making process,' he said in a statement.
The current AMA committee, known as the RUC, uses data gathered in surveys of doctors to set formulas for every kind of medical care. The committee suggests payment rates to Medicare's regulators, who almost always adopt them. The system is effectively zero-sum — any increases for one kind of doctor represents decreases for others. While private insurers are free to develop their own formulas for paying doctors, they tend to follow Medicare's lead, making the committee very influential on what kinds of medical care get the largest (and smallest) financial rewards.
The estimates are often outdated. Existing payments are reviewed on average only once every 17 years. A Washington Post investigation in 2013 reported on numerous gastroenterologists who had billed Medicare for more than 24 hours' worth of colonoscopies a day. The reason wasn't fraud. Medicare was still paying the doctors as if each test took 75 minutes to complete, when most doctors were able to complete one in 30 minutes. (The colonoscopy payment has since been adjusted.)
Under the new proposal, Medicare would pay 2.5 percent less for every procedure, operation and medical test in 2026, based on data suggesting there have been improvements in 'efficiency' over the years. Payments for treatments based only on time, like a consultation with a family physician or neurologist, would not be cut. Such adjustments would be repeated every three years.
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The proposal also looks to change the kind of data Medicare should consider instead of the relatively small surveys, noting that new sources of health data from hospitals and electronic billing systems could offer more accurate information.
The effort to adjust what doctors are paid for their work is just one part of the large rule, which also contains provisions to broaden coverage for telemedicine, pay for more mental health care, and reduce overpayments for a new and expensive type of skin bandage.
One other provision, meant to better account for the costs of running a medical practice, also affects the relative pay of different medical specialists. In some cases, those changes would reduce payments to the types of medical specialists whom the efficiency adjustments are meant to benefit.
That policy would adjust payments to doctors based on whether they offer services on a hospital campus or in a private practice office, effectively lowering payments in the hospital and boosting those elsewhere.
Taken together, the overall proposal would do more than just increase the salaries of primary care doctors. It would also increase the average pay of an allergist next year by 7 percent, and decrease pay for a neurosurgeon by 5 percent, according to estimates published by Medicare. It would lower pay by 6 percent for infectious disease specialists, who tend to earn low salaries and perform few procedures -- and increase average pay for vascular surgeons by 5 percent.
Dr. Adam Bruggeman, a spine surgeon in San Antonio who leads the council on advocacy for the American Academy of Orthopaedic Surgeons, said he was sympathetic to arguments that the current system may be paying for some medical procedures inaccurately. But he said the proposal — which would cut payments for all procedures next year — was too crude a solution to that problem. He described the 'efficiency' changes as 'taking an ax to the whole thing.'
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'We're just fighting an arbitrary number with another arbitrary number, and that doesn't help,' he said.
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