Here is one of the chapters in our book of “what happened?”.

Once upon a time, in August 2011, a group of Georgia family physicians filed a lawsuit against the “entrenched establishment”, seeking to interrupt a long-standing practice of high cost medical price fixing that has proven vastly detrimental to the economic health of the U.S., while threatening the quality of our entire health care system. Chaos went desperately seeking order.

These doctors went after the specialist interest dominated American Medical Association/Specialty Society Relative Value Update Committee, or RUC, because true primary care medicine was being dominated and subjugated by the interests of high-cost medical specialties. It’s in the realm of the protected ologists where the real waste lives, readers.

Because medical specialties are disproportionately represented on the RUC, the Georgia family physician Plaintiffs asserted that primary care providers, like themselves, are undercompensated under the physician fee schedule (PFS). Beyond the harm to their own practices and us (limited quality time with us patients), the family physicians maintained that the over-reliance on RUC in formulating the PFS has lead to the overuse of unnecessary procedures by RUC-favored specialists in a rampant fee-for-services environment resulting in a “devastating effect upon the nations’ health and health care spending.” Because new physicians entering practices are electing more lucrative specialties, one of the most damaging effects has been a continuing significant decline in the number of new primary care physicians. The real, front-line defense perimeter continues to thin.

So where does that put us? Let’s look at a picture of the disaster that continues to unfold in our system.

There should be a red light blinking in the corner of every American eye, signaling the approaching end of our health care system as we know it. The current warning step now heralded in our journey into the night is the predicted exhaustion of Medicare in 12 years, even while we cling tenaciously to our American right to over-demand, over-consume and over-deliver health care.

Shame on every doctor, every hospital, every insurance company, every health care consultant, every bought politician, every employer benefits manager, every lobbyist representing a special interest and every entitlement-minded consumer – who fails to see the need to innovate, compromise and embrace quality – prudently and at a reasonably good cost as job number one – ahead of the mindless greed and positioning that will wreck us in the end.

While they might be too nice to say it, I’m betting there are going to be a lot of good, justifiably irate primary care doctors thinking “we told you so”.

 The message is pretty clear. Unmistakable in fact.

Journalist Scott Burns, along with his fellow author and Boston University economist Lawrence Kotlikoff, are some of our best canaries in the coal mine. Burns recently wrote an article in the newspaper, describing the Medicare Trust Fund and the iceberg we’ve hit.

In 2024, just 12 years from now, the Medicare Trust Fund will be exhausted. Social Security will go bust in 21 years.

These scenarios are best case.

Unfortunately, no one, least of all Congress, seems to heed the message.

Appendix F in “Medicare and Social Security Trust Funds and the Federal Budget”, starting on page 234 explains how the trust funds relate to actual federal finance. In the past, it was somewhat ressuring that the dedicated tax revenues that went into the trust funds insulated them from the vulnerability that other federal programs (supported by general revenues) faced. That was of some comfort to seniors on Social Security and Medicare.

But Appendix F now tells us that Social Security and Medicare are becoming more dependent on general revenues. The rate is alarming – to the tune of $402.7 billion last year.  Any surpluses footnoted in the past are gone. Today, Social Security and Medicare benefits compete directly with other government committments.

And still we cavalier Americans avoid the difficult choices, as long as there are special interests that can turn heads in the pursuits of special agendas and zealously guarded profit motives. No one gives an inch of their turf. Physician ologist lobbies on the RUC continue to thwart our best chances to rectify the spending problem by keeping primary care medicine out in the cold and by keeping fee-for-service medicine supreme. The physicians who overspend on unnecessary and wasteful tests and procedures are digging our financial grave. Hospital systems in their mad dashes to control their geographic turf continue to overbuild and accumulate armies of beholden physicians. Everyone who looks only to what they can get today will  wreck our system.

We can only say once again that waste and overutilization in our healthcare system are robbing us blind. If we rely on the estimates of PriceWaterHouse Coopers of a few years back, that we were frittering away 52% of our health care spending budget per year, then by today’s standards we are throwing about $1.5 trillion down the rat hole.

Twelve years from now, we’ll be standing around a threadbare healthcare system asking “what happened?”

 SOMETIMES A PICTURE IS WORTH A THOUSAND WORDS

Tom Emerick sent a post on his blog about a story that was written up in the Denver Post. The beginning goes like this (it’s almost funny if it weren’t so fiscally tragic):

GREELEY, CO  — Hospital A bought a new helicopter.

Soon Hospital B, which already had a helicopter, bought the ambulance service from the county in a no-bid, hush-hush deal.

Hospital A, based in another city, started building an emergency room in the backyard of Hospital B.

So Hospital B started building a second emergency room for itself — 10 blocks from Hospital A’s new emergency room. When completed, they will be the fifth and sixth ERs in a 15-mile radius.

Then Hospital B teamed with the state’s largest HMO. So Hospital A started its own HMO with the state’s largest insurance company.

Hospital A launched talks to rebuild a small-town hospital. Hospital B quickly announced it would build a new hospital near there — less than 10 miles from another hospital it operates in an even smaller town.

Get the picture. Almost every time I talk to someone from a metropolitan area, the race for turf is on full bore. Seems like every town and suburb feels it doesn’t measure up unless it has a shiny new hospital, full of shiny new equipment. I know that’s how it worked in my own town. There are hospitals aplenty not far away, but my town had to have a shiny new hospital sprouted up by one of the big systems. Now we have two hospitals in the area, about 3 miles apart, and the older hospital has already opened up an emergency facility right across the street from the new hospital.

Could the turf wars be the reason prices are so outrageous? Is that why a family covered by an individual health insurance policy with a high deductible got an $11,500 ER charge to simply rule out that their daughter was having an appendicitis attack – which included a $6,500 CT scan charge? Well, somebody has to pay for shiny pieces of equipment and the people who operate them.

By the way, I spoke with a couple of pretty darned good doctors and asked if this type of full bore diagnostic process was warranted and they felt it was not. It was diagnostic overkill. One is a family practice doctor and the other is a pediatrician.

 The Denver Post article continues:

“Hospitals buy doctors and look more like insurance companies; insurers such as Kaiser build enough real estate to begin resembling hospital companies.

And the overall cost of health care goes relentlessly upward.

“What you’re seeing there is a microcosm of what we’ll see increasingly in health care over the next five to 10 years,” said Glenn Melnick, a University of Southern California health economist. Of all the moving parts in health care, Melnick said, “the big hospital systems are the most powerful.”

I wrote recently about the turf war between hospitals and the relentless campaign to get bigger and more powerful. They figure if they get big enough, they’ll have their way in negotiations with insurance companies. If they buy up enough physicians, they’ll have tremendous feeding tubes into their hospitals. And consumers will be like the little organ grinder’s monkey on a string. We’ll be collateral damage in the war to get bigger and more powerful.  

The story has probably gone viral on the web. In a University of California doctor’s study of 19,500 “routine” appendectomies performed in California, costs ranged from $1,530 to $182,955. The prices not only varied between hospitals, they varied within hospitals. The largest spread occurred at one hospital, where the cheapest appendectomy went for $7,504 while the most expensive charged was $171,696. There were numerous hospitals where the spread was $100,000 or more.

At DocOnomics we’ve just about had our fill of the gibberish the hospitals are trying to peddle. In cahoots with their so-called “collaborative” partners – the so-called “accountable care” initiatives that are being undertaken in areas around the country between hospital systems, governments, medical societies, insurance companies, so-called consulting firms, information technology companies – you name it – they (the hospitals systems) are trying to orchestrate efficient feeding tubes into their facilities. They figure if they get big enough, they’ll be able to have their way with the insurance companies when it comes to price negotiations. Not going to be that easy folks – there’s a war coming and consumers may well end up collateral damage in all of this.

What triggered this commentary was my slack-jawed hearing of the appendectomy report given by Diane Sawyer on the ABC National Nightly News. The message: there is a terrible lack of transparency in health care, coupled with the ease of keeping consumers ignorant. Duh! We can’t see it as easily, but the stink is there. In a past DocOnomics I reported on the folly of trying to ascertain a simple piece of information. I called the two big hospital systems in Dallas – Baylor and Texas Health Resources (THR) to get the cost for a “complete pelvic ultrasound” – CPT Code 76856. This was after reading a past report that the cost at Massachusetts General Hospital was $2,500, and down the road at the Harvard teaching hospital the cost was $900. When I called around to Baylor and THR, it was a comedy of call transfers, redirects, wait times and a couple of disconnects. All the while, talking with people who seemed disinterested and indifferent. I tried it again today, with the same comedy (but less time spent). What I learned was that Baylor charges nearly twice as much as THR.

[This little kudo goes out to Virginia at the John Peter Smith Hospital in Fort Worth – the big public hospital. Thank you for being so cheerful and so eager to help me find out the cost there. It was a pleasure to speak with you.]

Around the country, we consumers are being treated like ignoramuses. The hospitals are treating us like people who grow mushrooms – keeping us in the dark and feeding us a lot of manure.

So when you list the reasons our country is in so much fiscal trouble because of health care, consider the following ingredients in the sludge pot: 

• Greed
• Special interests
• Apathy
• Indifference
• Entitlement mentality
• Ignorance about who should lead our efforts
• Ignorance about what stuff costs
• Fee-for-service slot machines played 24/7
• Rudderless leadership in our delivery system

Maybe that explains why the recent 2012 Medscape survey shows that in just one year, the number of physicians who would still choose medicine as a career dropped from 69% down to 54%. Maybe a lot of good docs are getting fed up.

I know I am.

 I had a good conversation with my friend and colleague Tom Emerick this morning, following an active thread among our little “think tankers” group. As you may recall, Tom is a consultant to corporations nationwide, following a long career at the helm of some of this nation’s largest corporate health care benefits plans – as the health benefits executive at employers like WalMart, British Petroleum and Burger King.

Our think tank is made up of a cross-section of thinkers in the health care equation. Everyone of us welcomes debate, criticisms – no one’s ox is protected. We are a microcosm of what we wish were taking place out there.

Physicians like Richard Young, Guy Culpepper, Jay Haynes and Bob Kramer – all primary care docs who have been stumping for the cause of primary care medicine – and practicing, writing, teaching and speaking out about why we need a healthy, strong system of physician “comprehensivists” (my new word) to help straighten out the misguided spending spree we’re on. Richard has written a great book (American HealthScare) that skewers the GIMeC – “government industrial medical complex”.

Brian Klepper, PhD, a health policy analyst has been super active in writing and speaking about the cause of primary care and the demonstrable advantages of employer on-site primary care clinics to rein in mindless spending, because employers are our last bastion of potential to plug the terrible leaks in our system.

Authors, thought leaders and policy activists Rosemary Gibson and Shannon Brownlee have been outspoken and influential at places like the New America Foundation, The Dartmouth Institute For Health Policy, The Robert Wood Johnson Foundation and the American Enterprise Institute. They need no introduction to those who are well-read on the subjects of medical waste in our economy and the harm it is doing to us in the name of profits that push the health care players to peddle more and more of what we don’t need.

All these rich thinkers have kept my mind active, and have eagerly and willingly committed their thoughts on the subjects that matter in the effort to fix of our American healthcare ship without a rudder.

WELLNESS FOR THE MASSES

Our latest thread (ire) has focused on the myth of “wellness” that has been around forever and that hospital systems and insurance companies (and their brokerage “consultants”) have been pouring into our heads in the hope that this feel good crap will lull us into ignoring essential truths. By the way, one of these insurance brokerage “consultants” states on their website the following when it comes to their wonderful new “Angies List” approach to solving employers’ health care problems …

“In a word, say the executives of ACAP Health Consulting, the real enemy is disease—and the way to defeat it is with a collaborative effort that involves all stakeholders: employers, employees, hospitals and doctors, and insurance carriers.

Key to ACAP Health’s approach is the implementation of common-sense strategies to prevent the onset of lifestyle-related conditions like obesity, Type 2 diabetes, heart disease, and some forms of cancer. Results thus far show dramatic improvements in participating employees’ health and quality of life, coupled with significant reductions in health care costs and insurance premiums.

Really? Let me quote some of our “think tankers”, on a day that one of Dallas’ big hospital systems announces a major new push to make us all feel good about wellness – (and them about their profit potential s as more of this drivel wins over gullible employers and their employees).

Richard Young, MD writes:

“As a physician, I can’t make a well person weller. And as I point out in my book, for most common services we provide in healthcare, an ounce of prevention costs a ton of money.

I’ve actually been wrestling with this concept for awhile, trying to come up with a pithy saying that more accurately reflects the goal in cost-effective care. My current working aphorism is stability.  We should be promoting stability in patients, not wellness”.

For example, a person who has a bad case of heart failure will never be well again. A reasonable treatment goal might be to give him enough medicine to keep feet just barely swollen, but not too much so that he passes out when he stands up, but enough so that he can sleep reasonably well on 2 pillows at night. We want that state of health to remain  steady for as long as possible — his heart failure will naturally get worse over time — but with good primary care the medications can be adjusted to try to keep this level of health stable. When he destabilizes from that state, he will feel bad and then seek care in an ER, and often get admitted to the hospital.

Similar stories could be told for patients with COPD, diabetes, and bipolar disorder. Spending a lot of time and effort on people who feel fine and have no severe chronic diseases never saves money.

 Tom Emerick writes…

I see nothing in this but health and wellness and value-based purchasing rehashed.

They are using none of the right language to suggest they are going after misdiagnoses, overtreatment, over-surgery in the US. In short it looks to me to be just another effort to micromanage 20% of an employer’s health spending.  “Let’s stop the blame game and start working with high value doctors.”  We need action on the aspects of health care that are truly broken. If they had said they were focusing on the outlier population (where the huge costs reside) ….I might feel differently.  Or if they said they were targeting overuse and over treatment…but alas.  We have to get this message out.

The employers of DFW do not need more collaboration.  They need action on the causes that are driving us into a wall.  We offer action now.

 Shannon Brownlee contributes …

“Re: looking for incipient signs of illness in well people not only doesn’t save money it often turns a well person into a patient and sometimes does him harm. 

Anybody see the piece on cancer screening in the Science Times yesterday?” 

And …

“The only way wellness saves money is by changing the survival curve and compress morbidity. As far as I can tell, there’s no treatment or health regimen that does that. There might be some argument for wellness programs saving money if they push off expenditures on illness to a later date, but the only way we are going to save money is by paying less per unit of service and/or cutting out the incredible amount of waste/over treatment/high tech useless stuff and futile rescue care at the end of life.”

 Guy Culpepper, MD writes 

 The Wellness/Health Promotion jargon has been abused by multiple entrepreneurs looking to justify their efforts to capture healthcare dollars. No evidence exists that anyone is more effective at slowing disease progression than a good family doctor.

Yet sadly, employers desperately seeking to stop the bleeding have paid for this snake oil. And more companies are offering it. It’s a “savings placebo”.

Every insurance company promotes how they “help doctors to coordinate wellness care and prevent disease”. The wider they cast their net, the higher the premium charge. 

So now that some margins in insurance companies are threatened, their leadership joins forces with the insurance brokers to create another level of bureaucracy between doctors and patients… ”to help employers talk to doctors”

Brian Klepper, PhD writes …

“Fee-for-service has made healthcare a merchant enterprise. Every product and service delivers a margin, and so the industry does as many as possible. The payment system’s clear incentive is to deliver more care, and more expensive care, where the absolute profit dollars are higher.”

 And …

“Unless champions from the business community outside of health care arise, we may be doomed to stand by as a rapacious health care industry sucks the rest of the American economy dry.”

Readers of DocOnomics, I can’t add anything more or better than these comments of the people who make me smarter by the day. Their knowledge, opinions and insights give me hope that if enough people form reasoned thinking about the gigantic economic conspiracy taking place in this huge health care sub-economy, we might have a chance to avoid the inevitable – where everybody is standing around asking “what happened”.  

Health care costs are continuing to erode consumers’ budgets.

The cost to cover health care for the typical family of four under an employer plan will  top $20,000 this year, up more than 7% from last year, according to projections by independent actuarial and health care consulting firm Milliman Inc. In 2002, the cost was just $9,235, the firm said.

The projected increase marks the fifth year in a row that health care costs will rise between 7% and 8% annually.

While employers still pay for a majority of health care expenses, employees have been paying a larger portion of the total amount every year, according to Lorraine Mayne, principal and consulting actuary with Milliman.

Rising costs for employees is part of a long-term trend, said Deborah Chollet, senior fellow and health economist with Washington-based Mathematica Policy Research. “Employers have been unwilling to accept benefit cost increases at the rate that health care costs have risen,” she said.

As a result, they have been passing along extra costs to employees in the form of higher deductibles and co-pays, as well as more expensive premiums.

Last year, workers’ out-of-pocket costs rose 9.2% to $3,280 for a typical family of four, according to Milliman.

Those who buy insurance without an employer-provided plan are shelling out even more, Mayne said. The average premium for a family in a non-group plan was $7,102 in 2010, according to the nonprofit Kaiser Family Foundation.

Over the past five years, health care costs have comprised a bigger portion of the country’s household budgets as expenses continue to rise and incomes remain stagnant, according to the Bureau of Labor Statistics.

If the Supreme Court strikes down the Affordable Care Act, consumers can expect that their out-of-pocket percentages will increase even more as costs rise “very fast,” Chollet said. Without the law’s measures to promote preventative care and spread costs across a larger population, overall costs will jump, she explained.

Those with insurance through their employer will also pay more to cover the growing number of uninsured, she said.

Still, even if the Affordable Care Act goes through, it will do little to lessen the financial burden for those who are already insured, Mayne said. “It will take other changes to really bend the cost curve and make substantial changes in health care costs,” she said.

And still we continue to fritter away time with endless debates, bickering and jawboning about the dysfunctional system we have created with our excesses, special interests, profiteering and greed. We must find a way to cut the amount we spend on health care, and targeting waste and excess is the number one priority. Fee-for-service medicine must be stopped cold because it is the fertile growth medium for all of our wasteful spending.

DocOnomics will prescribe a cure for American health care. As you read below, please pay attention to key underlined phrases. They are the keys to a workable solution.

The task of bending the cost curve of health care in the U.S. is going to entail a monumental task for all. We can point fingers all we want at various players in the matrix of the cost and waste obscenities in our glutted health care budget – estimated at $2.6 trillion this year. Finger pointing and bickering has been going on for a long time and what do we have to show for all of the rhetoric and posturing that has occurred?

Yet, when patients have an active role in their own health care, the quality of their care, and of their care experience improves, as Commonwealth Fund researchers asserted in their analysis of 2011 global health consumer survey data published in the April/June 2012 issue of the Journal of Ambulatory Care Management. This survey is summarized in International Perspectives on Patient Engagement: Results from the 2011 Commonwealth Fund Survey, and you will find it published on The Commonwealth Fund’s website on March 29, 2012.

Hallmarks of patient engagement include shared decision making and health self-management of chronic conditions, which are penetrating health systems the world over. In the 11 countries The Commonwealth Fund surveyed in 2011, patient engagement levels vary across countries.

In seven of 11 countries, patients with below-average incomes were significantly less likely to have been engaged by their regular doctor in their care. These lower-performing nations include Australia, Canada, the Netherlands, Norway, Sweden, the United Kingdom and the U.S. The U.S. stood out once again for the widest income-based disparities.

In all of the countries surveyed, patients reported that quality communications and quality relationships with their regular doctors (let us call this the medical home) were more likely to rate the quality of care they receive as excellent or very good. The gap between high marks for care and low marks is greatest in the U.S., where 78% of patients who said they were engaged in their care rated their care highly, compared with 43% who were not so engaged.

Engaged patients were less likely to report a medical, medication or lab test error in the past two years, and felt more positively about their health systems than non-engaged patients.

The highest performing health systems based on patient engagement were Switzerland and the U.K. Even though they finance and deliver care very differently, with Switzerland having a more medical insurance-based market approach than single-payer U.K., both use the medical home concept where every health citizen is covered first by a primary care provider. These PCMHs act as referral agents for all aspects of care, ensuring continuity of care when referred to specialists, tests, and other services as required.

As we await the decision of the Supreme Court, the fate of the Affordable Care Act is anyone’s guess. One can only hope that whatever happens, the inclusion of medical homes and quality primary care expansion isn’t placed on the bottom of the pile of things we need to to accomplish in order to fix our badly broken system. Without primary care medical homes, the U.S. has little hope of bending the cost curve or improving quality on a par with the rest of the developed world.

THE DocOnomics PRESCRIPTION

1. Start with an underlying premise that a broad cross-section of American employers who provide health care benefits must be the catalysts for change in our system, since they are the free-market payers for a significant portion of this country’s health care.
2. Continue to focus on a terribly ignored truth and address our ignorance. Recognize and take steps to ensure that primary care medicine must become the cognitive core of American health care, through which we restore physician-patient relationships, reinvigorate the trust between doctors and their primary care charges, provide continuity of care, coordination of care, and reduce/eliminate many of the  wasteful expenditures that can be adequately and effectively delivered by primary care physicians when they are afforded sufficient time to do what they do best. Finally, expect and require that primary care physicians will be skilled at recognizing that, when significant medical conditions will require the most extensive and expensive care, that specialist physicians who and facilities which have demonstrated the most cost-effective, quality-outcome care are employed, and that specialists are openly inclined and willing to discuss all possible alternatives with patients who then become empowered as informed consumers.
3. At employers of sufficient size, establish well-managed, on-site primary care medical home clinics. For smaller employers, collaborate on shared clinics.
4. Recognize clearly that a small percentage of the population is responsible for the vast majority of health care costs, that wellness and other life modifying programs will not help those individuals when such high cost care is needed and that far too many treatments and procedures which generate huge bills are often performed without medical evidence or need and at facilities that offer lower-quality outcomes at higher prices. By some estimates, 5-10% of the population is responsible for 75-80% of health care costs.
5. At each primary care clinic, establish high quality-oriented large case management and centers of excellence to ensure that the most expensive treatments and procedures are delivered at the locations where the best outcomes and costs can be expected.

That’s it. Start here, as simplistic as that may sound, and we will take a quantum leap forward in reducing costs and waste and bending the curve. Tell the complainers and whiners to be quiet while we take the steps necessary to save our economy from destruction at the hands of health care. Ignore the special interests and the lobbysists, they are agents of our destruction.

Then, channel what we save into expanding an American health care  system that is reasonably accessible and affordable to those who go without

I have been involved in various aspects of healthcare for 40+ years. During that time I have observed the unraveling of our system as greed, waste, self-interests, ego, out-of-control costs, endless political bickering and an atmosphere of entitlement, indifference and ignorance have driven us off the tracks. The cast of players is comprehensive, where each player contributes unique straws that will one day be a burden sufficient to break the proverbial camel’s back. It is happening now, today in a health care system in the richest nation on earth (for now).

We have fashioned challenges of epic dimensions for our children and future generations that will surpass any of the other legacies borne out of our excesses. This is not just a matter of economics, but a matter that must address the very quality of health care that will be available to us and what overindulged Americans think our system can and should do for us.

Government and all of its regulations will not establish order in our relentless health care cost crisis. Maybe we should give our government a break. It’s not their job to fix health care, although too many of us believe that government should fix everything. On this matter, should we really expect government to carry out its responsibilities in the face of partisan politics that have pushed the fate of health care all the way to the Supreme Court? Even at the Supreme Court level of checks and balances, a decision on the ACA is still expected to be a partisan ideology issue at the end of the day. Even when we envisioned a system that would be more readily accessible to the millions who have gone without health insurance, politicians have been influenced by their own partisan agendas, political ambitions and the endless largesse of deep pocketed lobbyists. What was it – 8 lobbyists for every elected official during the heat of battle over the ACA? In the end, what we got was an unsettled law that, if it survives a partisan test of constitutionality, would look like bureaucracy on steroids. Forget government. Let’s move on.

Insurance companies may not be the biggest economic player, as Tom Emerick has pointed out to me. But the power base has essentially shrunk down to the BUCAHS (Blue Cross, United Health, Cigna, Aetna and Humana), and it seems these claims payers have come to regard themselves as tails that wag the dog. In a conversation with one municipality, I was told to my utter amazement that if the city wanted the United HealthCare network (where discounts are the flimsy excuse for cost management excellence), the city would have to get rid of all of its cost containment measures. I know where I would have told United HealthCare to go, in no uncertain terms. These claims paying demagogues seem to think they are in control and we need to convincingly debate their primacy.

Hospitals have become bush-beater organizations, trying to have enough drummers out there to drive business into the mother ships. Here in Dallas/Fort Worth, the struggle is on between two major systems to control turf. And to accomplish that aim, they are buying up primary care physicians who are lured by salaries larger than they could have earned in private practice – contingent on their driving business to the hospitals. Hospitals are doing this elsewhere as I’m told by colleagues in other cities. So scratch hospitals as purveyors of the public good in the health care food chain.  

Physicians organizations (professional societies and academies) are either stacking the decks in their favor, protecting their turf, or are just plain gutless when it comes to representing the good of the system. Brian Klepper and his primary care activist colleagues have written at great length how the RUC has maintained a stranglehold on primary care medicine, which in this writer’s opinion is the only hope we might have left to restore order out of this healthcare chaos. The RUC continues its total dominance over how payments are made – and made to favor specialists over true primary care physicians. And true primary care physicians, as many tell me, are being meekly led around by the RUC bully organization. They are wimps. The case in point is that the American Academy of Family Physicians which had demanded a better deal at the RUC table just sold their membership out by capitulating to the RUC and essentially submitting to the whims of the overwhelming ologist majority who will continue to rubber stamp in their own favor and mandate high speed assembly line medicine at the family doctor’s office.

Physicians contribute to the spending problem when greed or ego contribute to excesses and wasteful spending. When profits drive physicians to treat expensively and excessively without discussing alternatives, or when physicians treat (e.g., perform surgeries) because they are convinced their solutions are the only solutions, our fee-for-service system operates at its worst.

Employers must share in the blame, if one first accepts the premise that employers have a real ability to exert economic power because they are the major financial underwriters  for the health care system. As Tom Emerick points out, the human resource departments and private sector benefit managers at many companies are simply not being proactive enough in pushing for initiatives to implement new ideas or accept new thinking about fixing the system in areas where so much effort must be applied, i.e., reducing mindless excesses, overutilization and waste. Tom unabashedly tells me that too many in these potential crucibles for thought and change are just plain disconnected or just plain lazy. I have personally talked to many individuals in the HR and benefit areas of companies about employing proven initiatives to curb the unnecessary red ink flowing out the employers hands due to excess and waste. The reasons and excuses are sometimes mind-boggling. As one HR benefits manager once told me, “if I had to look at all of the good ideas to control our health care costs, I’d have to give up doing the rest of my job”.

Healthcare consumers don’t get a free ride. Americans are overindulged and look for the quick cures. They don’t want to wait and they expect their demands to be met promptly, even to the point of haste and lack of information. They cling to the notion that they must be catered to and they are not concerned about the plight of those who must forego care because of a lack of insurance or access.

We urgently need to help ourselves because the problem has not stopped accelerating.

Below is an article reposted by my friend and colleague in the good fight to fix our broken health care system. Dr Richard Young is a member of our team fighting to fix a broken, greed-infused and self-interested system of nonstop waste and excess that nobody seems to get will break our economic back. Even the medical academy of family physicians has sold their members down the road due to their cowardice as leaders. We’ll pay a price for this absence of intestinal fortitude. Below is Dr. Young’s repost that appeared in his American HealthScare blog www.healthscareonline.com .

The AAFP Should Leave the RUC

April 1, 2012

By Richard Young MD

I was going to write a post about the spineless leadership of the AAFP and how they caved in to the RUC (relative value update committee — the ologist-dominated committee of the AMA that makes physician fee recommendations to CMS). Visualize the AAFP dog whimpering pathetically with its tail stuck firmly between its legs cowering back to the master who has abused it for decades. Brian Klepper, PhD wrote a great piece about the travesty of this decision. With his permission, I’m re-posting his statement.

Last June the American Academy of Family Physicians (AAFP) sent a letter to the AMA’s Relative Value Scale Update Committee (RUC) demanding specific changes to the ways that the RUC conducts its business. Primary care has been severely compromised by the RUC’s recommendations, and there was an implicit threat that the nation’s largest medical society would withdraw if the demands were ignored.

I co-authored a Kaiser Health News article in January 2011 calling on AAFP and other primary care societies to quit the RUC. The campaign was given real teeth when six Augusta, GA primary care physiciansfiled suit last June in a Maryland federal court against the US Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS). The complaint charges that those agencies have refused to require the RUC to adhere to the stringent requirements of the Federal Advisory Committee Act, which ensures that policy is formulated in the public rather than the special interest.

In early March, after the RUC rejected the AAFP’s demands, that society’s leadership caved. Then, in a letter to its members, AAFP President Glen Stream, MD argued that the best course is to remain tied to the group whose recommendations to CMS have, by AAFP’s own admission, devastated primary care over the past two decades.

AAFP’s leadership’s decision to remain in the RUC is seriously misguided. It’s isn’t just about its members, but about everyone harmed by CMS’ reliance on the RUC. It is certainly bad for primary care but, far more importantly, it is very bad for patients and for purchasers.

AAFP’s leaders and members should clearly understand that, after this period of deep consideration, their society’s active participation renders them party to and complicit with the RUC’s actions, including those that create incentives for unnecessary services, those that inhibit primary care’s moderating influence on specialty care, and those that undermine the development of an adequate supply of next-generation primary care physicians.

AAFP’s continued participation makes it partially accountable for patients who are exposed to the physical risk associated with unnecessary procedures, and for the excess cost borne by health care purchasers. The society can argue that it is not culpable, but to everyone outside the RUC who understands the impacts of its maneuvering, the AAFP now owns the RUC’s actions.

This didn’t need to happen. In his defense of the decision, Dr. Stream flatly states that “Withdrawing the AAFP from the RUC would not delegitimize the RUC,” as though this should be taken at face value. Really? AAFP counts more than 100,000 members, one-seventh of the US physician population handling perhaps one-third of all physician visits. Wouldn’t a highly orchestrated and publicized exit have impact or raise questions? If not, then AAFP is admitting that it really is impotent in public policy.

Dr. Stream notes that “None of the other primary care physician organizations were interested in leaving the RUC,” as though that’s a surprise. The American College of Physicians, the American Osteopathic Association and American Academy of Pediatrics are dominated by sub-specialists, and so have been content with the RUC’s approaches. The only question this raises is why, from a strategic perspective, the AAFP hasn’t seized the opportunity to embrace, consolidate and leverage the broader primary care’s community true strength, which would significantly enhance its policy position.

As America’s only pure primary care society, AAFP may indeed stand alone in the health care industry. Primary care’s empowerment would diminish revenues resulting from inappropriate services throughout the care continuum, so nearly every other health care group favors the paradigm that has dominated for the past two decades.

But the non-health care business community is larger and more powerful than health care, has carried a tremendous excess health care cost burden, and has every reason to stand with primary care. The National Business Group on Health was an active participant on the AAFP’s Primary Care Services Task Force. They and other business groups would undoubtedly respond to a request to rally, if asked.

Finally, Dr. Stream claims, “Important strategic political partnerships outside the RUC could have been damaged if we withdrew, and that could have harmed the Academy’s advocacy efforts.” This undoubtedly was the clincher, but it is questionable whether it makes sense to depend on allies whose collaboration requires the acceptance of egregious terms.

For 20 years, AAFP has been at the RUC’s table, and the lot of family physicians has eroded dramatically. The decision to stay means continuing with the same behavior and expecting a different result.

But it is worse than that. The AAFPs now moves forward with a group it has publicly acknowledged actively works against the interests of patients, purchasers and primary care physicians. It is very difficult to justify that.

Brian Klepper is Chief Development Officer of WeCare TLC and blogs at Care and Cost.