Dividing the Medicare Pie Pits Doctor Against Doctor

By ANNA WILDE MATHEWS

One of the biggest disputes in the Relative Value Scale Update Committee came in 2005, when members clashed over primary-care groups' push for increases in the payments for doctor office visits, which are among the most commonly-billed Medicare services.

The primary-care societies argued that visits had become more challenging, partly because patients were older and had more complex conditions. At one point, the debate reached such an impasse that J. Leonard Lichtenfeld, who represented the American College of Physicians, and at least one other RUC member, Tom Felger, who represented family physicians, actually came close to ending their involvement in the talks, and asked for a break in the meeting, according to both men. They felt a surgical faction was blocking their push, they say.

"I was willing to leave the negotiations," Dr. Lichtenfeld says. "I felt that we were being stonewalled for economic reasons."

On the other side, surgical groups had argued there wasn't strong evidence that visits with patients had gotten more difficult. "There were some bitter feelings," says John O. Gage, who represents the American College of Surgeons on the panel.

After the primary-care physicians agreed to return to the discussion, the panel's meeting was closed to outsiders, Dr. Felger says. Members negotiated past midnight, fueled by pizza. The eventual compromise raised visit payments, but not as much as the primary-care doctors wanted, and the full effect was blunted by the Medicare budget process.

The tensions surfaced again in 2007, when Dr. Lichtenfeld and others tried to add a new primary-care seat to the panel—and got voted down. They said the committee, which includes among its 23 medical-specialty society slots cardiothoracic surgeons, otolaryngologists and neurosurgeons, wasn't representative of all doctors. Geriatricians, oncologists and gastroenterologists have also pushed unsuccessfully for designated seats.

Primary-care groups continue to argue that the panel's results, with other elements of Medicare's fee-for-service payment system, may hurt them. J. Fred Ralston, president of the American College of Physicians, says it is "concerned about the composition" which "seems to be a heavier weighting of specialties that are more procedure-oriented." Lori Heim, board chair of the American Academy of Family Physicians, says its approach is "skewed" and "the cognitive is not paid nearly as much as the procedures."

RUC Chairwoman Barbara Levy says the committee is an expert panel, not meant to be representative, and that members don't vote in blocs tied to their specialties' interests. "The voting is not partisan," she says. She and RUC documents highlight that the committee has endorsed increases for doctor-visit codes, including the ones that emerged from the debate in 2005 and 2006, which she says were worth more than $4 billion.

The Medicare agency is moving to "improve Medicare's physician systems to correct historical biases against primary-care professionals," said Jonathan Blum, deputy administrator for the Centers for Medicare and Medicaid Services, in an emailed statement. The agency made several changes that boosted primary care service payments this year, he said, and plans similar moves in the new rule for next year.

Corrections & Amplifications:
Lori Heim is board chair of the American Academy of Family Physicians. An earlier version of this article called it the American Association of Family Physicians.