One of hedge fund manager David Einhorn’s saying is “no matter how bad you think it is, it’s worse.” An article in Washington Monthly, Special Deal by Haley Sweetland Edwards, deep dives into one big and largely hidden reason why medical costs in the US are out of control and are unlikely to be reined in any time soon.
I can’t stress enough that you need to read this well-researched and written article in full. I’ll nevertheless recap some of its main points.
Three times a year, an AMA committee called the Specialty Society Relative Value Scale Update Committee, aka RUC, meets. Per Edwards:
…it’s the committee members’ job to decide what Medicare should pay them and their colleagues for the medical procedures they perform. How much should radiologists get for administering an MRI? How much should cardiologists be paid for inserting a heart stent?
While these doctors always discuss the “value” of each procedure in terms of the amount of time, work, and overhead required of them to perform it, the implication of that “value” is not lost on anyone in the room: they are, essentially, haggling over what their own salaries should be. “No one ever says the word ‘price,’ ” a doctor on the committee told me after the April meeting. “But yeah, everyone knows we’re talking about money.”….
In a free market society, there’s a name for this kind of thing—for when a roomful of professionals from the same trade meet behind closed doors to agree on how much their services should be worth. It’s called price-fixing. And in any other industry, it’s illegal—grounds for a federal investigation into antitrust abuse, at the least.
But this, dear readers, is not any other industry. This is the health care industry, and here, this kind of “price-fixing” is not only perfectly legal, it’s sanctioned by the U.S. government. At the end of each of these meetings, RUC members vote anonymously on a list of “recommended values,” which are then sent to the Centers for Medicare and Medicaid Services (CMS), the federal agency that runs those programs. For the last twenty-two years, the CMS has accepted about 90 percent of the RUC’s recommended values—essentially transferring the committee’s decisions directly into law.
The RUC, in other words, enjoys basically de facto control over how roughly $85 billion in U.S. taxpayer money is divvied up every year. And that’s just the start of it. Because of the way the system is set up, the values the RUC comes up with wind up shaping the very structure of the U.S. health care sector, creating the perverse financial incentives that dictate how our doctors behave, and affecting the annual expenditure of nearly one-fifth of our GDP.
Now technically, what the RUC is doing is not directly setting the size of the Medicare pie but providing the price parameters that determine who gets what, in terms of how much goes to primary care physicians v. specialists, and how much various specialists get relative to each other. And even if in any particular year, one can argue that the effect of the RUC process is merely distributive (which doctors get what), it’s hard not to infer that this process has played a major role in the ratcheting up of health care costs (I hope some health care policy wonks will pipe up, but based on reading a paper by Federal Reserve economists who took a hard look at the CBO health care cost forecasts, Medicare’s excess cost, adjusted for age growth of the population, grew faster than that of health care spending overall). And those Medicare rack rates determined private sector rates and billings:
Allowing a small group of doctors to determine the fees that they and their colleagues will be paid not only drives up the cost of Medicare over time, it also drives up the cost of health care in this country writ large. That’s because private insurance companies also use Medicare’s fee schedule as a baseline for negotiating prices with hospitals and other providers. So if the RUC inflates the base price Medicare pays for a specific procedure, that inflationary effect ripples up through the health care industry as a whole…
Over the past few years, a few well-placed health care figures from both parties have spoken out—at least once they’ve left office—about how crazy this system is. “The RUC is really just a giant cabal run by the AMA,” Thomas Scully, former head of the CMS under George W. Bush, told me. “A private trade association should not have that sort of control over the biggest spending account in the government. It’s an outrageous travesty of democracy.” Bruce Vladeck, former head of the CMS under Bill Clinton, agrees, calling the RUC “a significant part of the problem.”
The article sets for the sad history of how the AMA got in the position of being able to cartelize the pricing of medical services. And brace yourself for how institutionalized it is:
…by controlling the RUC, it controls much of the source code that our health care system uses to operate. Every single one of those roughly 9,000 medical services and procedures has its own five-digit code, known as current procedural terminology (CPT), and the AMA owns them all. That means that anyone—physicians, labs, hospitals, you name it—who wants to bill Medicare, Medicaid, or a private insurance company has to purchase either AMA books and products, or products from other software companies that pay AMA royalties and licensing fees to use the CPT codes. According to its annual report, in 2012 the AMA made $83.1 million in “royalties and credentialing products,” a large chunk of which comes from licensing CPT…
But in talking to a half-dozen current and former RUC members, including both generalists and specialists, the image of the committee that emerges is less a gathering of angels, cloaked by some Rawlsian Veil of Ignorance, and more akin to a health care-themed Game of Thrones. Several RUC members I spoke to mentioned that the chairwoman often reminds the committee to “Put your RUC hat on,” meaning: “Don’t think from your society’s standpoint.”
The article goes into considerable detail as to how the AMA uses procedures that inflate the estimate of the “work units” that it takes to perform a particular procedure. The effect over time is to greatly overcompensate specialists who are heavily represented on the RUC, at the expense of primary care physicians (I’m sure readers can provide examples of the absurdity of some specialist charges; I was stunned at the charge for a dermatologist to evacuate a not-very-large cyst, which I am certain could have been done as well by a nurse but that’s not how we do medicine in the US. Or how about the ridiculously priced MRI, which also generates tons of lucrative orthopedic false positives?).
But arguably the biggest flaw with the RUC process is that it never questions efficacy:
Perhaps the most damning aspect of the RUC’s methodology, however, is that, while its members often spend quite literally hours debating if a certain procedure takes three minutes or just two, the RUC never so much as flicks at the question of how much—or even whether—a procedure actually benefits patients. This failure, which is part of a broader flaw in federal health care policy, is enormously damaging to the practice of American medicine. Among other things, it means that many patients wind up undergoing expensive procedures for which more effective and less costly alternatives are available.
Edwards also describes how there have been some improvements around the margin in the RUC process, such as taking steps to curb redundant billing. And she also describes the provisions of Obamacare that could be used to leash and collar it, but almost certainly won’t be, given how the whole point of Obamacare was to enrich industry incumbents. She notes:
Even if these incremental steps remain in place, some critics argue they are akin to frosting on a rotten cake. “You can make these tweaks,” says Brian Klepper, a health care analyst and principal at WeCare, a primary care clinic and medical management firm, “but what you’re doing is ignoring the fact that this system is fundamentally insane. It’s so corrupt and collusive, it’s not something that can be incrementally fixed.”
Again, I strongly urge you to read the article in full. It’s another well-documented example of how deeply corrupt our society has become.
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“It’s another well-documented example of how deeply corrupt our society has become.”
There is nothing I see happening that will change this fact. And that is why we are heading for a serious collapse. I do hope I am proven wrong, but really, can anyone think of any of these travesties that have been exposed over the past 20 years that have actually been addressed in a comprehensive way?
I quite agree. I’ve made similar points: a society can only survive if it can contain the inevitable corruption to a manageable level. To base a society on corruption upfront is simply suicidal, and all of Amerika’s basic institutions are openly based on corruption, the medical-industrial complex being only one of them. Reality can be cheated but only for so long, and the accelerating increase in corruption guarantees the implosion will come sooner rather than later.
Think Mexico. Once you’ve gotten used to that, think Haiti.
I like to say that we have a “Tweed Courthouse” problem.
Nobody minds a little corruption as long as the building gets built. When the corruption has eaten twice the cost of the building and the building *still hasn’t been built*, then people start getting really angry.
I know I’m merely reinforcing what you’re saying, but I believe a lot of the corruption will be removed in the upcoming revolution.
Thanks, I suspect this article will be controversial, as many see only the lack of socialized medicine and not the RAW costs of EVERYTHING medical as being the problem. But the pay of doctors in the U.S. is also higher than the rest of the world.
The world that is taking shape: only workers whose jobs are legally limited and cartelized by the plenty visible hand of government will be allowed to do well. Unions once allowed non-cartelized jobs to do well but they barely exist anymore except in the public sector (I’m not counting public sector jobs as cartelization since whatever priviledges they have I don’t think that term applies). Unions were workers ways of bargaining. Now the RUC is. Only it’s not very many workers … Other skilled workers may SEEM at present to be doing well, such as STEM workers, however they are NOT part of the cartelization and that is why they will not do well in the long run and their jobs are being sold out from under them.
The vast and ever growing majority will be caught in a system that forces extortionary rents be paid to the cartelized. They can try to escape but they can’t (short of leaving the country maybe). They may seek solidarity against the 1%, but even if they manage by some miracle to convince the non-cartelized professional middle class to go along (because it finally realizes the *self-interest* in doing so!), they will never convince the cartelized, they truly are honorary 1%ers – they don’t need worker solidarity and unionization or even mutual aid. The rent paying majority can try to “drop out” of their corrupt society, but they won’t be able to get medical care since all the doctors are happily cartelized, and neither is that cost of cartelization entirely passed on to the government in the U.S. of course.
….and Ben says “Wall Street hasn’t benefited more from QE than main street”.
The fraud and looting will continue until confidence is restored.
I think this is what Carter is talking about when he suggests that American no longer has a functioning democracy.
http://www.spiegel.de/politik/ausland/nsa-affaere-jimmy-carter-kritisiert-usa-a-911589.html
There is a dead easy way to fix this problem through the old method of supply and demand. Increase the supply of Doctors.
Approve a new H1-B visa program for Doctors from India and other English speaking nations from around the World. Allow companies like Tata Consultancy, Wipro and Cognizant to ship in boatloads of Doctors on H1-Bs to the USA just like they ship in boatloads of Software Engineers today.
Software Engineers used to cost a pretty penny two decades back – until the H1-B arrived. While engineer salaries went down, the cost of software and software related products hit rock bottom. Is making a Tablet computer less or more complicated, less or more routine than taking a Kidney out?
Let the CMS hold qualifying exams like the board certification exams in India and other countries. Doctors who have successfully passed these exams should be able to be hired by companies like Wipro that can then bring there here.
In case you are wondering why this kind of a H1-B does not already exist then let me say ‘AMA” again to you. The AMA has successfully biased immigration policy and certification mechanisms favoring Doctors who are already here and have studied here. You will not get a visa from a US Consulate abroad even if you faintly smell of antiseptic. I know this because in 1990 I once stood in such a visa queue ahead of a Specialty Physician at a US Consulate abroad. The guy was trained in Germany and he told me a horror story of how every time he applied for a visa he could never get one. He showed me several press clippings of himself in popular and prestigious newspapers with photos detailing his pioneering work in Andrology an emerging field at that time. He had a successful practice and he wanted to visit the US to buy medical equipment but he would repeatedly be rejected. Right enough that time in front of me he was indeed rejected while my application was approved. I am an Engineer you see.
In the US, lowering a special interest group’s income in is the best method of decreasing their political power. The more real middle class you get, the more well behaved politically you become and the more you appreciate the plight of the poor and the lack or presence of opportunity in lifting one’s lot from poverty.
Regards
Anand Richard
Engineer-III
Phone:765-254-1154
arichard@maxoncorp.com
No reason to pay agents anywhere near 6% commission for flipping a house, brokers another few points, and so much to Wall Street that — since the Fed gives them money when they lose — makes so much money for nothing. Your solution can be applied here, too: Expand the H1-B program for real estate agents, mortgage brokers, product marketers, salespeople, and everyone else on Wall Street.
We should probably just set quotas without regard to particular skill sets and just let the market decide whom to hire on an H1-B.
Hear! Hear! All my Physician relatives who faithfully attend their ‘Revival Awakening’ Churches and watch Fox News and speak ‘Free Market’ get the jitters when I suggest this to them. I know two in particular who would have been sitting in an empty consulting room in some dusty town in India charging Rs.200 for a consultation. These same persons are now in the US courtesy of a marriage green card and mightily complain to me about ‘Medicare pays $1.50 per hour, who wants Medicare patients?’. There is another cousin who is a Specialist and part owner of his practice – a millionaire and he constantly peddles Fox News wisdom to me along the lines of ‘….when Social Security was introduced there were 10 workers for every retiree…. blah blah’.
It’s another well-documented example of how deeply corrupt our society has become. Yves Smith
The miracle is that it was ever non-corrupt?
One government-backed cartel leads to the need for others, no? Doctors have debts to pay, no? To the government-backed usury-for-stolen-purchasing-power cartel, no?
Occam’s Razor does not always apply but if the government-backed banking cartel isn’t at the bottom of this problem, it’ll be an exception, not the rule.
Of course ethical money creation is out of the question, at least until we try everything else two or three times at least.
Of course this is just a small part of a corrupt and unaccountable system. Another collusion between government and private interests. (So why is more government so often held to be the “solution”???) My accountant has told me that many general practitioners have very moderate incomes, and I have no reason to doubt him. The real problems are the specialists; oncologists being one example. They are free to prescribe their own chemo and charge excessively for the chemicals. This is another example of the customer having no viable choice, whereas in many other types of exploitation other than taxes one can decline to participate.
In addition, almost everyone knows about extreme hospital overcharges. One factor not so well known is what the hospitals charge the doctors.
In my international travels I have encountered many Canadians, and I question them as to their satisfaction with their system. I have always received positive responses.
putting the obvious “single payer healthcare” fix aside,
I’m not sure *who* we want to set the prices… corporations? conservative politicians?
Maybe a start would be to have more pushback than the 10% mentioned in the article, or to use other single-payer countries’ rates for comparison.
As Yves alludes to with her dermatologist comment, the AMA (and ADA) exert absolute control over the supply (and, therefore, cost) of medical care through their monopoly on credentialing–who can do what and with what supervision.
Experienced nurses and nurse practitioners cannot practice independently, but must be employees of MDs, who ostensibly provide medically necessary “supervision.” So sayeth the AMA. What they actually provide are price and supply controls.
Military medics, none of whom are trained physicians, have provided quality medical care on the battlefield for decades with stunning results, but here, in the homeland, they must be “supervised” by MDs to maintain quality of care, such as it is.
Dental hygienists have for years fought for the right to practice independently, particularly in the state of California. Patients could simply get their teeth cleaned at a cost that does not need to reflect the high overhead of a typical dentist’s office. Their efforts have been continuously beaten back by the ADA with arguments of “quality” and necessary “supervision.” The real problem, of course, is the hit what would be taken by the economics of practicing dentistry.
We don’t need more MDs–HB-1 or otherwise. We have plenty of talented people already here. There is no need for a professional who does an annual physical on a healthy individual to be trained to perform a kidney transplant. Identifying, counseling, monitoring and perhaps even arresting early diabetes or obesity does not require a surgery residency.
Of course, if the point were actually IMPROVE the health of this country, these things would have been identified and accomplished by now.
Some basic facts you should know when interpreting this article:
1. RUC gives relative values of procedures and visits to one another, taking into account costs and levels of difficulty, CMS sets the factor that these values are multiplied by to yield a price. This is the same for all physicians (with one exception). Thus CMS determines ultimate costs. Most insurers base rates on this CMS RVU x multiplier.
2. CMS, through its review policies, sets standards for what it pays for, based on what works and what doesn’t, according to current research. Its major failing is that while it will not pay for things that do not work, it will pay for things that marginally work, but offer minimal cost benefit advantage.
3. Physicians get about 10% of the healthcare pie and really are the most informed patient advocates out there. Your typical doc out there is on your side. No one else is.
4. The AMA does not represent most physicians in the US. Only 15% or so belong to it. They are basically an insurance related product, much like AARP, with a mind of its own, unrelated to those it purports to represent.
5. virtually all the AMA income comes from CPT code royalties. There is a necessary evil to this as that is how we can track a diagnosis and the related procedures, to see what works and what doesn’t, should the system become better at weeding out treatments that offer little benefit.
6. insurance companies and big pharma more than dominate healthcare, with hospitals next. None of these are patient advocates. They own Washington and nothing will change in healthcare for THEM as long as their money rules. Well, nothing that affects them, that is. We will all be in the Bronze Plans, paying 12,000 per year out of pocket plus the premiums for less care and longer lines.
Whether it’s banks or healthcare or anything else in this country, campaign finance reform is the only solution. Money must be taken out of politics and only then will anything improve for citizens. But you already knew that!
How do they get royalties on the codes?
The codes are not copyrightable.
The codes are not trademarkable.
The codes are not patentable.
Someone should break that monopoly.
I am a physician.
The RVS was created decades ago. At that point the AMA was largely controlled by surgeons. The RVS favors invasive procedures. Medicare commissioned a study on RVS in the 1980’s and utilized its findings to set what it considered acceptable compensation to physicians (published in the Federal Register). The long-standing fight in American medicine is that between those who practice primary care (who receive less money while expected to devote more time to patient care) and those who utilize invasive procedures (surgeons, gastroenterologists, interventional cardiologists, and the like). As Medicare ratcheted down the global pie, many physicians were force to increase volume to maintain an office staff (for the various insurance companies) and personal income. The result is the five minute office visit and the overutilization of testing, a development now reflected in medical education. Medicare reimbursement procedures have also led to the sale of many physician practices to hospitals. The next fight will be over distributing the coming global payment to hospitals for medical and non-medical services. It is unlikely the administrative costs will diminish. Refusing to accept insurance is punished in many ways.
Increasing the supply of physicians does not lower costs; the patient does not decide what care is required. That is why all state run systems control the number of physicians and specialists produced.
The lesser trained health care professionals have never had wide public acceptance when governments have attempted to use those physician extenders to provide health care(Germany, USSR, Cuba).
A single payer system can rapidly control administrative costs. A single payer system can control costs if a formulary is adopted, clinical trials are financed, and evidence based medicine is widely adopted as a response to payments. That is all possible without extensive waiting lists.
I would imagine that canned phrases like “lesser trained health care professionals” and “physician extenders” (ugh!) were not conceived to encourage “wide public acceptance” of alternative healthcare delivery methods.
“The system is fundamentally insane.” Or worse – institutionalized extortion. The RUC AMA price fixing cabal does their extortion hand-in-hand with private health insurance. How reassuring. This is Libor all over again. Or the TBTFs creating their own commodity out of electronic digits. Not to mention Pharma’s stranglehold on the price of drugs… just wait till their bill comes due for all the new tuberculosis drugs. But not to worry, these cutthroats won’t be slowed down by tafta or tpp; they will write their own clauses like all the other free-traders. Free-lunchers.
Yes. A hedge fund guy would know enough to say you have no idea how bad it is. Doctors aren’t dumb, sure, some of them are bill happy scumbags who put lawyers to shame in their passion for greed. Nevertheless, there are many good ones who can bring change, it’s worth the effort. Those nurses that Max Baucus had arrested reinforced the need for single payer.
Awesome summary.
Doctors are one of the core professions of educated liberals caught up in the collapsing credibility of our nation’s institutions.
“but what you’re doing is ignoring the fact that this system is fundamentally insane. It’s so corrupt and collusive, it’s not something that can be incrementally fixed.”
Fantastic quote. Applies to law, medicine, higher education, banking, media…
So, medical care isn’t a free market, but a cartelized oligopoly that fixes prices, barriers to entry, and farms citizens like cattle through their insurance and taxes?
Welp. Gee. Whocudathought?
So lets do more of all the things the medical industry is doing now, and that will surely fix it! More people paying, more taxes, more regulations, and then of course we need to increase prices to cover all that, right?
Like the housing bubble, QE, the education industry, FIRE economy, etc.
Perhaps the “more will fix it” meme needs to be trashed for all time, in every industry, because that meme is visibly and irrevocably destroying anything and anyone it touches.
So, as I have said before, cash basis medicine, education, anything.
It’s heartless and terrifying, but how is the unstoppable grind of everyone but a few into abject poverty any less horrifying?
It’s [cash basis medicine, education, anything] heartless and terrifying, but how is the unstoppable grind of everyone but a few into abject poverty any less horrifying? bluntobj
The solution is ethical money creation, not a stupid, cash-only society. What will you suggest next, a gold-standard?
Asset-backed money is the greatest invention ever for the creation of wealth. But it can be issued two ways:
1) As Liabilities
2) As Equity
BOTH create wealth via economies of scale and division of labor but only the latter “shares” it justly.
On Health Care Renewal we have been posting about the problems with the RUC since 2007. See: http://hcrenewal.blogspot.com/search/label/RUC
Hope now this gets some traction.
Amazing what professionals not subject to global wage arbitrage will do. Working stiffs might find out, join unions and there where would be all be!
Obamacare will exacerbate this price-fixing, with public insurance exchanges, touted as consumer-friendly “marketplaces” for competitive shopping, turned instead into one-stop price-fixing shops for the cartels. The protection rackets have all the toll booths and roadblocks to entry and competition built in to the bill.
Seeing as how it’s my ox you’re talking about goring, I thought I’d give my 2 cents.
1. RVU’s divide the pie, they don’t decide how big it’s going to be. The AMA is a self-serving bureaucracy that doesn’t represent me or 80% of physicians.
2. The payment bias toward procedural over non-procedural medicine is real. Again, I’m biased, but I believe it is justified. However, the training for surgeons is significantly longer and harder, a minimum 5, now typically 6 or 7 years vs 3 for most primary care doctors. Although the hours are theoretically capped at 80 per week, 90-100 hrs are not uncommon vs 50-60hr/wk for primary care. The decisions you routinely make are higher stakes, there is significantly greater risk involved in surgical procedure vs a visit for a cough or a fever. There is significantly greater liability risk associated with being a surgeon. Finally, the personal demands are much greater. Primary care docs don’t get paged in the middle of the night to take a patient with dead gut to the operating room.
3. As for the use of non-physicians in health care. While there is clearly a degree of cartel activity or rent seeking, you are deluding yourself if you think that NP’s and PA’s are of equivalent quality to a physician. First you’re picking from a very different part of the talent spectrum. Not to be obnoxious, but I know many very smart people who did not get into medical school. The barrier to entry for PA or NP school is low.
Second, both the depth and breadth of training are worlds apart. The best way to describe it is the difference between someone who can follow guidelines versus someone who understands the data that underlies the guidelines and is able to extrapolate from conclusions that were reached on a ‘hothouse’ research population to decide what should be done for an individual. PAs and NPs don’t know what they don’t know. I see this in the blithe confidence in which they make decisions that physicians often agonize over. I also see it in the inappropriate referrals for consultations, or the consultations with insufficient workup that I get from NPs. Medicine is full of simple things that are simple until suddenly they’re not. While I would see an NP for a formality, i.e., to order a test that I’m able to interpret myself. I would never settle for an NP if a family member were legitimately sick. Nor would I take a sick patient to the OR with only a nurse anesthetist instead of a trained anesthesiologist.
To be sure, an NP is better than no doctor. But no doctor is going have an NP as their family doctor.
But this is all rather academic isn’t it? These changes are a fait acompli. The ACA was passed and upheld by the Supreme Court. At the time I supported the ACA because I believe in extending access to care, even though I expected it would cost me financially. I didn’t realize that it was going corporatize medicine.
As I’ve watched the roll out I’ve become more cynical. I think we’re going to end up with a bifurcated system in which rich people pay a cash premium to get real doctors who devote real time to them and poor people are shuffled through an assembly line by NPs who are ‘just as good’. The middle class will gradually lose access to primary care physicians as declining re-imbursements and increasing regulatory burdens will spell the end of most private practices. The doctors will become employees of the hospital where they will manage NPs and in turn be managed like widgets, trapped like Gulliver in a web of regulations and held responsible to the P&L. As employees doctors will lose the independence that allows them to be patient advocates. Large hospital chains will gobble up smaller ones to become local monopolies and engage in truly impressive rent seeking. (If Cereberus is buying hospitals you know the looting is soon to follow) Centralized digitized medical records will no doubt prove irrestible to our watcher class.
You can write this off as self-interested fear mongering if you like. But I’ve dedicated the greater part of my adult life to taking care of people. I’ve laid down more things on the altar of surgery than I care to count. In the end it’s not about the money, the era of the rich physician has passed. I don’t know anyone who makes what your average partner at a top 100 law firm makes, let alone what your average Wall Street Managing Director makes. What I really care about is being able to do right by my patients and I believe that is threatened. I would also appreciate it if my profession weren’t dragged through the mud.
“The AMA is a self-serving bureaucracy that doesn’t represent me or 80% of physicians.”
So how do we break the AMA?
That would help. That would make it possible to campaign for something else. When you have a self-described trade organization which is a sell-out, it’s a serious problem.
The Relative Value Scale Update Committee (RUC) is far more influential. Over the past twenty years this group of 29 physicians convened by the American Medical Association (AMA) has been CMS’ primary advisor on how Medicare should value doctor visits and procedures. Many Medicaid and commercial health plans follow Medicare’s lead on payment, so the RUC’s influence on the $2.7 trillion health care economy is sweeping. While the RUC is not formally a FAC, it has been challenged as being a “de facto” FAC, a designation that has legal precedent .
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