Wednesday, July 1, 2009

American Geriatrics Society and the AMA: Time to Part Ways?

There is very eloquent letter from Richard Stefanacci and colleagues in the June edition of the Journal of the American Geriatrics Society about the relationship between the AMA and the AGS. (Stefanacci RG; Wasserman MR; Beers MH. Moving Beyond the American Medical Association. JAGS;2009:1117-1118).

The context is as follows. The AMA sponsors the resouce-based relative value scale updates committee (RUC). This very obscure sounding body is VERY important. It advises CMS on updates to the system that determines how physicians will be paid for their services. This is the system that ultimately results in much greater payments for procedural care than for services based primarily on talking to or examining patients. The reason the RUC is so important is that CMS accepts the vast majority of its recommendations. One way of looking at this: The CMS essentially relies on the AMA (via the RUC) to determine the relative value of physician services. The current approach to payment for these services is one of the most important factors limiting the development of Geriatrics and Palliative Care.

The AGS has been pushing its members to join the AMA. The AMA gives specialty societies a seat in its house of delegates (its primary policy making body) based on the number of specialty society members in the AMA. Without a seat in the house of delegates, the AGS will not have a representative on the panel which revises the billing codes considered by the RUC. The AGS is in danger of losing its seat in the House of delegates because relatively few of its members have joined the AMA.

It would be a mistake to believe that low AMA membership rates in the AGS reflect just an oversite or avoidance of membership dues by AGS members. Many AGS members have made an active decision not to join the AMA. There are many reasons for this, but most revolve around a belief that many of the actions the AMA takes do not reflect our values. Some feel the AMA has sometimes acted more as a trade organization than a professional organization. In fact, only a minority of US physicians are members of the AMA. Despite common misperceptions, the AMA should not be viewed as the voice of US physicians.

I agree with the letter writers that the AGS is pursuing the wrong strategy by encouraging its members to join the AMA. Rather than begging for a seat at this very broken table that is stacked against primary care, geriatrics, and palliative care, the AGS should be actively lobbying for a new table. The AGS should collaborate with partners such as SGIM and the AAFP to encourage CMS and congress to end the RUC, as it is currently structured. Our lobbying efforts and lobbying dollars should push for a new process that is independent of the AMA.

Drs. Stefanacci, Wasserman, and Beers said this very nicely:

"The AGS is seeking a seat at a table we have no business dining at. The time has come for the AGS and its members to step away and forge a new path so we can fulfill our vision of assuring that every older American receives high-quality patient-centered care. Membership in the AMA works against this goal. Furthermore, by participating in the present system, the AGS only lends credence to CMS's view that the RUC represents all physicians"

Many thanks to Drs. Stefanacci, Wasserman, and Beers.

6 comments:

Christian Sinclair, MD said...

Welcome to the blogosphere. And especially the Palliative Medicine Blogging world. We have a great community already and are always looking for more good bloggers.

It would be nice to see some more information about the bloggers and the mission for the blog.

We hope to see some great things from your writings. Keep it up!

Eric Widera said...

It took me a while this year to decide whether to renew my AMA membership. Why? I don't feel like my dues are focused on ways we can improve the care of my patients. Rather, it feels that my membership dues are used to protect interests of specialists - propping up a system that encourages procedures and interventions. The RUC is just one example of this with most of it’s members being from specialty societies (I count maybe 4-5 primary care focused members – is that right?). Other examples include the last AMA meeting debate about heath system reform, reminding me of all the other times the AMA has stymied health reform plans.

I agree with the sentiment of the Stefanacci, Wasserman, and Beers article, but I also don't see a way true change can happen with only a small group of physicians breaking away from the pack. How do we then create momentum for change?

As it turns out I did renew my membership – but it is of little surprise to me that AMA membership is declining as we are not alone in our fields to question the agenda of "our" association.

Alex Smith said...

Great post Ken! For a terrific summary of the structure and self-serving nature of the RUC, see a terrific summary by Dr. Mark Friedberg: https://www.sgim.org/userfiles/file/SGIM%20May%​202008-Web.pdf

Mark wrote, "The RUC has 29 members, mostly representing various medical and surgical subspecialties. Of these, only five members (from internal medicine, family medicine,
geriatrics, pediatrics, and osteopathic medicine) represent physicians whose main practice is
primary care. In 2007, an additional primary care seat on the RUC was proposed, but the existing RUC members voted down this proposal."

The RUC appears to be a vehicle for specialist self-interest, and as transformation from within seems unlikely (as apparent from Mark and Ken's description), perhaps it's time to lobby for a new solution.

Alex Smith said...

And to Christian Sinclair...we are huge fans of pallimed.org! Thank you for noticing our nascent blog. We appreciate any feedback you have as we develop this blog. Our purpose is to be a forum for networking between clinicians interested in the intersection of geriatrics and palliative care, a forum for discussing recent and important clinical and policy news in these fields, and providing critical commentary from leaders positioned at the intersection of geriatrics and palliative care. I'm going to update our site description with this blurb.

Alex Smith said...

Testing to see if my image appears with post (Thanks for the idea Christian!)

ken covinsky said...

Alex--thanks for pointing me to Mark's article. It is great reading material. (The link has changed. Mark's article can be found here:
http://www.sgim.org/userfiles/file/WC02_Friedberg_Mark_201414.pdf

I think this piece nicely points out the futility of hoping for meaningful reform within the existing RUC format. As Mark points out, it is very concerning that CMS is relying on the RUC to define the Medicare Medical Home (perhaps alarming is a better word).

It seems the best course of action is to lobby CMS, Congress, and the press for a new structure that will replace the RUC. We need to make it clear that the RUC does not represent the larger physician community. I'd be interested in knowing if others agree with this proposition, and what the organizations like the AGS and SGIM can do to effect this change.