Invisible Forces Behind Health Care

by Julie Nelson

Last month the Department of Health and Hospitals declared that they would integrate behavioral health into medical care for the nearly 1 million on Medicaid in Louisiana.

This is an admirable goal, but not an easy one. Integrative health care––where psychology is combined with physical health care––has been repeatedly shown to lower costs and improve outcomes. But even after decades of evidence, nothing much has changed.

One of the reasons change comes so slow in the US health care system is because of the forces behind what is paid for and how much is paid, the CPT and RUC.

CPT and RUC, short for “Current Procedural Technology” and “The Relative Value Scale Update Committee,” are the behind-the-scenes forces that shape the landscape of health care in the US. It is a system created by organized medicine with government, insurance, and hospitals.

Health care is the largest industry in the country, accounting for 18 percent of the Gross Domestic Product and about $2.8 trillion in sales. At the same time the U.S. trails peer nations in health but leads in costs. Various reasons have been suggested for this conundrum: aging population, high tech solutions, and chronic illness (heart disease, stroke, cancer) are at the top of most lists.

Chronic illness is a big part of the problem. The CDC estimates that three lifestyle factors– –poor diet, inactivity, and smoking––account for 80 percent of heart disease and stroke, 80 percent of type 2 diabetes, and 40 percent of cancer. Psychologists have pointed to the connections between lifestyle and behavior for decades. In an interview with primary care psychologist Dr. Michele Larzelere, she said there is scientific agreement for a 30 to 60 percent reduction in medical use with integrated behavioral health services.

But psychology and other groups have not been able to garner a place at the medical table. California Attorney David Ries of Human Capital Specialists tried to persuade federal Rule makers to include psychologists in the bonus plan for Accountable Care Organizations (ACOs) but failed. He told the Times that the final Rules were very disappointing. “The broad recognition of the importance of behavioral health to overall wellness indicates that ACOs are unlikely to achieve their treatment objectives under the clinical model proposed by the proposed rules,” he said.

Not surprisingly, primary care doctors, the specialty closest to the patient, are carrying water for behavioral health. In a special issue of the American Psychologist on Primary Care and Psychology (May 2014), Dr. Susan McDaniel and primary care leader Dr. Frank deGruy reviewed evidence that for each primary care physician added to a social system, “allcause mortality decreases by 5.3 percent.” Conversely, for every specialist added the mortality rate goes up 2 percent.

Dr. David Carmouche, Chief Medical Director and Senior VP at Blue Cross Blue Shield of Louisiana (BCBS) is working to build primary care back into programs. “Our strategy is to engage providers in communication so that patients develop a trusted relationship with a primary care provider,” Carmouche told the Times.

Still, when a person gets really sick, care becomes expensive. The top 1 percent spends $51,951, the top 5 percent spends $17,401, while the bottom 50 percent spends $850 or less on yearly health care, says Kaiser Health.

In “The Anatomy of Health Care in the United States” (November 2013, JAMA) authors contradict several common assumptions about the rise in costs. While medical costs are driven by chronic disease, they say, it is not due to an aging population. They show that 67 percent of those with chronic illnesses are younger than 65, and when trauma is included, about 80 percent of the total health care cost is accounted for by those under 65.

The authors, a group of physicians and MBAs, write that the common view that higher costs are being driven by the aging population and increased demand for services is wrong. They show that 91 percent of the increase in healthcare costs in the last decade was due to an increase in prices.

Overall, the US health care picture indicates two main issues. Prices are unreasonably high and we aren’t treating the right health problems. Both can be explained by the forces of the CPT/RUC.

At a recent meeting of the Louisiana Psychological Association, Dr. Tony Puente spoke about coming health care changes and CPT codes. Those attending were well familiar with using CPT codes, required to bill for health services. But Puente also spoke briefly about how CPT codes are developed. It turns out to be a system steeped in politics and power.

Officially, “CPT is a set of codes and descriptors for reporting medical services and procedures which provides a common language to accurately describe services in the health care profession,” writes the American Medical Association (AMA). CPT is owned by the Center for Medicare and Medicaid Services (CMS), leased to AMA, who then copyrights it.

CPT codes begin with three hundred “Advisors and Experts” who hammer things out and then attempt to influence the CPT Editorial Panel. The 17-member Panel makes the final decisions on which codes will be approved.

The 300 advisors come primarily from the AMA House of Delegates. They represent 109 medical specialties and they form into about 20 teams to lobby the Panel. The Panel includes 11 physicians from the Medical Societies, two representatives from insurance (Blue Cross Blue Shield and America’s Health Insurance Plans) and someone from the Center for Medicare and Medicaid Services (CMS). Then there are two people from the Health Care Professional Advisory Committee, the only representatives who are nonphysicians.

“Essentially the CPT tries to divvy it up in a way that is theoretically and empirically, and diplomatically and politically, correct.” Dr. Puente said. “That it is a very demanding and a very transparent activity.”

Actually, it is not transparent. Information about CPT negotiations is restricted, meetings are closed and participants have to sign confidentiality agreements and can be barred from future meetings if they disclose any information. No press is allowed.

The CPT system is dominated by organized medicine. “Every seat at the table has a vested interest, mostly not supporting your proposed code,” said Dr. Travis Thompson, professor, psychologist, and leader in the Association for Behavior Analysis International. He was speaking after it took him and colleagues three years to muscle through codes for the treatment of autism.

While the CPT approval is a first leg of a long journey, another element of this behind-thescenes influence is the a panel known as AMA/ Specialty Relative Value Scale Update Committee, or simply RUC. Since 1991 members of the RUC establish the value or price for the CPT codes. Somehow this is not considered price-fixing.

“The RUC Advisory Committee was constructed to allow participation by every specialty seated in the AMA House of Delegates, say AMA documents. “The RUC Advisors serve as advocates for their specialty, while RUC members must exercise independent judgment and are not involved in their specialty’s presentations.” But authors do not explain how a physician is to separate from his or her beliefs or biases.

There are 28 voting members on RUC, most who represent medicine specialties such as anesthesiology, cardiology, dermatology, emergency medicine, general surgery, neurology, neurosurgery, obstetrics, oncology, psychiatry, and so on.

The group’s design reflects the composition of the medical profession, rather than reflecting the needs of the consumer. But even within the medical family this led to problems because of an underrepresentation and undervaluing of primary care.In 1992 the Medicare payment for a primary care type office visit was $31 while cataract surgery was $941 and a lumbar spine MRI was $485.

While things have improved somewhat, there has been trouble in paradise. In a report on RUC and Primary Care, AMA Board of Trustees wrote, “The intense RUC review did lead to a divisive debate within medicine …” Trying to calm the waters, they said, “The Board of Trustees believes that organized medicine should work together to support the RUC’s efforts.”

Outcomes of these forces can be seen in how the profession is reshaping itself. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care produced a 2009 report that explained disincentives for medical students to choose a career in primary care over one of the specialties, and why shortages are becoming severe. Figure 10 from the Center’s report, compares the grow of incomes for primary care and specialty physicians.

Control of the CPT and RUC have helped shaped health care toward high tech/high price, services, less primary care, and probably lower quality primary care because these physicians might push toward higher volume to help make up for differences.

Dr. Puente explained to psychologists this past spring that the CMS would set the bar under the ACA, but that decisions would shift from national level to the state level. And they have.

Louisiana Department of Health and Hospitals (DHH) considers family medicine, general internal medicine, and pediatric medicine to be primary care. Fee schedules for Medicaid posted by the DHH indicate that office visits are paid at $25.78 to $40.83. For a more expanded office visit the fee is $49.16 to $70.63. Office visits of high complexity can be paid nearly $200.

But the fee for removing a foreign body from the eye in an out-patient, ambulatory setting ranges from $269.57 to $509.99. Or, for removing an ear lesion the physician can bill $412.84 to $805.45.

At the same time Medicaid fee for a Behavioral Health Counseling Therapy session is $17.02. Mental Health Assessment is $23.65. And, MultiSystemic Therapy is $32.83. While Medication Management is $46.32, a situation to drive providers to medication as the first treatment. Hopefully, the recent announcement to review and build integrated care will help.

The social and political influences stemming from the CPT and RUC systems appear not only to have helped create major barriers for those outside of medicine to make contributions, they has blocked innovation, quality and driven up prices.

“If you can’t describe the process, you don’t know what you’re doing,” wrote Edward Demming about quality. The system we have seems to be one of confusion, rather than insight, of entitlement, rather than performance.

The customer is not empowered and is almost entirely absent from the process that creates services. Considering what we know about conditions that support quality outcomes, any arrangement where the customer and vendor are so distanced from each other is doomed to perform poorly.

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