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Life Health > Long-Term Care Planning

Doctors Sue Over Medicare Rate-Setting Procedures

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Primary care doctors from Georgia are trying to get the Centers for Medicare & Medicaid Services (CMS) to change the way they set physician reimbursement rates.

The doctors – primary care doctors at the Center for Primary Care, Augusta, Ga., a midsize group practice – say they are suing CMS Administrator Donald Berwick and U.S. Health and Human Services (HHS) Secretary Kathleen Sebelius in an effort to change the way CMS now usesCaduceus data from the Relative Value Scale (RVS) Update Committee from the American Medical Association (AMA), Chicago, to set rates for primary care doctors and specialists.

Primary care doctors and the AMA have clashed for years over whether the RVS Update Committee sends CMS accurate, complete data and whether CMS uses the data properly.

The system “is not … dominated by proceduralists who do not understand the challenges faced by primary care physicians,” the committee says in a position paper on the AMA website. “Nearly all physician specialties report [evaluation and management] services and understand the work involved.”

The committee is not political, is not closed off to input, and is not responsible for CMS failures to improve payments for primary care, the committee says.

The Center for Primary Care doctors say in their suit, which was filed in a U.S. District Court in Maryland, that the current rate-setting system is illegal and drives up overall health care costs. CMS accepts about 90% of the committee’s recommendations, and the resulting pattern of increases in pay for specialists and decreases for primary care doctors has contributed to U.S. medical students’ reluctance to enter primary care, the plaintiffs say.

The plaintiffs are seeking an injunction that would freeze CMS’ relationship with the AMA, according to Kathleen Behan, the plaintiffs’ lawyer.

Rep. Jim McDermott, D-Wash., a physician and a member of the House Ways and Means Committee, has marked the filing of the suit by issuing a statement pointing out that he has introduced a bill, H.R. 1256, that would “require CMS to take into account the input of neutral third-party analysts, in addition to the [RVS Update Committee], when setting reimbursement rates.”

McDermott notes that Congress established the current CMS Medicare rate-setting system in 1992.

Congress “wanted to put primary care on an equal footing with specialty care – not only to improve the quality of care, but also to bring down our crushing national health care costs,” McDermott says. “Regrettably, because CMS relies so heavily on the specialist-driven [RVS Update Committee], the opposite has taken place.”

Other primary care reimbursement coverage from National Underwriter Life & Health:


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