What I Did Last Summer

Last summer I thought I could change things. I tried to be a force for justice. In the process I learned a lot about the politics of power and people. I’m not sure I made a dent.  You let me know what you think.

Why I’m A Family Doctor                                    

I never watched Dr. Welby

I chose to be a Family Physician because it suited my personality. I don’t like facing limits imposed from the outside; I want to set my own. A Family Doctor is trained to deal with problems from the cradle to the grave and must know one’s own limitations. But I also believed what the professors in my medical school said, that well- trained, hardworking, primary care physicians could solve the nation’s health care problems. Good primary care would lower costs and improve outcomes.  So I did Family Medicine for 20 years. I loved the work and thought I was paid well. But I saw that I was paid a third of what specialists were paid, outcomes were ignored, and less and less medical students were choosing primary care.  Then, two years ago, here in the Idaho legislature, I saw a chance to try to solve a very small part of this huge problem.

Getting Started

Idaho has an insurance program that pays doctors for treating injured workers. The Idaho Industrial Commission is required to annually bring to the legislature its schedule for payment to physicians who treat injured workers. In 2012 they suggested a 10% increase in payments since there had been no increase for the three previous years. By itself, this seemed reasonable, but here it gets complicated, so pay attention. We are going to get into the nitty-gritty of how doctors are paid for what they do.

Into The Weeds of Physician Compensation

Even big problems can be lost in the weeds

In 2006 the state of Idaho changed Industrial Commission payment to doctors from the Usual Customary and Reasonable (UCR) method to the Resourced Based Relative Value Scale (RVRBS) method. The UCR method says the doctor can charge and be paid what is usual, customary and reasonable for the area in which they practice. In other words, you can charge what is “usual” and insurance companies pay. But the RVRBS method says the charge for a certain service is based on what resources are brought to such an encounter. It was an attempt to develop a fair payment system, not based on charging history, but instead on what “work” or resources are required to do different “doctor things”.

When the Idaho Industrial Commission made this switch some doctors were mad. Indeed, it ended up in court, with the state of Idaho suing some surgeons for fixing prices. But the RVRBS method of payment is considered fair and most insurance companies use it, as does Medicare and Medicaid. But, because of historic differences in payments most insurance payment scales use conversion factors. Here’s how these work.

Dr. Jones sees a kid in the office for a rash. The RVRBS method would say her effort is worth, let’s say, 0.7 Relative Value Units (RVUs).  A surgeon takes out little Johnny’s appendix and that work comes to 5.9 RVUs. (All these are hypothetical values.) As a Family Doctor working in a clinic we would negotiate with insurance companies for payment and we might get paid $50/RVU. Surgeons negotiate with insurance companies and get $95/RVU. So even though the RVRB System is supposed to account for the different skills, time, effort and risk brought to the doctor’s work, payments still valued specialty and procedural care more than primary care.

When the Idaho Industrial Commission made the conversion to RVU payments, there was such an outcry from some Idaho surgical specialists that the Commission was afraid some would refuse to see Industrial commission patients, so they put in conversion factors. These conversion factors were applied to the different codes that doctors used to submit payments. Surgical codes would have an RVU multiplied by a conversion factor (in this case approximately $135). Office codes would be multiplied by a different conversion factor (approximately $55).  So again, we are valuing different care differently, even though the RVRBS payment method is supposed to account for this.

When the Industrial Commission came to our Senate committee in 2012 to increase payments to physicians, they just applied a small change to just a few the conversion factors.  I thought we should be narrowing the difference between the conversion factors faster.  They listened politely but said they had a subcommittee that made recommendations to them, and they were just passing on their recommendation. I asked to visit with the subcommittee. And I called the representative for the Idaho Medical Association.

Politics is about relationships and working with people. Passion can become an obstacle for compromise and process. I tried to maintain respect for the process, but I will always have a passion for the value of primary care.

Changing Oil and the Idaho Medical Association

I’m not this neat

The IMA said they could not support me to decrease the conversion factor difference unless they were directed by their board. It was suggested I come to the July House of Delegates meeting in Sun Valley and plead my case. I have only sparingly been a member of the Idaho Medical Association, since I didn’t think primary care was well represented in this group. But the new President was a Family Doctor, half the Board was in Primary Care, so I have been a member now for 3 years. I signed up for the July meeting and drafted a resolution to present to the body.

The Industrial Commission subcommittee met in June and I phoned in my concerns from my Moscow garage where I was changing the oil in my pickup. They were receptive but wanted input from the IMA.

I also met with the Idaho Academy of Family Physicians in June and tried to get them to support my effort. They said they had just had a board meeting and wouldn’t meet again until September, after the IMA House of Delegates. They encouraged my efforts, but could not officially take a stance.

So you are getting to see what I did for part of last summer.

Failure

I was disappointed in my political abilities with the Idaho Medical Association House of Delegates. I drafted a resolution that would move the multiple Industrial Commission conversion factors to a single one in a revenue neutral fashion over time. This would mean the highly paid surgical procedures would get less and the office visits would get more, but they would still be based on the RVU formula. I suggested a ten year transition period. Honestly, who knows what will be happening in health care in ten years, but I am a moderate guy, I like my burgers medium and I drive old cars, so there it is. But there were folks who wanted to make it happen right away. I feared this was asking too much and indeed, the motion got referred back to the Executive Board to decide. I felt I had not spoken up strongly enough for my vision. But I did learn the people, the trends and ways of acting.

I was also somewhat confident that the Executive Board would support the transformation, since most were primary care providers. I was heart-broken in the fall when I learned they had voted to take no action.

Success, sort of

So last summer, besides trying to adjust Idaho Industrial Commission physician payment, meeting in McCall and Sun Valley with a lot of doctors, I was also working in the ER and campaigning for the Idaho Senate in my new district. It was a close election, but I got voted in to come back to the Senate. And then I got reappointed to the same committee that reviewed IIC physician payments. I was very surprised to see their proposed rule that reduced the conversion factors from 7 to 6 and reduced the differences between the conversions. I asked them, why did they propose this? They said it was what their subcommittee suggested. I asked if the IMA was opposed. She shook her head and smiled.

I don’t think I won this battle, but we gained some ground. Health care costs are killing our country. And if this small skirmish in this small state in this small theater of the medical conflict is any sign of the effort it will take to turn this around, be prepared for the battle ahead.

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