For his second presidential term, Donald Trump stacked his health team with men who disdain the medical consensus. Mehmet Oz, who awaits Senate confirmation as the head of the Centers for Medicare and Medicaid (CMS), promoted hydroxychloroquine to treat COVID-19 (it doesn’t work this way) and once faced a Senate panel over his hawking of miracle weight-loss cures (they didn’t work either). Dave Weldon, Trump’s nominee to lead the CDC, has a long history of anti-vaccine comments. So does Robert F. Kennedy Jr., now secretary of Health and Human Services.
These perspectives are worrisome and divisive. Nonetheless, the incoming administration’s skepticism of entrenched health-care groups, if properly channeled, could help address a specific problem in the nation’s medical system: changing how Medicare pays health-care providers—in particular, specialists and primary-care physicians. In a recent executive order creating a Make America Healthy Again Commission, the president wrote of “protecting expert recommendations from inappropriate influence.” And HHS recently affirmed the administration’s aversion to outside views when it curtailed public comments on policy changes, which are often dominated by interest groups. By reexamining the priorities of doctors’ and hospitals’ groups, the Trump health team could do the miraculous: improve care and save money.
In the United States, physicians’ work is measured in relative value units (RVUs), which account for the time, technical skill, and mental effort involved in any office visit, test, or treatment. Those RVUs determine how much Medicare pays for specific services. Medicare payment also serves as the model for all other insurers, and thus influences most physician payments nationally. Doctors’ pay isn’t necessarily determined by RVUs alone, but for many physicians, compensation is closely tied to the number of RVUs someone working in their specialty is expected to generate. Even doctors who are paid a salary are often expected to meet certain RVU goals, and are paid bonuses for exceeding them.
The RVU system is biased in its very design. CMS relies on an American Medical Association committee to propose adjustments each year to RVU allocations. That committee is made up of 32 doctors—overwhelmingly specialists—and other health-care professionals. Those physicians have an inherent conflict of interest: They are in effect setting their and their colleagues’ pay. The committee estimates time spent for various types of work in part by surveying just a few dozen physicians, who, according to a 2016 report by the Urban Institute, give inflated guesstimates. CMS accepts more than 90 percent of the AMA committee’s recommendations.
As a result, surgeries, scans, and other medical procedures are consistently assigned higher RVUs than office visits or interactions in which a doctor, say, talks to a patient about smoking or regularly taking medications for their chronic disease—so-called cognitive patient encounters. A cardiac surgeon’s time and effort for an hours-long triple-bypass operation clocks in at about 40 work RVUs. A dermatologist applying liquid nitrogen to freeze benign skin growths—a simple, low-risk procedure that takes less than five minutes—amounts to about 1.11 work RVUs. Meanwhile, a primary-care doctor spending 40 minutes with an established patient who has diabetes, kidney problems, and a heart condition generates only 1.8 work RVUs. This visit is not comparable to removing benign skin growths. And while a primary-care visit might take less time than the surgery, it is not 20 times less valuable—especially because good primary care can prevent the need for the surgery to begin with.
The AMA has made some adjustments to address these problems. In a statement, the association said that its RVU committee is working within the bounds that the government requires: For instance, its work is limited to determining the work value of different codes, not their value to patients. And the group pointed out that nine committee members have a background in primary care. The association also noted that its recommendations are nonbinding, and that its committee has worked with CMS to increase the value of cognitive patient encounters and approved those increases knowing that they would require cuts in other codes, because of Medicare’s budget-neutrality rules.
But these adjustments are clearly insufficient, and fail to accurately reward high-value physician interventions. Indeed, the higher RVUs for specialty-related procedures mean specialists are paid more, whether or not that reflects the value of the work to patients’ overall health. A 2019 study published in JAMA found that increasing the number of primary-care physicians improved life expectancy more than increasing the same number of specialists by more than 2.5 times. It is clear that primary-care physicians deliver life-saving care—and deliver it efficiently. But their compensation does not reflect this utility. By one estimate based on tax returns, the average orthopedic surgeon or dermatologist earns roughly three times as much as the average primary-care doctor. And those pay differences mean that fewer medical students and residents will train to become primary-care physicians, which endangers Americans’ health.
The AMA likes to emphasize that its committee provides invaluable expertise and engages thousands of physicians in giving uncompensated advice to the government. This all may be true, but no advice is free. If the federal government disregarded the AMA committee’s advice, it could improve the system through three important reforms.
First, a committee made up of medical experts, health-policy and health-economics experts, actuaries, and others—unaffiliated with the AMA and free of conflicts of interest—could reevaluate the few hundred medical codes that account for the lion’s share of medical costs. They could reassign RVUs based not on physicians’ time, but on health benefit, cognitive skills, and difficulty, when possible. Second, if still relevant, the time that a given procedure takes could be determined by data from electronic health records, as opposed to physicians’ self-reports.
Finally, payments to physicians could be adjusted based on both quality and cost savings. For instance, Medicare could weigh physicians’ success in taking care of diabetes patients by the proportion of patients who have their blood sugars, blood pressure, and cholesterol controlled, and pass annual examinations tracking complications with their eyes and feet. Then, the program could adjust payments going forward: Physicians who achieve or maintain results above a certain threshold would be eligible for higher levels of payment. Similarly, surgeons should be bonused—or penalized—based on surgical-site infections, unexpected emergency-room visits, unscheduled post-procedure hospital admissions, and other quality metrics. These types of changes could usher in improved care, potentially in just a few years.
In its statement to The Atlantic, the AMA said that its committee does rely on medical records to inform its work when possible, but needs those data sets to meet certain criteria. The association also underlined that it supports alternative payment models, including value-based models, if they’re voluntary for physicians. Still, under the banner of more physician autonomy without financial penalties, the AMA and other medical societies have also frequently opposed payment programs or made them impossible to evaluate because they are voluntary and thus biased.
But payment programs could help improve the nation’s health quickly, and could allow CMS—soon to be led by Oz, if he’s confirmed—to focus on chronic illnesses, particularly high blood pressure, the nation’s most common and deadly chronic disease. Just under half of American adults have hypertension, and fewer than a quarter of them have their blood pressure controlled. We know how to treat this problem. Since the 1950s, more than 100 cheap, effective medications that lower blood pressure have been developed, and some medical systems and physicians have achieved blood-pressure control for 80 percent or more of their hypertensive patients. These systems all rely on care teams rather than the work of individual physicians, diagnose a patient in their home (where blood-pressure measurements tend to be more accurate), prescribe combination pills that contain two blood-pressure medications, encourage lifestyle changes, and have patients connect to a team member every two to four weeks.
In 2015, the AMA did launch a trademarked blood-pressure-control program—Target: BP, which shares some of these same insights. But despite all of these efforts, blood-pressure control has not improved, according to the CDC. Financial incentives could change that. Judging by previous experiments, those incentives would need to be large. For instance, Covered California, the California exchange, made blood-pressure control one of four quality measures for insurers, and penalized insurers who failed to meet targets with escalating reductions in premiums. In 2023, the first year the program ran, the penalty was a 1 percent reduction; blood-pressure control improved a remarkable 12 percent.
Adopting this approach, CMS could make achieving a certain threshold of successful treatment of hypertension the dominant measure for the quality assessment of Medicare Advantage plans, and link that measure to bonuses. CMS could also penalize those achieving less than 50 percent control.
Faced with such reforms—which could lower hospitals’ and doctors’ bottom line—the medical lobbying groups would, no doubt, rebel. The AMA, for one, has long had an aversion to what it calls “scope creep”: proposals enabling nonphysician providers to take some clinical responsibility for patients that is essential to team-based care. The association claims that scope creep results in worse quality and more expensive care. At the same time, physicians and health-care organizations would likely claim they can’t take an approach that requires more intensive contact with patients, because they aren’t paid enough to spend the time. Plus, those threatened by penalties for their poor performance would likely claim they have sicker and noncompliant patients.
Perhaps an administration filled with people willing to dismiss such self-interested pronouncements would be better at addressing chronic illness, as the president has said he intends to with the Make America Healthy Again Commission. If Kennedy and the rest of the administration focus on delegitimizing vaccines and defluoridating water, the nation’s health will suffer. But Trump’s Cabinet could also ignore special pleading by the medical establishment and fix physician payment and hypertension. That’s certainly a better prospect than more measles deaths.
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