The Relative Value Scale Update Committee (or RUC) impact on health care

On Kaiser Health News, Barbara Levy MD, the Chair of the AMA’s Relative Value Scale Update Committee (or RUC), published a glowing defense of the RUC’s activities.

Her article extols the work of the 29 physician volunteers who, “at no cost to taxpayers … generously volunteer their time, supported by advisers and staff from more than 100 national medical specialty societies and health care professional organizations.”

She fails to mention that the physicians’ and organizations’ efforts to craft the RUC’s recommendations have direct financial benefit to the physicians, specialty societies and health care professional organizations whose representatives dominate the RUC proceedings.

She points to the openness and transparency of the RUC’s proceedings, noting that ”the general public is able to comment on individual procedures, and processes are in place to ensure that input from all stakeholders is considered by CMS. Finally, the AMA ensures transparency of the process, making the data and rationale for each RUC recommendation publicly available.”

This, from an immensely influential Committee that refuses to share the identities of its members except by their societal affiliation, that keeps its proceedings private, and that can not be observed except by an invitation from the Chair. If anything, the RUC’s goings-on have been secretive and opaque. Go into any health care professional audience and ask, as I have, for a show of hands of people who know what the RUC is. It has been virtually unknown except in the wonkiest circles.

Dr. Levy also points out that, in Medicare’s budget-neutral environment, hard decisions have to be made, and that in 2006, $4 billion – a little more than  one percent of that year’s Medicare allocation – was transferred to primary care. The clear implication is that this came at the expense of specialists. But she conveniently ignores the vast majority of coding valuations that have increased specialty income while strangling primary care.

Dr. Levy’s article presumably responded to a growing chorus of recent voices that have detailed the RUC’s disastrous impact on American health care, beginning most recently last October with a Wall Street Journal expose by Anna Mathews and Tom McGinty, and an explanation on the New York Times‘ Economix Blog by Princeton health care economist Uwe Reinhardt. With David Kibbe MD, I wrote about this topic on Kaiser Health News in January, calling on the American Academy of Family Physicians (AAFP) to abandon the RUC. Then Paul Fischer MD joined in with his Family Physician’s Manifesto. All this work built on the foundation of many health care professionals – John Goodson, MD; Robert Berenson, MD; Thomas Bodenheimer, MD; Roy Poses, MD to name a few – who have carefully documented the biases and excesses that have been wrought by the RUC’s shadowy process.

Rep. Jim McDermott (D-WA), a psychiatrist, published a powerful argument against the RUC in the New England Journal of Medicine in January, and then, more recently interviewed MedPAC Chair Glenn Hackbarth on the RUC’s corrosive role in front of the House Ways and Means Committee. Interestingly, his comments found common ground with Rep. Tom Price (R-GA), an orthopedic surgeon. These activities have raised enough profile that they have been followed by publications like Politico and National Journal. Suddenly, the RUC is becoming more visible.

The New Jersey Academy of Family Physicians wrote a clear, to-the-point letter to Lori Heim, MD, Board Chair of the American Academy of Family Physicians. Here are a couple extracts.

We fear that our work towards building medical homes, reshaping the way primary care is delivered and how the system pays for it, and providing the care that our patients deserve will be wasted if the current payment policies are maintained, and we see no motivation for the subspecialist-dominated RUC to make those policy changes … we encourage in the strongest terms possible, that the AAFP Board … vote to publicly withdraw from the RUC, encourage other primary care organizations to do so as well, and simultaneously bring our advocacy efforts to bear on CMS to immediately replace the RUC with the alternative body that our policy supports.

So it has started. My most fervent hope is that this respectful, thoughtful nudge by a state chapter of family doctors will be what’s needed for other state chapters to also prevail on the AAFP to leave the RUC. Doing that publicly – meaning with as much visibility as can be mustered – would advance this effort to far greater notice and bring the bright light of public scrutiny on the RUC’s actual impacts on American health care, the one thing Dr. Levy’s article so scrupulously avoided.

Brian Klepper is a health care analyst who blogs at Care and Cost.

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  • Doc99

    This is how they play Divide and Conquer. For a so-called “Learned Profession,” we’re incredibly naive and flat out stupid.

  • family practitioner

    We have already been divided and conquered. Now, we need to try to repair the system.

  • skeptikus

    RUC member identities are secret. We only know institutional affiliations. Their deliberations and meetings are not public. This is where rationing occurs in our system. That it is so opaque is an insult to all doctors and healthcare consumers.

    This is government price setting.

    • gzuckier

      uh, you know that the Ruc isn’t a government body right?

  • Primary Care Internist

    I wish the ABIM, AAFP, AAP, and MSSNY (med society from my home state of NY) would finally publicly disown the RUC. kudos to NJ-AAFP.

  • American Medical Association

    The RUC is the physician voice. No one knows more about what is involved in providing services to Medicare patients than the physicians who care for them. More than 300 attendees, including representatives from all medical specialties, the government and researchers, participated in the last RUC meeting. Without the dedicated volunteers on the RUC, the voice of physicians would be lost and millions of taxpayer dollars each year would be needed to fund the cost of this time consuming work.

    The new March report from MedPAC noted that Medicare payments for primary care services have increased 20 percent since 2006 due in part to recommendations made by the RUC. And a letter was recently sent to Members of Congress by 47 national medical specialty societies in support of the RUC and the work it has done to increase values for primary care. In fact, the recommended changes that the RUC made to office and hospital visits in 2007 resulted in $4 billion being redistributed to these primary care services from other services. The RUC’s role with regard to primary care physicians’ overall compensation is overblown. While the RUC has made numerous recommendations with regard to increasing Medicare reimbursements, private insurance payments play a much larger role in a primary care physician’s overall payments.

  • family practitioner

    Methinks the AMA is sounding quite defensive.
    None of the above explains why the meetings are secret.
    And, although it may be true that primary care payments are up 20% since 2006, this was after years of neglect.
    Finally, “private insurance payments play a much larger role in a primary care physician’s overall payments” is a very misleading statment because almost every private insurance company sets their payments as a percentage of medicare; if medicare does not budge, then they do not have to.

    My advice to the AMA:
    1. stop with the secrecy
    2. stop selling prescribing info to drug companies without the prescriber’s knowledge/consent
    3. stop with your profitable monopoly on cpt/icd info
    4. admit that you have had an active role in driving primary care doctors to the brink of extinction and now you are trying to repair that (although it is probably too little too late)
    5. change your ways, or you will be extinct too.

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