The effect of the RUC overvalues procedural skill

An interesting legal case brewing in the medical world that’s worth sharing.

A group of six physician plaintiffs from Georgia are suing the government (the Secretary of Health and Human Services) in a federal district court claiming damages from the fact that Medicare, the massive program that covers the elderly and disabled, fails to execute due diligence by rubber-stamping a reimbursement structure that overvalues procedural medicine over cognitive services.


Some background is in order.

It’s no secret that specialists (e.g. radiologists, cardiologists, dermatologists, urologists, etc.) make higher incomes than primary care doctors (family doctors, internists, and pediatricians). Obvious reasons include more training, differentiated skill, and an ability to handle specific technical and/or surgical procedures that generalists aren’t able or authorized to provide.

But the non-obvious reason is a poorly publicized and shadowy body known as the Relative Value Scale Update Committee, orRUC. The RUC is a committee convened by the American Medical Association (AMA) and about two dozen medical specialty societies.

The RUC promulgates an annual report to CMS, the government’s Medicare and Medicaid arm. The update advises CMS on the ‘relative value’ of an extraordinarily lengthy list of medical services, including both procedures (things ‘done’ to patients) andcognitive services (those done for patients with a doctor’s hands, stethoscope, and brain).

The RUC has twenty-nine members, twenty-three of whom come from medical specialty societies. The list is publicly available.

Critics of the RUC point out that it’s a little like the Senate, in that smaller specialties gain outsized importance since representation is not proportional. This has in effect, so the argument goes, perpetuated the overvaluation of procedural skill over cognitive service. The downstream effect of this is twofold: a disparity in doctor incomes between generalists and specialists, but more importantly, ever-increasing cost of delivering health care as the premium on procedures incentivizes them.

Early commenters seem to suggest that the case will have meritorious legal standing. It certainly will be interesting to see what happens as the case wends its way through the judicial system.

John Schumann is an internal medicine physician who blogs at GlassHospital.

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  • Ardella Eagle

    –“Critics of the RUC point out that it’s a little like the Senate,…”–

    That makes me nervous about the impartiality within the AMA.  Are the members of the RUC, member of the AMA as well, partial to the persuasions of special interest groups and ‘lobbyists’ within the AMA?  What happened to the part in the mission statement about “…the betterment of public health”?  The AMA should be working as a cohesive unit to fairly advise in the allocation of funds, not be picayune to sub-specialists.

    Or, am I being too idealistic?

  • Anonymous

    Strangely, procedural skill is called “menial labor” when it comes to most other things in our society, and the cognitive specialists are the ones who are at the higher end of the wage spectrum. This is reversed in the medical world where privilege is still the issue at hand. Nothing really changes in that regard.