Are we unfair to the RUC? A view from the inside

Are we unfair to the RUC? A view from the insideA guest column by the American College of Physicians, exclusive to KevinMD.com.

I will begin this month’s column with a confession on something that most people don’t know about me. I hope it doesn’t lose me any friends. I am a member of the AMA/Specialty Society Relative Value Scale Update Committee, better known as the RUC. Actually, I’m an alternate, but that’s close enough. I just completed my first year on the RUC, having attended three meetings. If you don’t know much about the RUC (or even if you do, or think you do), I recommend that you read this summary on the AMA website first. You don’t need a password, security clearance, or WikiLeaks membership to access it. While you’re there, you should also read the other items on that page, including “The RVS Update Process Booklet” that describes the process that the RUC uses to determine relative values.

Over the years, more so recently, the RUC has been criticized by many who believe that it is biased in favor of procedural over cognitive services, resulting in the income disparity between primary care and non-primary care specialties. I joined the RUC as an alternate for the newly-added “Primary Care Rotating Seat” that was the result of pressure from the professional societies to address the imbalance between the number of primary care and non-primary care members of the RUC. Based on my first year’s experiences on the RUC, I would like to share a few observations.

The first one should be obvious, but is often misunderstood. The RUC is a technical committee of experts that determines the relative resource cost of physician work for every code in the CPT. It is not a policy making committee. Many think of the RUC as deciding “what’s it (the procedure or service) worth?” However, the RBRVS is built around “what does it cost?” Therefore, the RUC’s output is more an assessment of the raw material cost than it is a determination of retail price. It makes no distinctions based on supply and demand, cost-effectiveness, or characteristics of the physician who performs the service. So, when the RUC concludes that a procedure should have a physician work RVU of 1.4, it cannot then recommend to CMS that because the procedure is performed by primary care physicians, it should instead have a value of 2.4. Or, if it’s a procedure that has low clinical utility, the RUC can’t recommend a value of 0.7. That is not to say that these qualities are unimportant in the pricing of medical services, but they are for others, not the RUC, to address.

Another aspect of the RUC that I didn’t fully appreciate is that the RUC members are not advocates for their specialties. They are charged with using their expertise to evaluate recommendations for physician work RVUs that are presented by the specialty societies. I know that some of the RUC’s critics would put a “wink-wink” after that comment, but as someone who didn’t know most of the members at my first RUC meeting, I was impressed by the fact that I could not tell who was from what specialty based on their comments at the table. As I’ve gotten to know my RUC colleagues, that observation has not changed. In addition, RUC members must recuse themselves from agenda items that impact them directly. The RUC has a strict conflict of interest policy that is anything but hidden – all participants, from members who participate in surveys, to the RUC Advisors who present specialty society recommendations to the RUC, to the RUC members themselves are bound by it.

Critics claim that the confidentiality of the RUC’s activities enables the bias against primary care and encourages all kinds of mischief and malfeasance. The RUC’s harshest critics accuse the RUC members of conspiring to intentionally overvalue procedures at the expense of primary care services and using confidentiality to hide behind those actions. I have not seen or heard of any such behavior at the meetings, and based on the culture of the RUC membership that I have witnessed, I don’t believe that such activity would be tolerated.

The RUC’s confidentiality policy minimizes the negative influence of industry and others with vested interests in the RUCs recommendations. Analogous to the benefits of confidentiality in peer review, the RUC’s policy empowers its members to think and speak independently based on their expertise instead of for the interests of the specialty that appointed them.  Transparency is important, but I’m convinced that full transparency would have drawbacks. For example, would a surgical subspecialist on the RUC be as likely to support increasing the work RVU for an E/M service, or a primary care member to maintain a current RVU for a radiologic procedure if their comments and votes were on the record? In the ideal world, perhaps. In reality, full transparency would be more of a “feel good” move with substantial harms to the process.

Another eye-opener for me was how frequently the RUC recommends reductions in physician work values.  Some readers will question why this isn’t obvious when they look at what they are paid. It is obvious to those whose procedures have been cut. But because the “net savings” is redistributed to the rest of the physician payment pool, the increase to other codes is very small. In the aggregate, millions of dollars have been shifted from specialties that mainly perform procedures to primary care, but the impact per code isn’t as dramatic.

While the RUC members work in good faith to determine physician work values as accurately as possible and take very seriously the process that must be followed to achieve that goal, that process has weaknesses that should be called out. The surveys of physicians who perform a procedure under RUC review have been faulted for overstating the time spent before, during, and after the procedure, as well as the intensity of the procedure. These are all key factors in determining the amount of physician work. Estimating time can be a subjective process subject to recall bias. There is also a risk of exaggeration of time by those surveyed, who know how the survey will be used. How does one judge intensity? It may be easy to compare the intensity of treating esophageal varices in a patient with an acute hemorrhage to that of a well-adult visit, but not all the comparisons are that clear cut. The RUC is conscious of these limitations and challenges survey data that makes no sense. It is looking at ways of improving the survey process and considering other sources of data on time and ways to measure intensity.

Finally, the RUC’s work is all about relative values. If one is comparing code A to code B to determine code A’s value, the assumption is that code B’s value is accurate. If that is not the case, then that distortion is perpetuated.

None of these observations are original, and all of them are acknowledged by AMA staff and RUC members, who work during and between meetings on subcommittees that are charged with finding better and more accurate ways to determine relative values.  Are they reasons to scrap the process altogether? What would replace it and how would the replacement structure achieve the goal of developing methodologically sound recommendations from the medical profession to CMS?

The fact is that there are many things wrong with the way that health care is paid for in the United States. Not all of it, or even most of it, has to do with the RUC. The RUC is one instrument of a fee-for-service payment system that is inherently flawed. Pricing is one problem, and that is where the RUC plays the greatest role. No one disputes that many procedures are misvalued and the RUC needs to do the best job possible fixing that. Overutilization is another problem, and I’ve seen the RUC blamed for that one, the rationale being that if RVUs are kept high, they encourage overutilization. Then again, I’ve also listened to the argument that undervaluing procedures encourages overutilization – remember the behavioral offset? Decreasing the use of procedures and tests that have little or no value to patients is an important job, but it is not the RUC’s job. Paying based on quality and value to patients (and society) does not depend on the RUC; it is up to the policy makers and payers to decide if they want to use payment to drive change in how care is delivered. The work of the RUC can help to inform these decisions. In fact, RUC members have advocated for the development of new codes that describe the work that primary care physicians do and recommended their adoption by CMS. The new transitional care and comprehensive chronic care codes are examples.

In short, making the RUC the “whipping boy” for all of the ills of our system is simplistic and misses the mark. The RUC can certainly do things better, and its role should be part of the discussion of how to improve health care payment and delivery. That discussion would go much better if we stuck to the facts without the attributions, accusations, and name calling that make for interesting reading and whip everyone into a frenzy, but achieve little else.

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • DavidBehar

    Dr.Ejnes: You are an anti-competitive, authoritarian, anti-scientific, enemy of clinical care. Your unjustified arrogance knows no bounds. I believe your group, the ACP, is a left wing extremist collaborator with the enemies of clinical care. I may ask the Department of Justice Criminal Division to start an investigation into your lawless activities.

  • LIS92

    So why does talking to the patient receive such a low value?

    The issue with primary care is not that they should be paid more than specialists for procedures but the time they spend with patients should have a higher relative resource cost of physician work.

  • edpullenmd

    If this is all correct, then it would appear that if we want to increase use of valuable services and reduce use of less valuable services, we need a Real Value Committee to make estimates of what things we want to encourage, what to discourage, and adjust reimbursement based in part on that too.

    • Yul Ejnes, MD, MACP

      You raise an important point. What you describe is not the RUC’s (and for that matter RBRVS’s) role by design, though many commentators seem to think that is its role. Payers have adjusted payment based on “value” to a small extent, for example the 10% Medicare bonus and the two years of Medicaid/Medicare parity that are part of the ACA. Some private insurers have tackled it by creating different “conversion factors” for primary care and non-primary care doctors.

      These are the sorts of things that we need to be discussing as adults, instead of engaging in the childish rhetoric that dominates the conversation.

  • MarylandMD

    This “defense” of the RUC reminds me of the old Tom Lehrer song:

    Don’t say that he’s hypocritical,
    Say rather that he’s apolitical.

    “Once the rockets are up,
    who cares where they come down?
    That’s not my department,”
    says Wernher von Braun.

  • Seth Trueger

    Interesting perspective. 2 main issues:
    On the overvaluation of procedures: many of the procedures overestimate the time required, meaning that many procedures are overvalued (see recent Washington Post article) and proceduralists are grossly overrepresented on the committee.
    Second, Dr. Ejnes’ is correct: the RUC is primarily a technical group that assigns values to different aspects of care; the problem is that the RBRVS assigns values based on *input* costs, not whether or not a procedure actually helps patient.

  • buzzkillerjsmith

    Nah, The RUC is trash. Seth has it right. Value is based on output, not input.

    Perhaps Dr. E. should review Econ 1. It is a fundamental characteristic of intelligent persons to be able to quickly and almost automatically pierce the rhetoric to understand the essentials.

    Next case.

  • DavidBehar

    This left wing biased blog removed my comment in which I called for an investigation of the author by the DOJ Criminal Division, for reasons I set out.

  • azmd

    “In the aggregate, millions of dollars have been shifted from specialties that mainly perform procedures to primary care.”

    This sounds impressive, until one considers that the total sum expended on healthcare in the U.S. in 2011 was $2.7 trillion.

    More needs to be done, and done quickly, and if the RUC isn’t part of the solution, it’s part of the problem.

  • Brian Klepper

    There are so many things wrong with Dr. Ejnes’ representations that it is difficult to know where to start, but the bottom line is that its the result of a fuzzy critical analysis and is the political equivalent of Stockholm syndrome.

    Let’s start with his explanation of why the RUC added 2 primary care seats. Dr. Ejnes makes a simplistic and self-serving argument that I’ve seen before, from the American College of Physicians and the American Geriatric Society, both of which attributed new primary care RUC representation to “the result of pressure from the professional societies to address the imbalance between the number of primary care and non-primary care members of the RUC.”

    The problem here is that the RUC had been under that pressure for the previous 20 years. It was only when the RUC was looking at a legal challenge to its biases mounted by 6 Augusta,GA primary care doctors that it needed to convey course correction to the courts.

    Next, Dr. Ejnes has obviously been romanced by the process. He gushes about how open the process is and how well-intentioned the participants are. But none of that addresses either the systemic results of the RUCs effort over the past two decades or how those trace back to the RUC’s actions. He casually forgives the RUC’s core structural flaws – its opacity, its lack of accountability, it dramatic voting imbalance that favors specialty over primary care – that have worked so egregiously to the detriment of patients, purchasers and primary care physicians. In other words, he has whitewashed and is comfortable with a terribly corrupt process that demonstrably is stacked against his constituents, and then announced that the process matters far more than the results.

    But then he goes a step further to absolve the RUC from any accountability in this process. He argues that the RUC really doesn’t make any decisions, and that all the responsibility lies with CMS. This is the lobbyists’ lament, that they’re only there to better inform the process, without ever acknowledging that their process intentionally spins the information in ways that favors the special over the common interest.

    I can only hope, for the sake of Dr. Ejnes patients, that he’s a clearer critical clinical thinker than he is a political one. Certainly, primary care physicians, patients or purchasers hoping that he’s bought into a more open and fairer process for medical services valuation will be sorely disappointed. But from the RUC’s point of view, he’s a perfect new addition.

    • MarylandMD

      Well said! I was encouraged when I saw that someone from inside the RUC was responding to the criticism it has faced (especially with the 7/20 Washington Post article), but on reading, hope turned to disappointment turned to rage. Obviously, Dr Ejnes has been assimilated into the RUC. While initially there may have been some resistance, it was futile.

    • Yul Ejnes, MD, MACP

      Dr. Klepper,

      I realize that you have built a cottage industry and, for all I know, a business model, based on your criticisms of the RUC, so your response does not surprise me. However, unless your doctorate is in psychology and you have actually had an opportunity to talk to me in person, it’s best that you try not to psychoanalyze me, but instead stick to the issues. There is much to discuss about the RUC, its role in the pricing of medical services, and the payment system as a whole without getting into histrionics, character assassination, and otherwise unproductive bloviation. By no means did I give the RUC a free pass in my commentary. At the same time, to blame all the ills of the system on the RUC is simplistic, especially for such a superior critical thinker (and apparent mind reader) as yourself. Again, not surprising, but nonetheless disappointing.

  • NewMexicoRam

    How about for one year we let primary care take all but 2 of the seats on the RUC and specialists are limited to just those two.

    The howling would be worse than coyotes on the west mesa,

    • MarylandMD

      I thought the number of seats should be proportional to the number of outpatient visits in the specialty, but I like your idea better.

      What is funny is that when you start talking tough about reimbursement disparities, the specialists complain that we are “turning specialty against specialty.” I guess even though they have been happily pocketing huge incomes while primary care bleeds, they have been behind us all the way!

      • Mengles

        Those specialties are now more than happy to throw primary care under the bus and delegate them to NPs.

  • bill10526

    Obviously free market principles don’t work so well with medical care. Shopping isn’t as useful for appendectomies as for purchasing shoes.

    I am sure that RUC is manned by people of high integrity and good intentions. Their troubles show the magic of Adam Smith’s market.

    • Guest

      Having a faceless Central Committee setting prices is NOT “free market” anything. You need to re-read your Adam Smith.

      • bill10526

        Yes, that was my point.

        Faceless committees set fire codes, make up SAT exams, and determine electrical standards. They are an essential component of modern life.

        Adam Smith’s market sets prices with an invisible hand of dynamic interactions. It is wondrous when it works and terrible when it leads to housing bubbles.

  • Mengles

    Yes, instead you wish to antagonize doctors with your posts “Physicians need to compare themselves with their peers” and “the path for physicians who want to remain in private practice” You are not a physician, so please give us a break. You’d throw the primary care physicians who are foolish enough to work with you under the bus if you could.

    • Brian Klepper

      Mengles,

      Rather than assume, maybe you should contact the physicians who work for my firm, WeCare TLC. All our clinics are led by physicians. They see 1600 patients in a panel rather than the 2500-3200 load most PCPs try to cope with. They see patients for 20 minutes on average, and longer if they think they need to. They use 21st century risk identification and clinical decision support technology. Non-clinicians cannot second-guess their clinical decisions – there is a Medical Director who monitors clinical appropriateness – and we pay them at the 92nd percentile within their markets.

      My articles for physicians who wish to succeed in an increasingly competitive health care marketplace are just that. If they don’t apply to you, if you think you’ll always have all the patients you want or if you don’t think anyone will ever externally evaluate your performance, then don’t read them. Makes zero difference to me.

      All this said, I get calls every week from societies or groups asking me to talk to their docs about winning in the market. Apparently, yours is not the only view.

  • Walt Larimore, MD

    As the American Academy of Family Physician’s (AAFP) representative to the RUC, I recognize and appreciate the need for a healthy debate over the RUC process and methods.

    Indeed, the AAFP has challenged some of the methodologies and data used by the RUC. And, we will continue to do so whenever we believe there is additional information that could or should be considered by RUC. Our motive is to work with the RUC to help her even more accurately determine both reproducible and relative physician work and practice costs — both within families of services and across families of services.

    What we will not do is question the integrity of our physician colleagues who volunteer countless hours to serve RUC. It is an unproductive and unprofessional distraction from the key issues we should all be discussing for the betterment of our health care system and to better serve the patients for whom we all care.