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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