Is it time to declare independence from the RUC?

In a recent opinion column published in Kaiser Health news, two prominent voices in health care policy gave primary care physicians a piece of revolutionary advice: Quit the RUC.

If you don’t know what the RUC is, you aren’t alone.

RUC stands for the Relative Value Scale Update Committee, a group of 29 physicians from various medical specialties that meets three times a year to advise the Centers for Medicare and Medicaid Services on Medicare physician fee reimbursement and how certain procedures should be valued. Created by the American Medical Association in 1991, the committee has no official government standing, yet it yields great power.

CMS approves 90-94 percent of the committee’s suggestions, and because many government and commercial health plans follow Medicare’s lead to set their own fee schedules, its influence bleeds into other markets as well.

So what’s the problem? The committee is overwhelmingly dominated by specialists, outnumbering primary care physicians by a ratio of 6:1 or 13:1 depending on whether you count internal medicine, osteopathy, and pediatrics. As such, Brian Keppler, Ph.D., and David Kibbe, M.D., M.B.A., write that its payment recommendations have “consistently favored specialists at the expense of primary care physicians.” They point out that, on average, specialists out-earn primary care physicians by $135,000 a year and $3.5 million over the course of their careers.

In the $500-billion Medicare program, physician fees make up just one piece of the pie and the RUC cannot be blamed solely for the spiraling costs of health care. However, the authors assert that “the perverse incentives embedded in fee-for-service physician payments influence care decisions and are a principle driver of the health system’s immense excesses.” Further, “the system pays more for invasive approaches, so conservative treatment choices that are lower cost and lower risk to the patient may be passed over, especially near the end of life.”

They recommend that TAFP, along with other primary care medical specialty societies in the country, “loudly and visibly leave, while presenting evidence that the process has been unfair to their physicians and, worse, to American patients and purchasers.”

The AAFP Congress of Delegates has debated the question of leaving the RUC in recent years, and AAFP has been active on several fronts trying to get more primary care representation on the RUC and to get CMS to reconsider its decisions when accepting recommendations from the RUC.

There are also other ideas floating around to curb the RUC’s influence. One comes from physician-politician Jim McDermott, a U.S. representative from Washington. He wrote in an opinion column for the New England Journal of Medicine, “Congress should consider enlarging or realigning the composition of the RUC, if not demoting it to an advisory function and requiring greater transparency of its deliberations.”

Additionally, a provision in the health care reform law creates the Independent Payment Advisory Board that is tasked with capping Medicare spending beginning in 2015. Much of the momentum for creating such an entity was aimed directly at counteracting the inflationary bent of the RUC’s recommendations.

Interesting to point out is recent action from the AMA, American Hospital Association, and other specialty groups to weaken or quash the IPAB.

AAFP supported the concept, though has not been entirely happy with all aspects of the IPAB in the final legislation and continues to push for changes, such as including a primary care representative and a consumer representative to the board, including a public comment period before Congress acts on the IPAB recommendations, and including all segments of the health care industry (i.e., hospitals, nursing homes, pharmaceutical manufacturers, etc.) in the scope of the IPAB review.

Whatever happens, it certainly sounds like the RUC is in for some changes.

Read the Keppler/Kibbe article here: http://www.kaiserhealthnews.org/Columns/2011/January/012111kepplerkibbe.aspx

Read more about the IPAB here: http://www.kaiserhealthnews.org/Stories/2011/January/26/health-industry-lawmakers-medicare-spending-board-IPAB.aspx

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4 Responses to “Is it time to declare independence from the RUC?”

  • Yes, yes, yes, yes.

    We should loudly leave RUC and start the work of creating our own billing, coding, and payment methodology to take to insurers and CMS. The current E/M system was invented by ologists for ologists and does not reflect the work we do in caring for patients with more than one body part not working well. None of the 99215 examples from CMS look like my patients in my safety net hospital system clinic.

    RUC has done nothing but beat us down and its time to start the process of empowering our discipline by leaving the abuser.

  • Richard, it’s great to see you contribute here. What are your thoughts on the Independent Payment Advisory Board as envisioned in PPACA? Many of the medical organizations are opposed, but AAFP has supported it with some caveats concerning the eventual membership of the board, public comment period, etc., in hopes that the board would be a counterbalance to the RUC. As implementation continues, I expect more opposition from AMA and others. Do you think IPAB can work as hoped?

  • Jonathan,

    I’ve heard of the IPAB and on paper it sounds like a more balanced payment advisory board and process. I have a hard time answering your last question because 1) I’m not sure who’s doing the hoping, 2) I really don’t know the history of who created it and what their purpose was, and 3) I stay chronically confused which parts of the PPACA are explicitly written in the original law and which parts were designated to the Secretary of HHS to write rules to achieve a certain goal.

    Any ideas about this on your end?

    Richard

  • kalfano:

    Another great article from Brian Klepper published by Kaiser Health News on 3/3/11 — Fixing America’s Health Care Reimbursement System — http://www.kaiserhealthnews.org/Columns/2011/March/030311klepper.aspx

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