Roy Poses, MD, takes on the RUC in the Health Care Renewal blog.
He calls the RUC an "opaque and unaccountable process [that] has resulted in increases outstripping inflation in fees paid for procedures, while fees paid for 'cognitive' medicine, i.e., for primary care, and for services that involve diagnosis, management of acute and chronic disease, counseling, coordination of care, etc, but not procedures, have lagged inflation." In a similar vein, Dr. Bob Centor (a member of the ACP Board of Regents), partly blames the RUC for the shortage of primary care doctors. And Drs. Berenson, Bodenheimer, and Rudolf wrote this in an Annals of Internal Medicine Perspectives:
"The RUC process favors increases in procedural and imaging reimbursement for 3 reasons: specialty society influence in proposing RVU increases, the specialist-heavy RUC membership, and the desire of RUC specialists to avoid increases in evaluation and management RVUs. With their ability to create new codes and influence RVU updates, many procedural specialists can influence fees in a way that observers find to substantially overvalue procedural and imaging services. Moreover, high fees may encourage physicians to increase the volume of profitable services, leading to even higher income gains and greater spending growth."
The RBRVS Update Committee (RUC) is a panel of physicians hosted and chaired by the American Medical Association and made up of representatives from major physician specialty societies, including ACP. The RUC provides recommendations to the Centers for Medicare and Medicaid Services (CMS) on the physician work relative value units (RVUs) under the resource-based relative value scale. A simplified expression of the formula that CMS uses to set Medicare physician payment rates goes like this:
Physician work RVUs x Practice Expense RVUs x Professional Liability RVUs x $ multiplier = payments
The RUC provides advice mainly on the first piece - physician work RVU. This represents about 55% of the total RVUs for each procedure code. CMS accepts most of the RUC's recommended RVUs.
The RUC argues it is being unfairly maligned. Dr. Bill Rich, the RUC's chair, wrote this in response to the Annals of Internal Medicine:
"The RUC recommended significant increases to E&M (evaluation and management) services, which were implemented by the CMS on 1 January 2007. These permanent increases result in an additional $4.5 billion in E&M services payments each year! To imply that they are small and insignificant is preposterous. Family physicians may see their overall Medicare payment increase by 5% or more. A document on the American College of Physicians' Web site states: 'ACP estimates that internists will typically see an increase of $5,000 to $10,000 in total Medicare allowable charges'."
My sense is that the RUC's critics have a point, but so does Dr. Rich. The RUC deserves credit for the evaluation and management increases, and more recently, for estimating the physician work involved in care coordination for the Medicare medical home demonstration project.
But the RUC does need to look at its own composition and processes. It needs to be more representative of primary care and more transparent in its deliberations. The new Obama administration and Congress would be well-advised to insist that the processes Medicare uses to determine the values of physician services be as transparent as possible, and include sufficient and appropriate representation and expertise from primary care. They should also require a better process for identifying overvalued services.
But making the RUC the main villain in a system created and run by the government misses the mark. We have to remember that it is Congress and CMS, not the RUC, who makes the rules. As long as the Medicare payment system pays based on volume instead of rewarding prevention and care coordination, primary care physicians' incomes will lag behind specialties that can generate more volume, because primary care doctors can only increase volume by cramming more patients into an already over-scheduled day. This would be true even if the RUC were reconstituted to include more primary care doctors.
And, we need to ask if the RUC were to disappear, who should recommend the work involved in physician services? Economists and physicians hired by the federal government?
Today's questions: What do you think about the RUC? Does it need to change? Or should it be replaced- if so, with what?