Thursday, January 15, 2009

Out of the RUC - the American College of Physicians Initiates an Open Discussion

We and the other bloggers have been trying to provoke an open discussion of the secretive, unrepresentative, unaccountable process which the US Center for Medicare and Medicaid Services (CMS) uses to fix payments to physicians. That process may largely be responsible for the implosion of primary care in this country, and substantially responsible for how we manage to pay so much for health care, yet have worsening problems with access and quality.

See our previous discussions of the process, and the central role of the RBRVS Update Committee (RUC), most recently here, and in earlier posts (here, here, here, here, and here) and important articles by Bodenheimer et al,(1) and Goodson.(2)

The ACP Advocate blog, the apparently official voice of the American College of Physician on its advocacy efforts, took up the issue in this post authored by Robert B Doherty, ACP Senior Vice President for Governmental Affairs and Policy.

Doherty summarized some of the points made on Health Care Renewal and on DB's Medical Rants. He appeared not unsympathetic to some of the criticisms of the RUC and the process that Medicare uses to fix physician payments.

I will summarize some of the points he made in his responses below, and interpolate my replies. I have also submitted the same material as a comment to his post.

- The RUC just provides advice.

The RUC provides [just] 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.

++ My comments: The RUC may say that all it provides is advice, but that advice is almost always uncritically accepted by CMS. Per the also excellent article by Goodson(2), the AMA itself claims that CMS follows more than 90% of the RUC's "recommendations." ++

- The RUC did propose some increases to payments to primary care physicians. (Regarding this point, he quoted from a letter written by the Chair of the RUC:

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.

++ My comments: The RUC did very belatedly recommend some increases in evaluation and management codes, but these hardly made up for its years of neglect of primary care (to use polite terms), and this increase, as Dr Larson pointed out, benefited all physicians, not just primary care, or cognitive specialties, to the extent it was not nullified by across the board cuts necessitated by the SGR. ++

- The RUC is helping promote the concept of the medical home.

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.

++ My comments: How well the RUC did in the case of the proposed medical home is unclear. See this post and its links to a serious critique of this work. ++

- The RUC ought to be reformed, but not abolished.

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?

++ My comments: I surely agree that the RUC ought to be more representative of primary care and more transparent. As noted in Dr Goodson's article, primary care has had a very small representation on the RUC. There is not a single designated seat for general internal medicine, but orthopedics effectively has two (one for orthopedics, one for spine surgery, which has a separate society).

Note further that many of the specialty societies that support RUC members are supported heavily by industry, that is, by pharmaceutical, biotechnology, and device companies. Such corporations benefit from irrational exuberance about procedures, since they sell the drugs, devices and supplies that are used in procedures. See posts
here and here, for example, on some of the industry sponsorship of the AAOS, which sponsors an "orthopedic" seat on the RUC.
Such institutional conflicts of interest affecting the RUC have never been publicly

The transparency issue is not trivial. The identities of the people who sit on the RUC have been SECRET. A few members have admitted publicly that they are, but the AMA - I'll say it again - keeps the membership roster of the the RUC secret. One wonders what they have to hide. Not only is the membership secret, of course, but the group's deliberations are also secret.

It is the privilege of the AMA, a private group, to keep the membership of the RUC secret. But I would note, that secret is also kept from the general AMA membership, who are presumably paying their dues to support this secret committee.

On the other hand, since the RUC functions as a de facto government agency (note again that CMS seemingly gets input from no other source for its revisions of RBRVS), having such important government decisions, which have nothing to do with national security, made in secret is offensive.

It is true that Congress and CMS made the rules that allowed all this to happen. There are very big questions about why CMS pursued this course. Maybe some investigative reporter, some congressional agency, or in a new administration, CMS itself will investigate how this happened.

But the AMA did not have to go along with it. They could have insisted on an open,
transparent, representative, accountable process, and refused to participate were that not allowed. Instead, they at least went along with a fee setting process that is opaque, unrepresentative, unaccountable, and not obviously subject to any ethical standards.

The RUC should disappear. Medicare should develop an open, transparent, representative, accountable process to negotiate what it pays physicians. The names of the people involved should be public. The people involved should be free of obvious personal conflicts of interest, and should not be sponsored by organizations with obvious institutional conflicts of interest.++

At any event, I salute Mr Doherty for getting this important policy issue more into the light. The RUC seems to be one of those things that it was not considered polite, or politically correct, to talk about, much less criticize. Maybe an open dialog will lead to some measurable reform of a physician payment system that badly needs it.

1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. Link
2. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. Link

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