Thursday, October 28, 2010

RUC It Up - How the US Government Fixes Physicians' Payments Becomes Less Anechoic

We have frequently posted, first here in 2007, and most recently here and here, about the little-known group that controls how the US Medicare system pays physicians, the RBRVS Update Committee, or RUC. 

Since 1991, Medicare as set physicians' payments using the Resource Based Relative Value System (RBRVS), ostensibly based on a rational formula to tie physicians' pay to the time and effort the expend, and the resources they consume on particular patient care activities.  Although the RBRVS was meant to level the payment playing field for cognitive services, including primary care, vs procedures, over time it has had the opposite effect, as explained by Bodenheimer et al in a 1997 article in the Annals of Internal Medicine.(1)  A system that pays a lot for procedures, but much less for diagnosing illnesses, forecasting prognoses, deciding on treatment, understanding patients' values and preferences, when procedures and devices are not involved, is likely to be very expensive, but not necessarily very good for patients. 

As we wrote before, to update the system, the Center for Medicare and Medicaid Services (CMS) relies almost exclusively on the advice of the RBRVS Update Committee. The RUC is a private committee of the AMA, touted as an "expert panel" that takes advantage of the organization's First Amendment rights to petition the government. Membership on the RUC is allotted to represent specialty societies, so that the vast majority of the members represent specialties that do procedures and focus on expensive, high-technology tests and treatments. However, the identities of RUC members are opaque, and the proceedings of the group are secret.

To expand on the penultimate point, the current page on the AMA web-site that describes the RUC only lists its members in terms of their specialties and organizational affiliation. Their names do not appear. A response to a previous post by me on the subject by the then Chair and Chair-Elect of the RUC suggested that the RUC membership is not quite secret. They stated that "a list of the individual members of the RUC is published in the AMA publication, Medicare RBRVS 2009: The Physicians Guide." This publication is available from the AMA here for a mere $71.95. However, the book is not on the web, or in my local or university library, and I have no other way to easily access it. Thus, the RUC membership as at best relatively opaque.

To expand on the ultimate point, as Goodson(2) noted, RUC "meetings are closed to outside observers except by invitation of the chair." Furthermore, he stated, "proceedings are proprietary and therefore not publicly available for review."

The fog surrounding the operations of the RUC seems to have affected many who write about. We have posted (here, herehere, and here) about how previous publications about problems with incentives provided to physicians seemed to have avoided even mentioning the RUC. Up until now in 2010, after the US recent attempt at health care reform, the RUC seems to remain the great unmentionable. Even the leading US medical journal seems reluctant to even print its name.

That has just changed.  A combined effort by the Wall Street Journal, the Center for Public Integrity, and Kaiser yielded two major articles about the RUC, here in the WSJ (also with two more spin-off articles), and here from the Center for Public Integrity (also reprinted by Kaiser Health News.)  The articles cover the main points about the RUC: its de facto control over how physicians are paid, its "secretive" nature (quoting the WSJ article), how it appears to favor procedures over cognitive physician services, etc.

So the RUC has suddenly become less anechoic.

However, despite the best efforts of some very good investigative reporters, there still are important unanswered questions, questions we have raised before:
  • How did the government come to fix the payments physicians receive? Government price-fixing has not been popular in the US, yet this has caused no outcry.
  • Why is the process by which they are fixed allowed to be so opaque and unaccountable? Why are there no public hearings on the updates, and why is there no input from practicing physicians or organizations other than those related to the RUC?
  • How did the RUC become de facto in charge of this process?
  • Why does the AMA keep the membership on the RUC so opaque, and give no input into the RUC process to its general membership?
  • Why is the RUC membership so dominated by procedural specialists? Why were primary care physicians, who made up at least a sizable minority of physicians when the update process was started, not represented according to their numbers?
  • Why has there been so little discussion of the RUC and its responsibility for an extremely expensive health care system dominated by high-technology, expensive, risky and invasive procedures?
Without discussing how the incentives for physicians became so unbalanced, do we really expect we can fix them?  If we do not fix them, do we really think we can "bend the cost curve?"  If we do not control our costs, do we really think that we will be able to make good health care accessible for all?  At least now I can say that the issue may really be in play for health care professionals, health care policy experts, and the public at large.
See also comments on other blogs: DBs Medical Rants, GoozNews, and Managed Care Matters.

ADDENDUM - Additionally, see comments on the Retired Doc's Thoughts blog, and the Running a Hospital blog.

1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. (Link here.)

2. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. (Link here.)


Anonymous said...

It is this fixing of prices that is responsible for the inflation in medical care costs over the past three decades.

Anonymous said...

From the WSJ article Physician Panel Prescribes The Fees Paid by Medicare Oct 27, 2010 we have this quote:

“The group convened by the American Medical Association has no official government standing.”

Like every other pilot, trying to fly for fun, I live with this concept. While the AMA has no “official” standing, it sets the standards for many aspects of American life.

At the end of the Clinton administration the FAA along with all of the major pilot groups determine that the Third Class Physical served no purpose. Evidence had shown that people were not wrecking planes due to their health and there are other checks to assure pilot ability.

The AMA claimed eliminating this requirement would place a financial hardship on the general physician population. One must assume that then as now physicians are simply standing around empty offices waiting for some pilot to stop by for a physical. (Sarcasm)

The reality is that the AMA was only protecting a business model that, at the base, uses all tools possible to drive income. William Hsiao of Harvard: “You do not turn this over to the people who have a strong interest in the outcome.”

So we ignore the evidence and make a financial decision that impacts the lives of thousands of people with no recourse. How has this played out? The modern medical practice is driven by short visits and testing. The results have been pilots, who are a captive audience, are often subject to test for financial reasons, not to meet standards.

With a large Federal budget deficits the FAA maintains a staff whose sole purpose is to review all of this information. We are told as pilots to bring all of the paper work for any test with us to our physical so this can be included with our application; any test over six months old may be repeated.

These are the actions of a business whose sole purpose is to maximize income through regulatory control. Medicine needs to decide if it is a business or profession. Right now it is a business.

As a profession it should look first to the interest if its client/patient. Evidence based medicine and science should drive practice standards, not financial gain, as pointed out in the WSJ article regarding foot wounds.

Doctors need to, as done on HCR, step forward and challenge organizations and companies that only follow a win at all cost business model.

The reality is medical cost extend far beyond the doctors office. Aviation is only one area where ever increasing medical requirements are destroying not only an industry but a way of life. Older pilots are often subject to all the test their insurance will cover. The resulting paper work and questions make flying a cumbersome proposition. They fly less, the plane sits, less gas is purchased, fewer repairs are made, fewer meals are purchased, and quickly a small airport fades away.

We will not bend the cost curve as long as a small group can control medical standards with no oversight. Ignoring evidence based medicine and science, may further the financial interest of many groups, but will not serve the patient or public.

Steve Lucas