Brian Klepper
Yesterday on Kaiser Health News, Barbara Levy MD, the Chair of the AMA’s Relative Value Scale Update Committee (or RUC), published a glowing defense of the RUC’s activities. Her article extols the work of the 29 physician volunteers who, “at no cost to taxpayers…generously volunteer their time,” “supported by advisers and staff from more than 100 national medical specialty societies and health care professional organizations.” She fails to mention that the physicians’ and organizations’ efforts to craft the RUC’s recommendations have direct financial benefit to the physicians, specialty societies and health care professional organizations whose representatives dominate the RUC proceedings.
She points to the openness and transparency of the RUC’s proceedings, noting that “the general public is able to comment on individual procedures, and processes are in place to ensure that input from all stakeholders is considered by CMS. Finally, the AMA ensures transparency of the process, making the data and rationale for each RUC recommendation publicly available.” This, from an immensely influential Committee that refuses to share the identities of its members except by their societal affiliation, that keeps its proceedings private, and that can not be observed except by an invitation from the Chair. If anything, the RUC’s goings-on have been secretive and opaque. Go into any health care professional audience and ask, as I have, for a show of hands of people who know what the RUC is. It has been virtually unknown except in the wonkiest circles.
Dr. Levy also points out that, in Medicare’s budget-neutral environment, hard decisions have to be made, and that in 2006, $4 billion – a little more than one percent of that year’s Medicare allocation – was transferred to primary care. The clear implication is that this came at the expense of specialists. But she conveniently ignores the vast majority of coding valuations that have increased specialty income while strangling primary care. (More comprehensive background on the RUC, including articles by the AMA that describe the RUC’s perspective in detail, may be found here.)
Dr. Levy’s article presumably responded to a growing chorus of recent voices that have detailed the RUC’s disastrous impact on American health care, beginning most recently last October with a Wall Street Journal expose by Anna Mathews and Tom McGinty, and an explanation on the New York Times Economix Blog by Princeton health care economist Uwe Reinhardt. With David Kibbe MD, I wrote about this topic on Kaiser Health News in January, calling on the American Academy of Family Physicians (AAFP) to abandon the RUC. Then Paul Fischer MD joined in with his Family Physician’s Manifesto. All this work built on the foundation of many health care professionals – John Goodson, MD; Robert Berenson, MD; Thomas Bodenheimer, MD; Roy Poses, MD to name a few – who have carefully documented the biases and excesses that have been wrought by the RUC’s shadowy process.
Rep. Jim McDermott (D-WA), a psychiatrist, published a powerful argument against the RUC in New England Journal in January, and then, more recently interviewed MedPAC Chair Glenn Hackbarth on the RUC’s corrosive role in front of the House Ways and Means Committee. Interestingly, his comments found common ground with Rep. Tom Price (R-GA), an orthopedic surgeon. These activities have raised enough profile that they have been followed by publications like Politico and National Journal. Suddenly, the RUC is becoming more visible.
Yesterday, the New Jersey Academy of Family Physicians wrote a clear, to-the-point letter to Lori Heim, MD, Board Chair of the American Academy of Family Physicians. Here are a couple extracts.
We fear that our work towards building medical homes, reshaping the way primary care is delivered and how the system pays for it, and providing the care that our patients deserve will be wasted if the current payment policies are maintained, and we see no motivation for the subspecialist-dominated RUC to make those policy changes.
Then,
…we encourage in the strongest terms possible, that the AAFP Board … vote to publicly withdraw from the RUC, encourage other primary care organizations to do so as well, and simultaneously bring our advocacy efforts to bear on CMS to immediately replace the RUC with the alternative body that our policy supports.
So it has started. My most fervent hope is that this respectful, thoughtful nudge by a state chapter of family doctors will be what’s needed for other state chapters to also prevail on the AAFP to leave the RUC. Doing that publicly – meaning with as much visibility as can be mustered – would advance this effort to far greater notice and bring the bright light of public scrutiny on the RUC’s actual impacts on American health care, the one thing Dr. Levy’s article so scrupulously avoided.
Care And Cost 
As an advisor to physicians for 30+ years, I have observed the relentless erosion of primary care reimbursements at all levels. I cannot begin to reconcile how this repression of reimbursements to primary care physicians has occurred, other than to say that this has been allowed to happen in large part as a result of apathy and a lack of resolve on the part of the primary care practitioners and their professional academies. The bottom line is quite apparent: this better change. Either we fix this mess with all due haste, or we will one day find ourselves without the best gatekeepers to the most efficient, cost-effective medicine we can hope to have. We must identify a much better way to reimburse PCPs for the multivariety of patient services they provide, which is essentially ignored by the weighting of the RUC with the various ologists who make up the majority.
Some argue that we are inexorably heading toward the bulk of physicians being on salary (other than, yes, the cash-only concierge/boutique niche), that this whole inscrutable reimbursement formulation thing is antithetical to good care.
What would be an adequate salary range for primary care physicians?
BobbyG,
In the Replace the RUC effort, we believe that the challenges facing primary care physicians, who must be able to identify and manage a huge variety of conditions, have been dramatically under-appreciated. Both in respect to the difficulty of their task and to recruit desperately needed medical students into primary care, we believe it is essential that their payment be on parity with specialist reimbursement.
You won’t get any argument from me there. But, just for the sake of argument, what might be an appropriate salary range for primary care docs (I would rate it pretty high)? We don’t have any problem coming up with such data in other “professional/executive” fields.
When I look at what it takes in terms of education and skill to become a licensed physician, I am quite disappointed in the relatively low value we put on them.
In models where physicians have been on straight salary (no kind of productivity incentive) the results have been what you would think — they stop working as hard. An acceptable model would be one where there is a base salary for a resident coming out of training (say $150k/year) which goes up over time with experience, AND the physician is paid extra for meeting production expectations (there needs to be a point of diminishing returns on that though to discourage rushing through and doing a poor job) AND paid extra for meeting whatever quality indicators are germane to their field.