Dealing Strategically With the RUC to Boost Family Physician Payment

Lori Heim

First posted 7/13/11 on AAFP News Now

Brian’s Note: Regular readers will recall that in January, David C. Kibbe and I wrote a piece calling on America’s primary care societies to quit the RUC, the secretive, specialist-dominated AMA committee that has been the sole advisor to CMS on medical services valuation and reimbursement for the past 20 years. It is not unreasonable to assert that the RUC’s relationship with CMS is one of the deep roots of America’s health care cost crisis, an extraordinarily destructive mechanism that has had severely negative impacts on patients, purchasers and, of course, primary care physicians.

The AAFP initially rejected our suggestion, but has thought better of it over time. As Dr. Heim describes in this explanation to AAFP’s members, they issued a series of requests to the RUC: more primary care seats, a permanent seat for Gerontology, the sunsetting of some rotating sub-specialty seats, and the addition of some non-physicians (e.g., consumers, purchasers, health economists) to the committee. Obviously, the real question remaining is whether, if the RUC rejects these changes, the AAFP Board will have the will to walk.

All that said, her comments below are a good description of how they’re approaching this very complicated set of dynamics. 

Improving payment for the cognitive services we family physicians provide is, undoubtedly, the most crucial and challenging issue the Academy must resolve. The payment disparity between primary care and procedural specialties undermines every family physician who struggles to redesign and improve his or her practice in this economy, and it also drives medical students away from primary care.

The Academy has been working on many fronts to rectify this payment disparity. One important part of that effort is to make sure CMS receives recommendations on the relative values of CPT codes from experts who understand primary care. Unfortunately, that’s not happening now to the extent necessary. The only body making recommendations to CMS is the AMA/Specialty Society Relative Value Scale Update Committee, commonly called the RUC.

From its inception in 1991, the RUC has been dominated by procedural specialties whose representatives don’t fully understand the complexity of the cognitive services we provide. They also have a financial interest in keeping the values for procedural services high.

Furthermore, although the RUC’s methodology functions well when it comes to valuing one procedural code against a similar one, the methodology is flawed when comparing cognitive services with procedural services. The methodology also values our evaluation and management, or E&M, visits the same as the E&M visits of other specialties, not taking into account the multiple comorbidities we typically deal with in our patients.

As a result, the RUC often undervalues our cognitive services while leaving overvalued procedures alone — an ongoing disaster for us in the Medicare fee-for-service system. Since fee-for-service will be at least a part of how we’re paid for some time to come, this has to change. 

TWO-PRONGED POLICY

For several years, Academy policy on the RUC has called for two approaches. One approach is to reform the RUC itself with changes that include increasing the number of primary care seats; adding seats for external groups, such as consumers and employers, who would bring voices the RUC needs to hear; and instituting voting transparency for RUC members, who currently vote in secret.

STORY HIGHLIGHTS

But even if the RUC were reformed, it would still be limited because of the methodology it employs. Therefore, the second approach in our policy is to advocate creation of an alternative, multistakeholder advisory group to provide recommendations to CMS in concert with the recommendations from the RUC.

We’ve been open about our concerns with the RUC, working persistently through our RUC representatives and talking with AMA and RUC leaders to recommend solutions. We even wrote to CMS last year, urging changes in the RUC and the establishment of an alternative advisory group.

But we shifted strategy and went very public with our concerns on June 10, when we sent the RUC a letter outlining the changes we want and, for the first time, setting a deadline for a decision — March 1, 2012. We also issued a statement to the media about our letter.

THINKING STRATEGICALLY

Your Board of Directors thought long and hard before taking this bold new step. Some members and chapters, as well as some outside thought leaders, have called on the Academy to leave the RUC, and we’ve discussed this and other options for several years. Each time, we decided to remain in the RUC to keep pushing for change, with periodic reassessment of our participation.

In May, Board members discussed the situation in depth again. We were frustrated that our efforts weren’t getting traction within the RUC, even though the public and policymakers increasingly understood the payment disparity’s terrible implication for primary care. We knew that withdrawing from the RUC would be a dramatic gesture, but we kept coming back to this question: How would withdrawing advance our long-term strategy to improve payment for family physicians?

We knew that withdrawing would leave us with no way to keep pushing the RUC to change. For example, we were glad to support the bill recently introduced by Rep. Jim McDermott, D-Wash., that would require CMS to hire independent contractors to augment the RUC’s work, but the bill would do nothing to change the RUC itself. Furthermore, although withdrawing from the RUC might focus more attention on the bill, we weren’t optimistic about the bill’s chances in the Republican-controlled House.

We carefully discussed all of this during our May meeting and took the additional step of consulting with outside policy leaders and researchers to get their input.

In the end, we decided that withdrawing without sending the RUC a formal request for change would not benefit AAFP members. Our June 10 letter was that formal request.

THE SECOND FRONT

In that letter, we also apprised the RUC of a separate but related action the Board took in May. The Board decided it was time to act on our second policy approach to the RUC problem. We funded the creation of a task force to explore the development of alternative methods for valuing primary care services in the current fee-for-service model. In addition to representatives from the AAFP, the task force will include representatives of other primary care groups, health policymakers, researchers, consumers and employers.

I am chairing that task force, and I’m glad to report that everyone we’ve asked to participate has responded with enthusiasm. All task force members have now been identified, and we’ll announce their names shortly. We’ll also hold our first meeting in August.

The task force will submit its recommendations to the AAFP Board within the next six to nine months, and we anticipate sharing them with CMS for its consideration. We’ve already met with the CMS administrator and his senior leadership team to discuss the task force, and they were very supportive of this direction. As a matter of fact, CMS observers will attend task force meetings in order to understand the thinking behind the recommendations when they receive them.

SHARING YOUR OPINION

In closing, I’d like to encourage you to share your opinion about the RUC. If the RUC refuses to change, should the AAFP remain involved, or withdraw? Either way, there are ramifications for family doctors.

One good way to share your thoughts is to discuss them with your chapter leaders, because chapters let us know what their members are saying about the RUC.

After the RUC responds to our letter, your Board will once again discuss our continued participation in that body. Your opinion will help us as we move forward.

Lori Heim, MD is Board Chair of the American Academy of Family Physicians.