Brian’s Note: Last week David Kibbe and I posted a Health Affairs Blog column, Trusting Government: A Tale of Two Federal Advisory Groups, that compared the openness and transparency of the Health Information Technology Policy Committee (HITPC) and the AMA’s RVS Update Committee (RUC), as a way of showing how the behaviors of each engender public trust or distrust in government. HITPC, a Federal Advisory Committee, advises the Office of the National Coordinator for Health Information Technology (ONC) on matters pertaining to the ARRA/HITECH legislation. The RUC has been CMS’ sole advisor for two decades on the value of medical services. As regular readers know, over the past year, we have been highly critical of CMS’ inappropriate reliance on the RUC, and believe this relationship has been a key driver of excessive health care cost.
RUC Chair Barbara Levy, MD responded with a comment that merited close examination, not only for its content, but because it recycled arguments that the AMA has used repeatedly in this discussion. Dr. Kibbe and I took the opportunity to return the volley in more detail. This post republishes her comment and then ours.
Barbara Levy, M.D, RUC Chair
Physicians serving on the RUC bring valuable experience to the complex process of describing the resources used in providing care to patients. The work of the RUC benefits the entire Medicare system and is done at no cost to taxpayers.
The truth is: The RUC is far from secretive. More than 300 attendees, including all types of physicians and representatives from Medicare, participate in typical RUC meetings. Information on the panel is publicly available, including at http://www.ama-assn.org/go/rbrvs.
The RUC has a strict conflict of interest policy for both those presenting to the RUC and for members. RUC members would recuse themselves from discussion or voting on any issue related to a potential conflict.
The RUC is an independent group of physicians from many different specialties, including those in primary care, which will have two new seats on the panel beginning this spring. This change will help the RUC continue to make recommendations to Medicare’s decision makers on the work physicians do to care for an aging population and those with chronic conditions. Adoption of RUC recommendations has resulted in $4 billion in annual increased payments for the services most commonly performed by primary care physicians.
David C. Kibbe, MD, MBA and Brian Klepper, PhD
We welcome Dr. Levy’s comments to our article, and we welcome open debate on these issues. As a RUC panelist since 2000, and now its Chair, Dr. Levy can be expected to protect the process. But given the seriousness of this issue and the RUC’s wide-ranging impact on America’s health care system, it makes sense to address her comments in order and place them in context.
For example, she notes in her comment that “The work of the RUC benefits the entire Medicare system and is done at no cost to taxpayers,” as though the RUC is an altruistic activity. But in a 10/27/12 interview by Joe Eaton of the Center for Public Integrity, published on Kaiser Health News, Dr. Levy is on the record as saying that it is really about each specialty panelist advocating for as big a piece of the Medicare pie as possible. “We assume that everyone is inflating everything when they come in. They are wanting to fight for the best possible values for their specialties.” This makes it clear that the RUC is not primarily about what is in the public interest, for example how best to achieve quality, safety, or equity of care delivery.
Nor are all specialties allowed to similarly volunteer their efforts, suggesting that the RUC is more about divvying up resources than about public service. While some specialities have had permanent seats, others have been denied participation. Those on the outside include the specialty of geriatrics, which focuses on health care for the elderly and which presumably would have something useful to contribute to a program dedicated to that population.
Her spin on the RUC’s secretiveness is also not entirely accurate. So 300 physicians and CMS representatives attend meetings, and information is available on the AMA’s site. But the RUC’s recommendations directly influence the distribution of public dollars, and the meetings’ proceedings are not available to the public. Here, from the AMA page that Dr. Levy linked to in her comment, is a clear acknowledgement that they’ll control the information:
“RUC participants, including members, advisors, staff, and other designated specialty society representatives, may access detailed and up-to-date information about the RUC process online. RUC participants must contact AMA staff to access the site.”
The RUC may have a conflict of interest policy and members may indeed recuse themselves on issues when they have financial relationships with outside interests. We don’t know for sure because no record of this is available to the public. But the facts remain that the RUC is fine with its members having those relationships, and that, in the black box of RUC processes, we’ll just have to take her word that they’re rigorous about preventing financial conflicts. Of course, a reciprocal question would ask why organizations would seek financial relationships with RUC panelists unless they have come to expect a quid pro quo.
Finally, we congratulate the RUC for voting to add two more primary care seats. But it is reasonable to suspect that this change in the panel’s makeup, which has occurred 20 years after the RUC’s formation and against a backdrop of significant recent public visibility and a legal challenge, might be more a political accommodation than a change of substance. After all, it would now mean that, instead of 2 of 29 members (7%), primary care represents 4 of 31 members (13%) of the RUC’s votes. In other words, the RUC can now argue that it is course correcting without needing to acknowledge that, in the real world, about 35% of physicians practice primary care, and so the panel still vastly under-represents them. Nor will the change in composition alter the balance of power between the RUC’s procedural and cognitive medicine physicians.
In other words, there is much more to Dr. Levy’s public arguments than she would have us know.
Perhaps more importantly, Dr. Levy’s comments do not address the primary argument of our blog post, which is that transparency and openness as required by the Federal Advisory Committee Act, and demonstrated by the behavior and accomplishments of the HIT Policy Committee that advises ONC/HHS, helps to create public confidence and trust in government process and resulting decisions. And that we are desperately in need of a government we can trust. And that the RUC serves as a counter-example which only underscores the need for transparency and openness.
That the AMA and the RUC are reforming some of the practices of RUC, as Dr. Levy says is happening, is a very good thing in our opinion. The RUC has served for two decades as a virtual sole-source federal advisory body, but has not been required to adhere to the public interest rules specified by the Federal Advisory Committee Act. It is critical that, going forward, whatever replaces it should be required to do so.
Care And Cost 
We can only expect comments like these made by Dr. Levy. Given the obvious lack of transparency and general smoke and mirrored approach I do not expect to have much substance come from this dialogue. If the RUC is to advise in an unbiased manner and with a focus on the “PUBLIC” good they need to reconstruct their advisory board completely. Get people with a variety of different interests and expertise and a focus on what will change this currently broken system. I commend those who fight for what is right and have the fortitude to take on organizations like the RUC who have shown little interest in the common good to provide less costly quality care. I do hold out hope that some day this will change, and know it is people like Klepper and Kibbe that will help pave the way.
What is the Alternative to removing the RUC — my thoughts
Did the RUC decide to destroy primary care physicians and dissuade students from pursuing the field? Hopefully not. But when faced with a budget neutral re-distribution, it seems they are willing to sacrifice primary care physicians and keep sub-specialists income at the desired level.
Any increase to primary care distributions would result in decrease in sub-specialists salary, decreased reimbursement to hospitals and tech companies who provide the procedure technology. It seems like billions could evaporate from the system by redistributing more generously to primary care physicians.
That should be a strong incentive for the government to redistribute more generously – a great way to sell this and remove the RUC. The RUC should remember that if they do not government themselves — someone will come along and govern them and they won’t like the outcome. so the RUC should be working every single day to seriously fix the plight of primary care physicians. There efforts should be tangible and well publicized
Apart from remove the RUC, another quick solution is to increase the pie ( reimbursement budget ) by identifying administrative waste, streamlining it and placing the saved funds in the reimbursement pie.
We can only expect comments like these made by Dr. Levy. Given the obvious lack of transparency and general smoke and mirrored approach I do not expect to have much substance come from this dialogue..