Adding Seats: The RUC’s Sleight of Hand

Paul Fischer and Brian Klepper

Posted 3/14/12 on The Health Affairs Blog

©2012 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

On February 1, the American Medical Association’s Relat ive Value Scale Update Committee (RUC), Medicare’s primary advisor on physician payment, announced the addition of two seats: a permanent one for geriatrics and a rotating one for primary care. The American Geriatrics Society and the American College of Physicians praised the move as a step forward that will amplify the RUC’s appreciation of their physicians’ contributions.

But the RUC’s maneuvers are a cynical sleight of hand. They attempt to assuage charges of sub-specialty bias while continuing the RUC’s sub-specialty dominance. The additions reduce proceduralists’ share of votes from 27 of 29 (93 percent) to 27 of 31 (87 percent), hardly a power shift. Primary care comprises about 35 percent of US physicians, but cognitive medicine would have only 13 percent of the votes.

Nor do the RUC’s changes address its opaque processes, shoddy scientific methods or conflicts of interest. In other words, by any practical measure, the RUC’s character and function remain unchanged. It still fails to meet the requirements of the Federal Advisory Committee Act, ensuring that regulation is formulated in the public rather than the special interest.

Most telling, the RUC has flip-flopped to justify its current position. Less than a year and a half ago, RUC Chair Barbara Levy, MD insisted that the RUC is an expert panel, not meant to be representative, so additional seats for groups like primary care and geriatrics were unnecessary. “The outcomes are independent of who’s sitting at the table from one specialty or another.”

Suddenly Dr. Levy has changed her tune. Now the RUC needs additional expertise.”Their experience will be particularly important as we continue to work on meeting the unique health needs of an aging population and improving care coordination for patients with chronic conditions.” Dr. Levy is admitting that, for 20 years, the RUC has operated with inadequate knowledge about primary care and geriatrics. (It is particularly damning that, despite Medicare’s senior focus, the RUC has refused to allow geriatrics’ participation until now.)

The RUC’s announcement also promised to make its proceedings more transparent by reporting the vote counts on its decisions. Again, this doesn’t change anything. Individual voters presumably won’t be identified, and past participants have openly described the “horse trading” that goes into valuation. Dr. Neil Brooks, a family physician who served for 4 years on the RUC, said, “If radiology presented a new set of codes that had to do with imaging procedures, there was a feeling that some people would go along with that if radiology would go along with other things.”

Over the past year, we and others have argued that the RUC’s serious flaws are at the heart of much that is wrong with the US health care system. We have shown that the RUC has systematically undervalued the work of primary care, while over-valuing expensive, high-tech, sub-specialty care. We have illustrated that the perverse economic incentives in current valuations undermine medical professionalism, are foundational to the American health care cost crisis, and have precipitated a crisis-level shortage in the primary care work force. Dr. Fischer and five primary care physician colleagues have sued HHS and CMS because these agencies’ sole source reliance on the RUC foresakes their responsibilities to the public interest.

Last June, the American Academy of Family Physicians (AAFP), which currently occupies a RUC seat,wrote Dr. Levy demanding that the RUC’s primary care’s representation be increased to more fairly reflect the real-world composition of practicing physicians. They recommended the elimination of 3 rotating seats now held by sub-specialty groups, the addition of 4 primary care seats (family medicine, pediatrics, geriatrics and osteopathy), and the creation of 3 “external representative” non-physician seats like patients, employers, health systems and health plans.

Last January, Drs. Klepper and Kibbe called for primary care societies to de-legitimize the RUC’s excesses by publicly quitting. Against the backdrop of the resulting lawsuit that challenged the RUC’s continuing role, and the AAFP’s challenge to bring the RUC more to rights, the RUC’s response tries to convey course correction while maintaining the same path. It remains dedicated to special interest excess. The courts and the AAFP should recognize this.

The RUC, through its relationship with CMS, has exploited America’s health care payment system for two decades, taking our economy to edge of a precipice. The AAFP Board will decide next month to walk or accept the RUC’s deception. If it keeps faith with its members, the AAFP will walk. If it doesn’t, its members should. The rest of us can only hope that the courts are not taken in.