Why Aren’t Primary Care Physicians More Ticked off about the RUC? An Interview with Brian Klepper

If primary care physicians have a bigger enemy than the RUC, Brian Klepper, PhD, hasn’t heard about it.

The American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC) is a 31-physician panel that wields enormous influence with the Centers for Medicare & Medicaid Services (CMS) in setting the relative values of medical procedures, which are then used to determine reimbursement levels. CMS has historically accepted about 90% of the panel’s recommendations.

Klepper is arguably the RUC’s most outspoken critic, thanks to his Replace the RUC blog. He charges that the RUC is subspecialist-dominated and as a result has played a prominent role in subjugating primary care – holding down primary care physicians’ salaries while contributing to the frantic, hamster-wheel-like feel of today’s primary care practices that are forced to pack each day with wall-to-wall 15-minute patient visits to turn a decent profit.

Klepper has written widely on the RUC, and blasts the panel a “perhaps the most blatantly corrosive mechanism of U.S. healthcare finance, a star chamber of powerful interests that, complicit with federal regulators, spins Medicare reimbursement to the industry’s advantage and facilitates payment levels that are followed by much of healthcare’s commercial sector.”

Klepper is a healthcare analyst, author and speaker. He’s chief development officer with Florida-based We Care TLC, a company that operates primary care clinics for employers and health plan sponsors. In the Q&A below, Klepper discusses how the RUC harms primary care physicians, and what they can do about it.

Q: Why do you think more primary care physicians aren’t angry about the RUC?
A: They are demoralized as a group. Primary care doctors have their heads down and are running as fast as they can to care for their patients. Most probably have never heard of the RUC, are unaware of how the system came to be stacked against them, and doubt that they can do anything about it.

Q: How do you believe the RUC has most harmed primary care physicians?
A: First, the RUC’s greatest harms have fallen most on patients, then purchasers, then primary care physicians. The RUC, effectively an AMA lobbying group that, with the complicity of CMS, controls a key element of reimbursement policy, has over-valued specialty services and dramatically undervalued primary care, so much so that an ophthalmologist extracting cataracts and inserting an intraocular lens – arguably less complicated care than figuring out what’s going on with moderately complex primary care patients – earns 12.5 times a primary care physician’s (PCP) hourly rate. But most importantly, by driving down primary care’s reimbursement, it has forced shorter primary care visits, which make managing complexity more difficult, severely compromising primary care practice and opening a more direct patient pathway to lucrative downstream services. Primary care-to-specialist referrals have more than doubled in the past decade, distorting practice patterns and fueling an explosive systemic cost increase.

Q: You’ve called for the creation of a new primary care society. Why do you believe the existing societies like AAFP and ACP don’t adequately represent the interests of primary care doctors?
A: Primary care societies’ leaders are political animals who, certainly in the case of the RUC, demonstrated greater interest in placating the AMA than representing the interests of their members. Primary care physicians comprise more than one-third of all doctors, but they’re fragmented into seven different societies, most of which also represent subspecialists, and so have conflicted loyalties. So part of primary care’s ineffectiveness on the stage of power is due to its insistence on a diluted power structure. They could enhance their influence by having all primary care professionals – including non-physicians – and their current societies come together into a larger Congress. They should also recognize that their strongest potential ally is the business community that pays for more than half of healthcare and seeks greater value.

Q: At Medical Economics, we often hear from doctors who are frustrated with the government for intruding on the practice of medicine, but to me that anger seems largely misdirected. Your writing suggests to me that that anger would be more appropriately directed towards specialty societies, drug and device firms and hospitals that grab a bigger share of healthcare dollars. Is that a fair reading of your work?
A: The data are compelling that the health care industry is pulling the larger U.S. economy off a cliff. The industry’s most powerful tool has been the capture of law and regulation through lobbying. A recent RAND study showed that more than four-fifths of household income growth is now siphoned off by healthcare. We pay double for healthcare what other developed nations do, because the system has been structurally steered to get that result, with benefit that accrues to healthcare interests. This is the greatest current threat to our national economic security.

Q: What steps could potentially allow primary care to recapture its value to the American health system?
A: All primary care professionals must galvanize and mobilize to begin to serve as a counterweight to rest of the healthcare industry’s influence. It’s important to systematically promote primary care’s economic impact and value and to convey the role that primary care must play as a solution to the healthcare cost crisis and the U.S. budget crisis. To leverage your value, though, you must align with the nation’s largest and most influential group – nonhealthcare business leaders – to ensure that they understand that a system that subverts primary care cannot become more efficient. Develop the organizational capacity to manage clinical and financial healthcare risks that are beyond the capabilities of primary care. And advocate, in policy and the market, for approaches that promote value in healthcare.