The RUC Is Bad Medicine: It Has To Go

Brian Klepper

Posted 8/12/13 on Medscape Business of Medicine

BK 711“One of the biggest mistakes we made … is that we took the RUC … back in 1992 and gave it to the AMA. … It’s incredibly political, and it’s just human nature…the specialists that spend more money and have more time have a bigger impact.”

This was Tom Scully, former Bush II Administrator of the Centers for Medicare and Medicaid Services (CMS), previously the Health Care Finance Administration (HCFA). He was a panelist in a May 10, 2012 Senate Finance Committee RoundTable discussion by former HCFA/CMS Administrators and has become one of the RUC’s most outspoken critics. He was explaining how the American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC), a group that asked if it could help the government by overseeing a valuation process for medical services, came to dominate and distort the pricing used in Medicare, Medicaid and commercial health plans.

Mr. Scully echoed this sentiment recently.

“The idea that $100 billion in federal spending is based on fixed prices that go through an industry trade association in a process that is not open to the public is pretty wild. … Having the AMA run the process of fixing prices for Medicare was crazy from the beginning.”

Gail Wilensky, HCFA Administrator under Bush I, was wistful. “It happened innocently enough.”

It is remarkable and compelling to hear these federal health program ex-stewards express regret about a fiasco they had a hand in. Their “mea culpas” are almost palpable. Mr. Scully, in a recent Washington Post video interview, gave a quick aside, “It’s partially my fault.”

Continue reading “The RUC Is Bad Medicine: It Has To Go”

Response To RUC Chair Barbara Levy’s Comment on the Health Affairs Blog

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.

Continue reading “Response To RUC Chair Barbara Levy’s Comment on the Health Affairs Blog”

Trusting Government: A Tale of Two Federal Advisory Groups

David C. Kibbe and Brian Klepper

Posted 2/2/12 on the Health Affairs Blog

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

Americans increasingly distrust what they perceive as poorly run and conflicted government. Yet rarely can we see far enough inside the federal apparatus to examine what works and what doesn’t, or to inspect how good and bad decisions come to pass. Comparing the behaviors of two influential federal advisory bodies provides valuable lessons about how the mechanisms that drive government decisions can instill or diminish public trust.

Continue reading “Trusting Government: A Tale of Two Federal Advisory Groups”

A Legal Challenge to American Health Care’s Payment System

Late yesterday afternoon, six primary care physician from Augusta, GA filed suit in a Maryland federal court against HHS Secretary Kathleen Sebelius and CMS Administrator Don Berwick. Here is the press release associated with the filing.

Contact: Melody Collins                                                              FOR IMMEDIATE RELEASE

706-922-8242, mcollins@cpcfp.com

GEORGIA PRIMARY CARE PHYSICIANS SUE MEDICARE AGENCY

Government’s AMA RUC Relationship Illegal, Hurts Primary Care, Wastes Medicare Dollars

Six physicians from the Center for Primary Care in Augusta, GA, have filed suit in a Maryland federal court against HHS Secretary Kathleen Sebelius and CMS Administrator Donald Berwick, charging that the payment system arising from their agencies’ longstanding relationship with the American Medical Associations’ specialist-dominated Relative Value Scale Update Committee (RUC) is illegal, compromising primary care physicians’ abilities to ensure the best care possible, driving up cost and harming their financial interests.

The suit alleges that, for nearly 20 years, HHS and CMS have let the RUC, their primary advisor on physician payment, evade the Federal Advisory Committee Act’s requirements for representation, transparency, and methodological rigor. Kathleen Behan, the physicians’ lead counsel, said, “We’re filing this suit to bring America’s physician payment system into accord with law.” The plaintiffs seek injunctive relief that would freeze the relationship until the agencies comply.

The suit notes that the RUC has systematically overvalued many specialty procedures while undervaluing primary care. CMS has historically accepted more than 90 percent of their recommendations. The resulting higher income for specialist physicians has discouraged medical students from primary care, explaining the US shortage of generalist physicians. Worse, as Medicare reimbursement has dwindled, visit times have shortened while patients’ medical concerns have mushroomed and intensified. Plaintiff Rebecca Talley MD noted, “By favoring procedural over cognitive work, the RUC has made general medicine unappealing to our youngest colleagues, created mistrust between doctors and confused patients about who has their best interests in mind.”

While the suit must show the payment system’s harm to primary care physicians, it also hurts patients, purchasers and the larger American economy. Paul Fischer, MD, who spearheaded the group’s effort, said “Medicare lets a financially-conflicted AMA committee set physician pay, stifling primary care while promoting the overuse of expensive procedures that often provide little value. It threatens affordable care as well as the federal budget. We decided to challenge this.”

An article in The Hill quotes a RUC spokesperson as saying that “any increase in Medicare payments for primary care doctors will hurt specialists.”

The doctors have financed the suit themselves, for the sake of the public interest. Supporters can learn more and contribute to the legal defense fund at Save Primary Care.