“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.
“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.”
With the recent release of two mainstream exposes, one in the Washington Post and another in the Washington Monthly, the American Medical Association’s (AMA) medical procedure valuation franchise, the Relative Value Scale Update Committee (RUC), has been exposed to the light of public scrutiny. “Special Deal,” Haley Sweetland Edwards’ piece in the Monthly, provides by far the more detailed and lucid explanation of the mechanics of the RUC’s arrangement with the Centers for Medicare and Medicaid Services (CMS). (It is also wittier. “The RUC, like that third Margarita, seemed like a good idea at the time.”)
For its part, the Post contributed valuable new information by calculating the difference between the time Medicare currently credits a physician for certain procedures and actual time spent. Many readers undoubtedly were shocked to learn that, while the RUC’s time valuations are often way off, in some cases physicians are paid for more than 24 hours of procedures in a single day. It is nice work if somebody else is paying for it.
Recently, the leaders of the American College of Physicians (ACP) and the American Geriatrics Society (AGS) lavished praise on the American Medical Association’s Relative Value Scale Update Committee (RUC) for announcing the addition of a rotating primary care seat and a permanent geriatrics seat, and for promising to post vote tallies. Welcoming these maneuvers indicates not only a poor understanding of history but also misguided political and strategic instincts that will continue to harm patients, purchasers, and primary care physicians.
Relative to their specialist colleagues, primary care physicians have been generally passive about the politics that shape their professional lives, and they have been big losers. It is important for them to consider whether their societies are genuinely acting in their interests. I believe the evidence overwhelmingly reflects poor judgment by the societies that has diminished primary care’s prospects and, more importantly, caused significant harm to patients and purchasers.
Over at the ACP Advocate Blog on Wednesday, ACP Senior Vice President of Governmental Affairs and Public Policy Bob Dohertytook me to task for asserting that the American Academy of Family Physicians is the only “pure” primary care society. He’s right, of course, in the sense that the American College of Physicians (ACP), the American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA) have done yeoman’s work in the past few years in promoting the value of primary care. He’s also right, and I stand corrected, on my statement that AAFP is the largest society. The information on Wikipedia shows that ACP has 130,000 members while AAFP has less at around 100,000.
Posted 1/25/12 on The Future of Family Medicine Blog
The numbers do not lie. As stated in a previous post and its referenced links, the payment gap between primary care and specialists has increased since the American Medical Assocation started the Resource-Based Relative Value Scale (RVS) Update Committee (“RUC”) in the early 1990s. It is difficult to separate the two when the Center for Medicare and Medicaid Services (“CMS”) has accepted over 90% of the RUC’s recommendations throughout the years. This can be interpreted in a number of different ways but let’s be honest – I am a current intern and do not have enough time to go through the different interpretations – I will leave that up to your comments.
Recently, 6 Georgia physicians led by Dr. Paul Fischer filed a lawsuit against CMS alleging that “CMS has violated federal law and the U.S. Constitution by using a panel of doctors’ recommendations (the RUC) when establishing values for Medicare-covered services.” The suit also claims that “the agencies have functionally treated the RUC as a federal advisory committee. But they have not required the RUC to adhere to the Federal Advisory Committee Act’s (FACA) stringent management and reporting rules – e.g., balanced representation, transparent proceedings, and scientifically valid analytical methodologies – that keep the proceedings in the public interest. The plaintiffs request injunctive relief, which would freeze the relationship between CMS and the RUC until the advisory group complies with FACA’s requirement.”
Last Thursday Anna Wilde Mathews of the Wall Street Journal ran an article detailing the activities surrounding primary care’s gradual awakening and mobilization. With Tom McGinty, Ms. Mathews authored a damning expose on the RUC last October that precipitated our efforts on against CMS’ 20 year reliance on the AMA’s RVS Update Committee (RUC) for valuation of medical services.
One of the main considerations in physician pay under CMS’ relative value system is the training required to complete a task. This is generally thought to be well understood but is, in fact. a quagmire of controversy.
Take for example the specialty of family medicine compared with dermatology, anesthesiology, or ophthalmology. Family physicians make between 1/2 and 1/3 of what these other specialties make, so one would think that there is a huge training difference. The truth is that each of the four require 16 years before medical school, 4 years of medical school, and 3 years of residency. The 3 highly paid fields require 1 additional year in a transitional internship. So the family physician education represents 23/24 or 96% of the length of education required for the others. Since when is a 4% investment worth a 200% to 300% return?
The old doctors know. The practice of medicine has changed in a very basic way over the last 20 years. Physician relationships have lost their civility and have been replaced by a level of tension that takes the fun out of collegial interactions. I remember my first year of family medicine as the only doctor in Weeping Water, Nebraska. My personal medical community had gone from an entire medical school campus with limitless lectures and many physicians to share in “interesting cases” to an occasional phone call with a consultant in Omaha. These contacts became my primary source for medical education and updates for Weeping Water’s health care. The phone calls were collegial, respectful, and focused on what was best for my patients.
Last October, the Wall Street Journal ran a damning expose about the Relative Value Scale Update Committee (RUC), a secretive, specialist-dominated panel within the American Medical Association (AMA) that, for the past two decades, has been the Centers for Medicare and Medicaid Services’ (CMS’) primary advisor on valuation of medical services. Then, in December, Princeton economist Uwe Reinhardt followed up with a description of the RUC’s mechanics on the New York Times’ Economix blog. We saw this re-raising of the issue as an opportunity to undertake an action-oriented campaign against the RUC that builds on many professionals’ work – see here and here – over many years.
In a recent Wall Street Journalarticle, Barbara Levy, Chairwoman of the Relative Value Scale Update Committee (RUC), commented on the American Medical Association’s (AMA’s) decision to have minimal primary care participation on the RUC, saying the committee is an “expert panel” and not meant to be representative. Since the committee is made up of 27 specialists, one family doc, and a pediatrician, the AMA apparently believes it requires little in the way of primary care expertise but lots of experts from every minute surgical specialty.
This is, of course, reflected in the AMA’s coding system. Most of primary care is condensed into four Evaluation and Management (E/M) codes: a “focused” encounter, an “expanded” encounter, a “detailed” encounter, and a “comprehensive” encounter (99212-99215). It does not matter whether the problem is a cold or an acute myocardial infarction. It does not matter if you worked with just the patient or the entire family spanning three generations. It does not matter if the problem was simple and common (eg, essential hypertension) or rare and complex (eg, pheochromocytoma). It does not matter whether you completed everything in a single visit or spent hours fighting with an insurance company for payment. And it does not matter whether you dealt with a couple of well-established problems or a dozen new ones. It is clear that the AMA has little expertise in this area. What is amazing is that they think they have enough!
An under-the-radar revolution is going on out there. It is a revolt of primary care physicians against the AMA and CMS. It is a request for parity with specialists. It is a movement to replace how primary care practitioners are paid.
Why the revolt against the AMA and CMS? Because primary care doctors yearn to correct myths about primary care vis-à-vis specialists, and because they believe, by altering how the AMA and CMS pay doctors, health costs can be brought down, and primary care can be re-invigorated. Health systems with a broad primary care base have lower costs. In the U.S., two-thirds of doctors are specialists, and one-third are in primary care, the reverse of most nations, which have 50% or lower costs.
After an exciting and challenging day of caring for patients and teaching students, a third-year medical student on his family medicine rotation says to me, “I really like what you do, but I just cannot afford to go into family practice.” I realized that by “afford,” he was referring not only to finances but also to the expectations of his parents, friends, and medical school. After spending 35 wonderful years as a family doctor, I have been “dissed’ by a kid who wants to become a dermatologist.
So I am of two minds. Part of me is fulfilled by being needed, loved, and respected by my patients.
If you agree with this letter, please redistribute, particularly to other primary care physicians.
As many of you know, we have developed an effort to shine a bright light on the Relative Value Scale Update Committee, or RUC. A new site, Replace the RUC, provides a wealth of expert background information, and we’re working now to get more visibility on this issue.
A specialist-dominated panel within the AMA, the RUC is little known and under-appreciated, but extremely powerful and opaque. More important, through its longstanding relationship with CMS, it is central to the explosion in health care costs over the past 20 years, why primary care physicians are paid so poorly compared to their specialist colleagues and why few medical students now choose to enter primary care as a career. Meaningfully address the RUC, and you relieve America of more health system waste than all the cost control measures in the health care reform law combined.
Earlier this week, a comment arrived on a new site I developed to promote ending CMS’ cozy relationship with the RVS Update Committee (RUC). The RUC is the AMA’s specialist-dominated panel that has distorted the value of health care services, been most responsible for strangling primary care and driven the health care cost explosion.
It was from a physician responding to the article “Replace the RUC,” which tried to place the rationale and approach for this effort within a larger context. It urged primary care physicians to read up on the RUC’s background, and then demand that their societies publicly abandon it. He said:
Thank you, thank you, thank you.
This is exactly what many of us felt the AAFP should have done 15 years ago. The willingness of the primary care societies to continue to participate in the AMA’s intentional destruction of primary care must be some strange variant of the Stockholm syndrome!