The RUC (Again): Is there a Light at the End of the Tunnel? A Conversation with Brian Klepper

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David Harlow

Posted August 13, 2013 on HealthBlawg

Tunnel of Light TJ Blackwell Flickr CC http://www.flickr.com/photos/tjblackwell/3362987463/

dharlow-headshot-0210-60kb-2Recently, there were a couple of breathless articles about the RUC (Relative Value Scale Update Committee) published in The Washington Post and The Washington Monthly, reporting as news the state of affairs that has prevailed for years in the realm of re-setting the relative values of physician services annually for purposes of the RBRVS — which is at the heart of the Medicare Physician Fee Schedule (MPFS) and which affects physician reimbursement well beyond Medicare, since the RBRVS is used as a touchstone in determining payment levels under commercial payor agreements as well.

I thought this confluence of publications was a good excuse to call up Brian Klepper, who is an expert critic of the RUC, to discuss the latest stories and talk about the prospects for meaningful reform.

Have a listen to our conversation (about 30 minutes long):

Brian Klepper on RUC HealthBlawg Interview with David Harlow 07262013

Brian Klepper – RUC – HealthBlawg

A transcript is appended to this post.

As detailed in our conversation, the RUC is a committee of the American Medical Association, and it operates behind a veil of secrecy. When it issues its annual update recommendations, CMS generally accepts the recommendation, and promulgates the update as a rule: the annual MPFS rule. The RUC is dominated by specialists, so the system tends to overvalue procedures and to undervalue “cognitive” services, or primary care.

Continue reading “The RUC (Again): Is there a Light at the End of the Tunnel? A Conversation with Brian Klepper”

Why Congress Should Pass The Accuracy In Medicare Physician Payment Act

Brian Klepper and Paul Fischer

Posted 8/09/13 on The Health Affairs Blog

ALP_H_BK_0010Paul FischerWith 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.

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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”

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.

Rethinking the Value of Medical Services

Brian Klepper and David C. Kibbe

First posted 8/1/11 on The Health Affairs Blog

Copyright ©2011 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

One of American politics’ most disingenuous conceits is that health care must cost what we currently pay. Another is that the only way to make it cost less is to deny care. It has been in industry executives’ financial interests to perpetuate these myths, but most will acknowledge privately that the way we value and pay for medical services is a deep root of America’s health care cost explosion.

When the Resource-Based Relative Value Scale (RBRVS) became the framework for Medicare payment nearly twenty years ago, it equated a medical service’s “value” with four categories of physician work inputs: time, mental effort and judgment, technical skill and physical effort, and psychological stress. The assessment process, handled from the outset by the American Medical Association’s (AMA) secretive, specialist-dominated Relative Value Scale Update Committee (RUC), delineates and quantifies a service’s inputs in terms of its Relative Value Units (RVUs) which, with a monetary multiplier, define its worth.

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Dealing Strategically With the RUC to Boost Family Physician Payment

Lori Heim

First posted 7/13/11 on AAFP News Now

Brian’s Note: Regular readers will recall that in January, David C. Kibbe and I wrote a piece calling on America’s primary care societies to quit the RUC, the secretive, specialist-dominated AMA committee that has been the sole advisor to CMS on medical services valuation and reimbursement for the past 20 years. It is not unreasonable to assert that the RUC’s relationship with CMS is one of the deep roots of America’s health care cost crisis, an extraordinarily destructive mechanism that has had severely negative impacts on patients, purchasers and, of course, primary care physicians.

The AAFP initially rejected our suggestion, but has thought better of it over time. As Dr. Heim describes in this explanation to AAFP’s members, they issued a series of requests to the RUC: more primary care seats, a permanent seat for Gerontology, the sunsetting of some rotating sub-specialty seats, and the addition of some non-physicians (e.g., consumers, purchasers, health economists) to the committee. Obviously, the real question remaining is whether, if the RUC rejects these changes, the AAFP Board will have the will to walk.

All that said, her comments below are a good description of how they’re approaching this very complicated set of dynamics. 

Lori J. Heim, M.D., F.A.A.F.P.

Improving payment for the cognitive services we family physicians provide is, undoubtedly, the most crucial and challenging issue the Academy must resolve. The payment disparity between primary care and procedural specialties undermines every family physician who struggles to redesign and improve his or her practice in this economy, and it also drives medical students away from primary care.

The Academy has been working on many fronts to rectify this payment disparity. One important part of that effort is to make sure CMS receives recommendations on the relative values of CPT codes from experts who understand primary care. Unfortunately, that’s not happening now to the extent necessary. The only body making recommendations to CMS is the AMA/Specialty Society Relative Value Scale Update Committee, commonly called the RUC.

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Why Primary Care Needs A New Organization

Paul M. Fischer

First published on 6/15/11 on MedPage Today

A few weeks ago, the Board of the American Academy of Family Physicians (AAFP) announced that, for now, it would continue participating in the Relative Value Scale Update Committee (RUC), the secretive American Medical Association committee that, through a longstanding relationship with the Centers for Medicare and Medicaid Services (CMS), has heavily influenced physician reimbursement.

At nearly the same time, Medicare announced that it will go broke in 2024, a decade sooner than expected and only 13 years away.

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