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”

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”

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

Brandon Glenn

Published 4/30/13 in Medical Economics

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.

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The RUC, Health Care Finance’s Star Chamber, Remains Untouchable

Brian Klepper

Posted 2/1/13 on The Health Affairs Blog

BK PhotoOn January 7, a federal appeals court rejected six Georgia primary care physicians’ (PCPs) challenge to the Centers for Medicare and Medicaid Services’ (CMS) 20-year, sole-source relationship with the secretive, specialist-dominated federal advisory committee that determines the relative value of medical services. The American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC) is, in the court’s view, not subject to the public interest rules that govern other federal advisory groups. Like the district court ruling before it, the decision dismissed the plaintiffs’ claims out of hand and on procedural grounds, with almost no discussion of content or merit.

Thus ends the latest attempt to dislodge what is perhaps the most blatantly corrosive mechanism of US health care 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 health care’s commercial sector. Most important, this new legal opinion affirms that the health industry’s grip on US health care policy and practice is all but unshakable and unaccountable, and it appears to have co-opted the reach of law.

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How Primary Care Became the Job Nobody Wanted (and How To Fix It))

Brian Klepper

Posted 11/21/12 on Medscape Connect’s Care & Cost Blog

Here a link on SlideServe to my plenary presentation on CMS’ relationship with the AMA’s Relative Value Scale Update Committee (RUC), and how/why it has undermined American primary care. I delivered this overview at the Medical Home Summit in Philadelphia earlier this year.

Meanwhile, the team – led by Paul Fischer MD, a primary care physician in Augusta, GA – that sued CMS and HHS over their failure to require the RUC’s to adhere to the requirements of the Federal Advisory Committee Act is awaiting the appeal court’s ruling that will determine whether the case is at an end or whether it moves forward into discovery.

Given the seriousness and far-reaching impacts of the problem, it is shameful that America’s primary care medical societies have shrunk from supporting this action. In doing so, and in yearning to continue to align and participating with the AMA and the RUC, they have become complicit with them. They have not only compromised the primary care physicians who are their members, but ignored the much larger problems of patients who are too often put at unnecessary risk through care they don’t need, and purchasers – individuals, businesses and governments – who have been exploited for more than 2 decades with costs that are double those in other industrialized nations.

Strengthening Primary Care With a New Professional Congress

Brian Klepper

Posted 10/01/12 on Medscape Connect’s Care & Cost Blog

Three months ago a post on this blog argued that America’s primary care associations, societies and membership groups have splintered into narrowly-focused specialties. Individually and together, they have proved unable to resist decades of assault on primary care by other health care interests. The article concluded that primary care needs a new, more inclusive organization focused on accumulating and leveraging the power required to influence policy in favor of primary care.

The intention was to strengthen rather than displace the 6 different societies – The American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the Society for General Internal Medicine (SGIM), the American Academy of Pediatrics (AAP), the American Osteopathic Association (AOA), the American Geriatrics Society (AGS) – that currently divide primary care’s physician membership and dilute its influence. Instead, a new organization would convene and galvanize primary care physicians in ways that enhance their power. It would also reach out and embrace other primary care groups – e.g., mid-level clinicians and primary care practice organizations – adding heft and resources, and reflecting the fact that primary care is increasingly a team-based endeavor.

We have come to believe that a single organization cannot be serviceable. Feedback on the article suggested that several entities were necessary to achieve a workable design.

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