28 November 2007

Ranting on the RUC

(Cross-posted with my other blog at MedPage Today)
Over at DB's Medical Rants, rcentor comments on the machination of the RUC, also known as the "RBRVS Update Committee" and the way in which it has skewed and poisoned the medical reimbursement system, as documented in a recent JAMA article.

I couldn't agree more, and wish this issue would get more attention.

I have some experience with the RUC via the ACEP Reimbursement Committee, and while I have been pleased to some degree by the facility with which the representatives of Emergency Medicine have worked within that milieu, on the basis of self-interest, I can't stand the way in which it is structured and works.

Key points from the cited JAMA Article:

Medicine's generalist base is disappearing as a consequence of the reimbursement system crafted to save it—the resource-based relative value scale. The US physician workforce is unique among developed economies of the world. Virtually all European countries have a broad generalist foundation comprising 70% to 80% of practicing physicians. The United States is the opposite. [snip]

This problem will only be resolved with full recognition of its origins. Because physician decision making profoundly influences health care expenditures,11 the forces that affect these decisions must be addressed. Practice type and physician specialty are critical factors; both are associated with higher rates of test ordering and hospitalization. Generalists with long, continuous clinical relationships with patients tend to generate lower health care costs for their patients. Current reimbursement incentives substantially favor procedures and technical interventions and offer financial advantages for expensive care, thereby encouraging specialty services. [snip]

The American Medical Association (AMA) sponsors the resource-based relative value scale update committee (RUC) [...] The RUC has 30 members (the chair only votes in case of a tie) with 23 of its members appointed by "national medical specialty societies." Meetings are closed to outside observation except by invitation of the chair. Only 3 of the seats rotate on a 2-year basis. Other members have no term limits. Seventeen of the permanent seats on the RUC are assigned to a variety of AMA-recognized specialty societies including those that account for a very small portion of all professional Medicare billing, such as neurosurgery, plastic surgery, pathology, and otolaryngology. Proceedings are proprietary and therefore are not publicly available for review. Traditionally, more than 90% of the RUC's recommendations are accepted and enacted by CMS. [...] The resource-based relative value scale system "defies gravity" with the upward movement of nearly all codes. In 2006, based on RUC recommendations, CMS increased RVUs for 227 services and decreased them for 26. [snip]

By creating and maintaining incentives for more and more specialty care and by failing to accurately and continuously assess the practice expense RVUs, the decisions of CMS have fueled health care inflation. Doing so has affected the competitiveness of US corporations in the global market by contributing to years of double-digit health care inflation that have consistently increased the costs of manufacturing and business in the United States over the last decades.

The continued and sustained incentives for medical graduates to choose higher-paying specialty careers and for those physicians in specialty careers to increase income through highly compensated professional activities have been associated with the dwindling of the generalist workforce. The lack of incentives for medical graduates to choose generalist careers in internal medicine, family medicine, and pediatrics has had a profound effect on the workforce mix and, ultimately, US health care expenditures.

Residents are choosing not to enter the generalist fields. For instance, among first-year internal medicine residents, less than 20% have interest in pursuing careers in general internal medicine. Past trends indicate that only slightly more than half of these residents continue this commitment to general internal medicine to the completion of residency. If this continues, as few as 10% of those training in internal medicine will to work as general internists.

There's more, and I encourage those of you with access to read the full article.

I have blogged in the past about the perversity of the reimbursement system and the way it inappropriately rewards procedural services over cognitive services. It makes me crazy that I get paid more for stitching up a minor facial laceration than I do for deciding whether your chest pain is an impending heart attack. (CPT 12052 (laceration) = 4.37 RVU; 99285 (E/M) = 4.01 RVU) Several other excellent health care bloggers have opined, some extensively, on the same topic.

I don't take much issue, as does rcentor, in the relative secrecy of the RUC. My experience is that horse-trading like this is something best done behind closed doors. We don't expect GM and the UAW to open their negotiations to the public, and in the same vein, I would not expect the inter-specialty wrangling to be aired publicly. What I do take issue with is the composition of the committee, which I see as the key driver of weighting towards specialty services and procedures.

As noted above, the RUC is to a very large degree dominated by specialists. There is, I am reliably told, an informal alliance between the procedure-based specialists, which would include surgeons (General, Thoracic, Ortho, Spine, Neuro, Urology, Plastics, Optho, ENT, OB/GYN) and "medical specialists" who derive much of their revenue from procedures (cardiology, radiology, anesthesiology, dermatology). Together these specialties control about 60% of the seats allocated to medical specialty societies. The primary care specialties, in contrast, control only 13% or three votes (Internal Med, Family Med, and Pediatrics). (Four, if you count Emergency Medicine, which is naturally aligned with primary care.)

Notable in the compostion of the RUC is the inclusion of most of the surgical sub-specialties, and almost complete exclusion of the medical ones. Oncology, Neurology, and Pulmonary are there, and not a single other medical specialty is represented. Neither is there any proportionality to the representation. The 6,000-member American Society of Plastic Surgeons has the same amount of influence as the 124,000-member American College of Physicians.

In a self-serving game of "you scratch my back," the proceduralists support the inflated work values of one another's new procedures, and as the values float further and further higher over time, and as the number of procedures grows, the value of office-based or cognitive services diminishes in relation. And as there is only one pie to split up, the slice of the pie that goes to primary care shrinks and shrinks. Now we are at the crisis point. Primary care as currently practiced is no longer economically sustainable, and medical school graduates see this and make a rational choice to pursue more remunerative careers.

Sadly, I don't see this changing unless there is a major revision to how the RVU system is determined, and I fear that the established players are well-enough entrenched that they will be able to derail any meaningful reform. This is an arcane enough issue that it's hard to explain to the policy-makers, and those whose income would be threatened by changes will predictably object and confuse the issue enough to obstruct the changes. But at least this topic is beginning to gain attention and traction at a national level, and maybe, just maybe, this might be a small first step on the road to reform.

2 comments:

  1. in discussing the composition of the ruc, you neglect to include cardiology as a subspecialty of internal medicine. i wonder if at the time the committee was composed if the neurology and dermatology (and possible anesthesiology) were considered to represent internal medicine as well.
    in any case, addressing the makeup of the committee may help make primary care feel better, but i am unsure of whether it addresses the more pressing issue (imo) regarding reimbursement for all physicians.

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  2. anyone can do what an internal medicine doc does. it isnt special. it should be completely standardized as if it were a cookbook.

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