27 October 2010

Some sunlight on the corruption of the RUC

Interesting article (front page!) in the WSJ today about the RUC:

Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars.

The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement. [...]

The RUC, as it is known, has stoked a debate over whether doctors have too much control over the flow of taxpayer dollars in the $500 billion Medicare program. Its critics fault the committee for contributing to a system that spends too much money on sophisticated procedures, while shorting the type of nuts-and-bolts primary care that could keep patients healthier from the start—and save money.

I'm glad to see the RUC getting some much-needed scrutiny, and skeptical scrutiny at that. But they miss the point with the "fox watching the henhouse" angle, or at least they paint with too broad a brush. "Doctors" are not a monolithic group, and it is those subdivisions that make the RUC such a dangerous agency.  The author manages to touch on the critical dysfunction here:

"This system pitted specialty against specialty, surgeons against primary care," says Frank Opelka, a surgeon and former RUC alternate member who is vice chancellor at Louisiana State University Health Sciences Center in New Orleans.

Primary-care groups have pushed for more representation on the committee, and their leaders have argued its results are weighted against their interests. 

Dr. Levy says the committee is an expert panel, not meant to be representative, adding: "The outcomes are independent of who's sitting at the table from one specialty or another."

I believe is where one would feign a coughing spell and blurt "bullshit!" into your hand. While the theory is that the members are there as RUC members, the reality is that every specialty lucky enough to have a seat on the RUC leverages that seat as an opportunity to advocate for the economic interests of their specialty.  The general surgeons are famous for sending a team of lobbyists, lawyers and (really) healthcare economists to make sure the RUC does not make any changes that would undermine the income of surgeons. (And yes, ER docs also have representation, though they bring a less impressive posse, and they do advocate for EM-related services to be up-valued.) This is referenced in the (oddly unlinked) accompanying article, where primary care physicians recounted an epic battle from a few years ago:

At one point, the debate reached such an impasse that J. Leonard Lichtenfeld, who represented the American College of Physicians, and at least one other RUC member, Tom Felger, who represented family physicians, actually came close to ending their involvement in the talks, and asked for a break in the meeting, according to both men. They felt a surgical faction was blocking their push, they say.

"I was willing to leave the negotiations," Dr. Lichtenfeld says. "I felt that we were being stonewalled for economic reasons."

On the other side, surgical groups had argued there wasn't strong evidence that visits with patients had gotten more difficult. "There were some bitter feelings," says John O. Gage, who represents the American College of Surgeons on the panel.

This touches on an arcane point of procedure the RUC utilizes: a code is assumed to be correctly valued unless it can be shown the amount of work involved in that service has changed. So you are not allowed to claim that the codes are fundamentally imbalanced or misvalued or that the effects of the current valuation are undesirable as a matter of policy. You have to contort yourself to make the case that somehow what you do has gotten harder, that it is different from what it was five years ago. At least that's what you have to do to increase a code's value. They rarely go down in value, despite the (nicely documented in the article) fact that surgical procedures reliably require less work as time goes on and technology/practice make them easier to perform. So the effect is that surgical procedures are even more overvalued than they were to begin with. It's also telling that the RUC relies on self-reporting surveys of doctors to determine the work that goes into a particular code. I frequently get these surveys that tell me that how I answer this survey may impact how much I get paid for this service in the future, so how much work is this service: a little, a lot, or a super-lot? The validity of these surveys which are reported by people who have an interest in their results and *know* that their responses will translate into dollars gained or lost is pretty much nil.

But this is a less biasing factor than the non-representative make-up of the RUC itself. Check out the WSJ's awesome interactive graphic about the RUC. When you view it on their site, you can mouse over the RUC members and see their specialty affiliation:


You will note that the relative specialty vs primary care representation on the committee is striking. Not only are primary care (and other so-called "cognitive" specialties) far outnumbered by their surgical/procedural colleagues, consider that these few primary care docs represent a cohort of physicians far larger than the specialists in actual practice.  One neurosurgeon has as much representation as 150 internists in this body.

Now I would agree that this does not need to be a strictly democratic process as a matter of principle. While we Americans are kind of ingrained with the idea that equal representation is the ideal, there's no reason that it has to be the case with this sort of body.  However, as a matter of policy, in terms of creating economic outcomes and incentives that would tilt the balance towards higher quality, lower cost health care, a more representative or weighted composition of the RUC would be preferable. 

I should also add that while I rail against the corruption of the RUC, it's not meant as an indictment of the people on the RUC, but the process and the system. I know the EM representatives of the RUC (past and current) and they are absolutely awesome people of high integrity. But it is also fair to say that they understand the game they are playing, on a very pragmatic level, and they work within the framework they are given to produce the best results for Emergency Medicine. Good people, bad system.

If I were king (I can't count all the times I have said or thought that) I would remove the fig leaf of objectivity and allow RUC members to openly advocate for their interests (which they are already doing sub rosa), coupled with a rebalancing of the RUC to provide more proportionate representation. Then I would hire a couple dozen Jonathan Grubers to crunch the numbers and make recommendations to the committee, based both on physician work as well as on the macroeconomic impact of the RVU valuations.  Of course, if I were king I'd also probably disband CPT entirely and also the New York Yankees, so maybe it's just as well nobody has seen fit to entrust me with that much power. 



  1. I never understood how CMS could pay so little but now, I do. I wonder, do the EMS payments come from the same group? Or is there some special "administrator" place for EMS managers to go to find out their cut. What an awful system.

  2. many of those members are relatively new. i would suggest that feelings of being stonewalled are not necessarily intrinsic to the process, but may have been related to the interpersonal relationships at the time.

    also i disagree with your assertion that procedure codes are only rarely diminished over time. do you have any data that supports this? i think most of ct surgery has been gutted, cataracts have been gutted, cardiac stents, and many other procedures have been reduced. i'm happy to be proven wrong.

  3. If that was your platform, I'd totally elect you King (Dr.) Shadowfax.

  4. To charge the RUC with corruption is absurd. The AMA is proud that the hard work done by the volunteer physicians who lend their expertise to the RUC saves taxpayers millions of dollars. The RUC is also taking the lead in identifying overvalued services, a task the government was unable to do on its own. The RUC recommended major increases to primary care services in 1997, which were not fully implemented by Medicare, and 2007, which resulted in $4 billion in annual distribution to office visits and other primary care services.

  5. Of course the RUC is corrupt. But that's a mere symptom. The disease is central planning.

    When a group of "experts" (specialists, PCPs, ER docs, Grubers, whatever) are appointed to outsmart the market, the incentives favor corruption and the results are always (as in every single time it's ever been attempted) bad.

    If I were King, I would decree that every progressive take a couple of semesters of basic economics.

    perverse incentives corruption


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