Wait. What? The RUC doesn't skew toward specialists?

A new study adds to the already contentious debate

Primary care physicians have long claimed that the Relative Value Scale Update Committee (RUC) has skewed in favor of specialists, but a new University of Michigan Medical School report says there is no such evidence, which, no doubt, will only add to the contentious debate about the secretive committee.

As popular narrative contends, the RUC – an American Medical Association creation spurred into existence in response to the Harvard National RBRVS and the Omnibus Budget Reconciliation Act of 1989 – has long overstated many of the factors used to determine physician payment. This, according to a new report from the Public Citizen, has led to a weighted payment system that favors specialists over their primary care counterparts.

“To the extent that the RUC’s members are biased toward their own specialties, this results in the overvaluing of specialty procedures at the expense of primary care. Because there are significantly more specialty procedures than primary care procedures, the overvaluation of specialty and procedural services has caused U.S. specialists’ pay to rise much more rapidly than primary care physicians since the formation of the RUC,” the Public Citizen report said.

While this may be the latest large-scale criticism of RUC, it certainly isn’t the only one – The New York Times, The Washington Post, David Harlow’s Healthblawg and the American Academy of Family Physicians have all called out the committee for valuing and promoting corrupt methodology. Even one of the developers of the resource-based relative value scale, Harvard School of Public Health professor William Hsaio, has frowned upon what the RUC has made of his system.

“And that was the point where I knew the system had been co-opted … It had become a political process, not a scientific process,” Hsaio said in the Public Citizen report. “And if you don’t think it’s political, you only have to look at the motivation of why AMA wants this job.”  

In the thick of such dissent, it’s easy to skip over the latest findings from the University of Michigan Medical School. But overlooking those findings could yield more of the same broken formula, according to the study’s lead author Kevin Kerber, MD.

“You can’t really fix something when you don’t know what is actually broken,” Kerber told Healthcare Finance News’ sister publication, Medical Practice Insider.

And what’s actually broken here, according to Kerber’s study, is not necessarily the RUC or the Centers for Medicare & Medicaid Services. It appears that the salary discrepancy between providers who perform operations and those who don’t has more to do with how long it takes doctors to provide whatever care they give – “or rather, how long the influential Medicare payment system assumes it takes them,” the study argues.

“If the time is the dominant factor explaining the variance in RVUs, we then have to ask ourselves how accurate are the times,” Kerber said. “Which is a huge potential target because then we have to consider the methods used to determine the times. And they’re based on surveys that RUC performs that often have very low response rates and could have other methodology problems.”

The analysis undertaken by Kerber and the rest of the study team indicates that the RUC and CMS have not explicitly rigged the payment system to favor specialists over PCPs. There was no evidence suggesting that the groups assigning payments are giving more value to procedures and tests and not office visits, Kerber noted, adding that this is true “even after adjusting the analysis for the utilization of codes.”

Which brought the study team back to the $140,000 question (the difference between what surgeons, for instance, make on average [$300,000] and what PCPs make on average [$160,000]): What is the problem if CMS and the RUC are not explicitly favoring these specialists over primary care doctors?

It all comes down, again, to accuracy and time reporting, Kerber said.

“If the goal is to pay physicians across specialties the same amount per worked time, then one of the main targets has got to be exploring how valid the current times are and trying to come up with better methods to measure them,” he said.

That means considering “how well physicians know how much time they spend on individual codes,” and not overlooking an important possibility: “If physicians know that the times that they report are going to determine their pay, then whatever they report may not be accurate, whether they’re doing that overtly or subconsciously.”

Alongside information-gathering tactics, it’s also imperative to consider the added payments that Medicare makes for the overhead costs involved in each service, like tools and equipment, which, the report posits, can “unintentionally create profit sources and incentives for procedures.”  

Moreover, Kerber said it’s worth noting that the average surgeon works 5 percent to 10 percent more hours per week than the average primary care doctor, although this accounts for little regarding the wide difference in income.

Work still must be done in discovering the severity of the many factors contributing to the physician income disparity, but one thing remains clear for Kerber – the assumption that the payment system is skewed toward certain physician types is causing a lot of strain within the provider workforce.

“There are a lot of rumors out there that haven’t really explored the data well enough,” he said. “It’s becoming adversarial – certain groups are pitted against other groups and I think it’s become an impediment to actual progress.”

With an eye on the future, Kerber suggested that today’s medical students may be tempted to choose a higher-paying specialty over primary care, regardless of their passion, which could trigger PCP shortages.

The 30 physicians comprising the RUC met just last month in Chicago to “discuss how much money doctors are paid by Medicare for discrete procedures and, more broadly, how much private insurers pay for the same procedures,” reported the Public Citizen.

Get to know the current RUC representatives here.

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