The American Medical Association/Specialty Society Relative Value Scale Update Committee’s (RUC) meets behind closed doors and has a monopoly on making recommendations to Medicare for physician payments. A new bill in Congress would require Medicare to have their own expert panel to oversee the valuation of physician services and correct distortions in the fee schedule.
Primary care physicians have long complained that they have been stiffed by specialty care members on the committee and have subsequently been underpaid by Centers for Medicare and Medicaid Services (CMS). They even went to federal court to force changes.
Now Jim McDermott, M.D., a Democrat from Washington has introduced H.R. 2545 to require the oversight. Dr. McDermott said, “Currently, the RUC, a committee of 31 physicians, conducts reviews in closed meetings and provides limited release of the minutes of its proceedings. It is unevenly weighted by procedural specialists over primary care doctors and relies heavily on anecdotal and self-serving survey evidence, rather than forensic data. This causes skewed fees for procedure-based services such as pathology, surgery and imaging, eroding pay to primary care physicians.”
“No other area of the Medicare program asks providers to play such an active role in setting their own payments, ” continued McDermott. “Medicare certainly needs clinical expertise in order to fairly set reimbursements, but an outside organization, whose members benefit from $70 billion in annual public spending, needs checks and balances. No matter how well-intentioned, structural biases are inevitable and we’re seeing that effect as new doctors flock toward specialty care and away from primary care.”
The bill is based on a recommendation from the nonpartisan Medicare Payment Advisory Committee.
The panel would be composed of members without any direct conflicts of interest and would include patient representatives. It would also be subject to the Federal Advisory Committee Act, which requires advisory bodies to hold open meetings and publish minutes. Under the bill, Medicare could continue to request work from the RUC, but the independent experts would both initiate such requests and review RUC’s work product.
Thomas Sullivan of Policy and Medicine, wrote on September 20, 2013 that it is unlikely that given the current makeup of congress this bill has much room for success, but is does contribute to the debate to reform the physician payment system, which in the future with the right plan could muster bipartisan support.
Govtrack.us gave the bill a 1% chance of getting past the Republican-controlled House Energy and Commerce Committee and 0% chance of being enacted. Only 11% of bills made it past committee and only about 3% were enacted in 2011–2013.
Gauging the hard work and resources that go along with being a skilled healer should not be the sole jurisdiction of well-intentioned academics and bureaucrats. The AMA-convened relative value update committee ensures that the expert perspectives of physicians are heard by Medicare’s decision-makers.
While everyone is free to respond to the government’s call for public feedback on the Medicare program, only physicians are criticized for doing so in a manner so organized, thorough and accurate that our recommendations are often accepted.
Medicare holds the input of the 31 volunteer physicians who comprise the update committee in high regard because they apply an evidence-based approach that produces fair and objective recommendations. By tapping into the front-line knowledge of physicians, Medicare gains credible insights into the complexities of patient care and at no cost to taxpayers.
The AMA ensures transparency of the panel’s recommendations by making data and rationale publicly available and CMS has a seat at the table during all panel discussions. And while the panel submits recommendations to CMS for consideration each year, the agency is not obligated to accept them.
There are many factors beyond the control of the update committee that contribute to the current income differentials between primary care and specialty medicine. Despite this, there has been strong support for primary care within the update committee. Medicare payments for services often performed by primary care physicians had increased 25% in the past five years due in part to the committee’s recommendations. In the end, more than $6 billion has been redistributed to these primary care services.
Turning the update committee into an undeserving kicking post for all the ills of the Medicare payment system is “simplistic and misses the mark,” according to Dr. Yul Ejnes, former chair of the ACP’s Board of Regents and a current member of the update committee. His insider’s view posted on KevinMD – http://www.kevinmd.com/blog/2013/08/unfair-ruc-view.html – shows that the work of the update committee is much more nuanced than reported.