CMS Takes RUC's Advice Nearly 90 Percent of Time, Says Study

When the AMA/Specialty Society Relative Value Scale Update Committee (RUC) makes a recommendation regarding the relative values of CPT codes, CMS accepts that recommendation nearly 90 percent of the time, making the RUC highly influential in determining Medicare physician payment rates, according to a study (abstract) published in the May issue of Health Affairs.

The RUC makes recommendations to CMS on the work relative values of CPT codes used as part of the resource-based relative value scale. That is the basis for the Medicare physician fee schedule and many private-payer fee schedules, as well.

The study itself is based on a comparison of RUC recommendations for CPT codes and the actual values assigned by CMS. Researchers at Columbia University's Mailman School of Public Health; the University of Illinois; and the University of California, Los Angeles, found that CMS agreed with the RUC's recommendations 87.4 percent of the time between 1994 and 2010.

Miriam Laugesen, Ph.D., an assistant professor of health policy and management at Columbia University's Mailman School of Public Health and lead author of the study, describes the analysis as "a first step in drawing attention to the role of CMS and the RUC in determining work values."

According to the study, "There has been relatively limited empirical analysis of CMS's response to the update committee's recommendations. For example, it is not known whether CMS has increased or decreased the work values of some kinds of services more than others. Nor is it clear whether CMS gives newer services lower work values or is more likely to follow the committee's lead on these services compared to older ones."

Overall, the study found that CMS accepted 2,419 of the 2,768 work values proposed by the RUC during the time period studied, and, in doing so, it decreased 298 work values and increased 51 work values. The study also notes that from 1994-2010, percentages of agreement between the RUC and CMS fluctuated. "Some of the largest year-to-year differences have occurred in more recent years, such as the high of 90 percent in 2006 and the low of 62.2 percent in 2007," the study states.

The study also found that "CMS was no more likely to reduce recommended work values for new services than it was for existing services. The agency made significant increases in recommended work values in 1997 and significant decreases in 1999 and 2007 compared to 1994."

Laugesen and her colleagues said they were "unable to determine why CMS agreed or disagreed with the recommendations made by the committee based on the available data."

"Similarly, drawing definitive conclusions about the effects of the committee's recommendations on specific specialties would require additional data."

The AAFP and its members have expressed concern that the actions of the RUC are biased toward subspecialist procedures rather than evaluation and management (E/M) services, leading to an undervaluation of primary care services.

Primary care experts "have suggested that if more primary care societies were represented on the committee, the reimbursement levels for primary care physicians would be more favorable," says the study, which also points out that the Medicare Payment Advisory Commission (MedPAC) has said that CMS puts too much weight on the RUC's input. MedPAC recommends that CMS seek additional advice from other sources.

However, according to the study, "CMS was more likely to reduce the value recommended by the (RUC) for radiological or medical specialty services compared to other services," such as E/M services. For example, CMS reduced the RUC's recommended values for surgical services by 12.9 percent when compared with E/M services between 1994 and 2009, and by 20.4 percent for radiology services compared with E/M services during the same time frame.

The data on E/M codes "suggest that CMS's decisions are not more likely to penalize primary care providers than (sub)specialists," according to the study. "The agency is more likely to decrease recommended work values for medical specialty, surgical and radiologic services than for evaluation and management services. This is encouraging for providers in primary care and other specialties that bill the greatest proportion of these services. However, it does not explain why there has been no reduction in the income gap between primary care and (sub)specialists."