AAFP to CMS Administrator Berwick: Consider Changes to RUC

Agency Relies Too Heavily on Relative Value Scale Update Committee

October 22, 2010 03:50 pm News Staff

In an Oct. 8 letter to CMS Administrator Donald Berwick, M.D.(3 page PDF), AAFP Board Chair Lori Heim, M.D., of Vass, N.C., pushed for changes in the AMA/Specialty Society Relative Value Scale Update Committee, commonly referred to as the RUC.

"The role and influence of the RUC is well-documented, as is CMS' acceptance of the RUC's recommendations," said Heim, noting that the Academy is concerned that CMS relies "too heavily" on the sole committee that examines the valuation of codes in the Medicare physician fee schedule.

Heim reminded Berwick of the Medicare Payment Advisory Commission's 2006 recommendation that CMS establish a group of experts separate from the RUC to help the agency review relative value units, or RVUs.

The Academy has long supported that recommendation, said Heim.

"Although the RUC provides valuable expertise, the review process would benefit if CMS had an additional means of identifying misvalued services and validating RVUs," said Heim.

An expert panel that included consumers and employers could analyze supporting evidence without bias because they would be less invested financially in the outcome, she said. Such a panel should augment, not replace, the RUC.

Heim also pointed out that CMS and the RUC rely on physician specialty societies to identify misvalued services that merit review. However, in the current system, when changes in RVUs are budget-neutral across the fee schedule, "specialty societies have no vested interest in identifying potentially overvalued services," said Heim.

Although the RUC has made headway in recent years in its work to identify misvalued services via its five-year review identification workshop, Heim said it was unfair to rely entirely on the RUC to do this work.

"The review process would benefit if CMS had an additional means of identifying misvalued services," said Heim, again pointing out that supporting evidence should be examined by additional experts who are less invested financially in the outcome.

The Academy also asked Berwick to encourage more transparency in the RUC process, as well as a "fundamental change in the composition of the RUC that more equitably recognizes the value of primary care."

Based on previous CMS decisions -- such as the recent redistribution of work values to codes that support evaluation and management services most often provided by primary care physicians -- it is apparent that CMS "recognizes that a high-quality, efficient health care system must rest on a foundation of primary medical care," said Heim.

"Unfortunately, the composition of the RUC does not demonstrate a similar recognition," she added, noting that primary care currently has, at most, five seats on the RUC.

"We would encourage CMS, again as the primary recipient and user of the RUC's product, to insist on greater input from true primary care members of the RUC, consistent with the agency's emphasis on primary care as essential to a high-quality, efficient health care system," said Heim.