Primary Care Physicians File Lawsuit to Bring More Transparency to RUC Process

Physicians Allege That Relationship Between CMS, RUC is Illegal

August 12, 2011 05:50 pm James Arvantes

The AAFP has acknowledged the significance of a lawsuit filed by six primary care physicians in Georgia that seeks to terminate the current relationship between CMS and the AMA/Specialty Society Relative Value Scale Update Committee, or RUC, as a step toward achieving a more equitable payment system that accurately reflects the value of primary care physician services.

[Stock photo of judge's gavel and stethoscope]

"This lawsuit is an example of the incredible frustration that family physicians and others in primary care have had with the payment system for the past 20 years," said AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas. "To have a group of physicians resort to a lawsuit to address the problem underscores the significance of that frustration."

Currently, the RUC, which has 29 total members, 23 of whom come from medical specialty societies, acts as an expert panel and makes recommendations on the relative values of various CPT codes, including codes commonly used by family physicians. CMS frequently adopts the committee's recommendations for the Medicare program. However, many family physicians are convinced the RUC's recommendations undervalue primary care services.

Story Highlights

  • A lawsuit filed by six primary care physicians from Georgia alleges that the AMA/Specialty Society Relative Value Scale Update Committee's, or RUC's, relationship with CMS is illegal.
  • The AAFP has decided not to sign onto the lawsuit, but acknowledges that it is an example of the frustration primary care physicians have with the current system for determining the value of primary care services provided to Medicare patients.
  • Instead, the AAFP has established a task force to review the methods used to evaluate health care services provided via Medicare and to make recommendations about how to properly value and pay for primary care physician services.

The 74-page lawsuit, which was filed in the Maryland Federal Court against CMS and HHS by primary care physicians from the Center for Primary Care in Evans, Ga., alleges that the RUC's relationship with CMS is illegal.

"The law is clear in terms of what is required for committees that advise the federal government, and the RUC does not follow any of those guidelines," said family physician Paul Fischer, M.D., of Evans, Ga., one of six plaintiffs in the suit. "That means the relationship between CMS and the RUC is illegal and should be transformed into a process that follows the law."

The lawsuit also seeks to have the RUC declared a Federal Advisory Committee, which would force officials to open up the RUC's proceedings and records to the public. In addition, the lawsuit attempts to stop the implementation of the 2012 Physician Fee Schedule, claiming it discriminates against primary care services.

In the statement in response to the lawsuit, Barbara Levy, M.D., who chairs the RUC, said the organization "is an independent panel of physicians from all medical specialties, including primary care, who make recommendations to CMS as all citizens have a right to do. These volunteers provide physicians' voice and expertise to Medicare decision makers through their recommendations."

But Fischer has significant concerns about the power the RUC holds in determining his Medicare payments. "For a long time, I felt that family physicians were underpaid for what they do and that many of my colleagues who are (sub)specialists are overpaid for doing repetitive procedures," said Fischer, an AAFP member since 1976. "I never really understood who figured out what physicians were paid. I just assumed it was done rationally by someone who knew what they were doing. About a year ago, when I started to explore this, I found out it was largely determined by the RUC committee. The more I realized that, the more I realized I didn't want the RUC determining how much I made."

Goertz, meanwhile, pointed out that the AAFP chose to not sign on as a plaintiff in the lawsuit. After extensive deliberation, the AAFP Board of Directors decided to pursue an alternative option, including establishment of a task force to review the methods used to evaluate health care services provided via Medicare and to make recommendations about how to properly value and pay for services provided by primary care physicians.

"We agree that RUC is not valuing primary care correctly and that there must be an alternative methodology created that does," said Goertz.

In June, the AAFP sent a strongly worded letter to the chair of the RUC calling on the committee to make changes in the RUC's structure, process and procedures by

  • adding four additional "true" primary care seats to the committee, including one each for the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association;
  • creating three new seats to represent outside entities, such as consumers, employers, health systems and health plans;
  • including a seat for a representative of the specialty of geriatrics;
  • eliminating the three current rotating subspecialty seats when the current representatives' terms expire; and
  • implementing voting transparency among RUC representatives.

The AAFP has given the RUC until March to respond and will decide what action to pursue next based on that response, Goertz said.

"In America, we value what is important and what is important is typically rewarded and supported appropriately," said Goertz. "There is growing agreement that family medicine and primary care is increasingly valued and important, but it is not rewarded appropriately compared to others. Unless payment models come to deal with this issue -- the appropriate value of what we do as family physicians -- I don't think you are going to solve a number of current problems."