President's Message

RUC Process Comes Under Increasing Public Scrutiny

August 12, 2013 12:05 pm Jeff Cain, M.D.

Conversations about health care in our country today frequently focus on costs. And, perhaps for the first time, the public conversation now includes how payment for medical services affects the overall costs of services, as well as services provided.

[Balancing rocks]

Closer scrutiny of the Medicare payment system is focusing attention on how medical fees are structured, as well as on the role of the AMA/Specialty Society Relative Value Scale Update Committee (RUC), which provides guidance to CMS on valuation of CPT codes. Historically, CMS has accepted the RUC's recommendations as much as 90 percent of the time.

The RUC panel includes 31 physicians from a variety of medical subspecialties, but the number of representatives from subspecialty societies, collectively, is much larger than the representation from primary care. The primary data source used by the RUC is based on self-reported survey data from specialty societies and, historically, has been biased toward procedures and new technology rather than preventive care and chronic disease management.

The role of the RUC recently has been challenged by both the mainstream media and the government. In fact, an article from the Center for Public Integrity( actively called into question the RUC's influence on health care and potential conflicts of interest by its members. Additional reporting in the Washington Monthly( and The Washington Post( has shown how the process, which is based on fee-for-service, continues to undervalue and underpay primary care physicians for the services they provide.

The RUC process also has been criticized by the Government Accountability Office and the Medicare Payment Advisory Commission, the independent agency that advises Congress on Medicare issues.

This year, Rep. Jim McDermott, M.D., D-Wash., introduced legislation that would supplement the work of the RUC by establishing an expert panel within Medicare to oversee the valuation of physician services and to help correct distortions in the fee schedule. The AAFP has come out in strong support of this legislation, which mirrors some of the recommendations the Academy made to CMS earlier in the year.

The AAFP has had its own concerns with the RUC, contending that the RUC process and the data sources used consistently undervalue primary care services, which has led to a substantial gap in payments between primary care and subspecialty physicians.

In June 2011, the AAFP's considerable concerns about the RUC process led it to demand changes in the process, calling for increasing representation from primary care, representation from outside agencies (consumers, employers, health systems and health plans), and public transparency. A February 2012 response from the RUC indicated that although it would accept some of our requests, it would not accede to all of them.

That left the AAFP Board of Directors facing a decision to either withdraw totally from the RUC or to attempt to develop alternative methodologies separately to value the evaluation and management (E/M) services provided by primary care physicians.

In the end, the Board decided to remain at the table and to continue advocating for changes in the RUC process. However, the Board did notify the RUC that we would also be forming our own task force to create recommendations for CMS that would assess the appropriate value of physician work relative value units for primary care payments. Those recommendations now have been communicated directly to CMS.

In addition, the AAFP presented CMS with a proposal to create primary care-specific E/M codes in March 2013, which has helped with the addition of two new codes for chronic care management in the most recent proposed Medicare physician fee schedule.

Revaluing primary care services is important to our country on several levels. Recent studies have proven that the levels of complexity of primary care services have now increased to the same or higher levels as those of specialty care and are undervalued by the RUC.

Secondly, undervaluing primary care has meant a widening salary gap between primary care and subspecialists. Medical students often choose higher paid subspecialty careers because of educational debt, resulting in a potential shortage of primary care physicians. A report from the Council on Graduate Medical Education concluded that narrowing this payment gap is necessary to solve this crisis.

Your AAFP will continue to boldly advocate for proper payment for primary care services internally to the RUC, to CMS directly, and by advocating for alternatives to the current fee-for-service with new methods of payment, such as the patient-centered medical home, that reward value over volume.

It is good news to see increasing public interest in the RUC process. But the most important priority for our country is for all of the interested players, including CMS, physicians and members of the public, to come together to address how our dysfunctional payment structure adversely affects the cost and quality of our health care system. After all, in the end, it is our patients who are hurt the most by lack of access to quality primary care.