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AMA's RUC panel to provide minutes in limited transparency move


By Andis Robeznieks
Posted: November 4, 2013 - 6:00 pm ET
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(This story was revised on November 6, 2013 at 10:30 Central time.)

The American Medical Association panel that recommends values for physician services to the CMS for Medicare Part B payment purposes, which has been widely criticized for its closed-door process, has initiated some changes in an effort to make them more transparent.

The AMA Specialty Society Relative Value Scale Update Committee, commonly known as the RUC, will now publish meeting minutes and how the panel as a whole voted for individual current procedural terminology codes; how individual members voted will not be released. The information will be posted on the AMA website after the CMS releases its annual Medicare physician fee schedule. The new Medicare fee schedule typically is released around Nov. 1, but this year, because of the government shutdown, the CMS announced it may not be released until Nov. 27.

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“I think these are positive steps the RUC has taken regarding transparency,” said Dr. Douglas Henley, executive vice president and CEO of the American Academy of Family Physicians, which has pushed for greater representation of primary-care physicians on the specialist-dominated RUC panel. “Only time will tell whether these changes lead to a fair evaluation of all physician services—particularly primary care.”

Shari Erickson, vice president of governmental and regulatory affairs for the American College of Physicians, agreed. “Even the folks around the table don't know what the vote totals are,” Erickson said. “I think it will be enlightening to all—we'll be able to see if there are voting blocs and which votes are unanimous.”

The RUC has come under sharp criticism for its lack of transparency, and some critics argue that its recommendations have led to the large income divide between procedural specialists and primary-care doctors.

Critics say many procedural services are overvalued by the RUC, and that it's wrong for the government to turn a key part of the Medicare rate-setting process over to physician specialty groups whose members have a powerful economic interest in the results.

The AAFP board has taken heat from its members for participating in the RUC process, but Henley said the organization plans to continue being part of the RUC “for the foreseeable future.” He explained that it's part of a “two-pronged approach” whereby the AAFP works both inside and outside of the panel to upgrade payment for family physicians.

“We're not being hesitant or bashful to seek changes in the fee schedule,” he said. “If we disagree with the RUC, we'll take our case directly to the CMS.”

There are 31 individuals on the RUC with 28 having votes. Last year, two seats were added to the table—a permanent seat for geriatric specialists and a rotating seat for an actively practicing primary-care physician representative.

The RUC also announced that it will also publish its meeting dates and locations “with greater visibility” and refine its survey methodology. Often, decisions on the value of a physician service are based on results of about only 30 surveys. For services performed more than 100,000 times a year, at least 50 surveys will now be required. For services performed one million times, at least 75 must be completed.

“Nearly all of these are things that the ACP has supported and pushed for,” said Erickson. She and Henley both added that the CMS, as final decisionmaker on the value of physician services for purposes of Medicare payment, should be open to other sources of data. Henley said information from health systems, hospitals, physician organizations and health plans could also be weighed.

Dr. Robert Berenson, a researcher at the Washington-based Urban Institute, called the steps toward increasing transparency “a move in the right direction,” but still had serious concerns about the surveys. His objection stems from the survey's dependence on physicians self-reporting how much of their time certain services require.

“I don't think they've corrected the flaw in the methodology by just having more people responding to a flawed survey process,” Berenson said. “The respondents to the survey have an incentive to inflate the time.”

He said this “creates distortions in the fee schedule,” which could be easily avoided by working toward getting empirical data measuring how much time certain services require.

As examples of over-valued services, Berenson cited the time it takes to interpret advanced imaging explaining that the CMS is not taking automation of these services into account and that “it doesn't take anywhere near the time it did when these were established 20 years ago.”

Berenson also says that, according to the RUC, colonoscopies take between 70 and 115 minutes, but it's common practice to schedule them every 30 minutes. “So that's a pretty good trick,” he said.

For 2012, the CMS projected spending $80 billion for physician services, Berenson said. “Why would we base that payment on asking 30 or 50 or 75 doctors, when that information can be empirically derived?” he asked. “Why would we guess?”

In May 2012, Health Affairs published an analysis showing that the CMS followed RUC recommendations 87.4% of the time. But, according to the AMA, the percentage is even higher. On the AMA website is a chart showing what the RUC does and doesn't do. In noting the RUC's credibility, it stated that the “CMS has recognized the expertise of the RUC by adopting 95% of its work relative value recommendations.”

The next meeting of the RUC will be Jan. 30-Feb. 2 in Phoenix.

Note: An earlier version of this article incorrectly reported that the RUC recommends values for physician services to the CMS for DRG payment purposes.

Follow Andis Robeznieks on Twitter: @MHARobeznieks


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