Federal investigators say the current process to review and recommend how Medicare pays doctors leaves it susceptible to inaccurate reporting and conflicts of interests.
A report (PDF) released Thursday by the Government Accountability Office found “weaknesses” in the survey data used by the American Medical Association/Specialty Society Relative Value Scale Update Committee, also known as RUC.
Investigators said the committee's recommendation process “relies on the input of physicians who may have potential conflicts of interest with respect to the outcomes of CMS's process.”
In terms of the data, which is compiled by annually surveying physicians to provide updates on existing procedures and to introduce new ones, the report found the RUC survey's response rate was low. For 2015, the median number of responses to the 231 surveys conducted was 52 for a rate of 2.2%, with less than 30 respondents for 23 surveys.
“Given the process and data-related weaknesses associated with the RUC's recommendations, such heavy reliance on the RUC could result in inaccurate Medicare payment rates,” the report concluded.
The RUC consists of 31 physicians who span the spectrum of medical specialties. Since 1991, the committee has provided recommendations to the CMS on the value of physicians' work. The CMS in turn considers that and decides whether to approve the recommendations. Those are reflected in updates made to the physician payment schedule. The schedule comes from a resource-based relative value scale, a reimbursement system instituted in 1992 as an alternative to the previous payment model that was based on charges.
The physician's work is just one of three components the CMS considers when determining the total relative value of a service, but it is a major part, accounting for 48% of consideration, according to the AMA. The work value is based on factors such as the time it takes to perform a service, the technical skill and physical effort involved in performing the service, the mental effort involved, and the stress that a doctor may incur due to the potential risk to the patient that a procedure carries, according to the AMA.
RUC's influence over these rates has been controversial for years. Critics have called on HHS to use an independent body to prevent conflicts of interest.
The CMS sets payment rates for about 7,000 physicians' services, according to the report. Medicare spent approximately $70 billion for physicians' services in 2013.
The report recommended that the CMS better document how it reviews RUC's recommendations and develop a way to inform the public of potentially misvalued services identified by RUC.
In comments responding to the GAO's findings, the AMA said it agreed with the report's recommendations, but contended it failed to sufficiently acknowledge the challenges involved in collecting survey data that was reliable, particularly for services with low volume.
