Last week I was sitting in on a briefing for policymakers on the workings of the RUC, the controversial Relative Value Update Committee. The RUC is sponsored by the American Medical Association (AMA) to provide input into the Medicare physician fee schedule, the list of payment fees for the thousands of possible medical services. These fees not only determine how much doctors and all those who work for them are ultimately paid by Medicare, but also influence many other payers.
The RUC looks at the medical procedures described with the CPT--Common Procedural Terminology (the coding system created and owned by the AMA) and makes recommendations for revisions due to changes in how procedures are performed as well as the introduction of new services. Technically the RUC advises the Center for Medicare and Medicaid Services on assessments of the Work RVU (relative value unit), where work is a function of time spent and its "intensity." The other two elements of the fee are the Practice Expense RVU (e.g., office staff time, tongue depressors, or sonogram gel) and the Professional Liability Insurance RVU (malpractice insurance).
The RUC asks member societies of the AMA to survey their members in specific specialties to get estimates of the time required for various treatments. Intensity is assessed by considering the skill and training required to perform a service, the degree of physical difficulty, and the "stress" that it produces in the provider. "Relativity" (in the jargon of the process) comes into play in that all of these decisions are not absolute judgments, but comparisons of a medical procedure to others. Because all physician payment under Medicare is essentially a zero-sum matter, an increased RVU for one procedure reduces the RVU for others. Ultimately, an RVU translates into about $36 in 2010.
Many other commentators (see Health Renewal blog and Health Beat, for starters) have identified problems with this process and its outcomes, particularly the impact on payment for primary care services billed under the evaluation and management codes. But as I listened this time it came to me that the process also makes the fallacy of assuming that what IS, is what OUGHT to be.
We know that older adults only receive some 30% of indicated care for geriatric conditions in outpatient visits. For example, an older person who reports falling should be given the "get up and go test" in the office and should probably be checked for orthostatic hypotension--the tendency for blood pressure to fall precipitously when a person stands or shifts posture. But these checks are rarely performed. Here, what *IS* is definitely not what *OUGHT* to be.
Not only does the failure to provide appropriate services undermine the quality of care, but it also means that when physicians respond to surveys about their time and resources spent on a visit, they are going to report less than they OUGHT to have spent. This produces a classic death spiral: the fewer services doctors provide, the lower the payment will be set for the codes, and the less motivated providers will be to provide services that are not absolutely required. If surgeons sent patients home with some parts not sewed up all the way, someone would notice. But if a physician leaves out some recommended non-invasive services, especially those that are uncommon and unknown to patients, who will notice?
Coming soon: Potential fixes for the problem.
Resources:
AMA orientation for new RUC members
Brochure from AMA on RVS update process
From the American Academy of Family Physicians: What Every Physician Should Know About the RUC