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Monday, August 22nd 2011

On The RVS Update Committee

Brian Klepper and David Bibbe have an interesting piece on The Health Care Blog about a legal challenge to the American Medical Association’s RVS Update Committee.

I’ve commented on criticism of the RUC before.

As a brief refresher however the RUC is a committee made up largely of representatives from the members of the American Board of Medical Specialties. The RUC makes recommendations on how much Medicare’s fee schedule, known as the Relative Value Resource Based System, should pay for any given physician service. To be a little clearer, it spells out how much each physician activity should be worth as compared to other physician activities. For instance, how much should a doctor get paid for a craniotomy as compared to a primary care office visit.

In theory this isn’t new money; the RUC doesn’t recommend that the RVRBS pay a certain amount to physicians for certain activities but merely just recommend comparatively how much each physician activity should be worth.

“You should pay physicians ten times as much for a lithotripsy as for a pap smear.” I just made that up right now, but you get the idea hopefully. They’re just recommending how to divide up the Medicare pie.

The RVRBS was created by Medicare and came into play in 1991. Part of the reasons behind it being to close the income gap between primary care physicians and specialists. However, in the past two decades that gap has actually grown. This has become the source of chagrin from many sides, as demonstrated by Drs. Klepper and Bibbe’s piece.

The role of the RUC in failing to close the primary care – specialist income gap is a constant criticism of it. Major criticisms include the fact the majority of its members represent specialists, the secrecy under which it works and the fact that it’s recommendations are by and large accepted and implemented by CMS.

These criticisms are fair enough and I won’t go into a full fledged defense of the RUC. However I do have two concerns with attacks on the RUC:

First, it appears that the compensation between all procedures and E/M services such as office visits has actually narrowed per unit since the deployment of the RVRBS. See former RUC chairman Dr. William Rich’s letter in the Annals and pre-RVRBS commentary data on physician reimbursement here and here and elsewhere.

Second, this seems to imply and, at least cursory there appears evidence, that the growth in the primary care – specialist gap is largely based on volume and not the RVUs themselves.

If true that seems to excuse, not in full, but certainly in part the RUC. To be sure it appears fair to criticize that the RUC has not fully accounted for the time involved in each RVU for which they make recommendations. The RVUs are obviously supposed to account for the fact a colonscopy can be done in 20 minutes while a level 4 office visit takes substantially more time. However, there appears to be a much larger issue in physician reimbursement, well beyond the scope of the RUC. Perhaps attention is better focused on broader reform than RUC criticism.

Anyway go read the article at The Health Care Blog. It is thought provoking, as always when Dr. Klepper and others discuss the RUC.