Early this month, a group of 29 doctors gathered in a modern conference room at the Hyatt Regency Chicago, a few blocks from Lake Shore Drive. Over the course of four days, the little-known group of mostly specialists made a series of decisions crucial to the massive government entitlement program known as Medicare — issuing recommendations for precisely how Medicare should value more than 200 different medical procedures.
As the members of the organization waded through technical discussions ranking procedures by how much time, skill, and mental effort they required, more than 100 invitation-only consultants, lawyers, and medical society representatives hunched over their laptops taking notes.
If history is any indication, the Chicago group's decisions will weigh heavily on how much Medicare pays doctors. But the members of this powerful panel are not employed by the federal government. Instead, the group is comprised almost exclusively of physicians themselves, the very people who have the most to win or lose based on how Medicare values the work they perform.
Known as the American Medical Association/Specialty Society Relative Value Scale Update Committee, or RUC, the group is unknown to much of the medical profession. Yet for almost two decades, the committee has had a powerful influence on Medicare payment rates. Since 1991, the RUC has submitted more than 7,000 recommendations to the Centers for Medicare and Medicaid Services (CMS) on the value of physician work. CMS has overwhelmingly rubber-stamped RUC recommendations, accepting more than 94 percent, according to AMA numbers.
That record, critics say, means CMS is handing over some of its payment policy decisions to a physician organization with a massive and obvious conflict of interest. The arrangement has been criticized by bodies like the Government Accountability Office and the Medicare Payment Advisory Commission (MedPAC), the independent agency that advises Congress on Medicare issues. But no group has cried out louder than family doctors, who say CMS reliance on the secretive group has undervalued face-to-face consultation between doctors and patients while overvaluing expensive high-tech medical procedures and imaging.
In response to proposed federal rules for verifying medical procedure values, The American Academy of Family Physicians suggested in July that CMS find experts outside of the RUC to collect and analyze evidence for validating values. It suggested looking for experts who are "less invested financially in the outcome. In medicine, we call this 'getting a second opinion.'"
The AMA, which says the RUC costs more than $7 million a year to run (including volunteer physicians' lost wages), argues that the committee is nothing more than an independent group practicing its First Amendment right to petition the federal government. But the AMA does not try to downplay the RUC's goal. An AMA physicans' guide puts it this way: "From the AMA's perspective, the RUC provides a vital opportunity for the medical profession to continue to shape its own payment environment."
Shaping its Own Payment Environment
The story of how the RUC took a lead role in influencing Medicare payments to physicians began in the early 1990s, with the adoption of Medicare's Resource-Based Relative Value Scale (RBRVS), a reimbursement system that pays doctors for medical procedures, imaging, and tests based on the relative costs of providing them.
Under that reimbursement system, CMS defines physician labor in "work units," and ranks procedures relative to each other. For example, a doctor who performs a detailed office examination on a patient with moderate health issues is awarded 1.5 work units. Brain surgery to remove a tumor is awarded 57.09 units. Physician work units account for 52 percent, on average, of a procedure's total value. Practice expenses and malpractice insurance costs make up the rest.
Each year, CMS, through the federal rules-making process, sets values for new and revised medical procedures within the system. It performs a comprehensive review of values every five years.
The AMA has been involved in the reimbursement system since the beginning, serving as a contract liaison between practicing physicians and the Harvard researchers who initially ranked physician services. The role ensured medical societies were "involved in important aspects of the development of relative values for their specialties," according to an AMA handbook.
Since 1991, the AMA process to influence CMS payment rates has relied on two affiliated groups: The RUC's 29 members, and the RUC advisory committee, which includes representatives from 109 AMA-recognized specialty societies representing cardiologists, surgeons, family physicians, and others.
To develop the suggested work values for the new and revised services it passes on to CMS, the RUC directs specialty societies first distribute physician surveys that rank procedures based on time, difficulty, skills required, and other criteria. Members of the RUC advisory committee review the surveys, then propose a work value to the RUC committee. In most cases, members of the advisory committee representing specialists who perform that procedure make presentations to the RUC. For example, if the procedure is a heart surgery, a representative of the American College of Cardiology would likely help present the proposed work value.
Dr. Barbara Levy, who has served on the RUC since 2000 and is the current chair, said that since specialty societies have a vested interest in the procedures, the RUC assumes their suggestions are inflated. It's the work of the RUC process, Levy said, to reach a correct relative value.
"We assume that everyone is inflating everything when they come in," Levy said. "They are wanting to fight for the best possible values for their specialties." During the next part of the RUC process, however, Levy said the inflated values are revised.
After sometimes heated discussions of each value, RUC members vote by secret electronic ballot. If the value passes the RUC, it is sent to CMS. If CMS accepts the value, it is included in the Medicare physician fee schedule. New values are open for public comment and are considered final after one year.
The process is also highly political, with battle lines and alliances drawn between specialties, Brooks said.
"Certainly there were alliances," Brooks said. "People were protective of their turf. If radiology presented a new set of codes that had to do with imaging procedures, there was a feeling that some people would go along with that if radiology would go along with other things." Mostly, he said, it was primary care physicians against everybody else.
The AMA disputes reports of alliances within the RUC. Although it declined to make voting results public (the AMA said it does not keep records of votes), it said voting does not usually align in blocs, and is often contrary to the apparent self-interest of individual RUC members.
Despite paychecks that are influenced by positions taken during the RUC, and the fact that members are sponsored by medical societies who advocate for higher Medicare payments, Levy, the RUC chair, said RUC members don't vote to enrich themselves. "Each member votes as a member of the RUC and not a member of their specialty society," Levy said, although AMA staff acknowledged she does not see how individual members vote.
What truly happens in the RUC is secret. Votes are typically taken by electronic ballot, and RUC members are not informed of how other members voted. Meeting minutes are not released to the public. And all RUC members and observers agree to a confidentiality pledge that they will not disseminate documents or discussions from the meetings.
In 2007, Poses, who has blogged about the RUC, asked the AMA for a list of RUC members. The AMA declined, saying it does not give out the information to shield the RUC from industry lobbying. "Why isn't this a public process of some sort? That is a huge question, and I have no idea the answer," Poses said. The AMA did provide the current membership list to the Center, and the list is available in a book the AMA sells for $91.95, or $20 less to association members.
rest at http://www.publicintegrity.org/articles/entry/2571/
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