Tag Archives: RBRVS

How a Secretive Panel Uses Data That Distort Doctors’ Pay

By  and 

Published 7/20/13 in The Washington Post

When Harinath Sheela was busiest at his gastroenterology clinic, it seemed he could bend the limits of time.

Twelve colonoscopies and four other procedures was a typical day for him, according to Florida records for 2012. If the American Medical Association’s assumptions about procedure times are correct, that much work would take about 26 hours. Sheela’s typical day was nine or 10.

“I have experience,” the Yale-trained, Orlando-based doctor said. “I’m not that slow; I’m not fast. I’m thorough.”

This seemingly miraculous proficiency, which yields good pay for doctors who perform colonoscopies, reveals one of the fundamental flaws in the pricing of U.S. health care, a Washington Post investigation has found.

Unknown to most, a single committee of the AMA, the chief lobbying group for physicians, meets confidentially every year to come up with values for most of the services a doctor performs.

Those values are required under federal law to be based on the time and intensity of the procedures. The values, in turn, determine what Medicare and most private insurers pay doctors.

But the AMA’s estimates of the time involved in many procedures are exaggerated, sometimes by as much as 100 percent, according to an analysis of doctors’ time, as well as interviews and reviews of medical journals.

If the time estimates are to be believed, some doctors would have to be averaging more than 24 hours a day to perform all of the procedures that they are reporting. This volume of work does not mean these doctors are doing anything wrong. They are just getting paid at the rates set by the government, under the guidance of the AMA.

In fact, in comparison with some doctors, Sheela’s pace is moderate.

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Special Deal: The Shadowy Cartel of Doctors That Controls Medicare

Haley Sweetland Edwards

Published in the July/August 2013 edition of The Washington Monthly

cartoonIn the last week of April earlier this year, a small committee of doctors met quietly in a midsized ballroom at the Renaissance Hotel in Chicago. There was an anesthesiologist, an ophthalmologist, a radiologist, and so on—thirty-one in all, each representing their own medical specialty society, each a heavy hitter in his or her own field.

The meeting was convened, as always, by the American Medical Association. Since 1992, the AMA has summoned this same committee three times a year. It’s called the Specialty Society Relative Value Scale Update Committee (or RUC, pronounced “ruck”), and it’s probably one of the most powerful committees in America that you’ve never heard of.

The purpose of each of these triannual RUC meetings is always the same: it’s the committee members’ job to decide what Medicare should pay them and their colleagues for the medical procedures they perform. How much should radiologists get for administering an MRI? How much should cardiologists be paid for inserting a heart stent?

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The Secretive Group Behind Medicare Reimbursements

Kate Pickert

Published 7/29/13 in Time Magazine’s Swampland

Earlier this month, the Washington Post published a blockbuster front-page story about a secretive committee that determines what Medicare pays physicians for their work. Part of the American Medical Association (AMA), the committee estimates the time and intensity of various doctor tasks, and the recommendations are plugged into a formula that sets Medicare reimbursements. The committee overestimates the time it takes to perform myriad medical procedures, which thereby increases the amount doctors can earn from Medicare. One gastroenterologist in the Post story would have to work 26 hours, according to the committee time estimates, to accomplish what he gets done in a typical workday.

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Why Aren’t Primary Care Physicians More Ticked off about the RUC? An Interview with Brian Klepper

Brandon Glenn

Published 4/30/13 in Medical Economics

If primary care physicians have a bigger enemy than the RUC, Brian Klepper, PhD, hasn’t heard about it.

The American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC) is a 31-physician panel that wields enormous influence with the Centers for Medicare & Medicaid Services (CMS) in setting the relative values of medical procedures, which are then used to determine reimbursement levels. CMS has historically accepted about 90% of the panel’s recommendations.

Klepper is arguably the RUC’s most outspoken critic, thanks to his Replace the RUC blog. He charges that the RUC is subspecialist-dominated and as a result has played a prominent role in subjugating primary care – holding down primary care physicians’ salaries while contributing to the frantic, hamster-wheel-like feel of today’s primary care practices that are forced to pack each day with wall-to-wall 15-minute patient visits to turn a decent profit.

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US Senate Subcommittee Asks What the RUC Is About

Roy Poses

Posted 1/31/13 on Health Care Renewal

It has been a long time coming, but the issue of how the US Medicare and Medicaid system sets the fees it pays doctors, and hence sets the incentives on doctors that drive their health care decisions, finally got some public attention again.

The background is complex, and may glaze the eyes of readers hoping for simple solutions to simple problems.  One wonders if the complexity was deliberately created to discourage solutions.  Yet we have created a complex, obscure, opaque health care system.  If we want to meaningfully improve it, we must address its “inside baseball” qualities.  Those already familiar with and interested in the topic, skip the following section.

Background – the Resource Based Relative Value System Update Committee (RUC) 

We have frequently posted, first here in 2007, and more recently here,  herehere, and here, about the little-known group that controls how the US Medicare system pays physicians, the RBRVS Update Committee, or RUC.

Since 1991, Medicare has set physicians’ payments using the Resource Based Relative Value System (RBRVS), ostensibly based on a rational formula to tie physicians’ pay to the time and effort they expend, and the resources they consume on particular patient care activities. Although the RBRVS was meant to level the payment playing field for cognitive services, including primary care vs procedures, over time it has had the opposite effect, as explained by Bodenheimer et al in a 1997 article in the Annals of Internal Medicine.(1) A system that pays a lot for procedures, but much less for diagnosing illnesses, forecasting prognoses, deciding on treatment, and understanding patients’ values and preferences when procedures and devices are not involved, is likely to be very expensive, but not necessarily very good for patients.

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Adding Seats: The RUC’s Sleight of Hand

Paul Fischer and Brian Klepper

Posted 3/14/12 on The Health Affairs Blog

©2012 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

On February 1, the American Medical Association’s Relat ive Value Scale Update Committee (RUC), Medicare’s primary advisor on physician payment, announced the addition of two seats: a permanent one for geriatrics and a rotating one for primary care. The American Geriatrics Society and the American College of Physicians praised the move as a step forward that will amplify the RUC’s appreciation of their physicians’ contributions.

But the RUC’s maneuvers are a cynical sleight of hand. They attempt to assuage charges of sub-specialty bias while continuing the RUC’s sub-specialty dominance. The additions reduce proceduralists’ share of votes from 27 of 29 (93 percent) to 27 of 31 (87 percent), hardly a power shift. Primary care comprises about 35 percent of US physicians, but cognitive medicine would have only 13 percent of the votes.

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The Need for a Level Playing Field for Physician Pay

Paul M. Fischer

Everyone in medicine knows that some physicians are overpaid for the services they provide and some are underpaid. The list of specialties in each category is no secret, though we don’t talk about it much.  It’s part of the same ethic that teaches us not to criticize another doctor’s care.

But the sad fact is that in medicine, money is tied to prestige, power, public credibility, and medical student interest.  If we don’t deal with this problem, medicine will continue to fall hopelessly into the “haves” and the “have nots,” that is, those who “own” lucrativeCPTcodes and those who don’t. So the question is how did this inequity come to be and how can it be remedied?

History shows that physician pay rarely follows value, but rather aligns with power.  When I was a medical student, heart caths were new and were the domain of invasive radiologists. But it wasn’t long before the cardiology socialites took on the radiologists and successfully claimed heart imaging as their own.  Power and wealth followed.

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