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Join the Conversation: Should Primary Care Physicians quit the RUC?

Posted by Valerie Arkoosh, MD, MPH February 25, 2011 at 9:30 AM

Obscure acronyms clutter health care speak, but one that we should all know more about is the RUC – the Relative Value Scale Update Committee, a panel created by the AMA.   As Brian Klepper, PhD, and David Kibbe, MD, MBA, recently wrote in Kaiser Health News, the RUC is “a secretive, 29 person, specialist-dominated panel” that advises CMS on Medicare’s physician reimbursements rates. The RUC’s influence over payment rates is vast, representing a major factor in ever-rising health care costs.

Since 1991, 90% of the RUC’s recommendations have been adopted by Medicare, and those recommendations have urged pay increases six times more often than decreases. Because Medicare is such a large payer in the market, Medicaid and private health plans have typically followed suit, resulting in system-wide cost increases.

According to Klepper and Kibbe, because the RUC is a specialist-dominated panel, payments to specialists have far outpaced those to primary care doctors. Reimbursement rates favor procedures over primary care office visits, leading to lower income for primary care doctors. This has contributed to a primary care shortage as medical students disproportionately choose the more lucrative specialist fields over primary care.

Along with rising payments, Klepper and Kibber also point out that our predominantly fee-for-service payment system is a major contributor to the cost crisis because it encourages greater, and perhaps unnecessary, use of costly specialty services rather than less interventional treatments.

Because there is no serious threat to the RUC and this arrangement for determining physician reimbursement rates, Klepper and Kibbe argue that the primary care representatives serving on the RUC should quit, thereby de-legitimizing it and creating space for a more transparent and effective process. What do you think? Let us know.

For more on the RUC, check out Dr. Klepper’s new website – Replace the RUC.

4 Responses to “Join the Conversation: Should Primary Care Physicians quit the RUC?”

  1. Robert Keimowitz says:

    I think this is critical. As a former Dean of a medical school, I know that students have to consider finances when they consider specialty choice. (I also must add that I am convinced that we need other providers (PA’s and some NP’s) to meet the demand of real health care reform.

    We will not succeed in inproving care for our populations without a more equitable funding scheme for service providers. I recognize and appreciate the extra training demanded by specialization (although I also believe the neurosurgeons at the minimum have exploited this greatly) but do feel the reward for 2 hours dealing with a sick patient and his/her family is at least as worthy of recompense as a simple hernia or appendectomy.

    And as a functioning geriatic internist, I would also suggest a couple of geriatricians and at least one population-oriented epidemiologist might be helpful. I know that each specialty wants a place at the table, but again on population basis, we have to recognize the burden the 95 year old places on a routine visit.

    And finally, why not consider a two tiered committee, one with representatives from all specialties (but not with a majority of specialists and subspecialists) that makes a recommendation to a considerably smaller group that is at least balanced, but not with a pleurality of specialists), who then make the recommendation to CMS?

  2. Steve Smith says:

    I completely agree that the way we value services needs to change drastically. On Thursday morning, I had a skin tag removal, cryo for a plantar wart, and two subacromial bursa injections. These were the quickest, easiest,…and most remunerative of the cases I saw that morning. I spent way more time with a patient with end-stage pulmonary disease who was recently discharged from the hospital trying to deal with his myriad medical problems, living situation, and other care providers, but the billing charge for that was less than for the procedures.

    Bob Keimowitz’s idea of two-tiered system is worth exploring as are a number of other creative ideas to replace the RUC. But replace it we must!

  3. Benjamin Schaefer, MD says:

    As a cost-conscious cardiologist (CCC), I think in principle your are right – I would welcome the strengthening of primary care. I think another issue – and maybe the bigger one – is that much care is inappropriate. In Maine, where I work, we spend half the money on a Medicare patient than Florida. It is not unusual for a patient to winter in Florida and summer in Maine – and get their (questionably necessary) procedure down there. “Why don’t I get my yearly stress test, doc?” is not an uncommon question, “Because you are doing fine and don’t need it” an all too common answer.

    But when payments are reduced, either by the yet again averted SGR adjustment or by CMS (and outpatient cardiology got hammered in 2010, something that probably should be mentioned ), it affects everyone, regardless of their billings. While for a trigger happy interventionist that may put less $ in the bank, for a CCC that may mean closing shop and selling out to a hospital (where billings are higher, so cost will increase).

    I think what needs to happen is more thorough payment reform than is already planned. If primary care physicians quite the RUC it is symbolic act and a push in that direction, but the inherent problems of the current system remain.

  4. Mark Ryan, MD says:

    All sorts of reasons why the RUC needs to change. This slide show ( is a bit old, but still relevant. Sadly, the issues addressed are still in place.

    If primary care quits the RUC, it would stand to undercut the RUC and would highlight the issues at hand. This could help show the need to change the way by which health care services are valued, and could change the process that is more representative and is better for the nation.

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