A Growing Chorus on the RUC

Yesterday on Kaiser Health News, Barbara Levy MD, the Chair of the AMA’s Relative Value Scale Update Committee (or RUC), published a glowing defense of the RUC’s activities. Her article extols the work of the 29 physician volunteers who, “at no cost to taxpayers…generously volunteer their time,” “supported by advisers and staff from more than 100 national medical specialty societies and health care professional organizations.” She fails to mention that the physicians’ and organizations’ efforts to craft the RUC’s recommendations have direct financial benefit to the physicians, specialty societies and health care professional organizations whose representatives dominate the RUC proceedings.

She points to the openness and transparency of the RUC’s proceedings, noting that “the general public is able to comment on individual procedures, and processes are in place to ensure that input from all stakeholders is considered by CMS. Finally, the AMA ensures transparency of the process, making the data and rationale for each RUC recommendation publicly available.” This, from an immensely influential Committee that refuses to share the identities of its members except by their societal affiliation, that keeps its proceedings private, and that can not be observed except by an invitation from the Chair. If anything, the RUC’s goings-on have been secretive and opaque. Go into any health care professional audience and ask, as I have, for a show of hands of people who know what the RUC is. It has been virtually unknown except in wonkiest circles.

Dr. Levy also points out that, in Medicare’s budget-neutral environment, hard decisions have to be made, and that in 2006, $4 billion – a little more than  one percent of that year’s Medicare allocation – was transferred to primary care. The clear implication is that this came at the expense of specialists. But she conveniently ignores the vast majority of coding valuations that have increased specialty income while strangling primary care. (More comprehensive background on the RUC, including articles by the AMA that describe the RUC’s perspective in detail, may be found here.)

Dr. Levy’s article presumably responded to a growing chorus of recent voices that have detailed the RUC’s disastrous impact on American health care, beginning most recently last October with a Wall Street Journal expose by Anna Mathews and Tom McGinty, and an explanation in the New York Times by Princeton health care economist Uwe Reinhardt. With David Kibbe MD, I wrote about this topic on Kaiser Health News in January, calling on the American Academy of Family Physicians (AAFP) to abandon the RUC. Then Paul Fischer MD joined in with his Family Physician’s Manifesto. All this work built on the foundation of many health care professionals – John Goodson, MD; Robert Berenson, MD; Thomas Bodenheimer, MD; Roy Poses, MD to name a few – who have carefully documented the biases and excesses that have been wrought by the RUC’s shadowy process.

Rep. Jim McDermott (D-WA), a psychiatrist, published a powerful argument against the RUC in New England Journal in January, and then, more recently interviewed MedPAC Chair Glenn Hackbarth on the RUC’s corrosive role in front of the House Ways and Means Committee. Interestingly, his comments found common ground with Rep. Tom Price (R-GA), an orthopedic surgeon. These activities have raised enough profile that they have been followed by publications like Politico and National Journal. Suddenly, the RUC is becoming more visible.

Yesterday, the New Jersey Academy of Family Physicians wrote a clear, to-the-point letter to Lori Heim, MD, Board Chair of the American Academy of Family Physicians. Here are a couple extracts.

We fear that our work towards building medical homes, reshaping the way primary care is delivered and how the system pays for it, and providing the care that our patients deserve will be wasted if the current payment policies are maintained, and we see no motivation for the subspecialist-dominated RUC to make those policy changes.


…we encourage in the strongest terms possible, that the AAFP Board … vote to publicly withdraw from the RUC, encourage other primary care organizations to do so as well, and simultaneously bring our advocacy efforts to bear on CMS to immediately replace the RUC with the alternative body that our policy supports.

So it has started. My most fervent hope is that this respectful, thoughtful nudge by a state chapter of family doctors will be what’s needed for other state chapters to also prevail on the AAFP to leave the RUC. Doing that publicly – meaning with as much visibility as can be mustered – would advance this effort to far greater notice and bring the bright light of public scrutiny on the RUC’s actual impacts on American health care, the one thing Dr. Levy’s article so scrupulously avoided.

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4 replies »

  1. Hmmm, read this link about how the AARP is being charged with profiting from the PPACA, and yet another example of the less than transparent agenda of these alleged objective and concerned groups representing the majority interest of the public. Yeah, right.


    And we’ll see who comes rushing in to defend and minimize the behaviors!!!

  2. Bravo! Let’s hope other societies quickly follow New Jersey’s lead. I’m spreading information on your work to every primary care doc I know.

  3. Hear, Hear!

    My second-favorite canned AMA line in favor of the RUC is “at no cost to taxpayers…”

    Ridiculous. The cost to taxpayers is hundreds of billions of dollars annually wasted on excessive Medicare payments for procedures that are paid as if they take twice as long as they actually do and as if they _still_ require the same level of effort as they did when first developed decades ago (or more, if you believe the specialty societies that give the RUC its scientifically indefensible data). The entire Medicare Part B payment schedule is a giant toxic waste product of the RUC. And the RUC is the AMA’s last, desperate attempt to claw onto its specialty societies, who would otherwise happily part ways, leaving the organization with even less political legitimacy than it currently has.

    The RUC saying “at no cost to taxpayers…” is like your mugger saying he’ll take your wallet for free.

    However, my _favorite_ AMA canned line about the RUC is that it’s just a vehicle through which the AMA exercises its First Amendment rights to petition the government. True! But because the RUC has no statutory authority to determine Medicare fees, CMS is under no obligation to listen to it. It’s high time we hold CMS to account…and demand that CMS dump the RUC’s hopelessly conflicted and economically wasteful recommendations straight into the shredder, where they belong. CMS staff should _not_ be present at RUC meetings. I’m offended as a taxpayer!

    The last thing we need are secretive panels of “experts” whose own incomes are determined by their recommendations. Listen Levy, if you really want to be transparent (like MedPAC), let’s see a public release of RUC transcripts–every word uttered–and a public release of RUC member voting…nothing to hide, right?

  4. And anyone with half a brain and attentive to why any group of responsible physicians would support the PPACA, here is part of the truth. Face it, colleagues, the AMA is only interested in their own self worth and financial gain, and one reason why I left it a long time ago, before the AMA showed it’s true and ugly face as alleged allies.

    What an ugly sore on the face, or rather, the buttocks of the psuedo representation of physicians in this country. Hey, non physicians, just remember this little fact: about 20% or hopefully even less of practicing doctors belong to the AMA, which to me now means the Amoral Moneygrubbing Association.

    So who gives a fecal impaction what they allegedly think or care now for the public!