The RUC is a Symptom. RBRVS is the Disease

The RUC is an easy target. The RUC is flawed. But the RUC is not the problem. Several bloggers have written extensively about the RUC – How the RUC Escaped a Challenge to Our Deeply Flawed Reimbursement System and US Senate Subcommittee Asks What the RUC is About.

In no way can I defend the payment schedules that the RUC has proposed to Medicare. I can defend their recent changes. Radiology payments decreased last year; interventional cardiology payments decreased last year; and many other procedures have decreased dramatically. The relative payments are still wrong (in my opinion), but the RUC actually has been responsive to criticism. They have increased primary care payments (admittedly not enough).

But if one studies the problem carefully enough, one must decide that the idea of paying per episode almost must lead to gaming the system. Forget the RUC, the entire idea of time independent episode based payment must lead to worse medical care and higher costs. If physicians can make more money by doing more, then some will.

Practice administrators push primary care physicians to see more patients each day. If we can decrease the time spent per patient from 20 min to 15 min then we could see up to 8 more patients in an 8 hour day. Our overhead has not changed – hence the marginal financial benefits are huge.

But any honest physician will tell you that the result is rushed medical care. Do we want our surgeon trying to do 5 surgeries today rather than 4? Do you want to be the 5th patient? The problem is the RBRVS billing system, not the RUC. Whatever system CMS used to assign payments would lead to gaming the system! In the current system, primary care has suffered (relatively). Primary care groups complain vociferously about the RUC. More recently, other specialties are complaining.

So we can yell about the RUC. We can advocate for changes. We could believe that another commission would fix the problem, but the real problem is the entire construct of RBRVS.

We need a system that does not encourage physicians to do more. We need a system that encourages alternative communication schemes from the office visit – email, phone calls, etc. We need a system that allows physicians to take the extra time that some patients deserve.

We could pay physicians in a time based manner. Many claim that physicians would game such a system, and of course some physicians would game any system.

We could pay physicians salaries. Salaried physicians have not incentive to do more, they can return to their original incentive – doing what is best for the patient. RBRVS leads to perverse incentives, independent of the RUC deliberations. Physicians will do less and patients will do better if we scrap RBRVS and develop a more intelligent payment system.

Robert Centor, MD is an academic general internist at the University of Alabama School of Medicine. He serves as the Associate Dean for the Huntsville Regional Medical Campus of UASOM, and is also a frequent ward attending at the Birmingham VA Hospital. He blogs regularly at db’s Medical Rants, where this post originally appeared.

6 replies »

  1. Bob,

    I agree with Roy and Brad here. You are correct that the root problem is not the RUC, but RBRVS. But this is analogous to arguing that the problem in health care isn’t the overtreatment and excess that results from FFS reimbursement, but a Congress that allows lobbying interests to spin legislation to advantage.

    The fact remains that the RUC has been a key instrument for influence over policy by the American medical establishment, with support by the rest of the health care provider, supply chain and finance sectors, for 20 years. It is utterly unaccountable and focused on driving an agenda that is at odds with the public interest. In doing so, it has withered primary care and inflicted untolled damage on American patients and purchasers.

    So, yes, you’re right, but it isn’t the core, but it is significant enough that, so long as we have to live with FFS, we may as well try to course correct to ensure that agencies posing as being in the public interest actually are.

  2. Same way we do now: CMS decides and the market too. The RUC does not decide how much a unit is worth. They just decide the ratio between units. There should be no preordained relativity, but it then becomes time & materials, because some specialties make larger use of materials, and the cost of materials or equipment or staff is not that hard to calculate objectively. Bottom line should be that 1 minute of a cardiologist is equal to 1 minute of a pediatrician, for example. But even if people disagree, and insist that a super educated cardiologist is worth more than a country doc, it is still much simpler and infinitely more transparent to have 1 relative value per specialty, instead of obscuring the true intent inside thousands of little codes.

  3. “On the other hand paying based on time spent, is much less likely to foster abuse, or gaming, and is easily audited”

    I like that Margalit. Salary with no audit/oversight system will lead to as much abuse. I’d have the time-spent system record the time on their receipt.

    So now how do we determine who gets what per minute?

  4. 1–RUC and RBRVS as association: Yes
    2–RUC and RBRVS as causation: No

    3–RUC as enabler of HC cost growth: Partial
    4–RUC as valuing worth of practice specialty: Yes

    The title of you post should be, RBRVS Drives Cost; The RUC Cratered Primary Care

  5. I completely agree with Bob that the RBRVS system is itself deeply flawed. I also agree with him that a simple pay per time approach would be better.

    But given that we have RBRVS, the exclusive use of the secretive, unrepresentative (of many physicians), conflicted RUC to keep the RBRVS system up to date seems like a very bad idea. Unless someone has a really good idea about how to get the political system to throw out RBRVS, maybe we need to try to fix the worst aspects of RBRVS while we are stuck with it.

  6. Salaried physicians, or any other salaried people, have no incentive to do anything, unless there are specific incentives for specific activities.
    Most salaried physicians have incentives to do more of what is profitable to their employer. Hopping from the fire to the frying pan doesn’t sound like an optimal solution.

    On the other hand paying based on time spent, is much less likely to foster abuse, or gaming, and is easily audited, compared to today’s archaic audit measures. So if you want to make more money, you have to work longer hours, just like everybody else that is not engaged in speculation and semi-illegal activities.