H.R. 2545, a bill to create an “independent” panel within the Centers for Medicare & Medicaid Services (CMS) to advise on the relative value of physician services, repeats old and invalid criticisms of the American Medical Association's Relative Value Scale Update Committee (RUC) said Geraldine B. McGinty, MD, chair of the ACR’s Commission on Economics and a member of the RUC.
In addition, if the bill — which has been referred to the same two committees currently considering alternatives to the flawed sustainable growth rate formula — becomes a provision in a larger piece of legislation that is passed, it could create an advisory group that issues recommendations not based on the best information because it would not include physician input, McGinty noted.
According to the office of Representative Jim McDermott (D-Wash.), the sole sponsor of the bill, “[The RUC] is unevenly weighted by procedural specialists over primary care doctors and relies heavily on anecdotal and self-serving survey evidence, rather than forensic data. This causes skewed fees for procedure-based services such as pathology, surgery and imaging, eroding pay to primary care physicians.”
McGinty acknowledged that most of the codes the RUC reviews at the request of CMS are specialty codes, but that is not because of the makeup of the RUC. Rather it is due to the fact that most new technologies and procedures are first developed in specialty medicine. “That is just the way technology evolves,” she said.
In addition, the RUC rules prohibit members from reviewing codes that relate to their own specialty. When codes that directly relate to McGinty’s areas of medical practice come up, she recuses herself to avoid even an unintentional bias.
“As a member of the RUC, I act as an expert and not an advocate for my specialty,” McGinty said. “That is the first thing they drum into you.”
Finally, the charge that the RUC issues recommendations that benefit specialty medicine over primary care is undermined by the actual work of the RUC, McGinty pointed out. For example, the RUC’s recommendations for determining the values of primary care services in CMS’s medical home demonstration project received written letters of appreciation from the American College of Physicians (which represents Internal Medicine physicians) and the American Academy of Family Physicians.
In addition, in 2006, the RUC established the Five-Year Review Identification Workgroup (now called the Relativity Assessment Workgroup) to identify potentially mis-valued services using objective mechanisms for reevaluation, because despite reducing the work relative value units (RVUs) for nearly 400 services in the past, it faced criticisms that its process was biased in favor of identifying undervalued codes as compared to overvalued codes. Since the inception of the workgroup, it has identified more than 1,000 services through ten different screening criteria for further review by the RUC.
“It is important to understand that the RUC only makes recommendations to CMS,” adds McGinty. The bill proposes an independent group of experts (including patient representatives) within CMS to issue work requests to the RUC and evaluate its work, but these tasks are already done by CMS staff, and CMS is always free to adopt or discard the recommendations for the RUC as the agency sees fit. Bundled payments and the multiple procedure payment reduction (MPPR) for imaging are just two examples of where CMS set aside RUC recommendations.
From McGinty’s perspective, someone without close knowledge of how physicians services are delivered would naturally have a harder time evaluating the data on the service and coming up with a recommendation that fairly judges the value of that service within the context of all the other services in the Medicare Physician Fee Schedule (MPFS).
“If you are not going to involve physicians in the evaluation of services relative to each other, you are not going to get the best information,” she noted.