Wednesday, May 11, 2011

More Conflicts of Interest at High Levels: The Case of RUC

I don't believe that I have had occasion to mention the interesting group called RUC previously in this blog, so here's some background.

A while back Medicare decided to pay physicians according to an instrument called the resource-based relative value scale (RBRVS). This was originally designed to equalize payment between procedural specialists and primary care type docs by considering how much work physicians actually put into each medical task, rather than simply what past, customary payment had been. It has never worked out that way because the procedural specialists hijacked the mechanisms by which it was implemented, but that's another story. But a committee was needed to update the original payment framework as new procedures were added to the repertoire. Thus came the creation of the RBRVS Update Committee. You'd think that would be called the RBRVSUC, but they took pity on us and shortened that to RUC.

Funny thing, though. The decisions of RUC ultimately control how Medicare pays all physicians in the US, which in turn is often followed by other insurers. So you'd think that RUC would be a government committee and its proceedings would follow open-government practices. But in fact RUC was set up by the AMA, and is officially only an advisory committee to Medicare--though Medicare follows its "advice" 90 percent of the time, and has no alternative mechanism to get similar "advice" from anywhere else. In turn, the AMA has treated RUC in a wholly proprietary fashion, to the extent that even (until recently) the membership list of RUC was effectively kept secret.

RUC is made up mostly of representatives from the various specialty societies. This means that primary care physicians have basically 3 representatives on the panel, from family medicine, internal medicine, and pediatrics. (And since internal medicine and pediatrics number both primary care physicians and specialist physicians among their ranks, you could say their interests are divided.) The procedural specialists have the vast majority of seats. With this voting lineup, you'll be shocked to learn that the RUC has generally proposed physician payments that continue to widen the gap between the low-paid primary care docs and the proceduralists. In recent years, under significant political pressure, RUC has tried to modify this to some extent and has taken some action to narrow the gap just a bit. During these years, the number of US medical graduates seeking careers in primary care has steadily dropped due to the low income, despite the agreement of all health policy mayvins that the US really needs more primary care docs and fewer proceduralists.

Side note--some people like me have wondered why my own group, the American Academy of Family Physicians, keeps on legitimating this charade by attending RUC meetings, when its members' best interests would seem to be served by very publicly walking out and denouncing RUC. But the primary care people seem to have reasoned that even if they only come away with crumbs, sitting at the table is better for us than not being at the table.

OK, so in the past few years some light of publicity has finally been shown on RUC, and there is now at last a "Replace the RUC" movement:

Now to the news--our friends over at Health Care Renewal:
--took advantage of the fact that through all this agitation, the "Replace the RUC" group has finally managed to make public a list of the RUC membership. So the HCR gang did what I usually cannot find the time to do myself, which is Google all those people and make a list of their industry ties. And guess what? It turns out that roughly half of the RUC membership have significant conflicts of interest (which the blog proceeds to list person by person).

In the past the AMA used as one reason not to make the RUC membership list public, that the people might be harrassed and lobbied by those who wanted to affect the structure of the payment system. So now we can see the real worry. It turns out that the industries that have wanted to steer the physician reimbursement system in ways favorable to their profits, have had the desired access to half of the RUC membership all along. The AMA just didn't want the rest of us to have any chance to get our word in.

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