Sunday, July 21, 2013

Piling Up on the RUC--About Time

To follow our earlier post regarding the AMA's secret committee, the RUC, that helps the Center for Medicare and Medicaid Services (CMS) set physicians' reimbursement rates:
--Peter Whoriskey and Dan Keating at the Washington Post have printed their own investigation of the RUC's doings:

After so many years of totally ignoring the RUC, it's nice to see the American media finally doing a lttle bit of piling on.

The focus of this recent investigative piece is one aspect of the resource-based relative value scale (RBRVS) calculation that the RUC is supposed to be reviewing and updating regularly--the amount of time that a medical procedure takes, on average. The reporters first looked at the RBRVS calculations for common procedures in gastroenterology, ophthalmology, orthopedics, and some other specialties who routinely work in outpatient surgical centers. They then looked at the publicly available records of such centers in Florida and Pennsylvania to see how many procedures were performed each day.

Given the fact that the RUC bases its calculations mostly on surveys of the specialists doing the procedures, who are told up front that their responses will be used to set reimbursement rates for their specialty, you may not be surprised to hear that in virtually all cases, the RBRVS formula overestimates the time required to do a procedure, often by a factor of two. According to the figures the RUC has come up with, a lot of specialists working in outpatient surgical centers put in 12-hour days, despite the fact that the centers are not open that many hours. A few intrepid souls manage to do more than 24 hours' worth of procedures each day.

In fairness, the time required for a procedure is only one of several factors the RBRVS takes into account in deciding how many value units to assign to that procedure. But as the factors are multiplied together, if you overestimate the time, it is hard to fully correct for that.

The CMS folks, when this is pointed out to them, respond by saying that they are now relying less and less on RUC to set their own rates. But that means that while they used to accept the RUC's recommendations wholesale 90 percent of the time, they now accapt them only 70 percent of the time. I think you could call that baby steps.

CMS has also protested all along that however flawed the RUC system might be, they simply don't have the staff or funding to decide these things independently. Which is true; according to the Post story, CMS has only 7-8 people working part time on RBRVS calculations.

However, if you look to see what Whoriskey and Keating did to calculate their numbers, it is hardly rocket science; and had they had the in-house access to the numbers that CMS must have, it would have been even easier to show that the RUC calculations were simply ridiculous. It is hard to imagine that no one at CMS, over all these years, could have observed this same thing.

Whoriskey and Keating interviewed Dr. Amrit Narula, a gastroenterologist and owner-operator of an endoscopy clinic in Pottsville, PA. The three doctors who worked there took in $700,000 for doing colonoscopies alone in 2011, while the facility charged its own separate fees and showed a profit of $1.5M. Dr. Narula, the reporters noted, lives in a 5000-square-foot house in the community.

Dr. Narula was obviously a bit embarrassed by the way he and his colleagues rake in money off a procedure that's paid much more generously in the U.S. than in any comparable industrial nation, thanks largely to the RUC. But he also pushed back a bit: “'What is the right price?... Who can tell? A lawyer can charge $400 an hour. My accountant charges me for 15 minutes of time even if he just opens an e-mail from me. And what about the bankers? . . . Ultimately, this is for society to decide.'”

Dr. Narula has a good point. And if it's for society to decide, it should be done in an open forum, not behind closed doors and under the control of the same medical specialists who are paid according to the resulting formulas.

ADDENDUM 7/22/13: As this blog is about ethics and professionalism in medicine, it may be worth taking a minute to reflect on the career of the RUC. As this and previous posts indicate, when the RUC and its activities and processes are brought out into the light of day, there is a distinct aroma problem--what's going on doesn't pass the sniff test. It seems quite obvious to any members of the general public who take the time to inform themselves about these activities (all seven of them) that what's going on sounds more like corruption and extortion than how a supposedly "professional" organization ought to conduct its business.

The AMA was fat and sassy during a good part of the 20th century. The vast majority of American physicians were AMA members (you were considered a sleazeball if you were not a member of your county medical society, and for decades you were not allowed to be a member of the county and state societies unless you also joined the AMA). The AMA was one of the most powerful lobbies in Washington and was credited single-handedly with shooting down Truman's efforts at national health insurance; in the 1948 elections more than 90 percent of all Congressional candidates whom the AMA supported got elected. Most people had high praise for physicians and for the new advances in medical sciences, and credited the medical "profession" with standing for those advances for the good of everyone. Physicians still worked incredibly long hours and made house calls, and most of them drove Chevys, not BMWs.

By the 1980s and 1990s, this halo was starting to tarnish. The AMA was starting to lose dues as legal rulings prevented automatic membership requirements--sinking to the present level where fewer than a quarter of US physicians are members of the AMA. (Full disclosure: I am not and never have been.) Historians gradually gained attention as they rewrote the history of 20th century medicine, not as Ben Casey and Dr. Kildare selflessly saving lives, but as a powerful guild making more and more money, exercising more and more power, and justifying it all on the charade that everything was done for the public good and nothing was done for selfish reasons. The public noted that physicians' incomes suddenly took off like gangbusters after Medicare and Medicaid were passed and so many previous "charity" patients suddenly had decent insurance.

So in this environment, if you'd asked any thoughtful person what was going to happen if the AMA took over the RUC and ran it strictly for the financial bennies that accrued to physicians--and then, only for one segment of physicians, the procedural specialists--and the public interest be damned, then what was going to happen? And the answer would be--maybe for a while, maybe for a long while no one will notice. But when they do, some pretty serious chickens are coming home to roost. And the result won't be pretty for those who are trying to defend American medicine as something vaguely resembling a "profession."

So they could have connected the dots and been warned. But no, they had to succumb to greed. As the old folk song said, when will we ever learn?

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