Saturday, July 13, 2013

The RUC Revisited: More Corruption in High Places

A while ago I posted about the Resource-Based Relative Value Scale Update Committee, or RUC:

I explained how this committee, which is run pretty much secretly by the AMA but which has a huge influence over how Medicare and Medicaid reimburses doctors, is rife with commercial conflicts of interest, in addition to all its other problems—specifically, being immensely top-heavy with procedural subspecialists who can almost always outvote the primary care representatives to assure that the US health system keeps paying tons of money for procedures and specialty care while a dwindling handful of medical students are now entering careers in primary care, despite the growing need for the latter.

A bit more light has been shed on the workings of this group by Haley Sweetland Edwards in the Washington Monthly:

Edwards was able to get several current RUC members to talk with her as well as former RUC members and former administrators of the Federal Center for Medicare and Medicaid Services (CMS). (Members of RUC have to sign what amounts to a draconian gag order.) She pulls no punches in describing how corrupt this system is, where we basically ask the people who are going to get paid to decide what counts as a “fair” rate to pay them at, and to do it secretly behind closed doors.

The concerns that I raised in the earlier post are reinforced in Edwards’s account. Many of the physicians who sit on the RUC and represent the various subspecialty societies may have conflicts of interest with drug and device firms that make profits off the procedures that these physicians perform. These companies make a lot more profits if more and more physicians do more and more of these procedures, so there’s a huge financial incentive for the companies to lobby for higher reimbursement rates for those same procedures. Even if the individual physicians don’t have financial ties to the company, the same companies are often huge donors to the specialty societies themselves. As the companies want to make bigger profits, and the specialist docs want to all get paid more, there’s a uniformity of interest in favor of  raising the rates for these procedures and stiffing the poor docs who don’t do procedures and only spend time talking with patients and thinking.

As I reported in the past, while the average person (indeed the average American physician) has no idea that the RUC even exists, there has been an occasional drumbeat of protest. Why imagine that now anything is going to change, since this secret cabal has been having its way pretty much all along without challenge? Edwards notes that there is finally some pushback, with the CMS actually starting to reject some of the RUC’s recommendations. (Approval rates are down to about 60% from a long-time high of 90%.)

I am hoping Edwards’s piece will get some of the attention that it deserves because it now comes along following a series of major articles on out-of-control prices for US health care services and products, most notably Steven Brill’s epic article in Time, “Bitter Pill:”

With more and more people becoming aware that prices in hospitals are being fixed in ways that no semblance of a “marketplace” could ever explain or justify, then Edwards’s account of RUC, which several experts describe as nothing more or less than a price-fixing scheme, might start to make more sense.

I will repeat here my own disappointment with one member of the lonely primary care contingent on RUC, my own American Academy of Family Physicians. In recent years, aware of the huge gap between primary care and specialist income and how this is driving a future shortage of primary care docs, the RUC has tossed a few crumbs in the direction of primary care, and no doubt these few crumbs have been used by the AAFP as justification for keeping its seat at the table. I will repeat my own fervent wish that the AAFP, and any other organization on RUC that represents primary care and has some smidgeon of integrity, will walk away and refuse to be a part of this charade any more. The AMA has been able to market itself to CMS as the natural organization to run RUC (for which service, Edwards informs us, it gets paid $7M/year) in part because it can claim that it has representatives from all the involved groups of physicians. If any significant group were to walk away, the AMA could no longer make this claim and its house of cards would collapse. And finally, the Feds might be forced to appoint an actual government advisory body to set reimbursement rates, and to do so according to open procedures with full disclosure of conflicts of interest.

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