The Anechoic RUC: Some Small Efforts at Reform

I have previously written about the Resource-Based Relative Value Scale Update Committee, or RUC:
http://brodyhooked.blogspot.com/2011/05/more-conflicts-of-interest-at-high.html
http://brodyhooked.blogspot.com/2013/07/piling-up-on-ruc-about-time.html
http://brodyhooked.blogspot.com/2013/07/the-ruc-revisited-more-corruption-in.html

Now, along comes a long and thoughtful synopsis of RUC from our friends over at Health Care Renewal:
http://hcrenewal.blogspot.com/2014/08/now-politico-tries-ruc-raking.html
--which in turn highlights a piece in Politico by Katie Jennings:
http://www.politico.com/magazine/story/2014/08/health-care-costs-110184.html#.U_zgQYcg-ig

When I asked Dr. Roy Poses of HCR about RUC, his reaction was: "It's amazing how little traction this issue has gotten, despite its importance, and the fact that there is something in the RUC for nearly everyone to hate..."

Now, what's it about the RUC that should make people hate it?

• Is it the fact that it's run by the AMA on a nearly-secret basis, despite the fact that it more or less sets Medicare and Medicaid policies?
• Is it the fact that it overwhelmingly represents specialty societies who generally manage to practice "you scratch my back, I'll scratch yours" as a way to assure good payments for procedures?
• Is it the fact that primary care specialties are woefully underrepresented and usually end up with the short end of the stick when it comes to payment--assuring that primary care will continue to pay well below average and drive away med students despite the great need?
• Is it the fact that these high medical prices for procedures fit in well with the corporate interests that continue to dominate medicine?

I'll let Dr. Poses speak to this issue at some length in his conclusion:

"So since 1992, the RUC has had an outsize role controlling what Medicare pays physicians, and hence physicians' pay in general.  Over this time, the playing field has become increasingly tilted in favor of procedural services and away from cognitive services, especially primary care.  The result is that the US has the most expensive health care system in the world, but hardly the best health care or health care results in the world. 

"Economists have beaten us over the head with idea that incentives matter.  The RUC seems to embody a corporatist approach to fixing prices for medical services to create perverse incentives for physicians to do more procedures, and do less conversing with and examining patients, examining the best clinical research evidence about their problems, and rigorously thinking about how best to help them.  More procedures at higher prices helps physicians who do procedures.  It may help even more the corporations that provide the devices and drugs whose use is necessitated by such procedures, and the hospitals who can charge a lot of money as sites for performance of procedures.  It may even help insurance companies by driving ever more money through the health care system, and thus allow rationalization for higher administrative expenses as a function of overall money flow.

"Yet incentives favoring procedures over all else may lead to worse outcomes for patients, and more costs to patients and society.  If we do not figure out how to make incentives given to physicians more rational and fair, expect health care costs to continue to rise, while access and quality continue to suffer.

"Since we started writing about the RUC in 2007,  there have been some small changes in the RUC.  It has slightly more primary care representation, and its membership is no longer secret.  That is, however, about it.

"As I wrote last time, hopefully the Politico article, added to all the other attempts to shine light on the RUC, will succeed in increasing awareness of the RUC and its essential role in making the US health care system increasingly unworkable.  Of course, such awareness may disturb the many people who are making so much money within the current system.  But if we do nothing about the RUC, and about the ever expanding bubble of health care costs, that bubble will surely burst, and the results for patients' and the public's health will be devastating."

Dr. Poses' blog is based on a central metaphor which for some reason I find mildly irritating, the anechoic effect--the idea that something happens but it never leaves an echo, and so it gets ignored. (Why I find that irritating can be left for elsewhere.) But RUC seems to be a great example. It does all sorts of things wrong, in a huge way, and it just keeps rolling and rolling on the same pathway, and whoever criticizes it seems to be talking to nobody and never gets an answer. The basic factor favoring RUC is that even most physicians have no idea that it exists.