The RUC – A surgeon’s perspective


Recent changes in the Relative Value Update Committee process are going to have an impact on the committee’s work and output. Surgeons need to know what these changes may mean for our profession.

The RUC is a committee convened by the American Medical Association and composed of representatives of all the major medical specialties who meet to analyze in medical procedures and other work of physicians. Most specialties have four committee members: a delegate and alternate delegate who help deliberate the relative value of CPT codes, and an advisor and alternate advisor who present codes pertinent to the specialty they represent. The RUC does not determine monetary value of the work it reviews. The job of assigning payment rates is left to the Centers for Medicare and Medicaid. CMS takes into consideration the recommendation of relative work by the RUC and applies a complex algorithm to arrive at a payment schedule.

Dr. Chad A. Rubin

A forceful argument against the current RUC process is that of "the fox guarding the henhouse." In other words, the physicians are seen as setting their own payment. This is a misunderstanding or perhaps a misrepresentation of the way the RUC works. The RUC recommends, but CMS may or may not accept the recommendations. In the past CMS has accepted the RUC recommendations 90%-95% of the time. Last year CMS accepted only 75% of the recommendations. This trend is of interest to surgeons because most of the recommendations concerned surgical procedures. Many were "bread and butter" general surgical procedures such as thyroid, and as one might guess, CMS lowered the values.

The work done by the RUC is extremely deliberative and requires careful consideration and fairness by dedicated committee members. In addition, physicians’ work is very technical and requires specialized knowledge that only physicians can bring to the process. I cannot imagine an economist trying to determine the work, the intensity, the number of hospital visits, or the number of office visits for any procedure. Who can analyze the amount and type of work involved in medical practice better than those who actually do the work?

The RUC has proposed and implemented new rules in regard to transparency. Transparency in this context, however, is a double-edged sword. While transparency allows citizens and leaders to get a feel for the process, full disclosure of the discussions and debates involved runs the risk of interfering with that process. There can be tremendous medical, legal, financial and political consequences of the recommendations of the RUC, and it would not be unreasonable to expect significant attempts by a variety of actors to influence the process.

Making the RUC votes public may improve understanding of the RUC, but it could also work to the detriment of the committee’s process.

A two-thirds majority is needed for passage of a work value, and many specialties must agree each time a code passes. If individual votes are made public, the committee members are not protected from pressure from outside actors. Often specialties will vote to increase a code of another specialty. In a budget-neutral system, if your codes go up, mine go down.

Making the vote transparent may prevent a delegate from truly being deliberative to appear more supportive of his or her own specialty. Indeed, the specialty groups could monitor the votes to ensure the codes are "protected," and this has the potential to change the delegate from a "deliberator" to a protector of his or her specialty. That is not the role of the delegate. While I support the publication of the votes in aggregate, I do not support the individual votes for this reason.

There is no doubt that changes are needed. The idea that a survey of 50 specialists will accurately reflect the work may be at times incorrect. If a procedure is performed a few thousand times a year, 50 surveys may be sufficient, but other codes performed millions of times a year such as cardiac catheterization, colonoscopy, or hernia repair I believe need more evaluation than 50 surveys.

The proposed change to make the survey uniform is problematic. There is great variation in procedures, and I find it difficult to think a psychiatric session could be evaluated with the same form as a pediatric cardiac procedure. Regularly, an "expert panel," usually the coding and reimbursement committee of the medical specialties, reviews work and can often help tease out the type of survey and the numbers needed for a particular code. With the process now being undertaken by the AMA with a centralized online tool, the specialties will lose that ability.

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