AAFP to Berwick: Re-evaluate RUC

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The dependence on the use of Relative Value Scale Update Committees (RUC) needs to be re-evaluated and more focus should be placed in primary care, Lori Heim, MD, board chair of the American Academy of Family Physicians (AAFP), wrote to Donald Berwick, MD, the administrator of the Centers for Medicare & Medicaid Services (CMS), in a letter dated Oct. 8.

“As a participant society in the RUC process, we acknowledge that the RUC has extensive expertise and a unique infrastructure and perspective that facilitate the valuation of codes under the Medicare physician fee schedule,” Heim wrote. “However, we remain concerned that CMS continues to rely too heavily on the RUC in this regard.”

Earlier this week, the Wall Street Journal broke a story that raised questions about RUC and its panel of 29 doctors who are handpicked by medical specialty trade groups to make recommendations on how much to pay physicians. However, the problem is that these panel members are invested or may have ties to the decision-making process.

In 2006, Medicare Payment Advisory Commission (MedPAC) recommended to CMS that it establish a group of experts who would help to review relative value units (RVUs). And while AAFP “supports” MedPAC’s recommendation, Heim said the review process would be better suited if it also could identify misvalued services and validate RVUs. 

She said that this could be mended “if supporting evidence was collected and analyzed not only by medical specialty societies but also by experts who were less invested financially in the outcome.

“Like MedPAC, we believe that such a panel would not supplant the RUC, but would augment it,” she wrote.

Heim offered that the five-year review process may be inefficient and said that these reviews have led to more increases in RVUs than decreases. While the RUC has “made a concerted effort in recent years to identify potentially misvalued services” through the five-year reviews, it is “unfair to rely entirely upon RUC to do this work.”

Additionally, she pushed CMS to consider alternatives to the RUC process, including using experts who are not financially invested in the outcomes to collect and analyze data, while also creating more transparency within the RUC process.

Currently, RUC votes are conducted electronically and are kept secret. “We believe the process would benefit from greater openness and transparency in decision making, and we would encourage CMS, as the primary recipient and user of the RUC’s product, to insist on such transparency,” Heim wrote.

Additionally, Heim asked Berwick to consider adding additional primary care seats— including family medicine, general internal medicine and general pediatrics—to the RUC for greater primary care input.

Heim asked that the Medicare payment consultation codes, which were eliminated by CMS, be redistributed to evaluation and management services, which “remain under-valued.”