RUC flawed but functional

No cryptic cartel, the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC) is an indispensable piece of the healthcare payment puzzle that beats less logical options that have been proposed, dermatologists say.

Created by the 1989 Omnibus Budget Reconciliation Act, "The RUC is extremely important. Its process is not perfect, but it works," though lately it's been unfairly tarred, says Daniel M. Siegel, M.D., American Academy of Dermatology (AAD) adviser to the RUC. With a total of 15 years' experience on the RUC, he has served on its practice advisory committee and chaired its research subcommittee. He is also a clinical professor of dermatology and director of the procedural dermatology fellowship at the State University of New York Downstate Medical Center, Brooklyn, and AAD immediate past-president.

Mark D. Kaufmann, M.D., adds, "There's been a lot of criticism of the RUC," ranging from its influence on the Centers for Medicare and Medicaid Services (CMS) to its apparent secrecy. To such charges, he replies, "The RUC is continually evolving and is always attempting to improve itself." He is an associate clinical professor, department of dermatology, Icahn School of Medicine at Mount Sinai, New York, and the American Society for Dermatologic Surgery (ASDS) adviser to the RUC.

It's all relative

By definition, Dr. Siegel says, "The RUC is a purely advisory committee to CMS," which ultimately sets prices. As such, he says, the RUC's job is to "take every current procedural terminology (CPT) code and decide how much work the code is worth relative to the work involved in every other code." After considering the time, intensity, complexity and physician risk involved, he explains, the RUC assigns numerical values that allow between-specialty comparisons.

Dr. Kaufmann says that the average dermatologist may have an inkling about what the RUC does, but few appreciate the intricacies of RUC rules or how the committee functions.

Fitzgeraldo A. Sanchez, M.D., co-chair of the AAD Resource-Based Relative Value Scale (RBVS) committee, says that when he attended his first RUC meeting while serving as a fellow under the supervision of Dr. Siegel, "I found it incredible that they put so much detail into developing the value of a code," down to the 14 cents worth of gauze a procedure might require. He is also adjunct clinical assistant professor of dermatology at the University of Florida College of Medicine, Gainesville.

The process demands such detail, Dr. Kaufmann says, because RUC advisers understand that "The more value that goes to their procedures, the less is available for others, and vice versa." Overall, though, "The RUC strives to be fair and allows specialties to tell their side of the story." Additionally, he says, RUC advisers know that - because of checks and balances within the system - what they request must be realistic.

In this regard, he says that he - along with Dr. Siegel and advisers from the Society for Investigative Dermatology and the American College of Mohs Surgery - jointly develop strategies for presenting and defending codes. If RUC dermatologist surveys reveal that 70 percent of dermatologists do a follow-up visit within the 10-day global period allowed after wart destruction, for example, "That's very good evidence to take to the RUC showing that the value that's been assigned to that global period deserves to be there."

RUC surveys don't always work as intended, however. Despite AAD efforts to educate members about the RUC, Dr. Siegel says, dermatologists' misunderstanding or disbelieving AAD missives amounts to ignorance. When ignorance causes physicians to answer surveys lazily or inaccurately, he says, "People suffer," via reduced reimbursements.

Regarding the objectivity of the RUC process, Dr. Siegel says that when a dermatology code comes up for review, "The dermatologist on the committee is not reviewing it. Codes are primarily scrutinized and reviewed by people who do not have interest in that code."

As for characterizations of RUC meetings as obscure and boring, Dr. Siegel says, "They're actually rather exciting. Thirty-one of the brightest minds in medicine gather around the table to work these things out." This figure includes three nonvoting members; RUC recommendations to CMS require a two-thirds majority.

Regarding the RUC's appearance of secrecy, Dr. Siegel says, "The only reason the meeting is closed is that some people might be able to use what happens there unfairly." A tip from behind closed doors might result in "fire sales" on stocks of companies involved with a particular procedure, he explains.

To boost transparency, Dr. Kaufmann says, the RUC now releases vote totals after its meetings (without revealing how individual members voted). Since its inception, Dr. Siegel notes, "The efforts of the RUC are revealed in both the annual proposed and final fee schedules published in the Federal Register."

Fixes miss the mark?

Remedies proposed to eliminate perceived RUC problems fall short, Drs. Siegel, Kaufmann and Sanchez say. For example, Dr. Siegel says, the RVU validation model being built by the RAND Corporation is "potentially useful from the perspective of cutting expenditures, but does nothing for quality or outcomes. They're not getting input from people who actually practice medicine."

A similarly purposed Urban Institute project is "The cause of many significant cuts to values including phototherapy for psoriasis," he adds. Mandated with saving money, "The Urban Institute has come up with methodologies for trying to level payments regardless of site of service - hospital or office - that make no sense. Essentially they're responding to the government's desire to let a third party inflict pain, without a logical model."

Dr. Sanchez adds, "They want to review some of the dermatology codes, but they're not asking dermatologists to get involved. They're asking family practitioners, who aren't the typical practitioner" who uses those codes.

Dr. Kaufmann says that as a participant in the RUC process, he would prefer that these determinations remained under the RUC purview. However, he says, the specialty of dermatology will "have to abide by whatever recommendations these projects make to the RUC if CMS tells us we have to."

Additionally, the American Academy of Family Physicians (AAFP) has proposed that CMS create primary-care-specific E/M codes with higher relative values to reflect more demanding E/M requirements in primary care versus specialties. However, Dr. Kaufmann says, dermatology opposes specialty-specific codes.

"From the RUC perspective," he says, "an office visit is an office visit, no matter who's doing it."

Dr. Siegel adds, "The primary-care-as-gatekeeper model was tried in the 1990s and for an assortment of reasons fell out of favor."

Addressing the concern that RVUs always ascend over time, Dr. Siegel counters, "That's not true." Specialties in which payments have declined in recent years include pathology and cardiology, he says.

Furthermore, he says CMS does not simply rubber-stamp RUC recommendations. In fact, Dr. Kaufmann says that the percentage of RUC recommendations adopted by CMS has fallen from greater than 90 percent to 87 percent for 2012.1

Taken together or separately, Dr. Siegel says, the many proposed RUC remedies are all worrisome. "You never know which one the government is going to let grow legs."

Accordingly, he advises all physicians to become proactive in protecting codes they rely on. "And if things aren't working well, don't simply complain to your specialty society. Make it known to your congressman that they're tampering with things that don't need tampering." The best way to do this is "through a polite, well-constructed message that the AAD can provide. Your support of SkinPAC, the only political action committee dedicated to the interests of dermatology, is also critical."

Within the RUC, Dr. Kaufmann says, all specialties must follow the same rules. "As long as no one has a perceived advantage at the table, it seems to work." As such, he says, "It's a process we're happy to be involved with. We would be upset if these things were being determined without the specialty societies' input."

For more than two decades, Dr. Siegel adds, the RUC has managed to value CPT codes in such a way that all specialties that use a particular code - and those that don't - have been relatively happy. Accordingly, he says, "It's a functional system that's better than many other possibilities, such as the ones being put forth where the government arbitrarily decides things based on whimsy."

Perhaps Dr. Sanchez best sums up experts' attitude: "The RUC system could be better, but it could be a lot worse."

For additional coverage, see:

Liked or loathed, RUC wields broad influence

Physician payment determinations must include more evidence

INFOGRAPHIC: How a CPT's Medicare allowable is determined

Medicare fee schedule has foothold in contracting

Current RUC members

RUC flawed but functional

RUC committee takes steps toward transparency

New payment models gain traction