Brief History – The RUC started influencing procedure costs in the early 1990’s. At this point Medicare instituted the Medicare’s Resource-Based Relative Value Scale (RBRVS) which is a reimbursement system that pays doctors for tests, imaging and medical procedures. Using this system the CMS breaks doctor labor into work units and ranks procedures. Each procedure is awarded work units depending on the complexity and time involved. As an example brain surgery would be awarded 50 times the work units that a routine office exam is awarded. Every year the CMS sets values for medical procedures. The RUC is made up of 29 men and women doctors that meet to discuss and then vote by secret ballot on reimbursement rates for over 10,000 procedures. These recommendations are then passed on to the CMS.

How Much Influence Do They Have – The RUC has a tremendous amount of influence over rates as the CMS almost always accepts their recommendation. There has been some concern that this panel of 29 doctors wields too much influence and is in some ways setting its own pay scale which can lead to conflicts. The majority of the doctors that make up the RUC are specialists which may be one reason that specialists are reimbursed at much higher rates than a primary physician.

Problems With the RUC – There have been many complaints that the RUC wields too much influence on rates and that reimbursement rates are skewed higher for certain specialties. A primary physician is reimbursed at much lower rates than a specialist and while there is certainly more training involved in certain specialties, low reimbursement rates for primary physicians encourages most medical students to pursue a specialty which has lead to a severe shortage of primary physicians. There have been calls from many quarters to reconsider the RUC and the power it

wields. As healthcare costs continue to rise there is a need to reassess the RUC and its role in the determining rates.

Despite advances in Printed Circuit Board Assembly that have made equipment and procedures cheaper to perform, costs continue to spiral upward. The RUC has been very influential in setting reimbursement rates for medical procedures since 1992 and as its influence has grown there have been many complaints that prices for many specialist procedures have gone up unreasonably. The current drought of primary care physicians can be in many ways be blamed on the RUC and the unbalanced influence that surgeons and other specialists have on recommendations to the CMS. There have been many calls to overhaul this system and as healthcare costs continue to rise there is a good chance that serious cuts will have to be made.

What is the RUC – In the early 1990’s Medicare started using the Medicare’s Resource-Based Relative Value Scale (RBRVS) which is a reimbursement system that spells out reimbursement rates for doctors for all procedures. This scale covers everything from imaging, to surgery. Procedures are assigned a certain number of labor units which determines how much money will be reimbursed to insurers or doctors. The RUC or the Specialty Society Relative Value Scale Update Committee which is the full name of the committee is made up of 29 doctors who meet to discuss and vote on reimbursement rates. The RUC forwards these recommendations to the CMS which often accepts them without much fuss. The RUC and CMS meet yearly to review new procedures and update rates.

How it Affects Rates – The RUC obviously has tremendous impact on health care costs These 29 doctors basically set the pay rates for most doctors practicing today. The major complaints about the RUC is that it is stacked with specialists who form alliances to make sure their specialty gets the lions share of the money to be allocated. Because voting is by secret ballot it makes it easy for certain specialists to create alliances to ensure the rate they put forward is approved.

Affects on Healthcare Costs – As the reimbursement rates for specialists continue to rise, so do insurance rates. In addition the RUC and its rate approvals has led to a primary care physician shortage. Medical students coming into the medical industry must decide on a specialty or to work as a primary care physician. Primary care doctors are under represented on the RUC board and their reimbursement rates reflect this. A specialist can make millions of more dollars over a career than a primary care physician which means that fewer and fewer medical students are considering a career as a primary care doctor. This drought of primary care docs means that many people don’t get the appropriate care and attention by their over stretched doctor so they may end up needing to see a specialist, which of course costs much more.

It All Adds Up – While the RUC is not completely to blame for the high cost of healthcare it is certain not helping. Allowing doctors to basically set their own rate of pay with little to no oversight or input from patients can lead to abuse. As more and more med students choose the high pay route of specialties the lack of primary care doctors will lead to more expensive procedures being needed. All of these

factors have lead to a dramatic increase in healthcare costs over the last two decades. You can visit any number of websites put up by web designers Milwaukee, WI that discuss this issue for more details.

Technology – Using technology to lower healthcare costs can be something that both patients and healthcare providers can benefit from.

* Healthcare Providers – As a provider you can employ technology to communicate with patients. Skype and email can be a good way to consult on cases that are not life threatening, saving money for both patient and the client. Reminding patients of flu shots and other immunizations that are due can easily be done by text or email. When diagnosing, using technology like a GE Ultrasound instead of immediately going to the much more expensive MRI machine can result in lower costs. In many case an ultrasound will be able to provide images that are more than adequate for diagnosis.

* Patients – Most patients can use technology to monitor health and communicate with their doctor. Saving a trip to the office can be a big money saver. Getting texts and email alerts from your provider about immunizations and diet reminders can help you stay healthy. In addition to health reminders technology can help you monitor existing conditions. There are many devices on the market that let patients monitor conditions like blood pressure and help them lose weight while staying in shape which can help prevent a trip down to Ultrasound Service.

Changing Behaviors – Keeping patients healthy is the best way to control costs. This can be done by encouraging a healthy lifestyle and in some cases rewarding healthy behavior with lower insurance costs or even cash back. Educating patients about their health issues and conditions that could affect them in the future can be done use websites and emails. Staying a few steps ahead of diseases like diabetes can prevent patients from developing the disease. Getting patients to exercise and eat better can be difficult but with gentle prodding and rewards like lower insurance rates it is possible to change lifestyles for the better.

Used Equipment – It is not always necessary to have the newest equipment in your office. Using a Used Ultrasound can help lower costs while still providing the same imaging power as a new one. This philosophy can extent to the majority of equipment in a doctors office.

While there is no magic bullet to lower the cost of healthcare, there are many things that both providers and patients can do to help control the every rising cost of staying health.

Health Advice – Keeping patients healthy and out of the office is a great way to drive down health costs. Your website can offer advice on lowering blood pressure, alert patients to the importance of flu shots and offer tips on new medications and treatments. Using a blog or social media like Twitter to keep your patients up to date on staying healthy and educating them on health issues will get them healthy and lower healthcare costs.

Education – Use your website to stay in touch and educate your patients on common issues can keep them healthy and out of your office. Prenatal care is a great example. Many patients are unaware of how important prenatal care is to the delivery of a healthy baby. Updating them with blog posts and sending out quick Tweets at critical timeframes during the pregnancy can result in more healthy births.

Heart Disease is another condition that benefits from education. Letting your patients know what steps they can take to help prevent and control heart disease can result in fewer heart attacks which results in fewer trips to the emergency room, lowering healthcare costs.

Events and Reminders – A well designed website will let you alert your patients to events that are coming up at your practice or hospital. When flu season hits, a quick Tweet can remind them that it is time to head in for a flu shot. If your practice is having a free blood test day or promoting a blood drive using a website combined with a Facebook update or quick Tweet can make your event a bigger success. Don’t over do it with reminders and Tweets, your patients will appreciate information that is timely and informative but will quickly tire or daily pointless marketing messages.

Schedule Appointments and Chat – Depending on how complicated your site is you might be able to let patients schedule appointments, which can be a real time saver for both your patients and your staff. You site should allow patients to email questions about their health or just general medical issues. It can also be helpful to

set up times when a patient can chat with a doctor or nurse online about specific health issues.

Medical websites are complicated and you should absolutely have a professional design and maintain your site. Websites require constant maintenance and updating so look for Milwaukee web design that offer continuing service contracts. It is also possible to outsource your content, working with a professional writer to craft your content and updates. This frees up your time and ensures your content is clean, concise and professional.

On February 1, the American Medical Association’s Relative Value Scale Update Committee (RUC), Medicare’s primary advisor on physician payment, announced the addition of two seats: a permanent one for geriatrics and a rotating one for primary care. The American Geriatrics Society and the American College of Physicians praised the move as a step forward that will amplify the RUC’s appreciation of their physicians’ contributions.

But the RUC’s maneuvers are a cynical sleight of hand. They attempt to assuage charges of sub-specialty bias while continuing the RUC’s sub-specialty dominance. The additions reduce proceduralists’ share of votes from 27 of 29 (93 percent) to 27 of 31 (87 percent), hardly a power shift. Primary care comprises about 35 percent of US physicians, but cognitive medicine would have only 13 percent of the votes.

Nor do the RUC’s changes address its opaque processes, shoddy scientific methods or conflicts of interest. In other words, by any practical measure, the RUC’s character and function remain unchanged. It still fails to meet the requirements of the Federal Advisory Committee Act, ensuring that regulation is formulated in the public rather than the special interest.

Most telling, the RUC has flip-flopped to justify its current position. Less than a year and a half ago, RUC Chair Barbara Levy, MD insisted that the RUC is an expert panel, not meant to be representative, so additional seats for groups like primary care and geriatrics were unnecessary. “The outcomes are independent of who’s sitting at the table from one specialty or another.”

Suddenly Dr. Levy has changed her tune. Now the RUC needs additional expertise.”Their experience will be particularly important as we continue to work on meeting the unique health needs of an aging population and improving care coordination for patients with chronic conditions.” Dr. Levy is admitting that, for 20 years, the RUC has operated with inadequate knowledge about primary care and geriatrics. (It is particularly damning that, despite Medicare’s senior focus, the RUC has refused to allow geriatrics’ participation until now.)

The RUC’s announcement also promised to make its proceedings more transparent by reporting the vote counts on its decisions. Again, this doesn’t change anything. Individual voters presumably won’t be identified, and past participants have openly described the “horse trading” that goes into valuation. Dr. Neil Brooks, a family physician who served for 4 years on the RUC, said, “If radiology presented a new set of codes that had to do with imaging procedures, there was a feeling that some people would go along with that if radiology would go along with other things.”

Over the past year, we and others have argued that the RUC’s serious flaws are at the heart of much that is wrong with the US health care system. We have shown that the RUC has systematically undervalued the work of primary care, while over-valuing expensive, high-tech, sub-specialty care. We have illustrated that the perverse economic incentives in current valuations undermine medical professionalism, are foundational to the American health care cost crisis, and have precipitated a crisis-level shortage in the primary care work force. Dr. Fischer and five primary care physician colleagues have sued HHS and CMS because these agencies’ sole source reliance on the RUC foresakes their responsibilities to the public interest.

Last June, the American Academy of Family Physicians (AAFP), which currently occupies a RUC seat, wrote Dr. Levy demanding that the RUC’s primary care’s representation be increased to more fairly reflect the real-world composition of practicing physicians. They recommended the elimination of 3 rotating seats now held by sub-specialty groups, the addition of 4 primary care seats (family medicine, pediatrics, geriatrics and osteopathy), and the creation of 3 “external representative” non-physician seats like patients, employers, health systems and health plans.

Last January, Drs. Klepper and Kibbe called for primary care societies to de-legitimize the RUC’s excesses by publicly quitting. Against the backdrop of the resulting lawsuit that challenged the RUC’s continuing role, and the AAFP’s challenge to bring the RUC more to rights, the RUC’s response tries to convey course correction while maintaining the same path. It remains dedicated to special interest excess. The courts and the AAFP should recognize this.

The RUC, through its relationship with CMS, has exploited America’s health care payment system for two decades, taking our economy to edge of a precipice. The AAFP Board will decide next month to walk or accept the RUC’s deception. If it keeps faith with its members, the AAFP will walk. If it doesn’t, its members should. The rest of us can only hope that the courts are not taken in.

Computer and Network Systems – Medical practices and hospitals make use of computers and networking systems just about every minute of the day. As more and more medical records move online the importance of networking systems grows. Lowering the costs of printed circuit boards used in the servers that drive these systems can help control costs at hospitals and even small medical practices. These savings can be passed on to patients. It’s not just the guts of computer systems that have undergone an update in manufacturing techniques, wiring harness are benefiting from new technologies as well. Lower overhead costs and the ability to easily share records among healthcare providers will drive costs lower.

Medical Equipment – Computers and networking equipment are not the only machines to benefit from lower Electronic Manufacturing Services costs. Ultrasound machines, MRIs and even something as simple as a blood pressure machine make use of printed circuit boards and other electronic components. As the cost of these machines drop, that cost savings can be passed on to patients and insurance companies. Increasing the quality of the internal components while lowering costs makes used equipment more attractive as well. As these machines function longer the need to replace them disappears, creating additional cost savings.

Improved Technology – As electronic components become cheaper they are also making leaps and bounds in technology. Improved imaging technology often means that a hospital or medical practice can get the images they need using an ultrasound instead of the more expensive MRI. Getting quality results using equipment that cost less will lower the cost of healthcare for both insurers as well patients. As the cost of technology drops new machines and techniques can be developed and implemented which can further lower the cost of healthcare.

Long Distance Medicine – Keeping in touch with patients, reminding them of appointments and immunizations can help them stay healthy which keeps them out

of the office, lowering the yearly cost of their healthcare. Educating patients on healthy living choices and monitoring existing medical conditions can all be done through the use of technology, and all of these computers have printed circuit boards and other electronic components. Lowering the costs of electronic manufacturing is intensely linked to the cost of healthcare.

While it many not seem like it, the cost of electronic manufacturing is directly linked to the cost of healthcare, improvements in technology and lowering the costs of printed circuit boards will lower the costs of medical treatments. Technology is at the heart of healthcare these days and improvements in cost and manufacturing improvements will directly affect rates that patients and insurers pay for healthcare.

Americans increasingly distrust what they perceive as poorly run and conflicted government. Yet rarely can we see far enough inside the federal apparatus to examine what works and what doesn’t, or to inspect how good and bad decisions come to pass. Comparing the behaviors of two influential federal advisory bodies provides valuable lessons about how the mechanisms that drive government decisions can instill or diminish public trust.

The Health Information Technology Policy Committee (HITPC) advises the Office of the National Coordinator for Health Information Technology (ONC) on matters pertaining to the ARRA/HITECH legislation. ONC is responsible for deciding how to spend the roughly $25 billion Congress authorized in 2009 to stimulate doctors’ and hospitals’ adoption of electronic health records (EHRs) and other health information technologies. HITPC, a 24-member Federal Advisory Commitee (FAC) as defined and governed by the Federal Advisory Committee Act (FACA), makes recommendations to ONC on many topics – from certification of EHR technology and privacy/security regulations to governance and oversight measures for the Nationwide Health Information Network – that affect how that money will be spent, who is eligible to receive it, and what rewards and penalties will apply in the process.

The Relative Value Scale Update Committee (RUC) is far more influential. Over the past twenty years this group of 29 physicians convened by the American Medical Association (AMA) has been CMS’ primary advisor on how Medicare should value doctor visits and procedures. Many Medicaid and commercial health plans follow Medicare’s lead on payment, so the RUC’s influence on the $2.7 trillion health care economy is sweeping. While the RUC is not formally a FAC, it has been challenged as being a “de facto” FAC, a designation that has legal precedent.

Both HITPC and the RUC are comprised of volunteers. But the similarity stops there. A chasm separates their behaviors as advisory bodies, primarily because HITPC operates in the open and under public view, whereas the the RUC acts virtually in secret.

HITPC’s formal organization as a FAC obligates it and more than a thousand other similarly constituted entities to operate under FACA’s strict management and reporting rules, which seek to ensure that the regulatory agencies’ activities are in the public rather than the special interest. HITPC must have balanced representation in its membership. Its proceedings must be transparent, and its analytical methodologies must be scientifically credible. Indeed, FACA established a federal database that incorporates the proceedings of HITPC and all other federal advisory committees, and that facilitates government-wide advisory committee management and accountability audits.

HITPC is scrupulously compliant with FACA. Its mission and goals, membership roster, meetings schedules, and all documents issued by the committee are available to the public on its website. All HITPC meetings are open to the public and are broadcast over the Web or by teleconference. ONC makes audio recordings available within a day following a meeting, and a draft transcript is posted within a week. HITPC members must declare conflicts of interest, and must recuse themselves from votes that involve real or apparent conflicts.

By contrast, and despite its immense influence over Medicare and commercial health expenditures, the RUC proceedings are opaque. Its meetings are closed to the public – participation requires an invitation from the Chair – and transcripts are not publicly available. Members vote secretly by electronic ballot, and the AMA discards records of the votes.

Still, CMS has accepted more than 90 percent of the RUC’s 7,000 recommendations since 1991, often without further due diligence.

The RUC is also rife with conflict. Until 2009 the AMA would not reveal the RUC members’ names. While primary care physicians represent some 55% of all doctors, 27 of the RUC’s 29 members are specialists effectively lobbying their specialist societies’ interests. Roy Poses MD, who studies financial conflicts in medicine, recently wrote, “14 of 29 members of the RUC have financial relationships with pharmaceutical companies, biotechnology companies, device companies, companies that directly provide health care, and health care insurance companies.” None of these are publicly disclosed as a condition of RUC membership. Nor is there any publicly available record of whether real or potential conflicts of interest have caused RUC members to recuse themselves from votes.

These two advisory models represent different frameworks for operationalizing federal policy. The RUC’s secretive membership and proceedings hinder scrutiny. CMS near-total reliance on a clandestine special interest group is precisely the kind of governmental behavior that the public no longer trusts.

HITPC’s recommendations occur in the sunshine and are observable in real-time. Important regulatory decisions are forged in an environment of expert opinion, public discourse, and frequent opportunity for comment and debate. They follow FACA’s mandates for openness and broad representation, and offer a path to rebuilding trust that the American people now clearly desire.

In early August, six primary care physicians from the Center for Primary Care in Augusta, GA, filed suit against the US Department of Health and Human Services (HHS) and its subsidiary agency, the US Centers for Medicare and Medicaid Services (CMS).

The filing was a critical step in a campaign that David Kibbe MD and I began in January 2011 against the excesses that have arisen from CMS’ inappropriate relationship with the American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC).  But the effort was really given life by Paul Fischer, MD, the Augusta physician who brought a focused, practicing primary care perspective to the issue, and Kathleen (Kitty) Behan, the DC-based constitutional attorney who has orchestrated the legal process.

The case’s foundational argument is that the RUC near sole-source advisory relationship with CMS has rendered it a “de facto” Federal Advisory Committee (FAC). Therefore the RUC should be subject to the Federal Advisory Committee Act (FACA)rules that govern the behaviors of these entities, seeking to ensure that regulation is shaped in the public rather than the private interest. Even so, over time CMS has accepted more than 90 percent of the RUC’s valuation recommendations without further due diligence. The agencies’ clear failure to require the RUC’s financially conflicted and secretive behaviors to be adhere to these requirements has resulted in Medicare payment distortions and excesses that have directly harmed primary care, as well as patients and purchasers.

We believe that this case has profound ramifications that go to the heart of the ways American health care is practiced and the cost crisis that has resulted.

For those who wish to monitor the progress of the suit, here are the first three primary legal documents. If you’re willing to wade into the world of legal argument, you’ll find the discussion both fascinating and compelling.

First is the initial complaint, which lays out the legal argument. Next is the Defendants’ Motion to Dismiss. Third is the Plaintiffs’ Opposition to the Motion to Dismiss.

We will continue to make materials available as the process unfolds.

Thanks for your ongoing interest in this.

The old doctors know.  The practice of medicine has changed in a very basic way over the last 20 years.  Physician relationships have lost their civility and have been replaced by a level of tension that takes the fun out of collegial interactions.  I remember my first year of family medicine as the only doctor in Weeping Water, Nebraska.  My personal medical community had gone from an entire medical school campus with limitless lectures and many physicians to share in “interesting cases” to an occasional phone call with a consultant in Omaha.  These contacts became my primary source for medical education and updates for Weeping Water’s health care.  The phone calls were collegial, respectful, and focused on what was best for my patients.

What happened?

The RUC is the secretive committee of the AMA that has been CMS’s primary source of physician payment data over the past 20 years.  It has elaborately articulated the complexity of medical procedures but ignores and confuses the cognitive work involved in patient care – collapsing it into a few evaluation and management codes. As a result, many medical specialties have found that their financial success is tied primarily to doing things TO patients, rather than caring FOR patients.

The RUC has shifted these physicians’ attention away from the hard work of knowing patients over time and fine-tuning their treatments based on subtle changes discovered by history and physical toward focusing on which procedure can be done to a patient and legitimized to an insurance company.  Let the “primary” do that other stuff.

The Problem in Practice

• A patient with chronic abdominal pain is referred to a gastroenterologist.  Is it irritable bowel, sprue, or maybe porphyria?  The letter back from the “consultation” reads, “Your patient’s upper and lower endoscopies were normal.  Thank you for the interesting consult.”
• A patient with long-standing heart failure is seen at the cardiologist’s office.  Since the last visit, you have tweaked his diuretics, handled his depression, and switched him from an ACE to an ARB because of cough.  The patient returns to your office complaining that he only got to see the cardiologist’s PA, who wants him to have an implantable defibrillator. He is worried about having anything done that would shock him while driving.
• A patient is referred to an anesthesiologist who specializes in chronic lumbar pain.  After three epidural injections and nerve stimulation, the patient is seen back at your office, still in pain. He has been advised by the pain specialist to see his primary physician for oral narcotic therapy because the anesthesiologist does not prescribe “that kind of medicine.”

In each case, the medical specialist has been incentivized by payment realities to concentrate on doing procedures rather than thoughtfully caring for the patient.  My now-rare phone calls with consultant colleagues do not deal with the subtle signs of a patient’s heart failure but rather, disagreements about whether the patient’s quality of life will be affected by shocks delivered unexpectedly to the heart.  The tone is often adversarial rather than collegial.

This conflict is intensified when the specialist is “owned” by the hospital, which is increasingly the case.  Too often, the specialist’s procedure may not be good for the patient, but it is certainly good for the hospital’s bottom line.  Is it any wonder that we have so many unnecessary caths, defibrillators, endoscopies, and on and on?

The RUC has decimated the ranks of primary care, damaged patient care by encouraging unnecessary medical procedures, and taken the joy and honor out of the practice of many medical specialties. My specialty colleagues should be paid well to thoughtfully help me with difficult cases. It is unfortunate that instead, they must be focused on doing another procedure to pay the bills.

Paul Fischer MD is a family physician at the Center for Primary Care in Augusta, GA. Last week, with 5 of his colleagues, he filed suit against HHS and CMS to challenge the illicit relationship between CMS and the RBRVS Update Committee (RUC), which has shaped the current payment system. To read more or support the legal fund, go here.

On Wednesday, 47 American medical specialty societies sent Rep. Jim McDermott (D-WA) a letter, with copies to all members of Congress, containing a detailed defense of the American Medical Association’s (AMA’s) Relative Value Scale Update Committee (RUC). For 20 years, the RUC has exclusively advised the Centers for Medicare and Medicaid Services (CMS) on physician procedure valuation and reimbursement. On its face, the letter responds to a seemingly minor piece of legislation introduced by Rep. McDermott, H.R. 1256, the Medicare Physician Payment Transparency and Assessment Act, that would require CMS to use processes outside the RUC to verify the RUC’s recommendations on medical services values.

Conspicuously absent from the letter’s signatures were the nation’s three main primary care societies: the American Academy of Family Physicians (AAFP) – which has formally endorsed Mr. McDermott’s bill – the American College of Physicians (ACP) and the American Academy of Pediatrics (AAP). Last week, the New Jersey Academy of Family Physicians sent a letter to its parent organization, AAFP, “strongly encouraging” it to quit the RUC. It is as though the long-compromised primary care physician community, that makes up one third of American physicians and handles half of our office visits, is suddenly mobilizing.

The medical societies’ letter is more than a response to just Rep. McDermott’s bill. It also responds to primary care’s stirrings. Marshaling the influence and discipline of a medical establishment that is obviously distressed by the prospect of having its economic franchise disrupted, it presents the third public defense of the RUC in a little more than a week, following a column on Kaiser Health News by the RUC’s Chair, Barbara Levy MD, and aletter this past Tuesday to Rep. McDermott by AMA CEO Michael Maves. After 20 years of easily-validated intentional obscurity – ask virtually any room of physicians what the RUC is and watch the majority’s blank responses – this open activity in favor of the RUC is unprecedented.

The letter is also obviously orchestrated, using many of the same tactics and arguments that Drs. Levy and Maves employed in their defenses. It carefully avoids talking about the abysmal real world consequences of the RUC’s historical approach. It ignores the dramatic under-valuing of primary care, the plummeting rates of medical students choosing primary care, the over-valuing and over-utilization of a wide variety of specialty procedures, and the inherent incentive for the RUC to focus on under-valued rather than over-valued procedures.

Instead, it obfuscates. To counter the McDermott proposal that CMS should use means other than the RUC to assess the RUC’s recommendations, the letter argues that past efforts to use contractors have failed. Therefore, it is senseless to go down this path again.

In the late 1990s, CMS used a contractor to develop practice expense inputs for all physician services and when the process failed, the RUC stepped in to develop a new process with uniform standards and re-reviewed every service and cost input resulting in the redistribution of practice expense payments to primary care. Another CMS contractor hired to obtain the overall practice costs of each specialty could not fulfill its contract and, in 2007, CMS relied on the AMA and national specialty societies to collect the cost information. In addition, the RUC assumed the activity of identifying potentially misvalued codes, when CMS, using contractors, failed in its attempt. To date, the RUC has identified more than 900 services and redistributed more than $1.5 billion.

As a logical argument, this is roughly the equivalent of saying that patients have died in the past, so there is no point in having doctors now.

Next, the letter details different steps the RUC has taken to increase primary care reimbursement. It emphatically notes that, in a budget neutral environment, these increases have come at the expense of specialty reimbursement. But it fails to note that these few steps are the exception, not the rule, and that, 20 years after the RUC’s establishment, the average primary care physician can expect to earn $135,000 per year and $3.5 million during a career less than her specialist colleagues. The ramifications of this disparity are not lost on medical students, who now shy away from primary care in droves.

Third, the letter argues against the value of balancing the RUC’s physician-only composition.

Some, including MedPAC, have suggested an additional RUC-like panel, which would include economists and lay-persons in addition to physicians, to make recommendations regarding particular physician services that are perceived to be overvalued. We question the value of creating another panel and argue that this would not only be duplicative, but would add yet another bureaucratic layer to an already complicated process. In addition, the Secretary and CMS already enjoy considerable authority regarding the recommendations issued by the RUC and currently have the authority and ability to obtain input from economists and other individuals.

This is the keystone of the medical societies’ concern. Non-physician stakeholders might crimp the specialists’ agenda. Not mentioned here is the disproportionate high specialist representation in the RUC’s recommendation process.

While addressed to Rep. McDermott, a psychiatrist with deep knowledge of the RUC, the specialty societies’ letter is really aimed at Congress’ rank-and-file members, most of whom are not expert on the topic, and therefore susceptible to half-truths and innuendo.

The letter specifically ignores the core problems that CMS’ relationship with the RUC has created: economic incentives that encourage unnecessary and/or unnecessarily complex interventions while inhibiting primary care’s ability to moderate excessive care delivery throughout the continuum.

The arguments mounted by the AMA and the specialty societies are really nothing more than a vested industry’s efforts to preserve the status quo at all costs. (Think Wall Street’s apologists in this year’s Oscar-winning documentary, Inside Job.) But this approach has brought health care and the US economy to the brink of economic catastrophe.

Averting disaster will require an approach that dampens or bypasses the voices of the advisors who got us here, and strengthens the voice of primary care, which overwhelming data show produce better care at lower costs.