Over the next year, officials at the American Academy of Family Physicians will weigh the best strategy for getting their voices heard when it comes to setting the values that determine Medicare payments.
Traditionally, organized medicine has come together through a body called the Relative Value Scale Update Committee (RUC) to advise officials at the Centers for Medicare and Medicaid Services on the relative values that should be assigned to CPT codes. But over the past several years, primary care physicians have grown dissatisfied with the process, which has assigned lower values to cognitive services.
Most recently, several state chapters joined to urge that the AAFP either work to gain greater representation on the RUC or leave that body and seek an alternative way to advise the CMS.
That proposal was one of two RUC-related resolutions referred by the academy's Congress of Delegates for study by the board of directors. The board plans to issue a report in 2009.
The RUC is a multispecialty expert panel sponsored by the American Medical Association that advises the CMS on the values that make up Medicare allowable charges. Specifically, the 29-member group makes recommendations on the work- and practice-expense components of the Resource-Based Relative Value Scale (RBRVS) system.
Those recommendations help determine how the multibillion dollar Medi- care physician payment budget will be distributed, said Dr. Terry L. Mills Jr., a family physician in Newton, Kan., and the AAFP's advisor to the RUC. The RUC has no formal relationship with the CMS, but CMS officials put a lot of weight on the group's recommendations and have historically accepted their advice more than 90% of the time, he said. “It's the most powerful body in medicine that no one has ever heard of,” he stated.
One of the criticisms of the RUC is that it underrepresents primary care physicians. Only 4 of the current 29 RUC members are from traditional primary care specialties. Most of the rest are from specialties dominated by procedural work.
“There's too much self-interest involved” in the RUC process, said Dr. William Gillanders, director of the family medicine residency program at Providence Milwaukie (Ore.) Hospital.
Dr. Gillanders, who is also the treasurer of the Oregon Academy of Family Physicians, said there should be greater representation of primary care physicians in making recommendations on payments issues. However, he said efforts to get the RUC to change its structure voluntarily have failed, so he wants to appeal to the CMS to mandate a change.
He supports a resolution introduced at the Congress of Delegates that would instruct the AAFP leadership to petition the CMS either to develop an independent Relative Value Scale advisory board with membership that is representative of the current physician workforce providing care to Medicare beneficiaries, or to mandate a restructuring of the RUC.
But Dr. Robert Wergin, a family physician in Milford, Neb., who was involved in advocating for changes to the RUC at the recent AAFP Congress of Delegates, favors staying involved in the RUC and trying to work within that process to gain greater representation, and ultimately greater payment, for primary care. If that approach is not viable, then AAFP will need to consider alternatives, he said. By dividing the RUC, primary care physicians would risk having less influence on the payment system, he noted.
There should also be more transparency in the RUC decision-making process, about which little is known, Dr. Wergin said.
However, Dr. Mills argued that it is premature to give up on the RUC, despite the frustration with how cognitive services are valued. “The RUC remains tremendously important,” he said.
The greater problem may not be a failing of the RUC, but of the RBRVS system as a whole, Dr. Mills said. That system works well for compensating physicians for procedures, but it fails to account for the complexity of coordinating care for chronically ill patients, he said. It would ameliorate some of the problems if AAFP and others could lobby Congress to change the reimbursement system so that complex management is recognized through a regular chronic care fee, he said.
The AAFP board of directors has already been active in examining the RUC. Earlier this year, the board approved a statement saying that the RUC has “failed” and won't be viable until it is restructured to give primary care proportional representation. AAFP has also pledged to investigate alternatives to the RUC.