What is the RUC Process…and Why Should I Care?
There is nothing intuitive about the process by which Medicare determines payments for physicians. The AMA/Specialty Society Relative Value Scale Update Committee or “RUC” is an advisory group of “expert” physicians who provide recommendations on relative value units (RVU) for physician work, practice expenses and liability insurance for particular physician services.1
This effort, perhaps more than any other advocacy work, has a direct impact on reimbursement for GI services. I mention this because it appears that we have reached a critical juncture, the outcome of which will likely impact every gastroenterologist in the country. But first, some background…
Nearly a year ago, I traveled to Chicago to attend the RUC meeting for the first time. I had no idea what to expect. I could only imagine that a multispecialty group of physicians getting together to determine each other’s salaries might look more like a sporting event than an advisory committee meeting — but I was pleasantly surprised.
The only part of the process that was a little gladiator-ish was an AMA staff person who gave the “thumbs up” or “thumbs down” sign to indicate whether or not a proposal (or a plea) from a particular specialty met the approval of the majority of the RUC members. In fact, the RUC meeting was a solemn event during which I was impressed with the dedication and deliberation of the RUC members. Whether it involved studying the accounting details of practice expense reports or the more abstract task of determining the complexity and intensity of physician work involved in a procedure, the RUC members demonstrated a commitment to understand the details of the work they were sincerely trying to value.
The AGA is one of the two organizations that represents gastroenterology to the RUC. As it turns out, this is no small task. After a year of monthly conference calls, probably thousands of emails, several meetings and the patient tutelage of Dr. Joel Brill, AGA staff member Adam Borden, and our colleagues from the ASGE, Drs. Nicholas Nickl and Edward Bentley and ASGE staff member Samuel Reynolds, I remain somewhat puzzled by the complexity of the RUC and amazed by the dedication and attention to detail required to contribute to this process.
So, why should GIs care about the RUC process and how will it affect them during their every day practice? Although there is an attention to fairness that is part of the RUC process, the following issues place endoscopy in danger of becoming an undervalued service:
- CMS has identified endoscopic services as being potentially “misvalued” and has requested input from the specialties that perform these services. Depending on physician survey results and deliberations at the RUC, this will likely lead to reductions in payments for endoscopic services across the board. The AGA and ASGE are working closely with the Society of Gastrointestinal Endoscopic Surgeons to review and provide recommendations to the RUC.
- There is no permanent gastroenterologist member of the RUC, although the AGA has strongly advocated for a more fair composition of RUC members. There are two rotating seats that belong to all internal medicine subspecialties and this seat is being targeted for elimination by the American Academy of Family Practitioners.
- Although the valuation of physician work involves measurement of physician time as well as the complexity and intensity of the task, there seems to be a recent emphasis on physician time alone as being the central determinant of how CMS assigns work value. Unfortunately, current RUC survey methods do a poor job of capturing the physician time involved in delivering an endoscopic service. This is one of many reasons the GI societies feel the work of endoscopic procedures is underestimated by surveys. In a joint comment letter to CMS on the 2012 Medicare Physician Fee Schedule Proposed Rule, the GI societies advocated to CMS to value the administration of moderate sedation performed by the endoscopist.
- The current system of assigning work value based on a particular service does not account for the lifestyle differences between specialties. In other words, we are paid for the labor of an endoscopy done during the day, but the fact that we are required to perform these procedures at all hours of the night is not accounted for in reimbursement. The popular press reports on salary differences between office-based specialists and proceduralists, but does not account for differences in training, work hours and lifestyle.
- Even if the RUC supports our rationale that the current value of endoscopic procedures should be maintained, the Patient Protection and Accountable Care Act has given the executive branch of the government unprecedented authority to unilaterally reduce payment for any particular group of providers.
The AGA is working hard on all fronts to influence the factors that may have negative impact on reimbursement for GI services.
I admit that when I applied to become an alternate advisor to the RUC, I grossly underestimated the amount of work involved. I am a full-time community practitioner in a six-person group that provides care for a busy and remote community hospital in Massachusetts. I am also a full-time mom. It’s not always easy to find the time to do everything I would like, but I truly have no regrets about this commitment.
It has been an honor, a pleasure and a tremendous educational experience to work with the tri-society RUC and CPT advisors and staff, and I feel strongly that every moment I spend on this effort is repaid manifold in the brighter future for GI practice that we are all working to build.
- Specialty societies submit RVU recommendations to the RUC , which reviews and decides whether to accept, reject or modify the recommendations; read more. The RUC is not a federally chartered advisory body and operates under their first amendment rights to provide recommendations to CMS regarding how health-care providers should be paid.