Has the RUC Destroyed Medical Student Interest in Primary Care?

A recent study in the Archives of Internal Medicine comparing med students’ attitudes about internal medicine careers in 1990 and 2007 found that "while about the same percentage of med students — 23% in the earlier survey of 1,244 students, and 24% in the later survey of 1,177 students — plan internal med careers, the proportion planning to go into primary care fell to 2% from 9%... the appeal of primary care as a reason to go into internal medicine fell to 33% from 57%."

This study is also receiving attention from a number of media sources, including the Wall Street Journal, which specifically makes mention of the RUC:

To significantly shore up the appeal of primary care with more money and improved work-life balance, “bolder payment and practice reform” are necessary....

As the WSJ has reported, however, where the rubber meets the road on incentives — at least for Medicare, which also drives Medicaid and private reimbursement — is the Relative Value Scale Update Committee, known as RUC, which is made up of physicians who decide how to divvy up the Medicare pie between types of procedures and visits.

Any tipping of the financial balance from specialties to primary-care doctors would likely have to take root there, and primary-care docs have argued that the makeup of the committee makes that unlikely.

What is the RUC? Below is a summary - Click here for a more comprehensive explanation.

The AMA advocates for fair and accurate valuation for all physician services within the Resource-Based Relative Value Scale (RBRVS). To ensure that physician services across all specialties are well-represented, the AMA established the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The RUC makes annual recommendations regarding new and revised physician services to the Centers for Medicare and Medicaid Services (CMS) and performs broad reviews of the RBRVS every five years.

The RUC has faced a lot of scrutiny; more recently from those involved with "Replace the RUC." One graph attempting to link the RUC to the growing income-gap between primary care and specialists is shown below.

The income gap is referenced many times when looking at medical student interest in primary care. There must be some reason why between 70-90% and 50-70% (depending on source) of medical students choosing internal medicine and pediatrics choose to sub-specialize respectively. When examining the RUC, is it a coincidence that interest in primary care careers has decreased at a relatively similar rate to the increase in physician gap since taking form in 1992?

Who is on the RUC?

The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies including those recognized by the American Board of Medical Specialties, those with a large percentage of physicians in patient care, and those that account for high percentages of Medicare expenditures.

The above link contains the specifics. Basically, there are 29 members, 26 voting members. There is one family physician (via AAFP), one internal medicine physician (via ACP - currently an oncologist), one pediatrician (via AAP - currently a general pediatrician).  The AOA and CPT members are both general internists, the RUC Chair a gyn surgeon, and the AMA rep is a psychiatrist.  It is worth noting that the physicians representing specialties are nominated by their specialty societies and approved by the AMA - in regards to the primary care physicians, most could end up as sub-specialists within their nominating specialty society, the lone exception being the family physician. The RUC touts that 14 of the 26 voting members are from specialties that rely on Evaluation and Management ("E/M", "cognitive care") for the majority of their payment. The one problem here is that, at the maximum, about 5 physicians on the RUC will practice "primary care" as we know it. That leaves primary care representing much less than the "majority" of voting members relying on E/M. This is also an area of argument for many of those who oppose the RUC.

In response to many critics, the AMA released a statement, "The American Medical Association/Specialty Society RVS Update Committee’s Long History of Improving Payment for Primary Care Services," summarized below:

Recent concerns regarding primary care workforce issues and resulting comparisons to specialty physician income have led many health policy experts to question the accuracy of the Resource-Based Relative Value Scale (RBRVS). As a key advocate for improvements in the RBRVS, the AMA/specialty Society RVS Update Committee, commonly referred to as the “RUC,” is erroneously assigned blame for any perceived flaws in this payment system, utilized by Medicare,Medicaid, and private payors. The RUC has actually led the effort to improve primary care relativity within the RBRVS since 1992. The implementation of the RUC recommended improvements have been over-shadowed by a flawed sustainable growth rate (SGR) formula, reluctance by the Centers for Medicare and Medicaid Services (CMS) to adopt several recommendations, and distortions created by private payors in their implementation of the RBRVS....

Improved Payment for Evaluation and Management (E/M) Services: The RUC has recommended increases in E/M services each time that the primary care organizations and/or CMS have requested review....
Improved Payment for Preventive Services: The most dramatic improvement, immunization administration payment increases from less than $4 in 2002 to $23 in 2011, is a result of years of advocacy by the RUC and the AMA to ensure that the resource-costs required to provide immunizations are recognized.....

Continued Advocacy Related to Coordination of Care and Medical Home: The RUC
has proposed valuation and separate payment for care coordination, team conferences, patient education, and telephone calls, however CMS has failed to recognize these services as distinct, and therefore has declined to pay for these services. CMS has announced, however,appreciation of the RUC recommendations related to the Medicare Medical Home Demonstration Project. CMS, the American Academy of Family Physicians, and the American College of Physicians all expressed appreciation for the RUC’s unanimous decision to submit robust recommendations for the physician work and practice costs required to serve as a medical home....

The document is a very well-written piece semantically, with plenty to read between the lines.

1 - The use of "key advocate" is correct in that the CMS has accepted 95% of the RUC's work relative value recommendations since 1992. Some may argue that the RUC is the "main advocate" and not necessarily an "appropriate advocate" in the interest of primary care.

2 - The RUC did indeed lead the effort to improve primary care relativity within RBRVS since 1992. Did the RUC also "lead the effort" to further improve specialty relativity within RBRVS since 1992. As in number 1, there really are not many alternatives in regards to others who are making recommendations to CMS.

3 - The SGR has overshadowed many things, and is more of a distracter in this paragraph in regards to what CMS has not done rather than what the RUC has done specifically to help fix this issue. We all know it is about politics... keep reading

4 - Increase in payment for E/M services (cognitive care) is VERY important and I appreciate that the RUC continues to advocate for proper payment for cognitive care. However, E/M services are advocated by many specialties that may not rely as heavily on cognitive services as much as procedural services. Remember, up to 14 members on the RUC are considered to bill a majority of E/M services, but only a small minority are considered "primary care." Also, in a response to a blogger who dare question the entire process, the RUC specifically points out its impact on E/M services. This response is a very good read and is worth taking a look at. All RUC responses to publications can be found on this page.

5 - Preventive services, including immunizations, are offered by almost every specialty I have rotated with - primary care and sub-specialties - as well as the pharmacies and retail stores within my neighborhood. This improvement looks great on paper, but is not translating to practice. Advantage - primary care? I'll leave that to the physicians to answer.

6 - Coordination of care/medical home - This is a very positive area of support by the RUC for primary care. Again, good for the RUC for recognizing the importance of the medical home for primary care delivery. Hopefully, semantics will also not get the best of the RUC when non-primary care specialties and non-physician providers attempt to organize their practices to make them qualify as a "medical home." Will the RUC defend primary care physicians? Additionally, the term "medical home" has taken on scrutiny itself - is it worth re-branding? (we'll save that for another post)

In a June 2008 letter from CMS to the RUC ("Commendation of the RUC's efforts" on AMA's website, on the page "CMS Applauds RUC Efforts to Improve the RBRVS"), the CMS makes an interesting point:

A necessary component in moving to a value driven health care system is accurate pricing payment systems. As you are aware, there has been considerable concern expressed by the Congress, Medicare Payment Advisory Commission (MedPAC), and other stakeholders regarding accurate pricing under the Medicare physician fee schedule.

Despite the large increase in work RVUs for many medical visits during the last 5-year review of physician work, there continues to be concern that the presence of many overvalued procedures within the physician fee schedule disadvantages primary care services and creates distortion in our payment system that makes moving to value driven health care more difficult. Critics have pointed out the relative imbalance in the number of codes for which the relative values are increased rather than decreased in the three 5-Year Reviews of work RVUs.

This is a bit confusing. The RUC states that they are a key advocate for primary care, releases robust statements in which they argue the contrary, and defends stances taken since 1992 to defend primary care... yet in 2008 the CMS specifically points out inadequacies in recommendations from the RUC for primary care. Again, it is worth noting the headline: CMS Applauds RUC Efforts to Improve RBRVS.  Is CMS applauding the RUC's continued failed effort at valuing primary care?  What is being lost in translation? The CMS does like a lot of what the RUC recommends....

The CMS relies on 95% of the RUC's recommendations. Should there be another entity involved? This is an argument used by many societies, brought forth by the Medicare Payment Advisory Commission (MedPAC) in 2006:

The Secretary should establish a standing panel of experts to help CMS identify overvalued services and to review recommendations from the RUC. The group should include members with expertise in health economics and physician payment, as well as members with clinical expertise. The Congress and the Secretary should ensure that this panel has the resources it needs to collect data and develop evidence.

This idea is also the central component of Representative Jim McDermott's (D-WA) bill, HR 1256 - The Medicare Physician Transparency and Assessment Act of 2011, to require the use of analytic contractors in identifying and analyzing misvalued physician services under the Medicare physician fee schedule and an annual review of potentially misvalued codes under that fee schedule.  It is worth noting that Rep McDermott, a psychiatrist, is also joined by an orthopod, Rep Price (R-GA) in expressing arguments against the RUC.  

Psychiatrist and Washington liberal Jim McDermott is taking up the cause of primary physicians and targeting an AMA committee that recommends payment values for doctors. McDermott tells PULSE he is considering legislation to beef up the analytic abilities of CMS to sort through pay data that the AMA committee, known as the RUC, recommends to CMS. Rep. Tom Price, a Georgia Republican and orthopedic surgeon, also complained during a Ways and Means health subcommittee hearing Tuesday that primary care specialists are underrepresented on the RUC and that data used to set Medicare pay for the services they perform most often – office exams, emergency room visits etc. – is nearly 21 years old.

Is it possible to avoid such legislation?  Can the RUC be reformed so it accurately represents the viewpoints of all those involved with the care of our patients? The following recommendations are those that have been produced by many.

1: Never forget our patients!
Of the voting members, 40-50% should be primary care physicians, practicing and billing for primary care services. The RUC recognizes the need for cognitive care by attempting to give a slight majority to those who bill a majority of E/M services. A nice try - take it a step further, put your money where your mouth is, and embrace primary care as the foundation of the RUC. This would represent the workforce we need to serve the growing demands of our patients. I repeat, never forget our patients!

2: Never forget our future! Include medical student and resident presence with possible input +/- votes on the RUC. We may be naive, but we're not naive about the number of years and money we sacrifice to gain the knowledge and experience of those already in practice (we do recognize the gap in pay when choosing specialties). We also may be doing a lot of the scut work that our more experienced physicians and hospital networks are getting paid for, so it may be worthwhile to help increase representation to those in the trenches.

3: Never forget our teammates!
One non-MD/DO (a podiatrist) is not enough in proportion to the amount that our teammates help us in our care for our patients as well as the work we must get done to get compensated. Emphasize more inclusion, input, and voting members from non-MD/DOs in the appropriate primary care proportion who are key-players in physician payment. As we move forward with collaborative and patient-centered care, the RUC needs to include more of these important health-care team members in the process. By doing so, the RUC puts their money where their mouth is in regards to their support for the patient-centered medical home and collaborative/team-based care.

The RUC does a lot of time-intensive, budget-neutral work to help our profession get the credit it deserves.  A physician-only panel is optimal to help get physicians the payments they deserve.  However, these physicians cannot play well together... and that is a shame.

There were efforts in the past to increase primary care seats.  Unfortunately, efforts to increase primary care seats and proper representation has failed.  Even if we were to increase primary care representation by one seat, it still would not be reflective of an appropriate primary care workforce.  I have no confidence that this will change anytime soon.

Has the RUC really done as much as they could have over the years, or did they do just enough to say they helped primary care... could they have "sacrificed" more to help improve cost/quality/access for patients or was it an effort to minimize the losses in the interests of specialist/proceduralist physicians. We can say we kept the patient in the center of our decisions to help health care delivery in this great nation... but have we really kept the patient in the center of the RUC since 1992?  Have we kept to containment of rising healthcare costs in the forefront of RUC recommendations since 1992?

The 20th Report by COGME - Advancing Primary Care - outlines the parameters that must be accomplished to increase student interest - achieve primary care payment to 70% of specialists (rather than < 50%).  I do not believe that the RUC will make the appropriate and necessary changes quickly enough to help produce the balanced health care workforce that our country so desperately needs.  It has not only produced the contrary but may be a main factor in the current decreased medical student interest in primary care.

Which leads to the final question... what should happen next?  My prediction - it will not be left for physicians to decide and it will be of no one else's fault but our own.