Fixing the RUC


Category : Medical Rants

Many blog readers have read the recent NY Times editorial on health care costs The High Cost of Health Care. The editorial includes this paragraph.

Emphasize Primary Care. In a health system as uncoordinated as ours, many experts believe we could get better health results, possibly for less cost, if we changed reimbursement formulas and medical education programs to reward and produce more primary care doctors and fewer specialists inclined to proliferate high-cost services. It would be a long-term project.

This is why I believe the RUC is so important and the cause of so many problems in our health care system. Shadowfax of Movin’ Meat writes about the RUC this week – Ranting on the RUC

He says –

As noted above, the RUC is to a very large degree dominated by specialists. There is, I am reliably told, an informal alliance between the procedure-based specialists, which would include surgeons (General, Thoracic, Ortho, Spine, Neuro, Urology, Plastics, Optho, ENT, OB/GYN) and “medical specialists” who derive much of their revenue from procedures (cardiology, radiology, anesthesiology, dermatology). Together these specialties control about 60% of the seats allocated to medical specialty societies. The primary care specialties, in contrast, control only 13% or three votes (Internal Med, Family Med, and Pediatrics). (Four, if you count Emergency Medicine, which is naturally aligned with primary care.)

Notable in the compostion of the RUC is the inclusion of most of the surgical sub-specialties, and almost complete exclusion of the medical ones. Oncology, Neurology, and Pulmonary are there, and not a single other medical specialty is represented. Neither is there any proportionality to the representation. The 6,000-member American Society of Plastic Surgeons has the same amount of influence as the 124,000-member American College of Physicians.

In a self-serving game of “you scratch my back,” the proceduralists support the inflated work values of one another’s new procedures, and as the values float further and further higher over time, and as the number of procedures grows, the value of office-based or cognitive services diminishes in relation. And as there is only one pie to split up, the slice of the pie that goes to primary care shrinks and shrinks. Now we are at the crisis point. Primary care as currently practiced is no longer economically sustainable, and medical school graduates see this and make a rational choice to pursue more remunerative careers.

How can we fix the RUC? We must not let physicians determine RVUs! As Shadowfax has written, instead of logic and analysis, we have horse-trading. So physician reimbursement rates depend on back room bargaining and subspecialty coalitions.

We have a committee which has a procedural dominance. Earlier this year I wrote this rant – Thinking versus doing

That rant linked back to a previous rant where I wrote:

We live in a society that has a love hate relationship with thinking. Geeks are chic, but usually at a distance. We rarely show intellectuals the respect they deserve.

We all want the benefits if great thinking, but I fear that most in our society do not really respect the thinkers. We clearly respect the doers.

As I stated earlier this week, RBRVS represents a reasonable intellectual idea, but as usual interest groups have hijacked the concept to receive much higher pay, leaving cognitive specialists at a marked financial disadvantage. So we accept intelligent, thinking college graduates to medical school. We teach them to think. And then they look at the economics and choose specialties in which they do more than they think. And the doers make more money.

We should have a better method for determining reimbursement than the RUC. We must make this a major issue. If we could influence students and residents to enter the cognitive specialties, health care would improve and costs would decrease.

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Comments (2)

If Patients were more directly responsible for their own health care cost then maybe they would see the value of seeing a PCP for most of their problems vs an expensive specialist for minor problems.
as it stands now… patients have no incentive to seek cost effective care. Our system rewards consumption and increasing cost.

Until we as americans change expectations I don’t see the system improving.

Seems the profession is chewing itself up from the inside.

After so many years of trying to beat everyone else out, now they beat each other out….

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