RUC this

Bob Doherty takes on the RUC question this week – Have you been RUCed?

The RUC argues it is being unfairly maligned. Dr. Bill Rich, the RUC’s chair, wrote this in response to the Annals of Internal Medicine:

"The RUC recommended significant increases to E&M (evaluation and management) services, which were implemented by the CMS on 1 January 2007. These permanent increases result in an additional $4.5 billion in E&M services payments each year! To imply that they are small and insignificant is preposterous. Family physicians may see their overall Medicare payment increase by 5% or more. A document on the American College of Physicians’ Web site states: ‘ACP estimates that internists will typically see an increase of $5,000 to $10,000 in total Medicare allowable charges’."

My sense is that the RUC’s critics have a point, but so does Dr. Rich. The RUC deserves credit for the evaluation and management increases, and more recently, for estimating the physician work involved in care coordination for the Medicare medical home demonstration project.

Excuse me!  I will post this today, and personally speak to Bob next week about this issue.  The problem with the RUC is the long history of the RUC.  They claim that they are throwing us a half-chewed bone, after they have taken all the meat off the turkey.

Let me explain.  The RUC has systematically (either with or without malice) over valued procedures and undervalued cognition.  The discrepancy between a colonoscopy and and complete history and physical, or between and arthroscopy and a level 4 visit with a 66-year-old man with CAD, DM II, hypercholesterolemia, hypertension, CHF, osteoporosis and depression has increased almost yearly.  Cognitive visits take more time each year (as we have more drugs and more prevention to perform.)  The procedures generally take less time as proceduralists become more proficient.  How long does a CXR take to read, and how much time credit does the RUC give?

Any redress for past inequities would require a massive recalculation of RUC recommendations.  The current system is profoundly "out of whack."  Minor adjustments will not save primary care.  We need to rethink the entire menu and do it with transparency and equal representation. 

The colonists fought the Revolutionary War in part due to taxation without representation.  We have a preverted payment structure created without representation.  That is the problem.  I doubt that the RUC’s leaders want to discuss that problem.