The “leave the RUC” movement


Category : Medical Rants

Readers know my lack of respect for the RUC.  The idea of RBRVS seemed like a good one to an economist.  However, he (and we) did not understand that any payment system will lead to gaming that system.

I personally would like to see us go to a time-based system of payment.  Surgeons would make more per unit of time than me, but the ratio would be at most 2.  We could likely limit abuses just through audits of time – I think a good computer system could making billing more reasonable and accessible to audit.

In the meantime, there is a growing grassroots movement to have Congress rid us of the RUC.  This blog post addresses many of the issues – Facing Uncertainty: Why Primary Care Physicians Must Act Now

The remarkable upwelling of primary care indignation in the past few weeks has the potential to begin to remake American health care in a way that the tortured, purchased and highly political health care reform process could never do. At least in part, that possibility has emerged because there’s finally been a demand that we stop listening to the contorted defenses of an obviously flawed process, and start looking at what that process has brought us:

  • A medical system in which half or more of all expenditures provide zero value, and in which the excesses currently cost us something on the order of $1.4 trillion a year, nearly the equivalent of this year’s national debt.
  • A primary care workforce shortage approaching critical status, simply because the income disparity between generalists and proceduralists is too great for medical students to ignore. This translates into reduced management of care appropriateness downstream.
  • Compromised quality, as patients are routed to unnecessary and unnecessarily intensive diagnostics and treatments, often for little reason other than money.

Former JAMA and Medscape Editor George Lundberg MD, an icon of America medicine, recently observed to me that, “The whole pitch about the national RESULTS/OUTCOMES of the RUC approach is the final nail…” THIS is the point.

I view this movement with some trepidation, but I clearly understand its origins.  The status quo is not acceptable.  The political nature of the RUC (their protestations to the contrary) have hampered our ability to deliver cost-conscious medical care.

While I am not ready to take this radical step, I understand the movement.  Perhaps we do need a major crisis to solve this problem.

Comments (4)

No compensation proposal will be welcomed by all.  Any system will be perceived – and may truly be – unfair to some.  It will be nearly impossible for many to separate their own interests from the public's interest, which is perfectly understandable.  This is true with paying physicians per unit of time.  All time units are not equal in medicine, or in other professions.   Is the time it takes for a surgeon to insert a heart valve of equal value to the time taken to suture a laceration or treat a sprain?

Dr Kirsch makes a good point, but the current payment system is not sustainable for several reasons, lack of primary care doctors and unaffordability only being two of them. I have other objections to the system in that I feel it has altered the profession, for the worse. This blog just had a long  discussion in which it seems that some surgeons want to become pure technicians.We have created a situation where some subspecialists want to be  proceduralists – one example: I have no trouble getting an endoscopy done, but have had trouble getting a thoughtful evaluation of a complicated malabsorption patient. Well, in some countries nurse practitioners do the bulk of the endoscopies. You don't really need a gastroenterologist for that, but you may need a gastroenterologist for a patient with severe inflammatory bowel disease or malabsorption. It's also created a payment system where documentation is all  important. I recently saw an article in a medical newsletter entitled  "12 things I wish I had learned in residency". I turned to the article expecting to find some good clinical pearls but instead it was all about how if you document x.y.and z instead of x and y you can change the billing code and increase your income by 10 grand a year for the same amount of work. Thus notes become full of extraneous data which contribute little to patient care and the additional time spent documenting is  a waste of the patient's time, though it benefits the doctor financially. I won't discuss the ethics of this, but in an ideal world if it doesn't benefit the patient, we shouldn't be doing it, and we should be paid to do stuff that DOES benefit the patient. (Note that I'm not against documentation, but I am against useless documentation.)  I'm not sure how to fix these problems but altering the current payment system would be a place to start.

Can't agree more with Mt Doc's comments.  We have subspecialties of medicine that are purely technical in nature (pathology and radiology) where actual patient contact is unusual.  Procedural spuspecialties are also heading in this direction with less time spent caring for patients. This  part ot care is instead being thrust onto physician assistants, nurse practitioners, and hospitalists.  It raises the question in my mind of what defines a physician.  More often than not, these other aspects of the human condition with all the anxieties and fears asosciated with illness are ignored in the straightforward approach of getting the procedure done and completed while ignoring the psychosocial problems that illness creates. Are we truly physicians if we can simply concentrate on doing an operation or procedure while ignoring the bigger picture of the overall health and well being of the patient?
Some of this has been exacerbated by the current reimbursement system that richly rewards doing something to the patient rather than educting and diagnosing a patients problem.  We do a great disservice by undervaluing the cognitive aspects of medicine.  It serves to dehuminize medicine and make it very impersonal.
Primary care organizations should indeed leave the RUC and actively lobby for a more transparent and balnaced organization that includes input from other groups other than just physicians.  Where are hospitalists and NPs represented under this present system?  It seems at the very least the representation should be proportioanl to the number of previders rather than one from each specialty society.  Radiation Therapists get as much input as pediatiricans?  Come on! 

Perhaps we need a reimbursement "House of Representatives" section to complement the "Senate" structure embodied by the RUC.  Pediatrics could be Texas, and internal medicine could be California.  Radiation oncology…more like Wyoming.

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