In July, the Society for Vascular Surgery sent requests to its members to complete surveys regarding the work involved with creation, revision, and thrombectomy of hemodialysis access. These surveys form the basis of data used by the American Medical Association/Relative Value Scale Update Committee (also known as the RUC) to make recommendations to the Centers for Medicare and Medicaid Services (CMS) regarding the relative value of these procedures. It is surprising, then, that some members do not respond to these requests nor fully comprehend the importance of diligently completing the surveys. This could result in vascular surgeons being reimbursed too little or too much (for vascular surgery the latter is obviously very infrequent!)
Presumably the less than desirable response to these requests is because like me, some of us may not fully understand the RUC and how this committee is involved in physician payment. I am indebted to Sean Roddy, Bob Zwolak, David Han and Matt Sideman for helping me provide the following background information. In 1992, Medicare transitioned to a physician payment system based on the Resource-Based Relative Value Scale. The American Medical Association convened the multispecialty committee known as the RUC and in May of 1992 the RUC considered the first relative value recommendation from a specialty society. In the years since, thousands of codes have been presented to the RUC by specialty societies such as ours, with recommendations for each code’s relative value made to CMS for their final decision.
It is important to understand that the RUC does not set prices. That is up to CMS. The RUC is a multispecialty committee that analyzes and reviews data on new and existing Current Procedural Terminology (CPT) codes, specifically looking at the practice expense and relative effort of physician work and intensity. All new codes are reviewed; existing codes that are potentially misvalued are also reviewed. By law, all existing relative values are reviewed at least every five years (Section 1848 (C) 2 (B) of the Omnibus Budget Reconciliation Act of 1990).
RUC recommendations for relative values are based on data supplied by one or more specialty societies. SVS works closely with other specialty societies including the American College of Surgeons, Society for Interventional Radiology, and the American College of Cardiology especially when discussing codes that are performed by physicians from multiple disciplines. Specialty societies such as ours collect data from surveys that assess the time and intensity associated with the pre-, intra-, and postoperative care of our patients. Based on these data, expert panels from each society submit proposals for the time and relative value units (RVUs) associated with each procedure. These proposals are then subject to assessment and adjustment by the RUC, with final recommendations determined by vote of the RUC members. As part of the rule making process, CMS is open to public comment and accepts input from the RUC, just as it accepts input from the public. It is important to reiterate that the RUC does not set prices. Total Medicare payments for physician-provided services are determined by Congress and CMS each year. The RUC’s sole purpose is to serve as a volunteer expert advisory body to help determine relativity between very different services performed by all of the specialties throughout medicine. SVS believes that the RUC has performed objectively in this role since its inception.
However, recently, the activity of the RUC has been the subject of scrutiny and criticism by the media, including several articles and editorials in Washington Monthly, The Washington Post, and USA Today.
The gist of these articles is that in order to gain financially doctors who respond to the surveys and their specialty societies exaggerate the time taken to perform the procedures. The Washington Post’s reporter cynically proposed it would appear that some doctors are working 26 hours in a 10-hour paid day.
The AMA has responded that in many cases the RUC has actually resulted in devalued procedures. To quote a letter from the AMA to the Washington Post “In recent years, the committee has taken the initiative to identify overvalued medical services to help drive cost reduction. To date, they reviewed about 1,300 potentially misvalued services and recommended reductions to 500 previously overvalued services.” More importantly to us as vascular surgeons is the fact that the Medicare physician payment system is ultimately budget-neutral. Let me explain my concern. In other words there is no financial impact to overall Medicare spending if the government accepts a recommendation for increasing a medical service value. This is because any increase is automatically offset by decreasing values assigned to all other services. So if members of other specialty societies exaggerate the relative value of their services and the RUC and CMS agrees with these excessive RVU’s then they have to reduce other RVUs. So, if vascular surgeons don’t supply realistic data for our procedures we are likely to have our fees reduced.
THE AMA claims to have redistributed $2.5 billion to primary care and other services. It is this latter claim that makes me hopeful that our members will take these surveys seriously since I am sure we have not been the beneficiaries of this multibillion dollar redistribution. If we don’t complete the surveys it is likely that our procedures will be devalued and the monies CMS saves will simply be passed on to our primary care colleagues or other specialists.
Accordingly, I urge members of the SVS to take seriously these requests to fill out the RUC surveys. Do not under play how long it takes you to do the procedure but do not exaggerate either. An honest survey serves us and our patients best. SVS representatives have spent countless hours ensuring that the work of our members is fairly and accurately represented. The role of RUC advisor has been held for the last 20 years by Gary Seabrook, and beginning this year is being taken up by Matt Sideman. The next time you see either of them, be sure to give Gary your thanks, and wish Matt the best.