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The Medical Home Hits the RUC
Today’s post (#2 in a series) tackles several questions:
- What is the American Medical Association/Specialty Society RVS Update Committee (RUC)?
- What is the RUC’s role in the Medicare Medical Home Demonstration project?
- How are people reacting to RUC recommendations for PCMH reimbursement levels?
What is the American Medical Association/Specialty Society RVS Update Committee (RUC)?
The AMA formed the RUC to act as an expert panel in making recommendations to CMS on the relative values of Current Procedural Terminology (CPT) codes using the Resource Based Relative Value Scale (RBRVS).
The RUC is composed of 29 members, only 5 of whom are primary care physicians.
The RUC has come under severe criticism as being an enemy of primary care. For example…
…read Brian Klepper’s thorough analysis — Bad Medicine: How The AMA Undermined Primary Care in America. He links to articles in Annals of Internal Medicine, Journal of the American Medical Association, and the New England Journal of Medicine.
What is the RUC’s Role in the Medicare Medical Home Demonstration (MMHD) Project?
The Medicare Medical Home Demonstration project was authorized by the Tax Relief and Health Care Act of 2006, Section 204. Section 204 (e)(1) requires that the RUC develop the methodology for a care management fee code for payments and a value for the code.
Why was this requirement written into the Medicare Medical Home demo?
Beats me — this makes NO sense.
I’ve spoken with several colleagues about why the RUC is involved in setting fees for the MMHD. Some of their speculations include:
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RUC input to CMS for physician reimbursement is “customary”
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Sponsors of the legislation — primary care physician groups — had concerns about pushback from specialists. They believed that having fees set “objectively” by a specialist-friendly, established body (the RUC) would lead to greater acceptance.
Please comment if you’re knowledgeable about this.
On April 29, the RUC released it’s report. The report goes through elaborate machinations estimating physician time required and office expenses required to provide care management services to Medicare patients. The recommendations are not easily digestible or understandable, but here’s an example:
- The RUC recommends an intra-service time per patient per month of 9.2 minutes for a Tier 3 Medical Home
- The RUC recommends a work RVU per month of 0.35 for a Tier 3 Medical Home
How are People Reacting to RUC Recommendations for PCMH Reimbursement Levels?
Early reports are spewing venom at the RUC recommendations. Physician bloggers have been among the most critical.
Dr. Roy Poses of Healthcare Renewal blog
…[The RUC] is secretive, unrepresentative, and unaccountable. Neither its membership nor proceedings are public. It is dominated by proceduralists and sub-specialists. It is unaccountable to US physicians, much less the general public…putting the RUC, which seems to be the single most important cause of the decline of primary care, in charge of payment for this new version of primary care, appears to be a great case of putting the fox in charge of the hen-house.
…[the RUC] are the folks who created the mess, and they are trying to create a system that is “cost neutral”, that will pay for itself by not taking any money from their own specialties. It’s paying for itself alright. By punching primary care in the face. The payment rates that are recommended are insulting and downright degrading. (See his second commentary here).
Dr. Vijay Goel at Consumer-focused healthcare blog
The RUC is hastening the death of primary care– soon however will rise new mechanisms to remove it from the stranglehold of the “insurance” shakedown racket.
Dr. James Gaulte of retired doc’s thought blog
Anyone who thinks the Medicare funded Medical Home will be anything different from the morass of rules and tricks and traps of the fee structure and coding mysteries that typifies dealing with CMS should take a few minutes and read what RUC has authored.
Sean Khozin, MD, MPH at The Healthcare Weblog
Given the proposed reimbursement structure, the medical home demonstration project will be of little value to primary care physicians except those with the stamina to run faster on the hamster wheel of medical practice survival.
Jaan Sidorov, MD at the Disease Management Care Blog
I’m worried that underfunding of the Medical Home will doom it. In my humble opinion, the Medical Home will turn out to be a key component of future population-based health care solutions for patients with chronic illness.
Sandy Szware, BSN, RN, CCP at Junkfood Science blog
Journalists are uncritically reporting medical homes in glowing terms as the wave of the future….the past few days has revealed a different perspective of the medical homes that are being built for us.
…and you can add me to the list.
Are these reactions just a few lone bloggers, or the first whispers of the impending hurricane of outrage?
I suspect the latter.
FINAL POST IN THE SERIES: Can Primary Care Physicians Pull the RUC Out?
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I’ve been following this medical home debate and already found what appear to be some assumptions which invalidate the whole concept. Perhaps I have the story wrong so could someone address these:
First, are we assuming that the number of cases is constant except for prevalence increase, and that PCPs, faced with the prospect of much-incrased reimursement, won’t suddenly find many more chronically ill patients who need care coordination?
Second, is everyone else assuming that the level of preventable admissions and specialist visits (adjusted for increase in drug costs) is high enough to cover the program’s costs? The DMPC Outcomes Measurement database, easily the industry’s most valid with none of that actuarial voodoo, says there really aren’t that many admissons which are preventable without spending much larger amounts on drug costs. (Others have also noted that prevention can cost more than cure.)
Third, is everyone assuming that there is some kind of ongoing or imminent explosion in chronic disease-related events? once again, the DMPC database quite definitively says that usual care has kept overall event rates steady even despite pervalence increases.
Inquiring minds want to know