AAFP Calls for RUC Reforms, but Won't Back Suit

A lawsuit filed this week by six Georgia physicians illustrates the growing resentment and anger that primary care providers have with what they say is a secretive Medicare reimbursement process that is skewed towards specialists, says Roland Goertz, MD, president of the American Academy of Family Physicians.

"For a group of physicians to resort to legal action should give you an indication of how frustrated primary care physicians are," Goertz told HealthLeaders Media. "Their feeling is that the system over the last 20 years has not appropriately rewarded them for the care they provide. Nor has it appropriately positioned them for their importance in this system."

In a lawsuit filed this week in U.S. District Court in Maryland, the Georgia physicians, all from the Center for Primary Care in Evans, GA, complain that for nearly 20 years the Department of Health and Human Services and the Centers for Medicare and Medicaid Services have relied on the "specialist-dominated" Relative Value Scale Update Committee (RUC) for reimbursement advice.

The 74-page suit, filed this week in U.S. District Court in Maryland, claims that the RUC violates the Federal Advisory Committee Act's requirements for representation, transparency, and methodological rigor. As a result, the Center for Primary Care physicians claim, the RUC "has systematically overvalued many specialty procedures while undervaluing primary care." The plaintiffs want a federal judge to suspend the RUC process until HHS and CMS comply with FACA rules.

AAFP declined to join the suit, Goertz says, because the physician organization wants to change the way RUC does business without going to court. "We are taking a different tack at this point, sending a very direct letter to RUC itself and meetings with CMS to see if there is an alternative. One of the problems with shutting things down is what alternative would be used for payment?" he says.

The RUC now has 29 total members, 23 of whom come from medical specialty societies. Of the 23 physician-members, three are rotating seats and two of the three rotating seats are reserved for internal medicine sub-specialties The remaining six seats include the chair of the RUC, a representative of the AMA, a representative of the CPT-editorial panel, a rep of the AOA, a rep from the healthcare professionals advisory (non-physician provider), and a rep from the practice expense review committee.

Goertz says, the AAFP has asked RUC to:
? Create more seats for general internal medicine, general pediatric medicine, and general family medicine;
? Add three new seats for external representatives, such as employers, health plans, and consumers ("We believe the presence of three external seats on the board would provide a more transparent process with good input from those that the decisions impact");
? Create a permanent seat for geriatric medicine, which is now one of the rotating seats;
? Eliminate the existing rotating specialty seats as the current representatives on the board term out;
? Improve transparency on all votes.

Under the existing structure, Goertz says, primary care physicians are underrepresented and have little power. "There are a total of 29 votes at any given time and only three that you can identify as primary care representatives. One of the reasons for our request for the four new seats is that to pass anything at RUC requires a two-thirds vote. There is no ability to challenge a two-thirds vote when you only have three primary care votes."

The lack of transparency with the RUC process is particularly troubling, he says. "That is one of our requests for them -- that they make the process more transparent to the public because the public -- particularly the Medicare recipient -- is impacted significantly by the decisions that are made," he says.

Goertz says AAFP wants a decision on its demands by next March, "which would give the RUC group two meetings to consider our requests. In the interim we have created a task force made of the best minds we could put together from the physician payment world to develop a more-appropriate payment methodology for paying particularly primary care physicians."

Even though AAFP is not joining the Georgia physicians' suit Goertz says many of their complaints are legitimate. "Regardless of who you are, when you sit on a committee you represent your own interests no matter how the process may be set up to not reflect that," he says. "The proof is in how the payment process has separated primary care physicians from non-primary care physicians, particularly over the last 20 years since RUC has been in place."