Blog | Thursday, September 12, 2013

Do not blame the RUC, blame RBRVS

Blaming the American Medical Association’s Relative Value Scale Update Committee (RUC) for everything has become the latest fashion. Dad-burned RUC is causing climate change. The entire health care cost problem comes from RUC decisions. Alex Rodriguez took performance-enhancing drugs because of the RUC.

But the RUC did not create the system. They try hard to balance a system that is designed to achieve the wrong outcomes. The RUC has become a very easy and attractive kicking post, but the problem comes from the idea of resource-based relative value units (RBRVS).

As I understand it, RBRVS represents a series of economic formulae that will take into consideration the average time a medical encounter takes (obviously longer for an operation, shorter for most office visits), the complexity of the encounter, and the amount of training needed to adequately perform the encounter and the financial overhead involved. Thus, these complex formulae represent averages.

We know about averages. If we put one foot in boiling water and one in ice, on average we are comfortable. But the problem is that averages are deceiving. The RUC continuously has to revalue the complex inputs to these formulae. But revaluation takes time. If the original procedure took 3 hours, and technique advances allow one to perform the procedure in 1.5 hours, you just doubled you income rate. In fact that has happened often.

Even if the RUC was a full time committee that revalued continuously (obviously an impossibility), the idea of RBRVS leads to financial gaming. This wonderful post explains the dilemma – Physician Payment: Forget Carrots And Sticks, It’s Motivation

All professionals need to be paid for their work, and money is the mechanism to do that in all but a barter economy. However, payment reform must avoid one key pitfall if it has any chance to succeed: We must not try to replace motivation with an artificial charge. This will be challenging for many in the industry. Hospitals and health systems still use RVUs as the primary form of calculating total compensation, much like private sector companies put salespeople on commission. That must change. Health plans and Medicare continue to overwhelmingly use fee for service, much like farmers get paid by the bushel or the cattle head. And that must change.

The idea of RVUs disgusts me. It turns patient encounters into different valued widgets. It explicitly encourages us to see patients more quickly. It values all the wrong things.

So I do not blame the RUC. They have not done a perfect job, but they are working to patch a flawed concept. Our patient encounters are not widgets. There are too many variables to derive a satisfactory formula.

We need to evolve to a system that allows for internal motivation and rewards physicians fairly but without incentives to do more faster. We cannot blame the RUC for the system.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.