Even though neurologists are not entirely happy with the Relative Value Scale Update Committee (RUC) — the organization that influences how much neurologists are paid — they are not embracing a move to restructure or even replace the RUC.
“Beware of what you wish for because it may come true,” said Neil A. Busis, MD, chief of the Division of Neurology at the University of Pittsburgh Medical Center-Shadyside. Dr. Busis, who serves on the editorial advisory board of Neurology Today, once represented neurologists on the RUC.
“I don't think it has served neurology particularly well in many respects. On the other hand, I'm not at all sure that the alternative that the family medicine people are suggesting is any better for us.”
At issue is a growing controversy over the RUC, which critics hold responsible for the fact that physicians performing procedures and interpreting images often are paid much more than primary care physicians, neurologists, and others who deliver more cognitive services than procedures.
Convened by the American Medical Association, the 29-member RUC includes representatives from various medical specialties. The committee makes recommendations to the Centers for Medicare & Medicaid Services (CMS) about the relative value of physician services by considering the level of time, skill, training and intensity required to provide a neurologic exam, for example, or cardiac catheterization or a well-baby check-up.
CMS has generally followed the RUC's recommendations, although it is not required to do so.
The RUC's work was publicly called into question in late 2010 in a series of articles published in the Wall Street Journal. Since then, a “Replace the RUC” campaign (http://www.replacetheRUC.org) has won considerable attention in health policy publications; six physicians filed a lawsuit saying CMS should not rely on RUC's recommendations; and the American Academy of Family Physicians (AAFP) has asked the RUC to change its structure and processes.
Marc Raphaelson, MD, a Virginia neurologist who represents the Academy on the RUC, believes that neurologists and some other specialists are being short-changed in the way their work is valued. However, he thinks the campaign against the RUC is misplaced effort.
“If you concentrate on the RUC, you miss the bigger picture,” he said.
The AAFP, the largest medical specialty society in the country, is not party to the lawsuit criticizing the RUC. But it has taken a lead role in agitating for substantial change in the way the RUC works.
“Our primary concern is that the income disparity that's growing over time…is a huge disincentive to medical students to choose primary care specialties,” said AAFP President Glen Stream, MD.
Dr. Stream said the AAFP forecasts a shortage of 39,000 family physicians by 2020.
Analysis by the Medical Group Management Association shows the median primary care physician income is 54 percent of median subspecialists' income. The Accreditation Council for Graduate Medical Education has recommended that primary care income should be raised to at least 70 percent of subspecialists' income to attract more medical students to primary care. The AAFP thinks the only way that will happen is if the RUC is substantially changed or replaced as the arbiter of what medical services are worth.
Last June, the AAFP called on the RUC to make several changes, including adding four additional seats for primary care specialties, adding a seat for geriatrics, and adding seats for non-physician representatives such as consumers, employers, and health plans, and making RUC votes more transparent. It asked for RUC's response by March 1.
The AAFP has not said what it intends to do if RUC does not comply with its request, but it has established a Primary Care Valuation Task Force to make recommendations about how primary care services should be valued and paid for. That 22-member task force includes representatives from the American College of Physicians, the American Osteopathic Association, and the American Academy of Pediatrics as well as health policy analysts, health plan executives, and non-voting “observers” from U.S. Rep. Jim McDermott's office and CMS. No specialists outside of primary care are included.
The task force does not aspire to replace the RUC, but rather to identify the best way to determine the worth of evaluation and management codes, Dr. Stream says.
WHAT IT MEANS FOR NEUROLOGISTS
Dr. Raphaelson thinks neurologists should be just as concerned about the equity of the physician pay issue as primary care physicians, but he does not think attacking the RUC is the best way to advocate that position.
By looking to the RUC for guidance, CMS gives physicians considerable influence determining how to divide a set amount of money among physicians; Dr. Raphaelson said physicians can do this better than CMS administrators or Congress.
“Doctors have to be involved,” he said. “And it's going to be confrontational, to some degree, because it's a fixed pie, and whatever goes to one group or technology has to come out of the pool for another group or technology.”
In the past decade, Dr. Raphaelson said, CMS has accepted RUC recommendations that have redistributed pay from surgery and other procedure codes to the evaluation and management codes most commonly used in primary care, neurology and some other specialties so that the pay differential has flatted somewhat.
But he thinks two other changes are actually more significant to neurologists: To address the primary care shortage, Congress authorized a 10 percent pay bonus for family physicians, internists and pediatricians. And CMS ignored the RUC's advice and stopped paying for consultation codes, which have traditionally been used by neurologists and other so-called cognitive specialists. A neurologist evaluating a referred patient is paid under the same code as for a new patient to the primary care doctor; both are paid the same rate, but the primary care doctor also gets a 10 percent bonus.
“What has that done? It says that the extra years of neurology training don't count,” he said. “If you simply sit all day and see return visits, you are paid less per hour than the primary care doctors because they get a primary care bonus. So, what's the incentive to spend an extra four years studying neurology or six years studying neuro-ophthalmology — to get paid 10 percent less on an hourly basis?”
Over time, Dr. Raphaelson expects that policy will lead to a shortage of neurologists because medical students will see the financial disincentive of neurology training.
Commenting on the issue, AAN President Bruce Sigsbee, MD, said: “The gap between procedural and non-procedural specialties continues to increase. Neurologists mostly are non-procedural and as such are falling behind many other specialties with important consequences for the specialty. However, a change at the RUC will not effectively address this issue. Addressing the gap will require changes in health care policy at the national level, not at the RUC. The AAN leadership is well aware of the issue and is advocating daily for the needed changes in policy to address this gap.”
WHO WORKS HARDER?
A 2011 pilot study funded in part by the Academy may potentially influence the thinking by the RUC — and more importantly, by CMS — about how physician services should be valued. The study in Medical Care, led by University of Cincinnati researchers Ronnie Horner, PhD and Jerzy Szaflarski, MD, PhD, examined the “physician work intensity” experienced by a small sample of family physicians, general internists, neurologists, and surgeons in five states.
Among the findings, the paper reported that although physicians in each of the four groups experienced different kinds of work intensity, the overall magnitude of work intensity was similar. For example, surgeons reported that their work is more physically demanding than the other groups. But their work has less mental demand than neurologists and less time pressure than either neurologists or primary care physicians who may need to spend 45 minutes, for example, with a patient scheduled for a 15-minute visit, thereby backing up the entire day's schedule.
Dr. Szaflarski, an Academy member who was a co-principal investigator on the study, said the findings appear to support his suspicion that procedure-oriented physicians and non-procedural specialists are working equally hard — even though the pay scale suggests otherwise.
“Whether you are a neurologist or a surgeon or a PCP, the numbers, in the end, are about the same although this is not reflected in the current (pay) system,” he said.
Dr. Raphaelson said the Academy intends to sponsor other research that could support physician pay policy, including a study to explore the differences between a patient who visits a primary care doctor complaining of headache and a patient who consults with a neurologist because of headache.
“We don't want to just say we deserve more money because we're special people,” he said. “The Academy has decided to try to put forth some evidence upon which policy could be based.”