Transforming Health Care Through Evidence and Collaboration
Transforming Health Care Through Evidence and Collaboration

The Challenges of New or Specialized Pro-cedures

Estimating work values for new services that are not yet widely disseminated in practice and for services that are provided infrequently can be challenging. The RUC requires three years of utilization data before it will review a new technology but does not appear to require a minimum number of survey respondents to be familiar with a given service once it is reviewed; therefore people who have never performed the specific procedure may be providing data. In other cases, societies rely on physician lists provided by device manufacturers to identify providers known to be using the procedure. Manufacturers’ interests in ob-taining higher work values that could increase the uptake of their product might influence which physicians they no-minate for the survey sample. While it is important to note that there is no evidence that such a bias has been identified, more scrutiny of the issues of physician familiarity with the services being assessed and the role of the device industry would be beneficial.

Selective Use of Data

Even when specialty societies have survey data from 50 or more generally representative respondents, the RUC allows them to use expert panels to develop alternative estimates if they deem the survey data to be “flawed or incomplete.” For example, as one participant told me, if survey data suggest work values should be lower, a society can put forth alternative estimates from an expert panel to override the survey data. Specialty societies making their case to the RUC have the discretion to ignore survey findings if they think the survey participants misunderstood the questions or undervalued the work involved. While the RUC may reject specialty recommendations, ultimately these kinds of ad-hoc adjustments can — and do — end up in RUC recommendations according to CMS, which has increasingly highlighted work values that are not consistent with survey data.8

Making Improvements

The first step to improving the quality of the evidence and strengthening the integrity of the RUC-centered update process would be to insist on surveys that meet scientific protocols. The RUC’s recent move to require 50 to 75 completed surveys when collecting data for services that are performed frequently is a positive step, but as others such as Robert Berenson have argued this change does not address the incentive for physicians to increase reported times.9 Other improvements might come from using independent organi-zations to manage the surveys and discouraging specialty societies and RUC members from cherry picking survey data. If there are reasons to suspect the reliability of certain data, these concerns should be made explicit in the recommendations submitted to CMS or, ideally, a new survey should be fielded using a different sample. Likewise CMS can enhance greater accuracy by requiring reporting of sample sizes, response rates, missing values and non-respondent characteristics and continuing to question inconsistencies between survey data and recommendations.

Continued attention to validation and external oversight of the RUC’s work will also remain important. The Afforda-ble Care Act expanded CMS’s authority to review and adjust values for codes that are potentially misvalued; as a result, CMS has undertaken new re-search to assess the time spent providing various services. Last year, Representative Jim McDermott introduced legislation to establish a new federal com-mittee to review and supplement the RUC’s work. Although this bill never made it out of committee, in November 2013 the RUC began publishing meeting minutes and committee voting results.

In March legislation was passed that provided $2 million per year to CMS to collect additional data needed to determine appropriate relative values and mandated a report next year by the Government Accountability Office on the RUC process. And just in July in its proposed rule for 2015 physician payments, CMS sought comments on a plan to publish revised fee schedule values as proposed rather than interim final rules, allowing more time for public analysis and comment on the RUC recommendations.10 Ongoing evaluation of the update process thus appears likely – and desirable.

1 Sinsky CA, Dugdale DC. “Medicare Payment for Cognitive vs Procedural Care: Minding the Gap.” JAMA Int Med, 173(18):1733-7, 2013.
2 Laugesen MJ, Wada R, Chen EM. “In Setting Doctors’ Medicare Fees, CMS Almost Always Accepts the Relative Value Update Panel’s Advice on Work Values.” Health Aff, 31(5):965-72, 2012.
3 Jennings K. “The Secret Committee Behind Our Soaring Health Care Costs.” Politico Magazine, August 20, 2014.
4 Whoriskey P, Keating D. “How a Secretive Panel Uses Data that Distort Doctors’ Pay.” The Washington Post, July 20, 2013.
5 Braun P, McCall N. “Methodological Concerns with the Medicare RBRVS Payment System and Recommendations for Additional Study.” Report to MedPAC, 2011.
6 McCall N, Cromwell J, Braun P. “Validation of Physician Survey Estimates of Surgical Time Using Operating Room Logs.” Med Care Research Review, 63(6):764-77, 2006.
7 Cromwell J, McCall N, Dalton K, Braun P. “Missing Productivity Gains in the Medicare Physician Fee Schedule: Where Are They?” Med Care Research Review, 67(6):676-93, 2010.
8 Federal Register, Vol. 76, No. 228, November 28, 2011, p. 73105.
9 Robeznieks A. “AMA’s RUC Panel to Provide Minutes in Limited Transparency Move.” Modern Healthcare, November 4, 2013.
10 Federal Register, Vol. 79, No. 133, July 11, 2014, p. 40363. 

* The Robert Wood Johnson Foundation Investigator Awards Program funded the research reported here.

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In this essay, Miriam Laugesen peeks behind the scenes at the process used to develop work-value recommendations, assessing the accuracy of the RUC’s time estimates, noting flaws in the specialty society survey process, and highlighting ways to introduce greater precision and transparency to the task.