Relative Value Scale Update Committee Research Articles

Accuracy Of The Relative Value Scale Update Committee's Time Estimates And Physician Fee Schedule For Joint Replacement.

Even though relative value units guide 70percent of physician payment, little research has assessed their accuracy. We analyzed actual service time for total hip and knee replacements at two academic hospitals in the period January1, 2013-October1, 2016, using electronic health record time-stamp data, and we compared that time with the Medicare Physician Fee Schedule and most recent Relative Value Scale Update Committee recommendations. We found that the committee and fee schedule overestimated the operating time of original hip replacements by 18percent and original knee replacements by 23percent. Revision hip replacements were overestimated by 61percent and knee replacements by 48percent. In a multivariate analysis we found that faster operating time was not associated with more complications or admissions to the intensive care unit. Complication rates varied tenfold across physicians and twofold across hospitals. The fee schedule and the committee significantly overestimated operating times for original and revision hip and knee replacements. Policy makers should use empirical time-stamp data instead of self-reported estimates to determine physician payment.

Quantifying the Perioperative Work Associated With Total Hip and Knee Arthroplasty: The Burden Has Increased With Contemporary Care Pathways

BackgroundRecently, the Centers for Medicare and Medicaid Services (CMS) has labeled the procedural codes for total hip arthroplasty (THA) and total knee arthroplasty (TKA) as potentially misvalued and has asked the American Medical Association (AMA) and its Relative Value Scale Update Committee (RUC) to review this. To assess the validity of this claim, we aimed to catalog the specific service tasks and duration of time required for each task associated with the perioperative care of the patient who underwent primary THA and TKA. MethodsWe prospectively timed preservice and immediate postservice activities performed outside of the operating room (OR) by 7 arthroplasty surgeons over a four-week period. Specific timing data for preservice activities performed in the OR were obtained retrospectively from our institutional electronic medical record for 500 patients undergoing THA and 500 undergoing TKA. Results were compared with the current approved values reviewed by the RUC in 2013 and converted to work relative value units (wRVUs) based on the intensity coefficients used by the RUC. ResultsThe average total preservice evaluation time was 42.2 minutes. The average time from the patient entering the OR to incision was 40.8 ± 25.4 minute. Immediate postservice tasks took 30.0 minutes. Compared with the 2013 RUC weighted wRVU value of 1.394 for preservice and 0.560 for immediate postservice activities, we found that surgeons actually perform 1.567 wRVUs of preservice and 0.672 of immediate postservice activities. ConclusionPolicymakers should consider these findings when reviewing the time and intensity spent on perioperative care for patients undergoing THA and TKA.

Accuracy of Valuations of Surgical Procedures in the Medicare Fee Schedule

BackgroundThe Relative Value Scale Update Committee (RUC) of the American Medical Association plays a central role in determining physician reimbursement. The RUC’s role and performance have been criticized but subjected to little empirical evaluation.MethodsWe analyzed the accuracy of valuations of 293 common surgical procedures from 2005 through 2015. We compared the RUC’s estimates of procedure time with “benchmark” times for the same procedures derived from the clinical registry maintained by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). We characterized inaccuracies, quantified their effect on physician revenue, and examined whether re-review corrected them.ResultsAt the time of 108 RUC reviews, the mean absolute discrepancy between RUC time estimates and benchmark times was 18.5 minutes, or 19.8% of the RUC time. However, RUC time estimates were neither systematically shorter nor longer than benchmark times overall (β, 0.97; 95% confidence interval, 0.94 to 1.01; P=0.10). Our analyses suggest that whereas orthopedic surgeons and urologists received higher payments than they would have if benchmark times had been used ($160 million and $40 million more, respectively, in Medicare reimbursement in 2011 through 2015), cardiothoracic surgeons, neurosurgeons, and vascular surgeons received lower payments ($130 million, $60 million, and $30 million less, respectively). The accuracy of RUC time estimates improved in 47% of RUC revaluations, worsened in 27%, and was unchanged in 25%. (Percentages do not sum to 100 because of rounding.)ConclusionsIn this analysis of frequently conducted operations, we found substantial absolute discrepancies between intraoperative times as estimated by the RUC and the times recorded for the same procedures in a surgical registry, but the RUC did not systematically overestimate or underestimate times. (Funded by the National Institutes of Health.)

Understanding the Current Procedural Terminology Process.

This article describes the method by which U.S. health care services are valued and reimbursed, and the essential role practicing physicians, including breast imaging radiologists, and medical specialty societies play in this process. The American Medical Association has described the method for developing new and revised Current Procedural Terminology (CPT) codes as a 3-legged stool, with patient care as the seat supported by its legs: the CPT process (where the work is described), the Relative Value Scale Update Committee (RUC) process (where the work is valued), and coverage by Medicare (where the work is paid). Although the future direction of health care payment policy in the USA is uncertain and difficult to predict, CPT codes remain the foundation for the reimbursement of physician services. A working knowledge of the CPT process can be valuable to breast imaging radiologists, both for managing their practices at the current time and preparing them for future changes in payment policy.

An analysis of RUC methodology for determining the RVU valuation of sinus surgery.

The Relative Value Scale Update Committee, commonly known as the RUC, is responsible for defining the value of Current Procedural Terminology (CPT) codes. The RUC process uses survey responses reporting operative times to determine procedure reimbursement, but it is limited by low response rates, small sample sizes, and unclear generalizability of the results. By comparing actual reported intraoperative times to the times determined by the RUC process, in this study we sought to assess the performance of RUC methodology in endoscopic sinus surgery (ESS). The ESS CPT codes that were reassessed in 2016 using the RUC method were examined in this study. Intraoperative time data for these codes were retrospectively collected from 14 medical facilities, using time stamps in the electronic health record. These actual intraoperative times were compared with the 2016 RUC survey results. There were 143 RUC physician survey responses and 446 actual procedure times included in the final analysis. There was significant variability within the RUC survey responses (ie, unilateral anterior ethmoidectomy times varied from 5 to 90 minutes). There was also a significant difference between the RUC survey results and actual intraoperative times (p < 0.001). For example, frontal sinus surgeries showed a particularly poor correlation between actual and RUC times. The RUC process may not accurately estimate or value actual intraoperative times. Real-world intraoperative times are readily accessible and may be an alternative to survey-based methodology in the future.

Committee Representation and Medicare Reimbursements-An Examination of the Resource-Based Relative Value Scale.

The Resource-Based Relative Value Scale Update Committee (RUC) submits recommended reimbursement values for physician work (wRVUs) under Medicare Part B. The RUC includes rotating representatives from medical specialties. To identify changes in physician reimbursements associated with RUC rotating seat representation. Relative Value Scale Update Committee members 1994-2013; Medicare Part B Relative Value Scale 1994-2013; Physician/Supplier Procedure Summary Master File 2007; Part B National Summary Data File 2000-2011. I match service and procedure codes to specialties using 2007 Medicare billing data. Subsequently, I model wRVUs as a function of RUC rotating committee representation and level of code specialization. An annual RUC rotating seat membership is associated with a statistically significant 3-5 percent increase in Medicare expenditures for codes billed to that specialty. For codes that are performed by a small number of physicians, the association between reimbursement and rotating subspecialty representation is positive, 0.177 (SE=0.024). For codes that are performed by a large number of physicians, the association is negative, -0.183 (SE=0.026). Rotating representation on the RUC is correlated with overall reimbursement rates. The resulting differential changes may exacerbate existing reimbursement discrepancies between generalist and specialist practitioners.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Relative Value Scale Update Committee

The American Medical Association-Specialty Society Relative Value Scale Update Committee, also known as the RUC, plays a critical role in assessing the relative value of physician services and procedures. This committee provides access for all physicians, including dermatologists, to the reimbursement process. Since the introduction of the Resource-Based Relative Value Scale by Medicare, the RUC has done important work to evaluate and refine reimbursement for physician services. The RUC recommendations have also led the Current Procedural Terminology (CPT) Editorial Panel to develop additional reimbursement codes as new procedures and services are developed. In this article (from the series Future Considerations for ClinicalDermatology in the Setting of 21st Century American Policy Reform), we will review the RUC, including its history and membership, the RUC update process, and a brief discussion of a few issues of particular importance to dermatologists.

Relativity Screens for Misvalued Medical Services: Impact on Noninvasive Diagnostic Radiology

PurposeIn 2006, the AMA/Specialty Society Relative Value Scale Update Committee (RUC) introduced ongoing relativity screens to identify potentially misvalued medical services for payment adjustments. We assess the impact of these screens upon the valuation of noninvasive diagnostic radiology services. MethodsData regarding relativity screens and relative value unit (RVU) changes were obtained from the 2016 AMA Relativity Assessment Status Report. All global codes in the 2016 Medicare Physician Fee Schedule with associated work RVUs were classified as noninvasive diagnostic radiology services versus remaining services. The frequency of having ever undergone a screen was compared between the two groups. Screened radiology codes were further evaluated regarding the RVU impact of subsequent revaluation. ResultsOf noninvasive diagnostic radiology codes, 46.0% (201 of 437) were screened versus 22.2% (1,460 of 6,575) of remaining codes (P < .001). Most common screens for which radiology codes were identified as potentially misvalued were (1) high expenditures (27.5%) and (2) high utilization (25.6%). The modality and body region most likely to be identified in a screen were CT (82.1%) and breast (90.9%), respectively. Among screened radiology codes, work RVUs, practice expense RVUs, and nonfacility total RVUs decreased in 20.3%, 65.9%, and 75.3%, respectively. All screened CT, MRI, brain, and spine codes exhibited decreased total RVUs. ConclusionPolicymakers’ ongoing search for potentially misvalued medical services has disproportionately impacted noninvasive diagnostic radiology services, risking the introduction of unintended or artificial shifts in physician practice.

How Is Physician Work Valued?

Strategies to value physician work continue to evolve. The Society of Thoracic Surgeons and The Society of Thoracic Surgeons National Database have an increasingly important role in this evolution. An understanding of the Current Procedural Terminology (CPT) system (American Medical Association [AMA], Chicago, IL) and the Relative Value Scale Update Committee (RUC) is necessary to comprehend how physician work is valued. In 1965, with the dawn of increasingly complex medical care, immense innovation, and the rollout of Medicare, the need for a common language describing medical services and procedures was recognized as being of critical importance. In 1966, the AMA, in cooperation with multiple major medical specialty societies, developed the CPT system, which is a coding system for the description of medical procedures and medical services. The RUC was created by the AMA in response to the passage of the Omnibus Budget Reconciliation Act of 1989, legislation of the United States of America Federal government that mandated that the Centers for Medicare & Medicaid Services adopt a relative value methodology for Medicare physician payment. Therole of the RUC isto develop relative value recommendations for the Centers for Medicare & Medicaid Services. These recommendations include relative value recommendations for new procedures or services and also updates to relative value recommendations for previously valued procedures or services. These recommendations pertain to all physician work delivered to Medicare beneficiaries and propose relative values for all physician services, including updates to those based on the original resource-based relative value scale developed by Hsaio and colleagues. In so doing, widely differing work and services provided can be reviewed and comparisons of their relative value (to each other) can be established. The resource-based relative value scale assigns value to physician services using relative value units (RVUs), which consist of three components: work RVU, practice expense RVU, and malpractice RVU, also known as professional liability insurance RVU. The Centers for Medicare & Medicaid Services retains the final decision-making authority on the RVUs associated with each procedure or service. The purpose of this article is to discuss the role that the CPT codes and the RUC play in the valuation of physician work and to provide an example of how the methodology for valuation of physician work continues to evolve.

Integration of new technology into clinical practice after FDA approval.

Development of new medical technology is a crucial part of the advancement of medicine and our ability to better treat patients and their diseases. This process of development is long and arduous and requires a significant investment of human, financial and material capital. However, technology development can be rewarded richly by its impact on patient outcomes and successful sale of the product. One of the major regulatory hurdles to technology development is the Food and Drug Administration (FDA) approval process, which is necessary before a technology can be marketed and sold in the USA. Many businesses, medical providers and consumers believe that the FDA approval process is the only hurdle prior to use of the technology in day-to-day care. In order for the technology to be adopted into clinical use, reimbursement for both the device as well as the associated work performed by physicians and medical staff must be in place. Work and coverage decisions require Current Procedural Terminology (CPT) code development and Relative Value Scale Update Committee (RUC) valuation determination. Understanding these processes is crucial to the timely availability of new technology to patients and providers. Continued and better partnerships between physicians, industry, regulatory bodies and payers will facilitate bringing technology to market sooner and ensure appropriate utilization.

The Resource-Based Relative Value Scale and Physician Reimbursement Policy

Most physicians are unfamiliar with the details of the Resource-Based Relative Value Scale (RBRVS) and how changes in the RBRVS influence Medicare and private reimbursement rates. Physicians in a wide variety of settings may benefit from understanding the RBRVS, including physicians who are employees, because many organizations use relative value units as productivity measures. Despite the complexity of the RBRVS, its logic and ideal are simple: In theory, the resource usage (comprising physician work, practice expense, and liability insurance premium costs) for one service is relative to the resource usage of all others. Ensuring relativity when new services are introduced or existing services are changed is, therefore, critical. Since the inception of the RBRVS, the American Medical Association's Relative Value Scale Update Committee (RUC) has made recommendations to the Centers for Medicare & Medicaid Services on changes to relative value units. The RUC's core focus is to develop estimates of physician work, but work estimates also partly determine practice expense payments. Critics have attributed various health-care system problems, including declining and growing gaps between primary care and specialist incomes, to the RUC's role in the RBRVS update process. There are persistent concerns regarding the quality of data used in the process and the potential for services to be overvalued. The Affordable Care Act addresses some of these concerns by increasing payments to primary care physicians, requiring reevaluation of the data underlying work relative value units, and reviewing misvalued codes.

Application of the resource-based relative value scale system to pediatrics.

The majority of public and private payers in the United States currently use the Medicare Resource-Based Relative Value Scale as the basis for physician payment. Many large group and academic practices have adopted this objective system of physician work to benchmark physician productivity, including using it, wholly or in part, to determine compensation. The Resource-Based Relative Value Scale survey instrument, used to value physician services, was designed primarily for procedural services, leading to current concerns that American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) surveys may undervalue nonprocedural evaluation and management services. The American Academy of Pediatrics is represented on the RUC, the committee charged with maintaining accurate physician work values across specialties and age groups. The Academy, working closely with other primary care and subspecialty societies, actively pursues a balanced RUC membership and a survey instrument that will ensure appropriate work relative value unit assignments, thereby allowing pediatricians to receive appropriate payment for their services relative to other services.

APA Welcomes CMS Acceptance of Increased Work Values

APA Welcomes CMS Acceptance of Increased Work Values

Improving the Quality and Lowering the Cost of Health Care: Medicare Reforms from the National Commission on Physician Payment Reform

Improving the Quality and Lowering the Cost of Health Care: Medicare Reforms from the National Commission on Physician Payment Reform

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

Government Accepts Higher Work Values for Psychiatry Codes

Government Accepts Higher Work Values for Psychiatry Codes

Turned off and burned out: what will it take for "front-line" medicine to tune back in?

The United States is facing a severe shortage of physicians providing access at the front lines of care access. Specialties with provider shortages include general medicine, family medicine, and other fields providing longitudinal primary and comprehensive care.1,2 In fact, because nearly one-half of visits to subspecialists actually involve primary and general medical care services,3,4 the insufficient supply of front-line physicians to meet patient care demands may be even more extreme than current projections suggest. Despite this impending crisis, student and resident interest in these front-line longitudinal care fields has been stagnant at best in recent years and has declined drastically during the past 2 decades.5,6 For example, in 2012, only 6% of graduating medical students planned careers in family medicine.6 Additional data suggest only 2% of graduating medical students plan to practice general or primary care internal medicine,7 and only 1 in 5 internal medicine residents plans a career in general medicine after graduation.8

Annual Conference Gave Cautious Preview of LTC Policy

Annual Conference Gave Cautious Preview of LTC Policy

RVUs and DRGs: Do They Fairly Reimburse Physicians and Hospitals and Incentivize Improved Care?

* Abbreviations: BAS — : balloon atrial septostomy BW — : birth weight CPAP — : continuous airway pressure CPT — : current procedural terminology DRG — : diagnosis-related group ELOS — : expected length of stay LOS — : length of stay RVU — : relative value unit In 1989, Congress enacted the Omnibus Budget Reconciliation Act, which authorized the Health Care Financing Administration to adopt the use of relative value units (RVUs) as the basis for Medicare and Medicaid reimbursement to physicians. Each RVU is related to the complexity of the services by a defined current procedural terminology (CPT) code, and each has 3 components: (1) physician work RVUs account for the time spent, the cognitive and technical skills needed, and the overall difficulty involved in providing a service or performing a procedure; (2) practice expense RVUs account for nonphysician clinical staff time, medical supplies, and equipment used to maintain and run the facility where the medical encounter occurs; and (3) professional liability RVUs account for the cost of malpractice insurance. Congress assigns a dollar value to an RVU as part of its annual budget process. The geographic differences in costs across the United States are equalized by a geographic practice cost index applied to each RVU. Over time, the use of RVUs has become the reimbursement basis for many private health insurance carriers and for Medicaid and Medicare and has been used as a surrogate measure of physician productivity; it is of paramount importance that the relative value of a physician’s work be accurately reflected by the RVUs generated, especially when comparing physicians’ work across specialties. Of the three RVU components, physician work RVUs have proven the most controversial and challenging to accurately quantify. The Center for Medicare and Medicaid Services is required by Congress to review and update RVUs every 5 years. The Center for Medicare and Medicaid Services seeks input from a variety of sources including the American Medical Association–Specialty Society Relative Value Scale Update Committee, which is composed of 29 members, most of whom represent medical specialty societies. This committee meets 3 times … Address correspondence to David Rubenstein, MD, College of Physicians and Surgeons, Columbia University Medical Center, 3959 Broadway, CHN 1200A, New York, NY 10032. E-mail: sdr26{at}columbia.edu

Study: CMS Almost Always Accepts RUC Recommendations

For the most part, the Centers for Medicare & Medicaid Services has followed the advice of the American Medical Association's Specialty Society Relative Value Scale Update Committee when the agency decided how to update work values for Medicare's physician fee schedule, according to a study published in Health Affairs. This reliance on the RUC's recommendations didn't penalize primary care physicians, because CMS was more likely to decrease recommended work values for medical specialty, surgical, and radiologic services relative to evaluation and management services, the study's authors said (Health Affairs 2012;31:965-72). “However, it does not explain why there has been no reduction in the income gap between primary care providers and specialists,” the authors wrote. The authors, led by Miriam J. Laugesen, PhD, of the department of health policy and management at Columbia University in New York, analyzed the CMS's decisions on updating work values for physician services between 1994 and 2010. The analysis found that CMS agreed with 2,419 (87.4%) of the RUC's 2,768 work value recommendations. The CMS decreased 298 work values (10.8% of the total), and increased 51 work values (1.8% of the total). The rate of agreement between CMS and the RUC in 1994−2010 has fluctuated, and the investigators noted that “some of the largest year-to-year differences have occurred in more recent years, such as the high of 99% in 2006 and the low of 62.2% in 2007.” On average, the RUC recommended significantly higher work values than those ultimately accepted by CMS, and the average work value for new services also was significantly higher in the committee's recommendations than in the decisions ultimately made by CMS, the study found. Surgical services saw the widest gap between RUC recommendations and CMS decisions, whereas pathology and laboratory services saw the smallest gaps. CMS decreased the committee's recommended work values for radiology services by 2.7% and those for medical specialty services by 4.7%. Based on the available data, the authors weren't able to determine why CMS agreed or disagreed with the recommendations made by the RUC, the authors said. “One major question is whether primary care physicians are penalized in the process of updating physician work values,” the study said. “It is not easy to answer that question, given that the Medicare fee schedule includes services provided by many different kinds of physicians.” Nevertheless, the authors noted that CMS could strengthen the process through “long-term investment in the agency's ability to undertake research and analysis of issues such as how the effort and time associated with different physician services is determined, and which specialties – if any – receive higher payments than others as a result.” American Academy of Family Physicians (AAFP) president Glen Stream said in an interview that it wasn't surprising that the study found a high-level agreement between the RUC's recommendations and CMS's ultimate decisions on physician work values. “I do think they [the study's authors] got it right,” Dr. Stream said. “I wouldn't say this is new news, but it's a more thorough analysis.” Regardless, the RUC process does advantage procedure-driven specialties over cognitive services provided by primary care physicians, Dr. Stream said, adding, “then those biases are more often than not simply accepted by CMS.” The AAFP supported federal legislation last year that would have required CMS to compare data from independent contractors versus those in the RUC recommendations, but the legislation went nowhere, Dr. Stream said. Currently, the academy isn't advocating specifically for either CMS or independent contractors to provide recommendations on work values, he said, “but we need more [than the RUC]. Particularly for primary care services, we need a different voice – an alternative methodology.” Dr. Laugesen is supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.