Demystifying Medicine One Month at a Time

Tag: politics

Ruckus over the RUC

An interesting legal case brewing in the medical world that’s worth sharing…

A legal challenge to specialty dominance.

A group of six physician plaintiffs from Georgia are suing the government (the Secretary of Health and Human Services) in a federal district court claiming damages from the fact that Medicare, the massive program that covers the elderly and disabled, fails to execute due diligence by rubber-stamping a reimbursement structure that overvalues procedural medicine over cognitive services.


Some background is in order.

It’s no secret that specialists (e.g. radiologists, cardiologists, dermatologists, urologists, etc.) make higher incomes than primary care doctors (family doctors, internists, and pediatricians). Obvious reasons include more training, differentiated skill, and an ability to handle specific technical and/or surgical procedures that generalists aren’t able or authorized to provide.

But the non-obvious reason is a poorly publicized and shadowy body known as the Relative Value Scale Update Committee, or RUC. The RUC is a committee convened by the American Medical Association (AMA) and about two dozen medical specialty societies.

The RUC promulgates an annual report to CMS, the government’s Medicare and Medicaid arm. The update advises CMS on the ‘relative value’ of an extraordinarily lengthy list of medical services, including both procedures (things ‘done’ to patients) and cognitive services (those done for patients with a doctor’s hands, stethoscope, and brain).

The RUC has twenty-nine members, twenty-three of whom come from medical specialty societies. The list is publicly available.

Critics of the RUC point out that it’s a little like the Senate, in that smaller specialties gain outsized importance since representation is not proportional. This has in effect, so the argument goes, perpetuated the overvaluation of procedural skill over cognitive service. The downstream effect of this is twofold: a disparity in doctor incomes between generalists and specialists, but more importantly, ever-increasing cost of delivering health care as the premium on procedures incentivizes them.

Early commenters seem to suggest that the case will have meritorious legal standing. It certainly will be interesting to see what happens as the case wends its way through the judicial system.

There’s an excellent synopsis of the suit and the issues surrounding it on the Health Affiairs blog by Brian Klepper and David Kibbe, which I recommend to anyone with further interest. Here’s a key paragraph that may inspire you to click over:

The policy community should keep a close eye on this case, because its target is the beating heart of the American health care cost crisis. Aside from the primary care community, the plaintiffs are unlikely to have many organized supporters within a health care industry that has benefited so handsomely from the current payment regime. But the employer community as well as anyone who cares about the larger economic issues facing America should see the opportunity to largely correct a tremendous wrong in our system.

Docs & Politics

There was a fascinating piece in the NY Times suggesting that on the whole, the medical profession is moving leftward politically.

Here were the main reasons cited:

Definitely need some weathermen to know which way the winds blow.

  1. The demise of private practice in favor of salaried work. [For an analysis of this phenomenon, read here.]
  2. The hassles of administration [i.e. paperwork and bureaucracy] leading to a preference for a more idealized, streamlined form of “care for all.”
  3. Moral outrage at a patchwork system of health coverage the currently excludes ~50 million Americans.
  4. More women (and part-timers) in the profession.

What do you think?

If you’re a doctor, have you felt your politics changing or standing more resolute in the face of the passage of health care reform?

If you’re a patient, do you ever talk politics and/or health care reform in the U.S. with any of your doctors? What’s your take on their positions?

Rather than give you more of my spin, I’ll just excerpt the last four paragraphs of the article here to save you some clickage:

Even in Texas, where three-quarters of doctors said last year that they opposed the new health law, doctors who did not have their own practices were twice as likely as those who owned a practice to support the overhaul, as were female doctors.

Dr. Cecil B. Wilson, the president of the A.M.A., said that changes in doctors’ practice-ownership status do not necessarily lead to changes in their politics. And some leaders of state medical associations predicted that the changes would be fleeting.

Dr. Kevin S. Flanigan, a former president of the Maine Medical Association, described himself as “very conservative” and said he was fighting to bring the group “back to where I think it belongs.” Dr. Flanigan was recently forced to close his own practice, and he now works for a company with hundreds of urgent-care centers. He said that in his experience, conservatives prefer owning their own businesses.

“People who are conservative by nature are not going to go into the profession,” he said, “because medicine is not about running your own shop anymore.”

Not about running your own shop anymore…

Does he mean that the folks choosing medicine as a career nowadays are less entrepreneurial? Or simply less interested in controlling the means of ‘production’?

These are excitin’ times in the world of doctoring.

If you don’t believe me, just read ol’ Dr. Gawande’s commencement address at Harvard Med, courtesy of the New Yorker.

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