An Open Letter To Primary Care Physicians

Copyright 2011 – Paul M. Fischer and Brian Klepper

If you agree with this letter, please redistribute, particularly to other primary care physicians.


As many of you know, we have developed an effort to shine a bright light on the Relative Value Scale Update Committee, or RUC. This site provides a wealth of expert background information, and we’re working now to get more visibility on this issue.

A specialist-dominated panel within the AMA, the RUC is little known and under-appreciated, but extremely powerful and opaque. More important, through its longstanding relationship with CMS, it is central to the explosion in health care costs over the past 20 years, why primary care physicians are paid so poorly compared to their specialist colleagues and why few medical students now choose to enter primary care as a career. Meaningfully address the RUC, and you relieve America of more health system waste than all the cost control measures in the health care reform law combined.

In its present form, the Resource-Based Relative Value Scale (RBRVS) financially undervalues the challenges associated with primary care management of complicated patients, but favors complex procedures. It is fair to suggest that a significant percentage of the US’ rapid health care premium cost growth – 4 times as fast as general inflation over the past decade – is directly attributable to the RUC’s distortion of this system. Many health care economists now believe that half or more of all American health care expenditures are inappropriate and provide no value. This translates to nearly $1.5 trillion annually, a sum nearly equal to this year’s national debt, twice what we’ll spend on the military this year, or two-thirds again what we’ll spend over the next decade on the economic stimulus package. The health care cost drivers, as they’ve been constituted through RBRVS and the RUC, are the difference between America’s economic prosperity and decline.

We have undertaken a four-pronged effort aimed at replacing the RUC and RBRVS.

Make the public aware of the RUC’s role and urge the primary care societies to stop “enabling” the RUC through their participation.While one of the main goals of RBRVS was to rectify the payment gap between primary care physicians and specialists, the RUC has intensified it. After 20 years of minority participation on the RUC, the average primary care physician can expect to make $3.5 million less over a career than his/her specialist colleagues. Worse, though, is that often unnecessary but expensive procedures dramatically drive up cost while diminishing quality. If the societies loudly and visibly walked away from the RUC, with clear, at-the-ready explanations of why payment parity is critical to the future of primary care and how the lack of it has negatively impacted American health care and the nation’s economy, it would bring the issue to the fore and set the stage for the RUC’s and RBRVS’ replacement by better approaches that appreciate all kinds of complexity and measurable value. Health care funds are and should be limited. In an market that empowers primary care, fewer unnecessary services may translate to lower compensation for specialists.
Recruit experts who can credibly calculate the economic impacts of the RUC’s actions, and who can devise alternative payment methodologies. We believe it will be critically important to not simply demand an end to the current system, but to offer sensible alternatives.
Demonstrate the unlawfulness of CMS’ (and HCFA’s) two-decades long reliance on the RUC. We are exploring a lawsuit that would challenge CMS’ longstanding abrogation of its due-diligence process by outsourcing medical procedure valuation to the RUC, an informal, private, financially-conflicted group employing a highly questionable evaluation methodology. Even so, CMS has accepted 94% of the RUC’s recommendations, which most often increase cost.
Develop a collaboration between primary care and non-health care business. Most of the health care industry benefits handsomely from the excess associated with the current payment system. If it is threatened, they are likely focus considerable resources on blocking change. (The health care industry contributed $1.2 billion to Congress in 2009 to influence the health care bill.) Non-health care business is primary care’s best ally. They understand primary care’s value, are large enough, have the resources and the motivation to counterbalance the health industry’s influence.

We hope you’ll support this effort in several ways.

Contact your primary care society to demand that they withdraw from the RUC.
Broaden awareness of what we’re doing and why by rebroadcasting to your primary care colleagues.
Get in touch to help us with resources, relationships or approaches that can strengthen this project.

Thanks much for your time and consideration.

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