Robert M. Centor, MD; Larry Culpepper, MD, MPH; Robert W. Morrow, MD; Roy M. Poses, MD


March 05, 2013

In This Article

Commentary from Robert Centor, MD (Internist)

Editor's Note:
The following is an abridged version of Dr. Centor's blog post on this topic, The RUC Is a Scapegoat, RBRVS Is the Disease.

The RUC is an easy target. The RUC is flawed. But the RUC is not the problem.

In no way can I defend the payment schedules that the RUC has proposed to Medicare. I can defend their recent changes. Radiology payments decreased last year; interventional cardiology payments decreased last year; and many other payments have decreased dramatically. The relative payments are still wrong (in my opinion), but the RUC actually has been responsive to criticism. They have increased primary care payments (admittedly not enough).

But if one studies the problem carefully enough, one must decide that the idea of paying per episode almost must lead to gaming the system. Forget the RUC; the entire idea of time-independent, episode-based payment must lead to worse medical care and higher costs. If physicians can make more money by doing more, then some will.

Practice administrators push primary care physicians to see more patients each day. If we can decrease the time spent per patient from 20 minutes to 15 minutes, then we could see up to 8 more patients in an 8-hour day. Our overhead has not changed -- hence, the marginal financial benefits are huge.

But any honest physician will tell you that we should not rush medical care. Do we want our surgeon trying to do 5 surgeries today rather than 4? Do you want to be the 5th patient?

The problem is the RBRVS billing system, not the RUC. Whatever system CMS used to assign payments would lead to gaming the system! In the current system, primary care has suffered (relatively). Primary care groups complain vociferously about the RUC. More recently, other specialties are complaining.

So we can yell about the RUC. We can advocate for changes. We could believe that another commission would fix the problem, but the real problem is the entire construct of RBRVS.

We need a system that does not encourage physicians to do more. We need a system that encourages alternative communication schemes from the office visit -- email, phone calls, and so on. We need a system that allows physicians to take the extra time that some patients deserve.

We could pay physicians in a time-based manner. Many claim that physicians would game such a system, and of course some physicians would game any system.

We could pay physicians' salaries. Salaried physicians have no incentive to do more, so they can return to their original incentive -- doing what is best for the patient. RBRVS leads to perverse incentives, independent of the RUC deliberations. Physicians will do less and patients will do better if we scrap RBRVS and develop a more intelligent payment system.

Response From Roy Poses, MD

I completely agree with Robert that the RBRVS system is itself deeply flawed. I also agree with him that a simple pay-per-time approach would be better.

But given that we have RBRVS, the exclusive use of the secretive, unrepresentative (of many physicians), conflicted RUC to keep the RBRVS system up to date seems like a very bad idea. Unless someone has a really good idea about how to get the political system to throw out RBRVS, maybe we need to try to fix the worst aspects of RBRVS while we are stuck with it.