How Physicians Get Paid, the Arcane Differences Matter

Nice article by Katie Jennings in Politico

Physician compensation depends critically on the Relative Value Unit (RVU) scale set by the the AMA/Specialty Society Relative Value Scale Update Committee (RUC).

This area bears continued scrutiny.  It may seem arcane, but we are talking about half a trillion dollars of public expenditure.

1) There is a chronic undersupply of primary care docs and chronic oversupply of specialists.  Does not this indicate that we are systematically underpaying PCPs and over paying specialists?  Are not there economic models for what prices should be?  How badly skewed are the AMA RVU values?

2) Why does CMS continue to accept this system?  Any way to estimate how much biases in the RVU scale are costing Medicare?

3) Congress has specified the use of these codes by law and prohibited judicial review of the RVU system.  Is the committee de facto performing a government function and therefore subject to open government regulations?  Are committee documents subject to the Freedom of Information Act?

3) Who are the members of the AMA Committee?  Do they file conflict of interest disclosures?  What conflicts have been disclosed?  Aside from the final list of CPT codes and RVUs, does the committee keep and publish minutes, notes or other material?

4) The composition of the RUC (see AMA page) is heavily biased towards specialists with only 3 members from primacy care areas (internal medicine, family practice and primary care) but 30% of all physicians are in primary care and more are needed.  The AMA sites states that composition reflects Medicare expenditures but should it not instead reflect Medicare needs?  Does CMS have any input into the composition or membership of the committee?

5) Is the AMA copyright on CPT codes enforceable?  The final physician fee schedule is the result of a federal rule making process and is published in the Federal Register.  Does not this make the fee schedule including codes and definitions the result of government work and therefore uncopyrightable?  If the copyright on CPT codes and their definitions is enforceable, is CMS giving away public property by incorporating copyright codes and definitions into their reimbursement scale?  The AMA apparently makes a considerable amount of money licensing this material.  Anyone know how much?  The CMS website specifically prohibits public disclosure of CPT codes and which inhibits public discussion of reimbursement practices.  Does this violate the First Amendment?  For the purposes of promoting public discussion of RVUs, someone might want to publish the list of codes and definitions on a public website, but to do this they would have to license the material from the AMA.

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