As an outsider, one might think of the AMA/Specialty Society Relative Value Scale Update Committee (RUC) as a secret society where a small group of physicians sit around a table and heatedly debate valuation of work. I had the opportunity to attend the January RUC meeting as a first-time observer. I was fascinated by the complex nature of the process and hope to demystify it for others. When preparing for the meeting, one of the first things that stood out was the alphabet soup — the enormous number of acronyms. Some reading and research helped me understand the lingo that is second nature to our experienced ACR team. Even with preparation, it felt like I was drinking from a firehose. For those reading this with little prior knowledge, I’ll start with the basics. The RUC stands for the AMA/Specialty Society RVS Update Committee, with RVS the abbreviation for relative value scale. It is a volunteer expert group of 32 physicians and other healthcare professionals, including primary care and specialists.
The RUC makes value recommendations to CMS on the resources required to provide medical services. The resource-based relative value scale (RBRVS) is the physician payment system used by CMS and most other payers. It is based on the principle that payments for physician services should be founded on the resource costs for providing those services. The RUC provides medicine with a voice in the federal government. The input from the RUC helps ensure the valuation process is balanced, where physicians volunteer their expertise while the government retains oversight and final decision-making authority. Resource costs are divided into three components: physician work (just over 50%), practice expense (around 45%) and professional liability insurance (small remaining amount). The first day of the RUC meeting was focused on practice expense (PE). The PE Subcommittee assists the RUC in reviewing PE inputs for new and revised codes as well as codes identified through the relativity assessment process or by CMS. The presenting society submits a list of equipment and supplies that its members consider essential to the code in question. These direct expenses are reviewed in detail by the PE Subcommittee and are debated and amended if necessary. After approval by the RUC, the PE information is then submitted to CMS for inclusion in the payment formula used to reimburse that code. On the second day, there was a report from the Relativity Assessment Workgroup (RAW). Federal law requires CMS to review all relative values at least every five years and on an ongoing basis to identify services that are likely to be misvalued. The periodic adjustments are intended to account for changes in medical practice or improved technology that make physicians more efficient, resulting in shorter procedure times. The RAW uses filters and screens to identify potentially misvalued codes. Later on the second day, the RUC convened. The RUC’s annual cycle is coordinated with the CPT® Editorial Panel’s schedule for annual revisions of CPT, or current procedural terminology codes, and the CMS schedule for annual updates in the Medicare Physician Fee Schedule (MPFS). The CPT Editorial Panel meets three times a year to consider addition of new codes, deletion of codes that are no longer used and revisions in procedure descriptions. Changes in CPT necessitate annual updates to the RBRVS for the new and revised codes. The RUC meets after the CPT Editorial Panel to consider codes that are changed or added.
After the RUC has the list of codes to review, it consults with members of the physician specialty societies to gauge interest in developing a relative value recommendation. Members of the RUC Advisory Committee and specialty society staff with an interest in a code may survey society members to assess the time and intensity of a specific service as well as a recommendation for the total work relative value. Many of the codes are presented collaboratively with other societies. The physician work component considers both the time the physician needs to provide the service and the intensity associated with performing it, including cognitive effort and judgment, technical skill and psychological stress. The RUC has established methodology for standards to ensure it is acting on the most reliable and robust data.
One point that struck me was the importance of surveys. The RUC requires a minimum number of respondents for each survey, depending on the use of the service. The survey contains a code descriptor and vignette. The vignette describes a “typical” patient. “Typical” is a word that came up over and over during the meeting. The surveys also include questions that compare the service relative to other selected services. The society then reviews the survey results and prepares recommendations for the RUC about the relative value of the specific service. I found that the RUC relies heavily on survey data. The specialty societies’ advisors present their relative value recommendations to the entire RUC panel. RUC panel members are evaluators and must be unbiased. Many will be unfamiliar with the code so there is a portion of education built into the presentation. This is where it gets interesting. The RUC advisors must be master chess players — anticipating
next moves, flaws, questions and comments. They need to be 10 steps ahead. RUC members discuss and then vote on the recommendation.
CMS officials attend these meetings and often ask questions. The RUC then forwards its recommendations to CMS. CMS reviews the recommendations and publishes its preliminary relative value decisions as part of its annual proposed MPFS rule and later finalizes the values through the rule-making cycle. Lastly, but most importantly, our ACR RUC team is brilliant. Few people realize the number of hours they spend preparing for and attending these meetings, which are not a vacation. The ACR staff keep everything on track leading up to and during the meeting. The amount of knowledge and experience on the ACR RUC team is astounding, and I can assure you after attending my first meeting that we are in the best hands.