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Time to quit RUC-ing up the health-care system (column)

If we value our family doctors, why do we pay them so much less than specialists?

The Medicare payment system has been very good to physicians who use tools (scans, scalpels, stents, etc.) and not so good to those who use their heads.

A primary care physician's job is time-consuming: asking good questions, listening well, and thinking about possibilities. And yet there is little financial reward for those activities -- which is why primary care gets dissed in most medical schools and the ranks of family doctors are dwindling.

But why is the Medicare payment system so skewed? In January, Brian Klepper, an Atlantic Beach-based health finance consultant, co-wrote a columnthat did a good job of explaining why specialists earn, on average, $135,000 more per year than primary-care doctors.

This affects patient care more than you might think. As an "insidious and destructive" result of the dominance of specialists, Klepper writes, too many things get done to too many patients:

...(S)ometimes unnecessary specialty procedures may appear more valuable and appropriate than primary care services. The system pays more for invasive approaches, so conservative treatment choices that are lower cost and lower risk to the patient may be passed over, especially near the end of life. The resulting waste, half or more of all health care dollars, has fueled a cost explosion that has led the industry and the larger economy to the brink of instability."

How did this happen?

For 20 years, federal authorities have been setting Medicare fees based on advice from the American Medical Association's Relative Value Scale Update Committee, commonly called the RUC. Specialists dominate the RUC.

Since other health plans tend to follow Medicare's payment system, the RUC has vast powers to affect spending.

Klepper and co-author David Kibbe wrote that the Centers for Medicare and Medicaid Services (CMS) rubber-stamp about 90 percent of the RUC's suggestions even though the panel has urged payment increases six times more often than decreases.

It would be nice if CMS took care of the problem by ignoring the RUC, but Klepper says the device companies that benefit from the high-tech specialty approach to medicine will make that politically difficult.

So he urges the primary-care societies to stop playing along. Primary-care members of the RUC should simply quit -- loudly and visibly -- to rob the RUC of its legitimacy. Then maybe a fairer, more patient-friendly advisory group could take its place.

Klepper and a Georgia family physician Paul Fischer form Augusta, GA, have started a website to promote the idea:

This movement could lie at the heart of real health-care reform. Kudos to Brian Klepper and others involved!

--Carol Gentry, Editor, can be reached at 727-410-3266 or

Carol Gentry, founder and special correspondent of Health News Florida, has four decades of experience covering health finance and policy, with an emphasis on consumer education and protection.