New report mischaracterizes process for determining Medicare physician reimbursement, RUC says

There is an open process with representation by primary care when physicians gather to recommend reimbursement values of medical services, said the committee that does that job.

There are corrections and clarifications needed in a new national analysis about the process for determining what Medicare pays doctors for health care and services, according to the Relative Value Scale Update Committee, known as the RUC and overseen by the American Medical Association. The RUC has requested the corrections from the National Academies of Sciences, Engineering and Medicine (NASEM) said to a statement sent to Medical Economics.

Each year, the RUC provides recommendations to the U.S. Centers for Medicare & Medicaid Services (CMS) on what to pay doctors for their services. For years, physician organizations have argued Medicare reimbursement rates, which also are influential for private insurers, have not kept up with inflation. Health care spending generally, and the process of determining physician reimbursement, landed in the public eye during the 2024 presidential election season. Robert F. Kennedy Jr., now President Donald J. Trump’s secretary of Health and Human Services, met with advisers “about how to remove the American Medical Association from its role in drawing up Medicare’s billing codes,” according to a report from The Financial Times.

This year, NASEM published “Improving Primary Care Valuation Processes to Inform the Physician Fee Schedule.” A subgroup of NASEM’s Standing Committee on Primary Care used it to examine the process and data that CMS uses to valuate primary care in the Medicare Physician Fee Schedule.

The RUC statement addressed parts of the NASEM report, which made four recommendations for ways to improve the valuation process that CMS uses for primary care reimbursement.

Additional data

The NASEM report argued CMS should consider additional data such as electronic health record logs, time-motion studies, or reported data. The RUC statement said the committee could use that.

“The RUC utilizes and welcomes all credible data that are relevant and available to use in a fair, consistent manner in accordance with the definitions and standards for the RBRVS, as defined by CMS,” the statement said.

Who has a say?

The NASEM report recommended CMS invite other expert and technical advisory organizations to contribute to the annual valuation process. The RUC statement said those deliberations already draw a large amount of expert input.

“The open regulatory process used by CMS to gather input and create Medicare’s payment policies affords anyone the same opportunity as the RUC to provide recommendations to CMS,” the statement said. “Nearly 7,000 individuals and organizations provided recommendations to CMS on Medicare’s 2025 physician fee schedule rule and there are numerous instances where CMS modified valuation based on input from outside the RUC.”

Favoritism involved?

The NASEM study asserts that RUC members “may also favor their organizational positions and the interest of their professional societies over that of the public interest.” In reality, RUC members do not represent their individual specialties.

“The report unfairly omitted that RUC members are precluded from speaking to issues that are related to their specialty,” the RUC statement said.

Primary care in force

The NASEM report also stated that “there is underrepresentation of primary care, which accounts for 19% of seats despite constituting 24.4% of the workforce and accounting for 35 percent of all patient visits.”

In fact, the RUC statement said of the 29 voting seats on the RUC, each of the following seats are currently represented by a primary care physician: internal medicine, family medicine, pediatric medicine, geriatric medicine, primary care rotating seat, obstetrics and gynecology, AMA, and the American Osteopathic Association. These eight primary care physicians represent 28% of the voting seats on the RUC. While evaluation and management (E/M) services such as office visits make up the bulk of primary care’s billed services, it is important to note that 21 of the 29 voting members are from specialties whose Medicare allowed charges are primarily derived from the provision of E/M services.

Transparency on deliberations
The RUC strongly disagreed with the statement that “while RUC survey data, recommendations, minutes, and voting are sometimes made public, at the discretion of the AMA president, this is not always done.”

“This is not correct,” the RUC statement said. “AMA leadership supports the full transparency of the RUC and has never precluded release of this information.”

All RUC survey data, recommendations, minutes and votes are publicly available online.