Should family physicians leave the RUC?

Last June the American Academy of Family Physicians (AAFP) sent a letter to the AMA’s Relative Value Scale Update Committee (RUC) demanding specific changes to the ways that the RUC conducts its business. Primary care has been severely compromised by the RUC’s recommendations, and there was an implicit threat that the nation’s largest medical society would withdraw if the demands were ignored.

I co-authored a Kaiser Health News article in January 2011 calling on AAFP and other primary care societies to quit the RUC. The campaign was given real teeth when six Augusta, GA primary care physicians filed suit last June in a Maryland federal court against the US Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS). The complaint charges that those agencies have refused to require the RUC to adhere to the stringent requirements of the Federal Advisory Committee Act, which ensures that policy is formulated in the public rather than the special interest.

In early March, after the RUC rejected the AAFP’s demands, that society’s leadership caved. Then, in a letter to its members, AAFP President Glen Stream, MD argued that the best course is to remain tied to the group whose recommendations to CMS have, by AAFP’s own admission, devastated primary care over the past two decades.

AAFP’s leadership’s decision to remain in the RUC is seriously misguided. It’s isn’t just about its members, but about everyone harmed by CMS’ reliance on the RUC. It is certainly bad for primary care but, far more importantly, it is very bad for patients and for purchasers.

AAFP’s leaders and members should clearly understand that, after this period of deep consideration, their society’s active participation renders them party to and complicit with the RUC’s actions, including those that create incentives for unnecessary services, those that inhibit primary care’s moderating influence on specialty care, and those that undermine the development of an adequate supply of next-generation primary care physicians.

AAFP’s continued participation makes it partially accountable for patients who are exposed to the physical risk associated with unnecessary procedures, and for the excess cost borne by health care purchasers. The society can argue that it is not culpable, but to everyone outside the RUC who understands the impacts of its maneuvering, the AAFP now owns the RUC’s actions.

This didn’t need to happen. In his defense of the decision, Dr. Stream flatly states that “Withdrawing the AAFP from the RUC would not delegitimize the RUC,” as though this should be taken at face value. Really? AAFP counts more than 100,000 members, one-seventh of the US physician population handling perhaps one-third of all physician visits. Wouldn’t a highly orchestrated and publicized exit have impact or raise questions? If not, then AAFP is admitting that it really is impotent in public policy.

Dr. Stream notes that “None of the other primary care physician organizations were interested in leaving the RUC,” as though that’s a surprise. The American College of Physicians, the American Osteopathic Association and American Academy of Pediatrics are dominated by sub-specialists, and so have been content with the RUC’s approaches. The only question this raises is why, from a strategic perspective, the AAFP hasn’t seized the opportunity to embrace, consolidate and leverage the broader primary care’s community true strength, which would significantly enhance its policy position.

As America’s only pure primary care society, AAFP may indeed stand alone in the health care industry. Primary care’s empowerment would diminish revenues resulting from inappropriate services throughout the care continuum, so nearly every other health care group favors the paradigm that has dominated for the past two decades.

But the non-health care business community is larger and more powerful than health care, has carried a tremendous excess health care cost burden, and has every reason to stand with primary care. The National Business Group on Health was an active participant on the AAFP’s Primary Care Services Task Force. They and other business groups would undoubtedly respond to a request to rally, if asked.

Finally, Dr. Stream claims, “Important strategic political partnerships outside the RUC could have been damaged if we withdrew, and that could have harmed the Academy’s advocacy efforts.” This undoubtedly was the clincher, but it is questionable whether it makes sense to depend on allies whose collaboration requires the acceptance of egregious terms.

For 20 years, AAFP has been at the RUC’s table, and the lot of family physicians has eroded dramatically. The decision to stay means continuing with the same behavior and expecting a different result.

But it is worse than that. The AAFPs now moves forward with a group it has publicly acknowledged actively works against the interests of patients, purchasers and primary care physicians. It is very difficult to justify that.