Read on Twitter
So there is some truth here, but there's a n important nuance. The RVU based reimbursement system is skewed towards proceduralists in general, despite the fact that all* specialties have been represented at the RUC essentially for the beginning. https://twitter.com/screamingmd/status/1295754584338685952
Now that asterisk on the "all" is doing a lot of heavy lifting. First of all, not all specialties are represented. There are 21 specialties with permanent seats, and four seats that rotate. So a significant fraction of the "House of Medicine" is in fact not represented.
The other problem is representation isn't really representation if some specialties are more equal than others, is it? While the RUC is ostensibly a representative body, when each specialty has one vote, it really is not.
For example: the internal medicine body, with 163,000 members, has the same number of votes as the Neurosurgeons association, with 9,000 members.
Orthopedics, with 39,000 members, has the same representation as the Family Practice docs with 136,000 members.
Orthopedics, with 39,000 members, has the same representation as the Family Practice docs with 136,000 members.
So right there the pretense of a democratic organization is out the window. But then you look at which bodies are represented. https://www.ama-assn.org/about/rvs-update-committee-ruc/composition-rvs-update-committee-ruc
The specialties represented can be roughly grouped into those that make the revenue by office based E/M codes, and those that make their primarily by procedure codes. Depending on how you categorize them, I'd say there is a 13-9 advantage to the proceduralists
Ostensibly the members of the RUC are not supposed to represent "their" specialty, but all the medicine. I personally know members of the RUC and I admire them for their efforts to be unbiased in their assessment of the value of certain services. But, c'mon.
The ACS brings rafts of consultants to the RUC (behind the scenes) and they're not the only ones. The RUC members are absolutely fighting for the revenue of their co-specialists.
Even when RUC members are trying to be objective, there's an inherent bias. Surgeons are always going to have a higher estimation of the value of a procedure than those who don't do them. (and vice versa)
I'm not going to say that there's a quid pro quo, but the loose confederation of the proceduralist bloc inarguably systematically inflates the value of procedures.
And the value of procedures starts high and never goes down. When a lap chole was a brand new procedure, requiring special training and took longer to do, it was appropriately awarded a relatively high work RVU value
But now, 20+ years later, it's a staple of operative technique, better tools have been developed, and surgeons can do them quickly and efficiently. But the work RVU value was never adjusted downwards to reflect the increasing ease of this procedure.
Note: I'm picking on lap chole's unfairly - this applies to a very wide range of procedural services. The time required to perform them goes down, as efficiency increased. But the time required for a 15-minute E/M consultation is fixed.
And new procedures are invented all the time (which is good!) and they are *always* highly valued when introduced. All of this contributes to the systematic overvaluation of procedural services.
Also, when the RUC annually revalues all the codes (on a q5 year rolling schedule), it's required to be budget neutral. So if there are more procedures, or if one specialty's services are increased in value, then everybody else's are decreased proportionately.
IN FAIRNESS, the RUC is aware of this problem, and has addressed the value of cognitive services more than once.
But the budget neutrality element hits hard. Emergency Medicine got a 5% (?) boost in its codes last year. But this year the FP's codes go up and this completely reverses the gains EM made last year.
None of this completely explains the bizarre overvaluation of fracture care, though. That's a true aberration which I presume is a historical artifact. One sore spot for ortho is that EM often bills for fracture care and they are trying to change that at the RUC
If they do, I hope that opens the door for all the fracture codes to be re-examined and reduced in value.
Anyway, that's my RUC rant: It's an unrepresentative body that's biased both structurally and by membership to systematically overvalue procedural services, which contributes greatly to the income disparities across the various specialties.
Also none of this should be read as a slam on surgeons. You all didn’t create this system any more than we did, and what you do is important and should be paid fairly.
