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RVS UPDATE

The RVS Update

Committee and its Role

in Physician Payment

By Ezequiel “Zeke” Silva III, MD

Since the early The RUC includes approximately 29 members from multiple
1990s, physician pay- physician and qualified health provider specialties. The RUC meets
ment amounts have three times per year – each time, over a three-to-four-day period.
been determined by a Recommendations for valuation originate from the specialty soci-
system called the re- eties, which randomly survey their members regarding the elements
source-based relative of physician work and, sometimes also, on the elements of practice
value scale (RBRVS). expense. The specialty recommendation is based on relativity, which
The RBRVS is main- requires comparison to existing services within the MPFS. For ex-
tained by the AMA ample, a new procedure would be compared to an existing, but sim-
Subspecialty RVS Up- ilar, procedure for relative comparison. This is often within the same
date Committee, the RUC. I have been involved in the RUC process specialty, but comparison is also made to services provided by other
for over 11 years, eight as an advisor for the American College of specialties, ensuring that relativity is multispecialty. The specialty
Radiology and the last three as a member of the RUC panel. In this recommendation is either approved or altered by the RUC, and the
column, I describe how the RUC helps determine the amounts of subsequent recommendation is then shared with the Centers for
physician payment and how all of us can contribute. Medicare & Medicaid Services (CMS). CMS then internally vets the
As the name suggests, the RBRVS is a scale of relativity and the RUC recommendation and publishes its decision in the Federal Reg-
currency of the RBRVS is the relative value unit (RVU). Services ister as part of the MPFS-proposed rule around July 1 (and which
across the Medicare Physician Fee Schedule (MPFS) are assigned allows public comment) and then as the MPFS final rule. The new
RVUs, based on the resources necessary to provide services to valuations enter the MPFS in the subsequent calendar year.
Medicare beneficiaries. The more resources there are, the more We are fortunate that our AMA administers the RUC process and
RVUs. The total RVU includes three components: work, practice that physician specialties and individual physicians can contribute.
expense and malpractice. Work RVUs are based on time; mental ef- We are the ones who possess the clinical knowledge to inform these
fort and judgment; technical skill and physical effort; and psycho- valuations. It is critical that we maintain our engagement. If not,
logical stress, when an adverse outcome has serious consequences. there are others who may be willing to address valuation for us. For
Practice expense RVUs are based on the resources needed in order instance, the Affordable Care Act included provisions to create an
to provide a specific service and are different for the facility, (the Independent Payment Advisory Board, or the IPAB, to unilaterally
hospital) and nonfacility (the office). In general, physicians incur value physician services with no guarantee of medical specialty or
greater practice expenses in the office, where they pay for the nec- physician involvement. The IPAB was eventually eliminated by the
essary costs, which are defined as direct costs and indirect costs. Di- Bipartisan Budget Act of 2018. As I have described, the RUC
rect costs are specific to the individual service provided and include process is robust and requires the efforts our AMA, medical spe-
staff, supplies and equipment. Indirect costs are not specific to the cialties and numerous physician volunteers. At the ground level, it
service, such as utilities or the furniture. Work is sometimes referred is equally critical that individual community physicians participate
to as the Professional Component (PC) and Practice Expense is re- in the survey process.
ferred to as the Technical Component (TC). Combined, the PC and
TC constitute the global payment under certain circumstances, such Dr. Ezequiel “Zeke” Silva III, MD, is with South Texas Radiology Group
as diagnostic studies. The third component of the total RVU, the in San Antonio and was recently elected as an alternate delegate of the Texas
malpractice RVU, is determined by specialty-specific malpractice in- Delegation to the AMA.
surance premium data.

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