GAO: Not enough transparency in how CMS values clinical work

The process for determining how much work a physician puts into completing a particular clinical task is often inflated and inaccurate, creating problems when Medicare and other federal agencies attempt to place an appropriate value on the task, according to a new report by the Government Accountability Office (GAO).

The GAO report found that the American Medical Association's (AMA) Specialty Society Relative Value Scale Update Committee, or RUC, process to review physician services' work relative values may not be accurate "due to process and data-related weaknesses." Physicians who oversee the process may have conflicts of interest, leading to inflated worktime estimates, and AMA surveys often have low responses rates, with the median rate at about 2.2 percent. Of the 231 surveys undertaken for particular tasks, 23 had fewer than 30 respondents.

As a result, the GAO has concluded that the Centers for Medicare & Medicaid Services' "process for establishing relative values embodies several elements that cast doubt on whether it can ensure accurate Medicare payment rates and a transparent process."

The report noted that CMS does little to properly document the entire process. Nevertheless, the GAO said the agency usually accepts the RUC recommendations without input from other parties. As a result, it creates a risk of physicians overperforming overvalued services and underperforming those that are undervalued. Altogether, the agency values about 7,000 different clinical services and providers bill Medicare some $70 billion a year for these services.

The RUC process has come under fire in the past, with the AMA accused of skewing the process toward higher prices for specialty services, driving up the overall cost of delivering healthcare services. And it has also been criticized for being overly secretive in the way it goes about its business.

The GAO report recommended that CMS better document the process for establishing relative values for services, informing the public of potentially misvalued services, and incorporating data  and expertise from from more physicians and other relevant parties.

The U.S. Department of Health and Human Services concurred with better documenting the process and bringing in more input, but did not agree with making potentially misvalued services public, saying it would require complicated rulemaking and notices in order to do so. The AMA agreed with all three major recommendations, but expressed concern that publicizing misvalued services might delay the RUC process.

Eliminating conflicts of interests may also be difficult because there are few experts about clinical services outside of the doctors who actually perform the work, the Daily Caller reported.

To learn more:
- read the GAO report (.pdf)
- check out the Daily Caller article

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