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Inside the RUC: Why 30 Survey Responses Aren't Enough · Voices of Otolaryngology

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  Welcome to the Voices of Otolaryngology podcast series, where we spotlight
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  diverse perspectives and insights within the field of otolaryngology.
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  I'm your host, Rahul Shah.
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  Let's jump into it.
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  Welcome to Voices of Otolaryngology from the OTO Expo
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  floor of the 129th Annual Meeting of the American Academy of Otolaryngology.
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  It is Monday at 4 p.m..
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  We've almost made it, Pete!
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  Almost there.
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  Almost there. You're not going to leave early.
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  Are you leaving tomorrow?
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  Don't answer that if you're going to leave early. I'm leaving tomorrow.
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  You're leaving tomorrow? Good, good, good. Because the meeting is Saturday.
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  Sunday. Monday. Tuesday at. Correct. You got to see it through.
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  You got to see it through, Doctor Manes,
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  It's awesome to have you with this.
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  Could you introduce yourself?
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  Sure. My name is Peter Manes.
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  I am a rhinologist at the Yale School of Medicine.
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  Been there for about 15 years.
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  I'm also the industry consultant for the American Academy of Otolaryngology,
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  and I also serve as our RUC advisor, doing a lot of, coding reimbursement.
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  Okay.
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  So I always think of the title for these talks.
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  I never prep you. Did I prep you? You did not.
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  I knew you wouldn't.
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  So I didn't ask.
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  Good RUC.
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  What does that stand for?
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  Relative values scale update committee.
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  But R.U.C., RUC? I didn't make it up. All right.
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  Say it again.
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  Relative relative value scale update committee.
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  How does that impact a otolaryngologist in practice?
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  It ipacts how much they get reimbursed.
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  So this whole system was set up, in the 90s,
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  where codes are valued
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  based on a relative value unit an “RVU” system.
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  And there was a realization very quickly
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  that that needed to be updated periodically.
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  So and all of these codes are relative to each other
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  so that there is a relative value scale update committee
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  which updates the valuation of these codes.
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  Values, new codes, things like that.
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  All right.
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  So can we do you ever do like a fun game with your family or.
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  Actually, let's talk about your family? Sure.
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  So your wife's the smart one. Correct.
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  All right. Can we call her out? Hi, Jacqueline.
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  Yeah, but. Hi, Jacqueline. Who? What does she. Know? Excuse me.
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  Jacqueline Brewer,
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  my wife, is a comprehensive auto learning allergist in Connecticut.
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  Thank you.
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  So she's our our target audience.
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  Hopefully, she'll listen to us.
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  She'll be our only listener.
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  Okay. Don't have to listen, but I'll.
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  I'll. I'll put in a plug.
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  If I say parotid, can you say, like, how many work RVUs it is?
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  I can't. Okay. Toncils?
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  So I look this up recently.
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  I think it's 4 something. Ear tubes.
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  2? Maxillary antrostomy?
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  Three something?
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  This is a fun game.
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  Yeah, this is hard.
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  Okay, but.
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  So that's the work you do, right?
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  Is that the RUC Committee? Correct. Walk me through.
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  Take one of those that you know off the top of your head. Sure.
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  So let's say maxillary antrostomy.
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  So. Okay,
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  so sinus surgery codes were were revalued maybe about five, six years ago.
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  Which is extremely recent in the world. Right.
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  Five, six years. It goes like yesterday. It really is.
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  And so what happens is that code
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  hit a screen that's established by the AMA.
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  The AMA runs this whole process and there's a variety of different screens
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  the AMA uses to try and identify codes that need to be revalued.
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  Okay. So let's not get into that. But it hit a screen right.
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  And they said we're going to reevaluate. Yes.
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  And currently maxillary antrostomy gets how many RVUs?
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  About three. Right. Three.
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  So what happened 5 to 6 years ago when it hit that screen?
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  So what happens at that point is we as an organization
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  have to provide a recommendation to the RUC to this update committee.
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  Well, I'd say increase it. Correct.
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  Except we can't just say that.
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  Oh. So what we need to do is send out surveys to our members,
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  and our membership fills out the surveys
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  that ask them, how long does it take you?
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  How intense is it, how complex is it,
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  and how does it compare to current codes in the fee schedule so as to be relative?
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  You slow down because you're you're terrific. So
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  I get an email and I think I got this one because they asked me about a survey.
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  Do I fill out the survey?
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  Do I not fill out the survey?
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  I got an email for that.
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  You absolutely should fill out the survey.
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  So because your answers provide data
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  which will directly impact your eventual reimbursement.
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  Data, I don't understand. Explain it to our users.
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  So I fill out the survey. How will it impact my reimbursement?
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  So that data is the data that we then
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  present to this relative value scale update committee.
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  My individual data point, or do you roll it up?
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  We roll it all together.
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  So and so.
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  We will tell them we had and we usually don't get a ton.
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  But you know we had 30 respondents.
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  We had 40 respondents to this survey.
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  And the is that good or bad?
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  Is it embarrassing for us to have that many or is it good?
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  I'd say it's typical of most medical specialties, but to me
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  it just shows that we are not involved in the process.
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  So you want a lot of respondents? I want more.
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  I want people to tell us what's really happening.
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  I want good data. Okay. So we get a survey.
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  You want to know, you want you want a large response.
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  Correct? Okay.
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  So so keep going through that example. You get the data.
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  So we get the data put it all together.
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  And so for example we look at it and say okay on average our respondents say
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  that this procedure takes 30 minutes and is this intense or this complex.
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  And there's measurements of that and it should have an RVU of something.
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  Well I want it to go up.
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  So I said up! Right. And that's fine.
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  But you have to have the data to back that up.
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  What does that mean? The data is the time.
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  But I'm getting faster. I'm a slick surgeon. Complexity.
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  Well that's the then that's the deal.
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  So faster.
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  So I can't have it both ways.
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  You cannot have it both ways okay.
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  And when I fill out the survey, do I pick
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  how adept I am or my average surgery time?
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  Or if you can't talk about I understand.
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  You take you pick what would be typical.
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  And so your average surgery.
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  So not my fastest toncil, which would be three minutes - mean I might take me 15.
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  Typical. What does this normally take you.
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  And that's honest good data that we're looking for.
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  Understood. Really appreciate it.
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  So you go to the RUC Committee.
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  You you represent us. Correct.
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  And how many how often does it meet? Meets three times a year.
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  And you go sit with the RUC Committee. Yep.
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  So we present to this committee that.
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  The AMA folks are in CMS. It's physicians.
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  And so it's physicians from - but who convenes it?
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  The AMA convenes it.
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  Physicians from a variety of different specialties.
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  There is an otolaryngologist on that committee.
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  But if we are presenting, that person is not allowed to speak.
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  Oh, so this is interesting.
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  So we're presenting maxillary antrostomy to non-otolaryngologists?
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  Absolutely. So how does that.
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  So that's part of the presentation.
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  You have to explain to them what it is.
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  You have to explain to them how intense, how complex it is.
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  You have to explain to them why it's worth what you claim
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  it is worth and how that fits into the overall fee schedule.
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  So let's say let's pick a random case, because I don't ever
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  want to get you in trouble.
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  Let's let's pick procedure “Shah”.
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  Let's call the “Shah” procedure.
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  Yes. And it’s four RVUs, you do a survey
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  and then you have 25th, 50th, 75th percentile of time.
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  Correct. Or what we think it should be worth.
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  Some people say three, some people say five RVUs.
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  Some people say seven. Sure. Are we going to get the seven?
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  So what happens inevitably is if something is revalued or something,
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  even if it's new, it's looked at very, very carefully.
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  It's typically not on the higher end.
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  If anything it's typically on the lower end.
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  But one of the jobs that than I have is to argue and try and craft arguments
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  to explain why is it worth what we're claiming it's worth.
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  Exactly.
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  What we need in order to do that is good data.
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  We need time to back it up.
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  We need intensity to back it up, and we can't have one without the other.
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  Understood? Understood.
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  Thank you very much.
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  So you do that, then it gets valued by that committee
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  and that's it?
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  That's not it.
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  So that committee provides recommendations to CMS
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  and then CMS
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  gives us an indication of what they're thinking usually in the summer.
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  And something called their proposed rule.
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  Now they may agree.
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  Generally they do generally.
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  So generally they do.
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  It used to be about 90%.
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  Now it's getting in the orders of the 60s to 70s percent.
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  And so. And I bet you they don't raise it.
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  They would not raise it if, if they change it, it's likely going down.
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  So I've got two groups coming at my knees.
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  Yes. Okay. Yeah.
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  And then if they agree with it, great.
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  It'll likely be then finalized in what's called the final rule,
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  which comes out sometime in
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  around November and then is enacted into the fee schedule in January.
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  I would pound my fist on this table, but I might break the mics.
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  I agree, but this is probably the most important thing
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  for the economic viability of your wife's practice and other practices.
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  So that’s what I said earlier, because we are directly responsible
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  for the reimbursement as physicians, as survey respondents.
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  If physicians survey respondents give good data,
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  give adequate intensity and complexity, and again appropriate.
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  Yeah, yeah, yeah.
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  You know, we complain all the time I can't fix it.
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  I can't do anything.
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  We actually can answer the survey.
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  Fill out the survey please.
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  Let's not let's not leave this in the hands of 30.
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  And be honest. And absolutely always be honest.
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  So you're an academics.
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  Yes. It's Jacqueline. Yes. Jacqueline.
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  Hello.
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  We've helped your practice.
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  How does this help academics?
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  Same way. Well, explain it to me.
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  I mean, what do you mean?
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  We all get reimbursed based on this whole system.
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  So how does it affect Pete Manes in your academic practice?
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  Well, in my academic practice, I'm.
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  You have RVU targets.
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  Is what you mean? Yeah.
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  So I have RVU targets to meet.
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  So if I have if I do a procedure and the RVUs went down well,
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  I got to do something else to make up for that.
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  So a smart guy like me might say it's even more important for academics.
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  You know what I really do think it affects us all.
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  Wow. There's no there's no division there.
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  If we take let's take 30 survey respondents.
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  Are they usually private or academics or half and half?
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  Who answers the surveys?
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  So we don't look at private versus academics and it is de-identified.
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  So you have no idea. You're anonymous which is good. Yeah.
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  Yeah. Yeah. Your point is just answer the survey.
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  Answer the survey appropriately. Honestly. Okay.
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  So you took me down this tangent,
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  which was a 14 minute tangent because you - I did this?
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  You did, because I said, describe your roles.
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  And you said, RUC, and I said, let's define it.
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  Got it. All right. So let's go back to your role.
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  So what do you do for the Academy?
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  You are our inaugural industry consultant.
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  And then you're also.
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  Our, on the board of directors. Yep.
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  And then also our RUC advisor. RUC advisor.
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  So I've also then heard so is there a committee that's RUC or what?
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  Because you used to be. Right.
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  So there's a
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  there's a workgroup called the 3P, which is physician payment and policy.
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  I previous- Is that physician comma payment comma policy?
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  I haven't looked at the or is a physician payment policy.
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  That's a great question.
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  Sorry but 3P. I'm going to look into that.
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  And is 3P RUC? Or what is 3P?
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  3P looks at all socioeconomic health policy issues.
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  So it involves
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  we have a standing part of our agenda that discusses the CPT and RUC process.
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  We have standing areas that look at, advocacy,
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  that look at private payer issues.
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  All of all our position statements,
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  go through 3P prior to going on to our executive committee.
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  So it looks at all of it.
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  And so you had a prior role there.
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  You were the I was the previous chair of that.
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  And Lance Manning is now the chair.
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  And what you were chair of that and that was your only role.
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  I was the coordinator for, well, originally the coordinator
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  for health policy, then the coordinator for advocacy,
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  the name changed a few times.
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  And now it's now Lance Manning’s
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  our coordinator of advocacy and health policy. Correct.
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  I did, seven years of a four year term.
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  Yeah. Understood. Thank you.
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  Thank you.
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  Really, your contribution to the Academy and the economic viability of our,
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  members is awesome.
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  So you mentioned CPT.
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  Yeah.
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  So our audience now understands RUC- Yeah.
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  Relative value.
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  Relative value scale update committee.
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  Relative value scale update committee, what we call RUC.
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  Talk to us about CPT.
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  How does the Academy get involved.
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  What committees does it go through?
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  So you know CPT process CPT.
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  We think of codes.
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  You know, procedure codes. Yeah.
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  31255 whatever.
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  61782 well, those have to be created. Okay.
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  And so when there is a need to create them and that can start at a committee level,
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  that can start at an individual physician level sometimes industry.
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  Absolutely. Or an academy level. Yeah.
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  We see a need for or as a neuromodulation for sleep or - Yes.
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  We look at that very closely.
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  As a group, we have a separate CPT team that's led by Jim Lynn.
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  Is that a committee or team?
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  It's, it's more it's it's it's a team.
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  A really so.
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  So doctor Jim Lynn leads this committee.
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  Doctor Jim Lynn leads this committee, and he will,
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  in working with the interested parties, put together a CPT application.
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  So an actual application for a new code.
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  And what where does that go in the universe of health care?
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  So that is then submitted
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  to a CPT panel which again is run by the AMA.
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  Okay. So how often does.
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  That mean that meets three times a year as well.
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  This gets very confusing. It does. All right.
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  So the CPT panel a code change application goes in
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  a, opportunity for us to discuss a code that happens three times a year.
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  Doctor Lynn and I believe Doctor Lindsey partner?
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  Yes. Doctor Lynn and Doctor Lindsey partner on this.
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  And do you have a partner on the RUC side?
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  I do, Brian Boyce. Great, great.
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  And what I mean by partner doctor Lindsey and Boyce are new to the team,
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  and we're trying to build that bench. You want to talk about billing?
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  Well, that's what we need to do.
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  You know, we need more people involved in this.
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  It does. It takes a lot of time. It takes a lot of effort.
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  You got to have some interest in it, and you got to want to do it.
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  And so we need that.
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  But we have that.
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  We have an academy with a smart model.
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  Motivated, interested.
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  So, Doctor Lindsey, you're on the team, partners with Doctor Lynn.
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  Yeah.
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  They go three times a year to a CPT/AMA meeting.
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  Correct.
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  And then and they put it similarly to what we do with the RUC.
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  They present this code to that group, and that group will say yay or nay.
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  And let's say they say yay.
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  Well that then starts the clock on our job to actually get it valued.
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  Wait a minute. Hold on, hold on.
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  So they say yeah, yeah.
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  And then what happens then it of gets.
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  Turned over to us. Well what the CPT is the first part.
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  Exactly says that it needs to be value needs to.
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  Be valued and gets. Back to you. Yes.
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  Amazing. Amazing.
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  And is there a committee for that at the academy?
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  For the valuation?
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  No, for the CPT RUC, is there a separate committee we mentioned 3P.
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  Does 3P follow- 3P follows this.
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  We sort of discuss it at 3P and then our CPT team and our RUC team
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  meet once a month to kind of go over all this stuff,
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  make sure we each know, make sure the left hand knows what the right hand.
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  Yeah. And I'm looking the audience in the eye.
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  If it makes you feel any better I'm at all those meetings, okay?
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  I'm not with you when you hit the road. Right?
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  Because I can't be really.
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  But back home at all those meetings.
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  So I'm learning and listening.
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  These are the real experts. But, thank you for having me there.
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  Now you're there. It's it's helpful.
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  So think hard.
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  You weren't prepped on this.
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  Your biggest RUC win?
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  And now you said seven, maybe eight, nine years you've been doing this.
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  Are you are you allowed to talk about it or you're not allowed?
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  I don't know.
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  I wouldn't describe it as a win.
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  Maybe some of the stuff that I'm kind of proudest of.
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  Okay, fine. I call them wins. I know, but I it's, you know.
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  All right.
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  When are you most proud of?
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  If you can't talk on specific.
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  There were two.
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  There was an emergency tracheotomy code.
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  Okay. I’d increase that. Anyone else wants to answer that?
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  We got, so, you know, our responses of surveys are divided into
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  what did the 25th percentile say with the 50% out?
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  We got the 75th percentile for that.
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  And Ames was great. Why?
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  Because it was scary.
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  We made it appropriately scary to the panel members.
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  And how often do we do that? P once a year. Once.
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  And this is not a liability to you you know.
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  And you do that and you save a life.
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  And you're kind of just like oh my God, what did I do.
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  Yeah. So there's no our views on that.
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  I mean you save some. So yes. Exactly. That's just one.
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  Was that revalued, Pete?
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  How long ago?
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  I'd have to look maybe a five, six years ago or so.
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  And then we redid the sinus surgery codes, all of them.
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  15 and 16. And they were they went down.
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  But honestly, they could have gone down a lot more.
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  Because people didn't answer the survey.
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  Didn't answer the survey.
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  So while I was not happy.
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  Yeah that we lost some we it I, I was
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  I was proud that it wasn't as bad as it could have been.
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  I it's like the Mets game.
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  I called you the Mets game when you were at the finals. Yeah.
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  And they lost, but not as bad as they could have.
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  You didn't really need to bring up the. Yeah. No, it's all right.
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  I thought I would. Be trying to throw me off.
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  Yeah, it's a true story. It's great.
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  So you averted what could have been a significant loss?
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  Well, all of us, you know, we were just. It was. Yeah.
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  It was.
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  That would have been really bad.
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  And, we
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  we lessened the pain.
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  Are we respected?
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  When you go to Chicago or the sites in New York for those meetings?
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  Does otolaryngology get respect? I'd like to think so. No. For real?
• 17:21
  No, really, I do.
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  I think they realize that we are.
• 17:25
  We're not gaming a system. We're just trying. To.
• 17:27
  We're not.
• 17:28
  We're honest people.
• 17:29
  We will tell it like it is.
• 17:32
  If we don't think something's worth something, we're not going to try
• 17:35
  and put up a lot of smoke and mirrors, and.
• 17:37
  And that goes a long way.
• 17:39
  Because when you do care about something, when you do need something,
• 17:41
  then you're the honest broker.
• 17:43
  So that's the structure of how a code and valuation runs there.
• 17:49
  Fair correct I think. Do we miss anything at now.
• 17:51
  So you mentioned that a code
• 17:54
  was reevaluated 2015 and 16.
• 17:57
  That was fess,
• 17:59
  and and we said that's like yesterday.
• 18:01
  It's very recent.
• 18:02
  What are some other big reevaluations that have happened in 2011/2012
• 18:07
  or anything in, in that time that our members should really know about?
• 18:11
  Well, you know, there was actually even creation of codes, a lot of,
• 18:15
  in-office laryngoscopy codes, like with interventions.
• 18:18
  When did that happen? That was a big family.
• 18:20
  Probably about 2012, 2013?
• 18:23
  So they do up to be renewed or?
• 18:25
  No, not necessarily because they may not hit one of those screens.
• 18:28
  And so they may just kind of exist as they are.
• 18:31
  So are the screens or is it too complicated to list what a screen?
• 18:34
  They're, they're very complicated.
• 18:36
  Oh, and they use algorithm.
• 18:37
  They do these weird algorithms that say, you know, if you know, if it's used 50,000
• 18:41
  more times, you know, in and it has an RVU value of this,
• 18:45
  and I guess I should say it was a lot of a lot of things.
• 18:47
  So let's make it all about Jacqueline.
• 18:50
  She’s going to love this. She's going to love this. Yeah.
• 18:52
  So what should Jacqueline take home?
• 18:55
  The nice 20 minute discussion we've had.
• 18:57
  What are the big points you want members to know?
• 18:59
  I really want members to know what role they can play in this process.
• 19:04
  And that is all they should play in this process,
• 19:06
  which is - Look them right in the eye.
• 19:08
  Fill out the surveys.
• 19:09
  We send you a survey.
• 19:10
  Please, please, please fill it out.
• 19:12
  We need you to.
• 19:14
  And if you think it doesn't matter,
• 19:15
  it actually completely directly matters and completely directly.
• 19:20
  But the rules are tricky.
• 19:21
  I can't be picking up the phone, call my friend saying fill out. So it's true.
• 19:24
  That's illegal.
• 19:25
  We're telling you now when you get those surveys, fill them out.
• 19:27
  Fill them out. Filling out honestly, fill them out fairly.
• 19:30
  So that's one thing they can do. What else can they do?
• 19:32
  There's a lot of issues with physician payment
• 19:35
  and Medicare reimbursement and things like that.
• 19:40
  Get involved.
• 19:41
  And what does that mean?
• 19:41
  That's such a silly thing to say.
• 19:42
  But honestly, talk to your legislators.
• 19:46
  Come to the Hill. Or talk to us.
• 19:48
  And learn how to do it. Or talk to us.
• 19:50
  Just tell us when you have an issue. Is that a law? Right.
• 19:53
  We have agreed to pass it along to our team. Right.
• 19:56
  You want to talk about that?
• 19:57
  They give us queries all the time. Member inquiries.
• 19:59
  Our health policy team. That works for the academy.
• 20:02
  They're fantastic.
• 20:03
  They care about what's going on with our members
• 20:06
  and they are there to help us.
• 20:09
  And so if you're having issues
• 20:12
  they want to know about, it may not be able to fix every issue.
• 20:15
  But one of the things that helps us do is identify trends,
• 20:18
  because we need to identify those trends, is then
• 20:20
  that allows us to act on these things, Before they spiral and go too far.
• 20:25
  Correct. Just a couple minutes on your new role.
• 20:27
  Very grateful to you to be our industry consultant.
• 20:31
  We're unique as an organization.
• 20:33
  We have a surgeon CEO, which is me.
• 20:35
  So I have some competence and aptitude, but it's awesome.
• 20:39
  Have a use in an industry consultant.
• 20:41
  Do you want to talk about the role?
• 20:43
  You've disclosed all your conflicts.
• 20:44
  I don't care about that.
• 20:45
  But talk about your role and what you do.
• 20:47
  We've had several meetings here and you've been invaluable for members.
• 20:50
  Talk about your role.
• 20:51
  Yeah, we've been working a lot with industry.
• 20:53
  One of the things we realize, honestly, you've realized and through discussions,
• 20:57
  we've, you know, come to these conclusions that we need to partner with industry.
• 21:01
  We need innovation, we need to be able to get technology and treatments
• 21:07
  into the hands of our members so we can use it for patients.
• 21:11
  And that's a lot.
• 21:12
  There's a lot that goes into that.
• 21:14
  And we as an organization need to help foster that.
• 21:17
  And so there's a lot of relationships that we can develop with our industry
• 21:20
  partners, things that we can help them with in order to do that.
• 21:24
  So that's yeah.
• 21:25
  The the 50,000ft view of what, I'm trying to do in this new role.
• 21:30
  And you also are helping with market access, reimbursement,
• 21:35
  but reimbursement,
• 21:36
  how do we ethically partner with them to make sure that we win
• 21:39
  for our patients, setting up the right codes
• 21:42
  so our providers use them to get technology to patients?
• 21:45
  Well, that's I mean, that's the whole game.
• 21:47
  And honestly our our industry partners, they're they get it.
• 21:51
  They're ethical.
• 21:52
  We might have distance arguments with them.
• 21:54
  And so we'll be honest.
• 21:55
  They're good people.
• 21:56
  There are neighbors. There are friends worthy and worth.
• 21:59
  They're honest with us and we're honest with that is.
• 22:02
  I really do think you're one of the most important people in the academy.
• 22:05
  And as a member, because of your role, you and Doctor Lynn and Lance Manning
• 22:09
  and all your committees, you know, all dozens of you that work hard day in
• 22:13
  and day out for the coding to make sure that our our practices stay in tune.
• 22:16
  That's not to say.
• 22:17
  Thank you for that.
• 22:18
  So, we're about to wrap up.
• 22:20
  I'll tell you, I'm a huge, Red Sox fan.
• 22:23
  Was it the 86 World Series, Red Sox and Mets when it went underneath
• 22:27
  Bill Buckner's feet and the Mets won?
• 22:30
  A well, that was game six.
• 22:31
  Did they win?
• 22:32
  They won game six, but then they had to come back and win game seven.
• 22:35
  I don't. Remember. Did they. Oh yeah, I don't remember.
• 22:37
  I was a Red Sox fan I didn't remember. No I don't remember.
• 22:40
  I just forgot it.
• 22:41
  I was ten years old, I remember.
• 22:42
  It, but I know Buckner lost it.
• 22:44
  Should have won game seven.
• 22:45
  Thank you very much Pete, for everything you do for our members.
• 22:48
  Incredibly awesome.
• 22:49
  You're going to be attending a innovation course, taking a week from your life
• 22:53
  to help us learn how to be innovators.
• 22:55
  So I just love the work you're doing.
• 22:57
  I can't wait.
• 22:58
  It's going to be great. I'm loving this. Awesome.
• 23:00
  Thank you so much, Doctor Manes. And thank you.
• 23:02
  We hope today's episode sparked some fresh ideas.
• 23:05
  If it resonated with you, please subscribe and share it with friends.
• 23:09
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• 23:10
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• 23:12
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• 23:13
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• 23:15
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• 23:19
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