Washington has finally discovered something physicians have known for years: The way Medicare determines what doctors are paid is deeply flawed.
The Trump administration is scrutinizing the American Medical Association’s role in that system, including its ownership of current procedural terminology, or CPT, and the influence of the CPT and AMA’s Relative Value Scale Update Committee processes on physician payment policy. Good. The system deserves scrutiny. But Washington may be asking the wrong question.
The problem isn’t simply whether the AMA has too much influence. The deeper problem is that America has spent decades pretending that the value of medical work can be calculated with remarkable precision while progressively disconnecting that calculation from what it actually requires to care for a patient.
I have spent years representing surgeons in the CPT and RUC processes, and I know their strengths and shortcomings from the inside. The RUC isn’t perfect. Physician surveys can have inadequate response rates. Specialty societies advocate vigorously for their members. Historical assumptions about procedure times and resources deserve re-examination. Greater transparency and better empirical data would improve the process.
Reform is warranted. But reform shouldn’t confuse measurement with understanding.
CPT and the RUC perform different functions that are often conflated in public debate. CPT gives American medicine a common language for describing services and procedures. The RUC recommends values and resource inputs that help inform Medicare’s valuation of physician services. CMS ultimately determines Medicare payment.
A database can measure how long an operation lasted. It can count supplies, personnel and postoperative visits. It can tell us how often a procedure is performed. But it can’t fully measure what happens inside an operating room.
Consider a complex spinal osteotomy, an operation in which the surgeon deliberately cuts through bone to realign the spine. Cutting bone can produce substantial bleeding that obscures the operative field. The surgeon must continue working around vulnerable neural structures while controlling blood loss, exercising technical judgment and recognizing that every additional minute under anesthesia can increase risk.
Two operations may take exactly the same number of minutes while imposing profoundly different demands on the physicians performing them.
The stopwatch sees equivalence. The surgeon doesn’t.
Physician work therefore encompasses more than time. It includes technical skill, physical effort, mental effort and judgment, and the psychological stress associated with risk to the patient. Replacing imperfect physician surveys with objective data sounds like progress, and often it will be. But we should be careful not to replace imperfect subjective expertise with precisely measured ignorance.
There is another problem with Washington’s emerging debate: It risks focusing on who divides the Medicare pie while ignoring what has happened to the pie itself. Physicians operate within a payment system constrained by budget neutrality. Recognizing increased resources for one group of services can mean reductions elsewhere. Meanwhile inflation, staffing, malpractice, technology and the costs of maintaining a medical practice continue moving in the opposite direction.
Washington is debating who should measure the slices while physicians watch the pie shrink.
The consequences extend beyond physician income. Independent practices disappear. Physicians become employees of increasingly consolidated health systems. Innovation becomes harder to introduce. Smaller practices have less capacity to absorb administrative costs. Eventually patients experience the consequences through diminished access, consolidation and fewer choices.
None of this means the AMA or RUC should be immune from scrutiny. If CPT has effectively become part of America’s healthcare infrastructure, questions about transparency, licensing and public access are legitimate. RUC recommendations should be tested against reliable empirical evidence. Procedure times should be reassessed. Claims, electronic health records and other sources can supplement physician surveys. Conflicts of interest should be disclosed and managed.
But Washington should resist a familiar temptation: assuming that because a private institution is imperfect, centralized administrative judgment must therefore be superior.
There is a better approach: Keep physicians at the center of defining physician work while surrounding their judgment with better evidence. Use auditable data to challenge assumptions, not to pretend that data eliminate the need for judgment. Make the valuation process more transparent. Separate legitimate questions about ownership of CPT from the separate question of how physician work should be valued.
And confront the larger problem that neither CPT nor the RUC created: a Medicare payment system that repeatedly asks physicians to become more efficient while the economic foundation of medical practice erodes beneath them.
If Washington genuinely wants reform, physicians should welcome the conversation. But the objective shouldn’t be to transfer power from the AMA to another bureaucracy. It should be to build a system that more accurately recognizes the resources, expertise and responsibility required to care for a patient.
A government database can tell you how long an operation lasted. It cannot tell you how hard it was to keep the patient alive.
Before America replaces physician judgment in the name of reform, it should make certain that what replaces it understands medicine better than the physicians who practice it.
Dr. Lorio is a past president of the International Society for the Advancement of Spine Surgery and chair emeritus of its Coding & Reimbursement Task Force.
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