Why are Ob/Gyn RVUs so low?

Or, why am I only getting 0.89 RVUs for that whole pessary fitting?

OK, now we have learned how RVUs work. That was a boring, yet necessary, piece of math homework. Now we’ll get to the juicy stuff!

The RUC Has the Power

Why are the RVU values for Ob/Gyn work so crummy? Why is a penile biopsy reimbursed with 1.9 work RVUs while a vulvar biopsy is reimbursed at 1.10 work RVUs? Who assigns the RVUs to a given procedure, anyway?

The answer, my friends, is a somewhat obscure committee of the AMA called the Relative Value Scale Update Committee, or RUC.

This is the group of 32 people that literally determines how many RVUs every single medical procedure in These United States is worth! There are 22 members from various specialty societies, including ACOG, and 10 additional members.

You may see the composition of the committee on the AMA website. Today, 9/15/2024, there are 5 women and 27 men on this committee, with female representation at 16%. Women make up 38% of active physicians in the United States.

I had to do quite a bit of digging to find out which specialty all the folks on the RUC come from. It’s not on the AMA website. Some specialties are represented a few times, which is overall understandable, since some seats, such as “American Osteopathic Association representative,” could be held by a doctor of any specialty. Here are, as best I can determine with my friend Google, the specialty breakdown of the RUC members:

Anesthesia (1), Cardiology (1), Cardiothoracic surgery (1), Dermatology (1), Emergency med (1), ENT (2), Family med (2), General surgery (1), Geriatrics (2), Internal medicine (2 [1 primary care, 1 hospitalist]), Neurology (1), Neurosurgery (1), Ob/Gyn (1), Ophthalmology (1), Orthopedic surgery (1), Pathology (1), Pediatrics (1), PM&R (1), Physical therapy (!) (1), Plastic surgery (1), Psychiatry (1), Pulmonology (3), Radiology (2), Urology (1), Vascular surgery (1)

I find it interesting that two subspecialties of general surgery, cardiothoracic surgery and vascular surgery, have their own dedicated seat on the RUC, while no Ob/Gyn subspecialties do. Granted, CT and vascular surgeons have their own specialty societies and accredited fellowships. On the other hand, so do gyn oncology and MFM (for example). In fact, it can be argued that the difference between what an MFM and a Gyn Oncologist do is more vast than the difference between what a thoracic surgeon and a vascular surgeon do.  

For context, there were 42,496 Ob/Gyns practicing nationally in the last AAMC Physician Specialty Data Report and 24,881 general surgeons (33,369 if you count the thoracic and vascular surgeons, who are reported out separately). 

Let’s get back to how RVUs are assigned.

First, let’s say there is a new procedure code that has to be created for a brand-new procedure that has never been coded for before. There have been a few of these in recent years that affect Ob/Gyns – for example, telehealth E&M visits (have not seen these finalized) and laparoscopic ablation of fibroids with devices such as the Acessa (CPT code 58674, 14.08 work RVUs).

Then, ACOG sends a survey out to its members to see who has performed this procedure. The appropriate members fill out quite an extensive survey on how much time they spend pre-op, intra-op, and post-op related to this procedure and also about the skill level, mental energy and practice expenses surrounding the procedure.

Then, the AMA has a formula of sorts that takes all of the information from the survey and assigns RVUs to the new procedure. The RUC has the final decision on the RVU values.

ACOG can also ask the RUC to consider having an existing code re-valued if they think it is not being fairly reimbursed. The same process is followed.

Finally, ACOG can petition to have CPT codes redefined completely. A different but related AMA committee, called the CPT Editorial Panel, is in charge of this.

So, why is Ob/Gyn reimbursement so crummy?

Well, I have heard a lot of theories about this over the years. I can share some of them here. I have never been on the RUC nor privy to the inner workings of ACOG, but I do think it is important to share these, so we can learn from our history!

No need to be a RUC survey hero

First of all, I have heard that when the RUC surveys go out, very few Ob/Gyns respond to them, and those that do take it as an opportunity to brag about how fast they can operate. I have heard Ob/Gyn leaders say that, although Ob/Gyns complain about low reimbursement, the responses to the RUC surveys do not help them in their quest to be better reimbursed, and they are puzzled about the responses because they do not seem realistic.

Now, let me be the first to say that it is very important to be honest in responding to these surveys. All we have in this life is our integrity, and I stand by that. However – when you are thinking about, say, how long it takes you to do a TLH – the point of filling out the RUC survey is not to think about your most chip shot hysterectomy on the best OR day of your life when you had the OR nursing A-Team and everything just came together. Unless that is literally your life every single day, in which case, you are probably just living your best life and not reading my blog.

When filling out RUC surveys, it is important to think about your average hysterectomy. I know for me, my average hysterectomy is not my most perfect OR day on a chip shot patient when there are no logistical hiccups. And operating does not always go as quickly as I like, or as quickly as I am capable of under ideal circumstances.

It’s also important to accurately report the amount of prep, mandatory dinking around, and personal and office staff time spent both pre and post-op when considering RUC surveys.

Finally, I recommend becoming a member of ACOG so that you can contribute to RUC surveys! When people say, “ACOG does nothing for us,” this is literally exactly what ACOG does for us. Although we would all like more success in this endeavor, they are quite honestly trying to move the needle in increasing our reimbursement. And I can tell you, nobody else is.

The OB Global Billing Problem

Another perennial problem for Ob/Gyn reimbursement is the Global OB package. Oh my god, what a disaster. Literally, we are paid the exact same amount per pregnancy for taking care of a 42 year old type 2 diabetic with a BMI of 55 and chronic hypertension as we are for a healthy 23 year old multip. It is absolutely insane and endlessly frustrating for Ob/Gyns, especially those of us in underserved areas where Family Medicine and nurse midwives take care of the healthy, low-risk patients, leaving us with practices full of highly complex, risky, and difficult patients who take many times as much of our time and office staff and reimburse the exact same amount. Moreover, sometimes the payors don’t even reimburse complex Triage visits because they are just bundled into the Global. OK, let me drive to the hospital at 3 AM to evaluate this preterm vaginal bleeding, order a bunch of tests, spend hours by the patient’s side, but don’t worry, it’s included in the Global, no big deal!

The Global OB package dates back many years, at least to the late 1980s, according to a mentor of mine. The idea behind the global OB fee was actually to simplify the lives of Ob/Gyns decreasing the time taken up with charting and billing, and indeed, it is nice to not have to write a full E&M note on every routine OB patient for every visit. (Although, given the complexity of practices nowadays, many Ob/Gyns write a full E&M note on every patient anyway…)

It made sense at the time. When most of the OB patients were young and healthy, when most deliveries were routine and low risk, when an office OB visit was just the “tummy check” and the labor nurses would take care of triage and labor and just call the doctor in for delivery. “Some are easy. Some are hard. You get the global,” they say at the coding conferences, and when more were easy than hard, it was a fair deal.

However, in the last decades , the consequences to OB practice of the global fee have been devastating, especially with the OB shortage and older, sicker and more complex patients all the time.

ACOG has actually initiated a joint effort with the AMA (ed note - page no longer exists publicly, and link is broken) to rethink the global OB package.   It is in its early stages, and we’ll see how it goes.

The consequences of inadequate RVUs

I don’t have any easy answers. But I hope this article helps Ob/Gyns to understand how we got here, to the point where longstanding private practices are closing their doors because they can’t cover their overhead , MIGS surgeons go cash-only because they lose so much money billing insurance for endometriosis resections, and your average Ob/Gyn has to work so hard to keep herself afloat that she burns out and drops OB by age 50. While certain specialties that shall remain nameless rake in the cash, throw lavish Christmas parties, pay mid-levels to do all their rounding, orders, and post-op visits, and have every fancy new gadget their hearts desire.

Karla Solheim, MD, FACOG