Perspective Proposes RUC Revaluation Task Force to Address Primary Care Underpayment

A perspective published in the Journal of General Internal Medicine examines the systemic economic pressures facing primary care medicine in the United States and outlines a proposal to revalue primary care services through an emergency task force within the American Medical Association’s Relative Value Scale Update Committee. Authored by Allan H. Goroll, the analysis details how persistent underpayment has created an existential crisis for the primary care sector, leading new medical graduates to shun the specialty, prompting veteran practitioners to leave clinical practice, and forcing independent practices to sell their operations to large health networks due to severe resource constraints.

The paper highlights that despite the National Academy of Medicine designating primary care as a vital social good and the cornerstone of a functional health delivery system, access to essential services has become increasingly difficult for patients across the country. Consensus recommendations issued by the National Academy emphasize that structural payment reform is the foremost requirement to revitalize the sector, yet large-scale implementation remains remarkably slow. Meanwhile, procedural specialties continue to absorb an ever-increasing proportion of total healthcare expenditures, accounting for approximately forty percent of all outpatient spending compared to only about five percent directed toward primary care services.

This substantial disparity in financial reimbursement fosters severe income gaps between cognitive medical specialties and procedural fields, creating distortions in career decisions and undermining recruitment and retention efforts. The perspective notes that the financial strain on primary care practitioners is further intensified by uncompensated operational responsibilities, with recent observational studies identifying up to three hours per day of uncompensated administrative and care coordination work. Two primary barriers continue to impede payment increases: statutory requirements to cap total health expenditures, which currently exceed eighteen percent of the United States gross domestic product, and a reimbursement framework that provides generous compensation for specialty interventions while systematically undervaluing cognitive evaluations.

To provide historical context, the author outlines the implementation of the Resource-Based Relative Value Scale system by Medicare in 1992, which replaced earlier usual, customary, and reasonable reimbursement methods with an objective framework designed by Hsiao, Braun, and colleagues at the Harvard School of Public Health. The relative value framework assesses physician work by accounting for time, technical skill, mental effort, judgment, risk, and stress, while separately calculating practice expense—such as clinical staff salaries, office rent, supplies, and medical equipment—and professional liability costs. These individual metrics are translated into relative value units, with physician work units constituting a major determinant of final physician reimbursement across both public and private payers.

Although the American Medical Association initially opposed the statutory adoption of this relative scale, it subsequently established and maintained the RBRVS Update Committee to advise Medicare on valuation metrics. The committee assigns one representative seat to each member specialty recognized by the American Board of Medical Specialties, resulting in specialist representation outnumbering primary care seats by nearly ten to one. Because Medicare lacked the independent operational resources to conduct extensive surveys and convene expert valuation panels directly, it historically accepted the overwhelming majority of committee recommendations for the Physician Fee Schedule, challenging only about ten percent of determinations in more recent years.

The perspective argues that this advisory process suffers from critical structural and methodological flaws, including the reliance on four-decade-old clinical vignettes that fail to capture the complexity of modern primary care workflows. Additionally, inherent conflicts of interest arise because surveyed specialty physicians and panel members understand that their submissions directly dictate the collective income of their clinical peers, incentivizing representatives to maximize reimbursement rates for their respective constituent organizations. Furthermore, the committee rarely revalues procedural interventions downward once surgical and diagnostic techniques become standardized and routine, allowing procedural codes to retain high valuations that crowd out available funding for cognitive evaluations.

Existing reform efforts have struggled against statutory budget neutrality rules, which mandate that reimbursement increases within the physician fee schedule must be offset by equivalent reductions elsewhere, effectively creating a zero-sum environment. The specialty community has demonstrated substantial resistance to voluntary reductions, as evidenced by intense pushback against a previously proposed two-and-a-half percent efficiency adjustment in Medicare procedural reimbursements. While Medicare introduced the G2211 add-on code to compensate for complex longitudinal care management, the resulting payment covers only a fraction of the historical shortfall, and proposed adjustments for 2027 remain insufficient to address the wider structural gap.

Similarly, other targeted federal initiatives have encountered operational obstacles, such as the Advanced Primary Care Management Program, which requires substantial monthly patient copayments that have sharply suppressed enrollment, and demonstration projects from the Center for Medicare and Medicaid Innovation that suffered from heavy administrative reporting requirements and insufficient base funding. While broader consensus recommendations from primary care professional societies and the National Academy advocate transitioning to prospective, risk-adjusted hybrid capitation models—such as multiyear legislative initiatives advanced in Massachusetts—these policy transitions require extended implementation phases that do not resolve immediate workforce attrition.

In response to these delays, the perspective proposes establishing an emergency primary care relative value update task force through a formal petition to the update committee by primary care medical societies and multistakeholder groups such as the Primary Care Collaborative. Under this design, the task force would consist of twenty members with equal representation divided between primary care clinicians and specialty delegates chosen by their respective boards, preserving medical profession oversight while rebalancing voting authority. The group would be tasked with reviewing independent data sources, conducting prospective and transparent practice audits, and establishing revised relative value determinations for primary care evaluation and management codes within a twelve-month deadline.

The perspective concludes that a majority vote from this balanced task force should be binding on the broader committee for direct transmission to Medicare officials, creating a streamlined mechanism to recalibrate physician work metrics using modern electronic medical record data and independent empirical surveys. However, the author cautions that upward revaluations within a budget-neutral system will inevitably compel a broader revaluation of specialty procedures or necessitate state and federal legislative adjustments to raise total Medicare physician spending caps temporarily. If the medical profession cannot successfully adapt its valuation structures to correct these chronic imbalances, primary care workforce attrition will continue to threaten national healthcare delivery.

The analytical blueprint for reforming relative value determinations draws upon specific proposals advanced by independent health policy researchers. In their evaluation of physician payment methodologies, Skopec and Berenson set forth an agenda prioritizing independent surveys alongside prospective, transparent, and auditable data collected directly from electronic medical records. Similarly, McMahon and Song emphasize the necessity of securing objective empirical data on clinical work, systematically recalibrating work equivalencies across medical disciplines, and updating the conversion metric of dollars per revised relative value unit. Proponents argue that relying on independent data collection is essential because previous attempts by Medicare to mandate survey reassessments repeatedly foundered. Under earlier federal directives, surveys were frequently repeated but continued to rely on the same conflicted data sources and specialty-dominated panels, inevitably generating the same skewed valuation outcomes.

Addressing these structural deficiencies requires reconfiguring the governance rules that govern committee recommendations. Within the existing committee structure, procedural specialists command an overwhelming majority that far exceeds the two-thirds vote required to submit official recommendations to Medicare, allowing them to systematically protect constituent revenues. To counter this institutional bias, the proposed petitioning coalition is designed to extend beyond primary care physician organizations to incorporate professional societies representing advanced practice clinicians alongside multistakeholder alliances like the Primary Care Collaborative. Structuring the resulting task force with twenty seats evenly split between primary care and specialty delegates represents a deliberate concession to the American Medical Association, maintaining administrative oversight within the organized medical profession while neutralizing procedural dominance.

Under this structural framework, the task force would execute four distinct operational mandates to overhaul cognitive service evaluations. Specifically, the body would be formally empowered to review existing work estimates from independent entities, secure authority and dedicated funding to conduct supplementary independent surveys and practice audits, re-estimate relative valuations across disciplines, and establish binding relative value determinations for evaluation and management codes. Goroll notes that recalibrating these relative values could yield broader professional advantages by assisting other medical constituencies that feel similarly undercompensated under current fee schedules, including acute care surgery.

The push for structural reimbursement reform is also rooted in the operational imperatives of high-performance clinical care. Health policy consensus emphasizes prospective, comprehensive capitation because assembling and supporting the multidisciplinary care team necessary for modern chronic disease management requires guaranteed upfront funding, even while preserving modest fee-for-service reimbursements for discrete preventive tasks such as immunizations. Facing persistent stagnation in federal payment models and compounded by disrespectful attitudes toward primary care within elements of the specialty community, employed clinicians in large corporatized networks have increasingly sought alternative remedies. In particular, a pioneering effort to organize and unionize employed primary care physicians represents a novel strategy, although this initiative currently remains stalled before the National Labor Relations Board. In the interim, state legislative initiatives highlight that regional authorities are increasingly prepared to intervene directly, demonstrating a growing willingness to mandate primary care payment increases across commercial insurers.

Subject of Research: Proposal for RUC-based revaluation and payment reform for primary care physician services

Article Title: A RUC Rescue of Primary Care?

Article References: Goroll, A. H. (2026). A RUC Rescue of Primary Care?. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10998-z

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10998-z

Keywords: primary care, physician payment reform, Resource-Based Relative Value Scale, RBRVS Update Committee, Medicare Physician Fee Schedule, relative value units, work RVUs, health care finance, National Academy of Medicine, cognitive services, specialty care reimbursement, budget neutrality, fee-for-service, capitation, alternative payment models, primary care workforce