Who Actually Controls How Women’s Health Gets Paid For

The players shaping reimbursement — and why every woman in this industry needs to understand the game.

The first time I heard the word “RUC” in a meeting, I had to Google it under the table.

It turned out to be one of the most important rooms in American medicine — a 32-person volunteer committee that meets three times a year and shapes what gets paid for in this country more than almost any other body in existence. Most people in women’s health, including me at the time, had never heard of it.

If you work in women’s health — as a clinician, a founder, a product leader, or an advocate — understanding how reimbursement actually gets decided might be the highest-leverage education you can get right now. So here’s the map.

The CPT Editorial Panel: Where Services Get Named

Before anything can be reimbursed, it has to be coded. The AMA’s Current Procedural Terminology Editorial Panel — 21 members, 19 of them physicians — decides what counts as a billable service in the first place. New services like novel diagnostics, digital therapeutics, or new care delivery models all have to go through this panel to get a code at all. That process takes time, requires organized advocacy, and is often where innovation goes to wait.

Ob-gyn’s seat at this table is currently held by Kathy Y. Jones, MD, FACOG — a private practice owner since 2002 who previously chaired ACOG’s Committee on Health Economics and Coding (CHEC). One person. One seat. Showing up for a 21-member panel that decides what every clinician in this industry is allowed to bill for.

The RUC: The Room That Actually Prices Your Work

Once a service has a CPT code, it has to be valued. That’s the RUC’s job — advising CMS on the Relative Value Units assigned to physician services. Historically, CMS has accepted RUC recommendations more than 90% of the time. That is an extraordinary level of influence for a volunteer committee most people outside of medicine have never heard of.

RVUs are the unit of currency in physician compensation. A service valued at 1.5 RVUs pays roughly half what a service valued at 3.0 RVUs pays. When women’s health services are undervalued — and they historically have been — that undervaluation flows downstream into every practice contract, every health system compensation model, and every business plan that depends on clinical revenue.

The downstream math is brutal. The cost of running a medical practice has risen 59% since 2001. Medicare physician pay, adjusted for inflation, has fallen 33% over the same period. That gap is why ob-gyn practices are closing. And because commercial payers benchmark to Medicare, that gap shows up everywhere.

The Global Code Elimination: What CHEC Actually Did

The most concrete example of what advocacy in these rooms looks like just happened.

For decades, ob-gyns were paid under global obstetric codes — a single bundled payment covering all prenatal visits, delivery, and postpartum care. The bundled rate didn’t account for patient complexity, made it nearly impossible to bill separately for mental health screening or social determinants of health work, and created chronically unsustainable economics for many practices.

CHEC worked with the AMA’s CPT Editorial Panel to redesign the entire structure. Effective January 1, 2027, the global obstetrics codes end — replaced with a visit-by-visit system using E/M codes and new labor and delivery codes that finally let clinicians bill for every touchpoint of care they actually provide. That change took years of sustained, technical, inside-the-room advocacy. It required people who understood both the clinical reality and the coding mechanics. That is the model for how change happens in reimbursement.

CMS and Commercial Payers: Where Policy Becomes Dollars

CMS takes the RUC’s recommendations and turns them into actual payment rates via the annual Physician Fee Schedule. It also governs prior authorization, telehealth coverage, Medicaid rules, and value-based care — all of which directly affect what women’s health services are financially viable to provide. Every year there is a comment period. The clinicians and organizations that show up consistently have a meaningful voice in the outcome. The ones who don’t, don’t.

Then there are the commercial payers, who build their own structures on top of Medicare — with enormous variation. A CPT code Medicare reimburses today may take two to three years to be adopted by a commercial plan. Coverage policies differ by payer, by product line, by state. And unlike Medicare, where the RUC process is at least nominally transparent, commercial payer coverage decisions often happen with no public process at all. For founders, that means a product Medicare will cover in 2027 may not be covered by your customers’ commercial plans until 2029, or later.

The room where women’s health gets priced has ob-gyn’s name on the door — but only because organized advocates fought to put it there and keep showing up. The RUC, the CPT Editorial Panel, CMS, and commercial payer medical policy teams are not impenetrable bureaucracies. They are processes with known rules and known entry points.

The global obstetric code elimination didn’t happen by accident. It happened because one person, in one seat, kept showing up. That is the model. And it is learnable.

See you in the work,

This is the 201, 301, and 401.

We’ve covered Reimbursement 101 across a few IWH webinars this year — the basics of how women’s health gets paid for and why it’s broken. The IWH Reimbursement Summit is where we go deeper. Three 90-minute virtual sessions, built as a sequence: Know the rules. Change the game.

$299 Early Bird · Regular price $399 after May 1 · All three sessions included · Klarna & Afterpay payment plans · Recordings provided · Secure checkout

Three handpicked from this week’s board.

Where reimbursement, advocacy, and growth meet hiring.

Three pieces worth your reimbursement homework.

Women’s Health Week Summit (WHW USA) — May 13–14 · New York

The W. Women’s Health Week Summit lands in New York on May 13–14 at the New York Academy of Medicine — bringing together founders, investors, payers, and policy leaders from across the global women’s health ecosystem. If you’re building or investing in this space, this is one of the most concentrated rooms you’ll find all year. 700+ attendees last year, and this year is shaping up to be bigger.

Where to find the IWH community next.

100+ open roles in women’s health this week.

Across 30+ companies. Updated every Sunday. Curated, not scraped.

Nobody warns you that the most important rooms in healthcare are run by 32 volunteers and an Excel spreadsheet. Now you know. Bring snacks to the Summit →