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PubMed1988

Results, potential effects, and implementation issues of the Resource-Based Relative Value Scale.

This article presents the overall results of the Resource-Based Relative Value Scale (RBRVS) study. We present resource-based relative values for selected services in each of the 18 specialties we studied. We found that preservice and postservice work represents close to 50% of total work for invasive services and 33% of total work for evaluation/management services. We also found that the work per unit time (a measure of intensity) for invasive services is about three times that of evaluation/management. We developed a simple model and simulated an RBRVS-based fee schedule for the Medicare program under a "budget-neutral" assumption. Results for 30 commonly performed services show that office visit fees for evaluation/management services could rise by 70%, while some surgical fees could drop by 60%. We also simulated what the Medicare outlays would have been in 1986 for categories of medical services under an RBRVS-based fee schedule. We found that total Medicare payments for evaluation/management services would have increased by about 56%. Invasive, imaging, and laboratory services would have decreased by 42%, 30%, and 5%, respectively. We also discuss implementation issues related to an RBRVS-based fee schedule, such as the determination of a monetary conversion factor, practice costs, billing codes, and the need to evaluate the potential impacts of an RBRVS-based payment system on the cost and quality of health care.

Costs and Cost Analysis↗
PubMed1994

Maxillofacial prosthetics: a preliminary analysis of Resource Based Relative Value Scale.

A study done by the American Academy of Maxillofacial Prosthetics to evaluate the Medicare Resource Based Relative Value Scale (RBRVS) as it relates to maxillofacial prosthetics. The method of RBRVS formulation is described. The degree of difficulty and treatment time were determined for nine Physicians' Current Procedural Terminology-edition 4 (CPT-4) codified maxillofacial procedures. A preliminary survey indicates that practice expense and malpractice expense ratios were 66% and 1%, respectively. Correlation of maxillofacial procedures to other medical procedures was not performed because an additional study with a greater sample size is needed.

Ear↗
PubMed1995

Cross-specialty linkage and extrapolation of resource-based relative value scales.

This article describes methods used to produce a RBRVS (resource-based relative value scales), a common scale from two specialties (internal medicine and general surgery) and explains the newly developed extrapolation process within each specialty. To produce a common scale, we selected six 'same' services as linking services common to both specialties. Then we used the bi-weighted least squares method to locate all the same services on a single, common scale. By using the same method, we tried to extrapolate all the services within each specialty, not by the method of Kelly et al, dividing all the services within the specialty into families (small homogeneous groups of services) to apply charge-based ratios. To compare both methods, we extrapolated all the services of general surgery according to each method. With the correlation analysis to compare both results to American RVUs, we found that general surgery's RVUs from our own extrapolation method turned out to be more highly correlated with American RVUs than from Kelly's extrapolation method. Consequently, extrapolation with bi-weighted least squares method gave reasonable results.

General Surgery↗
PubMed1992

Measuring the determinants of work values for psychiatrists' services in the resource-based relative value scale study.

OBJECTIVE: As part of the Harvard resource-based relative value scale study, the authors investigated how well the codes in the Physician's Current Procedural Terminology, 4th edition, or CPT-4, match psychiatric services to the work involved in evaluating and managing patients and how patient care characteristics affect different levels of psychiatric work. METHOD: A random sample of over 200 psychiatrists and subspecialists was asked to use 68 typical clinical examples or vignettes to evaluate services described by CPT codes. Data were analyzed by multivariate statistical methods. RESULTS: The survey showed that the existing coding system does not adequately describe the work that psychiatrists do. Within a single code (e.g., 90844, individual medical psychotherapy), there was wide (more than twofold) variation in the estimates, from multiple measurements based on different vignettes, of the amount of work represented. Estimates of work values varied significantly according to treatment setting and patient characteristics: psychiatric services in the hospital showed an average work value 25% greater than that for office services; treating new patients involved 18% more effort than treating established patients; and treating patients described as at risk of harming self or others increased the psychiatrists' work effort by 36%. CONCLUSIONS: Revisions in coding evaluation and management services in the new Medicare fee schedule for psychiatric services should be further refined and then implemented. These revisions would bring the coding system into line with psychiatric practice, making it a better way of accounting for the relative work involved in treating patients of varying difficulty.

Fee Schedules↗
PubMed1988

Psychiatry and the resource-based relative value scale.

Attention to reform of reimbursement for psychiatric inpatient services largely focuses on the use of prospective payment systems, e.g., payment based on diagnosis-related groups (DGRs), for hospitals. Recently, there also has been interest in proposals for altering physician reimbursement (inpatient and outpatient) by using physician DRGs, capitation models, or relative value scales instead of the charge-based, fee-for-service model. The authors review the resource-based relative value scale (RBRVS) as an option for psychiatry. The RBRVS uses the setting, the time spent, the difficulty in treating the patient, the training, and the psychiatrist's role to determine reimbursement rates.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1989

The use and misuse of relative value scales under Medicare.

Phoenix-like, the concept of using a relative value scale as a primary mechanism for Medicare reimbursement has risen from the ashes of past rejection. Medicare has already initiated a modified RVS program for anesthesia services; RVS programs for radiology and pathology services may be established within the year. In this article, the author predicts that a modified "resource based" RVS will be adopted for all Medicare physician services over the next several years.

Anesthesiology↗
PubMed1990

Comparison of measured and perceived time values for radiologists' work: impact on relative value scales.

The authors compared the actual time required by radiologists to perform and/or interpret common diagnostic radiologic examinations with the times the same radiologists perceived were necessary (as determined with a survey) to perform and/or interpret those same examinations. Average measured times ranged from 1.7 minutes for radiologic examinations of extremities to 113.2 minutes for interventional procedures. Average survey times ranged from 3.2 minutes for examinations of extremities to 84.4 minutes for cerebral angiography. The mean difference between measured and survey times for all examinations was 48.6%. Relative value scales were developed based on measured and survey times, with the upper gastrointestinal examination assigned the base unit of 100. The difference between the measured-time and survey-time relative value scales was 98% on average for the 16 examinations compared. The study suggests that there is a need for actual measurement of at least the time component of physician work if resource-based relative value scales are to be used as the basis for physician compensation.

Academic Medical Centers↗
PubMedDate not supplied

Using cost accounting in a medical group practice. An application using the resource-based relative value scale.

With the presence of managed care increasing in our health care environment, today's practice administrator needs a method to determine whether the negotiated fee schedule, capitation rate, etc., is adequate. The only true method to make this determination is to undertake a cost study of physician activity. However, this approach could be tedious, cumbersome and beyond the resources of the practice. The author demonstrates a method to approximate the cost of a physician's activity by identifying the cost of a relative value. The relative value scale used is the resource-based relative value scale (RBRVS). The article also proposes other applications: comparative analysis, allocation of capitation payments and fee schedule development.

Accounting↗
PubMed1993

Medicare's resource-based relative value scale fee schedule portends a gloomy future for trauma surgery.

Medicare's resource-based relative value scale (RBRVS) fee schedule dramatically restructures physician reimbursement; providers of cognitive-based services are projected to gain at the expense of those with procedure-based services. In this study, we computed the impact of the new payment system for Medicare comparing trauma surgery to four other surgical specialties. Plastic surgery will see a 4% increase in revenue, but the other specialties will experience a cut (trauma, minus 14%; general, minus 4%; vascular, minus 5%; cardiothoracic, minus 10%). As expected, with the exception of plastic surgery, there was a decrease in procedure reimbursement (trauma, minus 13%; general, minus 12%; vascular, minus 8%; cardiothoracic, minus 10%). However, when analyzing cognitive services, trauma is the only group that will sustain a reduction. This is largely explained by the fact that trauma cognitive services are inpatient based, whereas the RBRVS fee schedule is biased toward outpatient cognitive services. In conclusion, the RBRVS fee schedule will challenge the economic stability of trauma surgeons. Because Medicare reform will set future standards for other forms of physician reimbursement, trauma system planners need to take a proactive role in this evolving process.

Cardiac Surgical Procedures↗
PubMed1990

Physician reimbursement and the resource-based relative-value scale.

This article assesses the situation that led to the development of the Resource-Based Relative-Value Scale (RBRVS), describes the scale and how it might be applied, and compares it to other reimbursement schemes. Potential weaknesses of the RBRVS are also discussed.

Data Collection↗
PubMed1997

Vascular surgery and the Resource-based Relative Value Scale five-year review.

PURPOSE: The first 5-year review of the Medicare Resource-based Relative Value Scale (RBRVS) work values (RVUs) began in 1995, and adjustments became effective January 1, 1997. This report summarizes the methods used by The Society for Vascular Surgery (SVS) and the International Society for Cardiovascular Surgery, North American Chapter, (ISCVS-NA) Joint Council Government Relations Committee (GRC) to evaluate vascular surgery work RVUs and the results that were achieved. METHODS: The GRC performed a work study to determine accurate skin-to-skin operative times for typical vascular and nonvascular operations. These were compared with the original Harvard/Hsiao time estimates and intraservice work per unit time (IWPUT) values that had been used to determine work RVUs. For most vascular procedures the current operative times were longer than the original Harvard estimates, resulting in calculated IWPUTs substantially less than the Harvard values. This lack of correspondence was not identified in the nonvascular procedures, where operating room times and IWPUT values were more consistent with Harvard data. These study results were then used to support compelling evidence arguments in a petition to the Health Care Financing Administration (HCFA) that identified vascular surgery as being undervalued in the RBRVS. Nine commonly performed vascular procedures were cited for review in the 5-year update, and five distinct work analysis methods were used to justify each recommended RVU increase. These techniques included a standardized survey from the American Medical Association (AMA)/Specialty Society Relative Value Update Committee (RUC), a work calculation using accurate intraservice times and appropriate IWPUT values, and an evaluation and management (E&M) building-block approach. RESULTS: The RUC met throughout 1995 to assess codes submitted for review, and recommendations were forwarded to HCFA. The Notice of Proposed Rule Making (NPRM), which contained HCFA's preliminary RVU determinations, was released in May 1996. RVU increases from 11.5% to 44.6% were proposed for the nine vascular services cited by the SVS/ISCVS-NA. Also included were two increases and two reductions in less-common vascular operations. Of far greater overall fiscal import, HCFA proposed substantial increases in the work RVU for all E&M except that performed within global surgical packages. The SVS/ISCVS and most other surgical societies appealed HCFA's proposal regarding E&M. The Final Rule for the 1997 Medicare Fee Schedule was published late in 1996. CONCLUSIONS: The Final Rule upheld the 11 vascular work value improvements and the E&M increases that excluded global service packages. Because most surgical E&M is performed within 10- or 90-day global periods, the E&M ruling will produce an estimated annual $2.5 billion shift from surgical to nonsurgical specialties. Because the overall fiscal impact of the 5-year review was mandated to be budget-neutral, HCFA imposed an 8.3% reduction in the work payment of every service in Part B of the Medicare program, primarily to compensate for the increased nonsurgical E&M payments. The net fiscal impact of the 5-year review for vascular surgery has been estimated at +0.5%.

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

Impact of a Resource-Based Relative Value Scale fee schedule on reimbursements to neonatologists.

We investigated the possible effect of the Resource-Based Relative Value Scale (RBRVS) fee schedule on reimbursements for neonatologists. This payment system may prove attractive to most third-party payers and is predicted to result in lower procedural reimbursement, which is a significant component of neonatal care. We studied the charges and reimbursements for the portion of our intensive care nursery patient population covered by Medicaid for a 1-year period. Total, procedural, and nonprocedural reimbursements under three current systems and the RBRVS were compared. The RBRVS system produced overall improved reimbursement compared with Medicaid, but decreased reimbursement compared with the other two systems. Nonprocedural services were relatively better reimbursed than procedural services. The impact of RBRVS will depend on the population mix of third-party payers, the proportion of nonprocedural charges in a particular neonatal intensive care unit, and the conversion factor used by the third-party payer.

Fees, Medical↗
PubMed1993

The resource-based relative value scale: methods, results and impacts on urology.

Increased concern for rising health care costs in the United States has led to the passage of legislation to reform physician payment for Medicare services based on resource inputs. In January 1992 the Health Care Financing Administration began implementing the new law, which replaces the existing Medicare system of physician payment with a fee schedule based on the resource-based relative value scale (RBRVS). We summarize the methods and data used to derive the RBRVS for urology. A national random sample of 115 practicing urologists completed structured telephone surveys to provide ratings of physician time and work required before, during and after most frequently performed urological services. Subsequent survey cycles with urologists provided further refinement. Urologists then participated in a cross-specialty physician panel to link services from all specialties onto a common scale. This common scale was adjusted for geographic differences in practice overhead costs and malpractice insurance premiums. A monetary conversion factor, determined by the Health Care Financing Administration, was then applied to convert the RBRVS into a Medicare fee schedule. The merits and demerits of the scientific process used to develop and maintain the relative value scale are extensive. While statistically valid and reproducible, the study results have been altered in the political arena. The results and impacts of the new Medicare payment system on urology will be significant, although it is not yet clear how urological practice will be affected. Although faring better than most surgical specialties, urologists stand to lose approximately 8% of their Medicare income when the new fee schedule is fully implemented. There will be relative gains for evaluation and management services and losses for most invasive procedures.

Fee Schedules↗
PubMed1996

The measurement of physician work and alternative uses of the resource based relative value scale.

On January 1, 1992, the Medicare program implemented a new payment system for physician services based on the Resource Based Relative Value Scale (RBRVS). The RBRVS has been widely accepted as a rational and systematic approach to measuring the resource costs associated with physician services. In addition to deriving physician payment rates, the RBRVS provides a useful metric that allows the measurement and comparison of provider utilization rates and productivity across physicians performing a varied mix of services. In this study we describe the measurement of physician work, discuss alternative ways in which work values can be used to monitor physician service utilization (e.g., profiling physician practice patterns), measure physician productivity, and determine physician compensation.

Efficiency↗