Strategies for responding to the Medicare Resource-Based Relative Value Scale (RBRVS). Task force on Resource-Based Relative Value Scale.
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Audiology↗
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AMA policy on the Resource-Based Relative Value Scale and related issues. A summary of AMA Board of Trustees Report AA.
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American Medical Association↗
AMA policy on the Harvard resource-based relative value scale and related issues.
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American Medical Association↗
Issues in the application of the resource-based relative value scale system to pediatrics: a subject review. American Academy of Pediatrics. Resource-Based Relative Value Scale Project Advisory Committee.
In today's rapidly changing health care environment, it is crucial to understand the genesis and concepts of the Medicare Resource-based Relative Value Scale (RBRVS) physician fee schedule. Many third-party payers, including state Medicaid programs, Blue Cross-Blue Shield agencies, and managed care organizations are using variations of the Medicare RBRVS to determine physician reimbursement and capitation rates. Because the RBRVS fee schedule was originally created for Medicare only, pediatric-specific Current Procedural Terminology codes and pediatric practice expense issues were not included. The American Academy of Pediatrics agrees with the use of the Current Procedural Terminology codes and the RBRVS physician fee schedule and continues to work to rectify the inequities of the RBRVS system as they pertain to pediatrics.
Child↗
Underreimbursement of obstetric and gynecologic invasive services by the resource-based relative value scale.
OBJECTIVE: To compare the relative value of work and reimbursement by the resource-based relative value scale (RBRVS) and the charge-based McGraw-Hill relative value scale for invasive services performed for women only (obstetric-gynecologic), for men only (urology), and in a gender-neutral specialty (general surgery). METHODS: Two hundred nineteen obstetric-gynecologic, 125 urology, and 105 general surgery invasive procedures were compared by the mean for each specialty of 1) the ratio of the procedure-specific work component of the RBRVS unit to the total relative value unit, and 2) the ratio of the procedure-specific total RBRVS unit to the McGraw-Hill relative value unit. All procedures were weighted equally. Ratios are reported as percentages. Statistics were compared by analysis of variance with Newman-Keuls test for multiple pairwise comparisons when significant differences were identified. Statistically significant differences were defined as P < .05. RESULTS: The mean percentage of the procedure-specific work component of the RBRVS unit to the total relative value unit and the total RBRVS unit to the McGraw-Hill unit were significantly lower (P < .01 for all comparisons) for obstetric-gynecologic (49.7 and 139.5) than for urology (55.1 and 207.1) or general surgery services (53.2 and 181.0). There were no significant differences between urology and general surgery services among the procedures studied. CONCLUSION: The data support a lower relative value of work and reimbursement for services performed for women only. This may be the result of 1) high initial estimates of work for urology and general surgery services, 2) low initial estimates of work for obstetric-gynecologic services, or 3) a carry-over of reimbursement bias from the charge-based environment to the RBRVS by the methods used in its development.
Female↗
Physician and practice characteristics, frequency of performance, and the Resource-Based Relative Value Scale.
The Resource-Based Relative Value Scale is based in part on the ratings of the work of services obtained from a random sample of physicians in a specialty. Ratings are used without regard to board-certification or other characteristics of the physician, or to the physician's experience with the service. Critics have suggested that all physicians may not be equally qualified to rate the work of services. Using data obtained from the Resource-Based Relative Value Scale surveys and analyzed using multiple regression methods, the authors found that physician and practice characteristics explain, at most, a small fraction of the variation in ratings of work. Any increase in the precision of the work scale obtained by adjusting physicians' work ratings according to physicians' characteristics could be achieved at lower cost by a slight increase in sample size. Associations between frequency of performing a service and ratings of work are about as likely to be in one direction as another. Most of the differences between estimates of work, excluding and including physicians who have not performed a service, are less than 2% in absolute value, and all are less than 10%. Estimates of work using ratings of physicians in the upper half in frequency of performance are usually within 10% of estimates using other ratings. Even if the observed associations are not due to chance, the potential improvement in accuracy of estimates of work appears too small to justify using data on frequency of performance.
Bias↗
Resource-Based Relative Value Scales: impacts and recommendations relative to chiropractic practice.
PURPOSE: The American health care financing and delivery system is changing at a rapid pace. As part of recent reform of payment systems for physician services, Medicare has adopted a resource-based relative value scale (RBRVS) that is becoming a national standard. Research has now documented characteristics of physicians' work and the overhead for providing specific health services for most medical specialties and disciplines. This information is being used to develop service descriptions (billing codes) and reimbursement levels. No such data exist relative to chiropractic, which may hinder chiropractic's efforts to be included in evolving reimbursement schemes. RBRVS and its relevance to chiropractic is reviewed, information on work levels and practice costs is discussed, chiropractic practice is reviewed and a research and policy agenda for documenting chiropractic work, overhead and service descriptions is provided. METHODOLOGY: A manual systemic review of available recent and relevant medical and chiropractic literature was undertaken to characterize how the RBRVS system for reimbursement of physician services was developed and implemented. Payer and trade association literature was used to determine what established work value and practice costs for DCs there are. Published payment scales from governmental commissions were also obtained. CONCLUSIONS: Resources are urgently needed to survey levels of work by chiropractors in providing their various health services. The methodology should be the one used by the Health Care Financing Administration to assess other specialties. A range of generic manipulation codes should be developed and tested in a similar fashion for submission for inclusion in Physician's Current Procedural Terminology (CPT). A seed range of descriptions is presented. A systematic collection of practice overhead costs and malpractice risk should be undertaken and documented using standardized methodology.
Centers for Medicare and Medicaid Services, U.S.↗
A critique of the practice-expense values of the resource-based relative value scale.
The resource-based relative value scale (RBRVS) was implemented by the Health Care Financing Administration on January 1, 1992. The practice-expense payments from the old Medicare fee scale were moved unchanged into RBRVS. This resulted in underpayment of office-based practice expenses and overpayment of hospital-based practice expenses. For example, office visits are underpaid by $10.28, whereas coronary angiograms are overpaid by $123.00. Unpaid practice expenses reduce the after-expense physician-work fee of the average office visit by about one half, yet overpayment of practice expenses for some hospital procedures almost doubles the after-expense physician-work fee for some subspecialties. Inflation will likely increase the actual practice expense of the average office visit to the point that the after-expense physician-work fee for the family physician will be reduced to zero by the year 2001.
Centers for Medicare and Medicaid Services, U.S.↗
Use of the resource-based relative value scale for private insurers.
Medicare's resource-based relative value scale (RBRVS) was implemented 1 January 1992 for physician payment using a conversion factor of $31 for each relative value unit (RVU). We calculated a conversion factor of $42.24 for The Travelers Insurance Company's group health plan business using the RBRVS methodology and the calendar year 1990 Travelers Large Case Norms Extract of active employees. This DataWatch describes two important applications of the relative value scale for private insurers: for pricing and for analyzing claims expenditures.
Cost Control↗
Nurse clinician productivity using a relative value scale.
The use of relative value units to measure the productivity of nurse clinicians in four primary care practices is described. Relative value points and equivalent dollar values assigned to services provided by professionals yielded a different assessment of productivity than that provided by a count of patient visits. The physician-nurse clinician teams studied were only 6 percent more productive than the physician-nurse teams when productivity was measured by the number of patient visits processed during an 8-hour period but were 26 percent more productive in terms of the value of services they produced per day.
Efficiency↗
Estimating physicians' work for a resource-based relative-value scale.
We have developed a resource-based relative-value scale as an alternative to the system of payment based on charges for physicians' services. Resource inputs by physicians include (1) total work input performed by the physician for each service; (2) practice costs, including malpractice premiums; and (3) the cost of specialty training. These factors were combined to produce a relative-value scale denominated in nonmonetary units. We describe here the process by which the physician's work was defined and estimated. The study asked two questions: What is the physician's work for each service performed? and Can work be estimated reliably and validly? We concluded that a physician's work has four major dimensions: time, mental effort and judgment, technical skill and physical effort, and psychological stress. We found that physicians can rate the relative amount of work of the services within their specialty directly, taking into account all the dimensions of work. Moreover, these ratings are highly reproducible, consistent, and therefore probably valid.
Economics, Medical↗
An examination of the Resource-Based Relative Value Scale cross-specialty linkage method.
The Resource-Based Relative Value Scale (RBRVS) was developed by surveying panels of physicians from single specialties, then merging the specialty-specific results into a common work scale. The merging process involved two steps: 1) specification of links or equivalent services across specialties: and 2) use of links to align work values from each specialty onto a common scale. This study examines the sensitivity of physician relative values of work (RVWs) to changes in both the specification of links and in the method for aligning specialties. Using the same survey data employed in developing the RBRVS, we calculated new RVWs based on an alternative specification of links and an alternative method for aligning specialties. Total RVWs declined by almost 50% for anesthesiology, and increased by more than 20% for allergists, neurologists, and thoracic surgeons. Most of this change was attributable to our specification of links. We conclude that future use of the linkage procedure employed in developing the RBRVS is not warranted without further research. Instead, efforts to update and revise work values could be based on a common scale of work developed by cross-specialty panels, thus eliminating the need for a linkage procedure.
Economics, Medical↗
Refinement and expansion of the Harvard Resource-Based Relative Value Scale: the second phase.
The Harvard resource-based relative value scale (RBRVS) for physician services has assumed a critical role in physician payment reform. We have demonstrated that the relative resource costs of providing physician services can be defined and measured in a rational and systematic way and that the results are reliable and valid. Consequently, the RBRVS is a viable basis for national payment policy and could be used for establishing a national fee schedule for physician services or to identify "mispriced" physician procedures. Since the release of the final report of the first phase of the Harvard RBRVS study in September of 1988, there has been extensive review, discussion, and criticism of the RBRVS. Dr. Laurence F. McMahon, Jr., in the accompanying article, provides a further critique of our research. In this paper, we review the RBRVS study and results and respond to the major criticisms that have been raised by Dr. McMahon and others. We then describe the tasks we are currently undertaking to expand and validate our research and address the important criticisms and limitations.
Data Interpretation, Statistical↗
An examination of cross-specialty linkage applied to the resource-based relative value scale.
OBJECTIVES: Analyses were performed to reproduce and examine the sensitivity of the cross-specialty linkage algorithm used by Hsiao et al(1) to obtain the currently implemented resource-based relative value scale for Medicare physician reimbursement. METHODS: The cross-specialty linkage procedure designed and implemented in Hsiao et al is an important component of the resource-based relative value scale underlying current Medicare Fee Schedule. This linkage procedure aligns independent intraspecialty relative value scales onto a common scale, and therefore determines the level of reimbursement accruing to each specialty. The complexity of the algorithm to perform this alignment has prevented critical review of the methodology. The authors examine the statistical properties of the algorithm, and diagnose its sensitivity from changes in the data and small modifications to the numerical procedure. RESULTS: Our examination of the linkage algorithm uncovered some issues requiring further consideration. These include the questions raised about the use of "biweighting," and about the benefits of incorporating correlation information into the analysis. Moreover, simulation analyses demonstrate that the existing relative value scale is sensitive to changes in the input data and methodology. Certain specialties' reimbursement can shift by as much as 32% using Hsiao's algorithm. Most importantly, the interspecialty linkage algorithm underlying the current fee schedule downweights pairs of linked services even when such links are deemed more important from a clinical point of view. As a result, in some cases clinically superior links received little or no importance in the algorithm. CONCLUSIONS: The cross-specialty linkage procedure described in Hsiao et al may not adequately perform the task of aligning intraspecialty relative value scales onto a common scale because of the sensitivity of the algorithm and the choice of statistical methodology. The authors suggest improvements to Hsiao's method resulting from our analyses. If widespread adoption of the Medicare Fee Schedule is a component of health care reform, reconsideration of the process determining each specialty's payment level assumes new importance.
Algorithms↗
Seeking the just price: constructing relative value scales and fee schedules.
Many conceptual issues underlie the current policy debate over how to reform the fee-for-service method of paying physicians, including the development of a relative value scale for physicians' services and the relationship between a relative value scale and a fee schedule. We consider the relationship between fees and costs and the criteria for judging whether a fee is appropriate or right and then propose a two-step process for constructing a relative value scale. A fee schedule based on a relative value scale is the most practical way to reform the current fee-for-service system and makes the most sense from both clinical and economic viewpoints.
Costs and Cost Analysis↗
Resource-Based Relative Value Scale (RBRVS), coding, and Medicare reimbursement.
Many changes occurred during 1996 in the Resource-Based Relative Value Scale that determines physician payment for services to Medicare beneficiaries in 1997. These issues include the 5-year review of physician work values, the Correct Coding Initiative, changes in the surgical Conversion Factor, and a new Medicare payment formula. Likewise, several more changes on the horizon in 1997 will dramatically impact the 1998 Medicare Fee Schedule, primarily the upcoming resource-based Practice Cost Relative Value Scale, and possible elimination of the separate surgical Conversion Factors. There are also several new Current Procedural Terminology codes that will receive Medicare payment in 1997 and 1998. This article summarizes these events and issues from a vascular surgical perspective.
Centers for Medicare and Medicaid Services, U.S.↗
The potential impact of the resource-based relative value scale on the practice of nuclear medicine.
The Resource-Based Relative Value Scale (RBRVS) is finally here. A system designed to equate physician work across the specialties, it has its own peculiar and unique problems. Modeling of the system was based on the single physician-patient interaction; it may not work properly for laboratory specialties. There are other unique considerations concerning how the model was constructed. Although data were collected specifically for nuclear medicine, they were not used in the final computations. There is disagreement over whether those data would benefit or hurt nuclear medicine reimbursement. As presently implemented, the RBRVS poses grave dangers for the future of nuclear medicine. These dangers come not only in the professional reimbursement section of the rules but in the technical component areas as well. Estimates for reduction of income by 1996 range as high as 55% for nuclear medicine. When one factors the implementation of the RBRVS by independent insurance carriers into the equation, the entire economic future becomes muddy. A brief historical review of the RBRVS, as well as discussion of potential future implications of this type of reimbursement system, is presented. Prognostication is at least as inexact a science as reimbursement. Hopefully, the author's outlook on the future of nuclear medicine is more pessimistic than it need be.
Cost Control↗
Applying the resource-based relative value scale to the Emory angioplasty versus surgery trial.
The resource-based relative value scale developed for use in the Medicare fee schedule can also be very useful in profiling and comparing physicians' cardiovascular utilization across different medical activities. This article applies relative value units (RVUs) to data from the Emory Angioplasty versus Surgery Trial. The Emory Angioplasty versus Surgery Trial was a randomized clinical trial to determine the efficacy of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass surgery (CABG). All physician services in the clinical trial provided to 2 groups of patients--those undergoing CABG and those receiving PTCA-over the course of 4 years were assigned physician work RVUs (representing the intensity of physician work required) and total RVUs (representing both the intensity and practice costs). Physician charges were also compiled. These data were used to profile and compare physician services to the 2 groups of patients by type of service, distribution over time, and clinical department. Comparisons based on RVUs contrast sharply with differences based on charges. Mean physician charges, in 1996 dollars, were $27,158 for CABG patients and $21,491 for PTCA patients, a 26% difference (p <0.001). Physician work RVUs generated an 18.3% difference (p = <0.001). Using total RVUs, the difference between the 2 groups was 3.3% (p = 0.249). Resource-based relative value weights are a valuable tool for analyzing and comparing physicians' use of cardiovascular resource. The results suggest that conclusions about physician resource utilization based on physician charges should be carefully evaluated. When possible, physician work RVUs should be compiled and evaluated along with physician charges.
Angina Pectoris↗