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PubMed1992

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↗
PubMed1977

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↗
PubMed1990

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↗
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↗
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.↗
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↗
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↗
PubMed1990

A critique of the Harvard Resource-Based Relative Value Scale.

Physician payment reform has assumed a prominent place in the national health policy debate. A key component in this debate is the Harvard Resource-Based Relative Value Scale (RBRVS). The Harvard research effort relied upon several necessary methodologic assumptions and compromises that must be understood to appreciate the RBRVS's strengths and weaknesses. For example, the Harvard group surveyed too few cases to cover the range of clinical practice in a specialty, had too little input in the selection of cases that were judged to be the same or equivalent between specialties, and used an unproven extrapolation methodology to assign final values for total work to non-surveyed physician services. This methodology led to a number of anomalies in the final RBRVS, such as values for comprehensive services for some specialties that were lower for new than for established patients, and total work values for many new patient office services that were lower for Internal Medicine than for Family Practice, a finding inconsistent with empiric evidence. The Harvard RBRVS represents a significant contribution that increases our understanding of physician practice. The system should not be viewed as a finished product. Further investigation and explanation of the assumptions and anomalies are needed to construct a system that reflects adequately the complexity in physician work.

Economics, Medical↗
PubMed1992

An overview of the development and refinement of the Resource-Based Relative Value Scale. The foundation for reform of U.S. physician payment.

Responding to distortions in payment rates between services, policymakers in the United States have sought a systematic and rational foundation for determining physician fees. One such approach to paying physicians, the Resource-Based Relative Value Scale (RBRVS), determines fees by measuring the relative resource costs required to produce them. On January 1, 1992, the Medicare program implemented a new payment system for physician services based on the RBRVS. This article provides a brief history of the RBRVS and a summary of the methods and data used to derive it. This overview represents the culmination of 6 years of research by the Harvard RBRVS study team and provides a road map to the study's concepts and definitions. The overview also provides a context for the articles in this issue that describe five major studies undertaken since 1988. The study's overall results are presented in the last article of the series.

Data Collection↗
PubMed1991

Analysis of the resource-based relative value scale for Medicare reimbursements to academic and community hospital radiology departments.

The authors examined a homogeneous sample of 40 radiologists from four academic centers (ACs) and four community hospitals (CHs) to assess the prevalence, accuracy, and sources of knowledge regarding the resource-based relative value scale (RBRVS) reform of Medicare. The radiologists were also asked to estimate the relative intraservice work values of 12 of the radiologic services in the original RBRVS study, using the same definitions and the same standard service. The radiologists were found to be relatively well informed and accurate regarding the RBRVS-based Medicare reform. However, the standard errors of estimated work in the sample were much greater (from 56% to over 800%) than those reported for the nationally based RBRVS. The AC and CH radiologists also appeared to differ qualitatively in their perceptions of intraservice work. These findings suggest that the RBRVS may not represent accurately the spread of perceived relative work values among radiologists, including differences between AC and CH components in terms of site-specific radiologic work.

Health Knowledge, Attitudes, Practice↗
PubMed1992

Results and impacts of the Resource-Based Relative Value Scale.

On January 1, 1992, the Health Care Financing Administration implemented the 1989 legislation reforming the Medicare payment system for physicians' services. The cornerstone of the new payment reform is the Medicare Fee Schedule (MFS), which is based on the Resource-Based Relative Value Scale (RBRVS). In this article, the major findings of the RBRVS study and its impacts on physician payment are summarized. The authors report the impacts of a RBRVS-based fee schedule on Medicare fees and physicians' income if it were fully implemented, assuming budget neutrality and absence of volume changes in services. Under this scenario, fees for evaluation and management services increase by 15% to 45%, while fees for invasive services and diagnostic tests decrease by 20% to 30%. These changes increase the Medicare income of family practitioners by more than 30% while decreasing the income of most surgical specialties by 10% to 20%.

Economics, Medical↗
PubMed1991

A critical analysis of the resource-based relative value scale.

UNLABELLED: BACKGROUND--There is a general perception that procedural medical services are reimbursed at an inappropriately greater rate than cognitive services. By congressional mandate, the Health Care Financing Administration (HCFA) has been directed to establish a Medicare fee schedule to shift funding under a budget-neutral assumption from procedural to cognitive services. To provide a rational basis for this change, Hsiao et al (Harvard-Hsiao) developed a resource-based relative value scale (RBRVS) that equates the value of a service to the resources necessary to generate the service. METHODS--Instead of focusing on relative values and fee schedules ("price-per-unit-service"), the present study employs the standard commercial/industrial method of determining reimbursement rate (income divided by hours of labor) for 15 medical and surgical specialties. Data from independent sources are used to determine income and hours of professional effort for each of the specialties studied. Harvard-Hsiao and HCFA predicted the percent change in income for each of the specialties under the initial RBRVS and the HCFA fee schedule. The predicted income was then employed in this study to recompute reimbursement rates under the newly proposed payment systems. RESULTS: CURRENT PAYMENT SYSTEM--Average annual incomes for medical and surgical specialties are $124,500 and $176,600, respectively, a 42% difference (P = .03). Average weekly work hours (nominal hours, as adjusted for overtime) for medical and surgical specialties are 70.6 and 87.8, respectively (P = .005). Average hourly reimbursement rates for medical ($33.90) and surgical ($38.80) specialties are not substantially different (P, not significant). The difference in annual income is explained by the 17.2 hours per week of additional work hours by surgeons. The erroneous perception that procedurists are reimbursed at a higher rate than cognitive practitioners likely arises from differences in billing methods by which surgeons shift charges for cognitive work hours to the 18% of their time spent in the operating room. RESULTS: PROPOSED RBRVS AND HCFA PAYMENT SYSTEM--The income of all specialties is equalized about a mean of $132,500 (+/- $21,400 [1 SD]) by varying reimbursement rates in such a way that the effect of working hours is fully discounted. Reimbursement rates under the proposed payment system make no recognition of the hours of professional effort, postgraduate specialty training, or putative differences in the nature of the physician's work. CONCLUSION: --The RBRVS, and the HCFA fee schedule to the extent that it is based on that scale, are inappropriate bases for the reform of the physician reimbursement system.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1990

Resource-based relative value scale: a new payment system for practitioners under Medicare.

Congress has directed the Physician Payment Review Commission to evaluate ways that the Part B Medicare program may be changed to modify the way physicians are reimbursed and to slow down the growth of expenditures in the program. This survey article summarizes the work in the development of a resource-based relative value scale (RVS), discusses the major issues dealt with by the PPRC, the results of Congressional action, and the issues of concern for optometrists.

Fee Schedules↗