Medicare Resource-Based Relative Value Scale Research Articles

Why Pediatricians Should Use RBRVS-based Fee Schedules

Why Pediatricians Should Use RBRVS-based Fee Schedules

Economic consequences of diagnostic imaging for vocal cord paralysis

The purpose of this retrospective study was to estimate the economic consequences of evaluating suspected vocal cord paralysis with magnetic resonance (MR) imaging and computed tomography (CT). Reports from MR imaging (n = 30) or CT (n = 19) studies of the neck in 49 patients were retrospectively reviewed for causes of vocal cord paralysis. The patients were divided into high-suspicion (n = 20) and low-suspicion (n = 29) groups, based on the presence or absence of a clinically detectable abnormality other than vocal cord immobility. Clinic and inpatient charts were examined to determine the work-up in all cases. The Medicare Resource-based Relative Value Scale was used to estimate the costs of most procedures. The high-clinical-suspicion group included nine true-positive, four false-positive, seven true-negative, and no false-negative cases. Further work-up was performed in seven true-positive, three false-positive, and one true-negative cases. The total cost of immediate diagnostic work-up in these 20 patients, including MR imaging and/or CT, was $20,737 ($2,304 per true-positive case). The low-suspicion group included two true-positive, nine false-positive, 18 true-negative, and no false-negative cases. Further work-up was performed in both true-positive, four false-positive, and two true-negative cases. The total cost of immediate diagnostic work-up in these 29 patients was $21,698, (mean, $748; $10,849 per true-positive case). The average cost of finding space-occupying lesions in patients with vocal cord paralysis is more than 4.5 times higher in patients without suspicious antecedent clinical findings than in those with such a history. The benefits of obtaining negative findings and of detecting a small number of space-occupying lesions should be weighed against the costs of such examinations and of additional work-up for false-positive findings.

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.

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

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. 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. 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. 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%.

Increased Medicare RBRVS use on the horizon

Pediatricians are becoming intimately familiar with the Medicare Resource-Based Relative Value Scale (RBRVS) physician fee schedule. A 1995 Physician Payment Review Commission study revealed that almost 40 percent of state Medicaid programs were using the Medicare RBRVS physician fee schedule to reimburse physicians for medical services provided to Medicaid recipients. The remaining state Medicaid programs were either planning to implement the Medicare RBRVS or were exploring its application. Additionally, many other third-party payers, including Blue Cross-Blue Shield agencies and managed-care organizations, are incorporating components of the Medicare RBRVS physician fee schedule into their physician reimbursement systems.

Cost-effectiveness of Noninvasive Testing for Osteomyelitis-Reply

ABSTRACT In Reply. —Economic analyses of health care strategies must carefully differentiate costs from charges.1 Costs represent the actual amount paid for resources consumed in providing a service, while charges represent the price requested for reimbursement of that service. Because market forces affect charges, large and seemingly arbitrary differences between costs and charges for different services may exist.2 We agree with Dr Makler that it is important to use costs, which correspond more closely to actual resource consumption, and not charges, when performing cost-effectiveness analyses.Makler believes that the costs listed in our analysis are not representative, quoting the 1993 Medicare resource-based relative value scale—based reimbursement for a three-phase bone scan of $204.06 as proof. We believe this is an underestimate, which may include neither the costs of the radiopharmaceutical nor the hospital costs for the addition of a three-phase scan to the regional scan. Unfortunately, even costs vary

Panel Processes for Revising Relative Values of Physician Work

In this study, a set of meetings was conducted to pilot a group-discussion-based method anchored by a reference set of services with agreed-on values for revising the Medicare Resource-Based Relative Value Scale (RBRVS). The authors focused on the method as it evolved over the sequence of meetings, rather than on whether the relative values of work obtained were more or less valid than relative values of work obtained elsewhere. Four pilot panels, composed of 46 physicians from different specialties (including primary care), were conducted to rate total physician work. One panel examined 80 urologic services, another panel examined 80 ophthalmologic services, and the last two panels considered the merit of appeals from five specialty and subspecialty societies to 68 and 48 services, respectively. Rather than using the method of ratio estimation relative to a standard service, panelists were asked to estimate magnitudes relative to an established multispecialty reference set of values. Prominent members of that reference set were graphically displayed to panelists on a "ruler." Measures included physicians' preliminary and final ratings and detailed notes of the group discussions conducted between the ratings. The authors found that a panel process for refining relative values of work is practical, provided that panelists are provided with a valid reference set for comparison purposes and provided that care is taken that all members feel comfortable engaging in the discussion. In Summer 1992, the Health Care Financing Association conducted a series of multispecialty panels based on the methods presented here to produce the 1993 RBRVS; in addition, the RBRVS Update Committee of the American Medical Association is employing group processes and a reference set in determining the relative work values of new Current Procedural Terminology codes.

Government revises neonatal care reimbursement

The U.S. Health Care Financing Administration (HCFA) ended a seven-year negotiation with pediatricians and other providers of newborn care last month by releasing work values for physicians directing the care in neonatal intensive care units (NI-CUs). The move clears the way for including NICU physician work values in the Medicare resource-based relative value scale (RBRVS).

Ophthalmology and the Resource-Based Relative Value Fee Scale

The Medicare Resource-Based Relative Value Scale for ophthalmology has significantly reduced the level of reimbursement for surgical fees and only minimally increased evaluation and management fees. Some observers have felt that the methods for determining fees were flawed, and, generally, practitioners have been concerned about a potential loss of income. While reimbursement for individual services is being cut, projections through 1996 indicate that ophthalmology, as a specialty, will receive 55% more funding due to historical trends and increasing ranks of providers. This will translate into a more moderate global reduction in revenue of approximately 11%. The possible implications of the Resource-Based Relative Value Scale include a concentration of ophthalmic surgery into fewer practices, which may be able to distribute medical liability costs over a larger number of procedures. To counter the constraints of fee limits, individual physicians will probably seek to enhance their net income by greater use of paraprofessional personnel, the acquisition of new technologies, and the application of improved management skills.