Physician Payment Review Commission Research Articles

Tribute to John M. Eisenberg

This issue is dedicated as a tribute to John M. Eisenberg, M.D., M.B.A., in recognition of his lifelong achievements in health services research. We have selected six articles, described below, which represent areas where John made significant contributions, either as a researcher and administrator or as a champion and mentor. In addition, on behalf of the entire Editorial Board of HSR, our publisher, and the leadership at AcademyHealth, we would like to announce the establishment of an award for excellence in health services research, designed to recognize exceptional articles from HSR which advance our understanding in an area championed by John. Selection of these awards will be announced periodically in HSR, beginning in 2004. We also gratefully acknowledge support for the publication of this tribute provided by a grant from The Robert Wood Johnson Foundation in Princeton, NJ, and funding by W.K. Kellogg Foundation in Battle Creek, MI. John Meyer Eisenberg was born in Atlanta, Georgia, in 1946 and died from a brain tumor on March 10, 2002. From 1997 until shortly before his death, John served as Director for the Agency for Healthcare Research and Quality (AHRQ; formerly called the Agency for Health Care Policy and Research) of the U.S. Department of Health and Human Services (HHS). He also served as the Senior Advisor to the Secretary of HHS on Quality; cochaired the Department's Data Council; chaired the Federal Quality Interagency Coordination Task Force; and served as Principal Deputy Assistant Secretary for Health and as Acting Assistant Secretary for Health. Although this partial list of his titles illustrate the breadth and importance of his many contributions to the nation's health care system, it fails to capture the charisma, enthusiasm, and strengths with which he tackled these roles and policy areas. He was a champion of policy-relevant research in order to increase the “value” of health care services by improving its appropriateness, safety, and effectiveness while also monitoring and improving its accessibility to all. In taking on these challenges, he managed to engage researchers, clinicians, and policymakers alike in his vision for excellence in research to improve the nation's health care. He recognized that such efforts required continuous encouragement and mentoring of those who would undertake them. He was a magna cum laude graduate of Princeton University (1968) and the Washington University School of Medicine in St. Louis (1972). He was also a Robert Wood Johnson Foundation Clinical Scholar, earning a Master of Business Administration degree with distinction at the Wharton School. A clinician and researcher from the beginning of his career, John held many key positions in academic and clinical medicine and was widely recognized as a leader in both medicine and health services research. His positions included Chair, Physician Payment Review Commission; President, Association for Health Services Research (now AcademyHealth); President, Society for General Internal Medicine; and Vice President, Society for Medical Decision Making. He was also a member of the Institute of Medicine of the National Academy of Sciences and published over 250 articles and book chapters on topics such as physicians' practices, test use and efficacy, medical education, and clinical economics, as well as writing a seminal book that influenced how many of us view medical decision making: Doctors' Decisions and the Cost of Medical Care (Eisenberg 1986). John dedicated his career to ensuring that health care is based on a strong foundation of research. He challenged the field to address topics important to policymakers—both inside the clinic and inside the “Beltway”—with research that was methodologically sound, grounded in the “real world” and accessible to a broad audience. The first six articles in this issue were selected as a tribute to his contributions in these arenas:

Interview with a quality leader. Linda Aiken on the healthcare industry and workplace issues. Interview by Susan V. White and Colleen J. Hewes.

Linda Aiken, PhD MSN, is director of the Center for Health Outcomes and Policy Research and The Claire M. Fagin Leadership Professor of Nursing and Professor of Sociology at the University of Pennsylvania in Philadelphia. Dr. Aiken's other appointments at the University of Pennsylvania include senior fellow at the Leonard Davis Institute for Health Economics and research associate in the Population Studies Center. Before joining the University of Pennsylvania faculty in 1988, Dr. Aiken served as vice president of the Robert Wood Johnson Foundation. She is a member of the Institute of Medicine, a fellow of the American Academy of Arts and Sciences and of the National Academy of Social Insurance, a former president of the American Academy of Nursing, a distinguished fellow of the Academy for Health Services Research and Health Policy (now AcademyHealth), and a member of the Council on the Economic Impact of Health System Change. Dr. Aiken served on the Medicare Physician Payment Review Commission for 6 years and was a member of the 1982 Social Security Advisory Council and of President Clinton's National Health Reform Task Force. Her recent work, for which she received the Sigma Theta Tau International Clinical Research Award in 1999, has focused on accounting for variation in hospital patient outcomes in the United States, Canada, the United Kingdom, and Germany. Dr. Aiken received her bachelor's and master's degrees in nursing from the University of Florida, Gainesville, and her doctorate in sociology and demography from the University of Texas at Austin.

House Calls for the 21st Century

House Calls for the 21st Century

Book Reviews

Journal Article Book Reviews Get access Health Policy, Federalism, and the American States, edited by Robert F. Rich and William D. White. Washington, D.C.: The Urban Institute Press, 1996, 350 pp., $26.95 paper, $69.50 cloth. David Colby David Colby Physician Payment Review Commission Search for other works by this author on: Oxford Academic Google Scholar Publius: The Journal of Federalism, Volume 27, Issue 2, Spring 1997, Pages 216–218, https://doi.org/10.1093/oxfordjournals.pubjof.a029910 Published: 01 January 1997

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.

Organ transplantation in an era of economic constraint: Liver transplantation as a case study

A L T H O U G H EFFORTS to reform the health care system have fallen on hard times, the issues that spurred contemporary debate remain unresolved. 1-3 Although th~ annual rate of increase has decreased, health care expenditures reached approximately $1 trillion in 1994. While hope springs eternal, there is still cause for concern. As a society, we have responded to the symptoms of an impending catastrophe, but we have not addressed the root cause that made health care reform a social issue. Over time, people soon recognized that the reform of our health care system had a significant expense, a price few people, including employers, were willing to bear. What people realized in the end, is what they should have known all along: it was impossible to insure the uninsured, expand health care benefits, and aggressively pursue technological innovation, without substantially increasing total health care expenditures. 4-6 Even preventive health care initiatives, despite their intuitive appeai, are costly; rarely do they decrease health care expenditures. It is against this backdrop that we now consider liver transplantation. Significant changes have begun to take place in the health care delivery system: Whereas the Clinton Administration endorsed managed competition as the preferred strategy, employers and third-party payers were more impressed with a less-radical a l ternat ive--managed care. 7-m If change was necessary, those persons and organizations most affected were inclined to endorse an alternative that was less extensive and more familiar than managed competition. Managed care had the necessary assets and the fewest disincentives. By networking providers, and selectively contracting based on quality and price, traditional third-party payers and managed-care plans have settled on an approach to control the costs and assure the quality of expensive medical and surgical procedures. Often mistakenly referred to as of excellence, designated centers for transplantation at tempt to balance economic goals with quality concerns. 1~-17 A1though the approach does not usually diminish the significance of quality relative to price, critics often refer to transplant centers of excellence as of discount. This accentuates a fear that, in the end, quality is truly relative to price. Unfortunately, health policy anecdotes, much like clinical anecdotes, are neither valid nor generalizable. Many transplant networks are composed of excellent transplant programs and, most importantly, their excellence is not necessarily compromised by the price of their services. While there are reasons clinicians should be fearful of managed care, there are many experiences that underscore the value of the approach. As defined by the Physician Payment Review Commission (PPRC), managed care is:

APM's statement to the physician payment review commission

APM's statement to the physician payment review commission

Reforming graduate medical education; Summary report of the physician payment review commission: Schwartz A, Ginsberg PB, LeRoy LB. JAMA. 1993;270:1079-82

Reforming graduate medical education; Summary report of the physician payment review commission: Schwartz A, Ginsberg PB, LeRoy LB. JAMA. 1993;270:1079-82

Counting Generalist Physicians

THERE HAS recently been renewed interest in the specialty balance in the US physician workforce, with many groups calling for increased production of generalist physicians. A number of factors are responsible for this, including declining medical student interest in generalist careers, 1 continued shortages in rural and inner-city areas, 2,3 increased demand from managed care organizations, cross-national experience, 4 as well as some evidence of cost savings from higher proportions of generalists. 5,6 The Council on Graduate Medical Education 7 has called for a reduction in first-year graduate medical education positions to 110% of US medical graduates with a 50:50 generalist-to-specialist mix, and the Physician Payment Review Commission 8 has also considered such changes. Similar recommendations have been proposed in the Clinton Health Security Act as well as independently in Congress. Such changes are significant and could be approached from a variety of educational, financial, and regulatory perspectives. In order

A Statement on the Generalist Physician From the American Boards of Family Practice and Internal Medicine

PROFOUND change is under way in the health care delivery system for Americans. As our health care system moves to center on the generalist as the primary provider of health services, the acknowledged deficiency in the number of such physicians has emerged as a fundamental concern. The Clinton Health Security Act, the Council on Graduate Medical Education, the Physician Payment Review Commission, and others have called for a near doubling of the output of generalists by the end of the decade. Family physicians and general internists provide the vast majority of adult generalist care and must continue to do so to ensure the highest quality of care for the American public. The American Board of Family Practice (ABFP) and the American Board of Internal Medicine (ABIM) accept their respective roles in meeting this challenge and to this end believe there are many areas in which the two disciplines can more

OBRA Fee Reduction and Physician Behavior

To the Editor. —In a recent article 1 inThe JOURNAL, I reported that the Medicare fee reductions for overpriced procedures under the Omnibus Budget Reconciliation Act of 1987 (OBRA 87) did not affect the use of physician services by Medicare patients. Drs Ginsburg and Hogan, 2 in an accompanying Commentary, disagree with my conclusions, alleging methodological problems with my study. They contrast my findings with those of the Physician Payment Review Commission (PPRC), 3 which found that the OBRA 87 fee reductions resulted in higher use of surgeons services (ie, a behavioral offset). Ginsburg and Hogan contend that the changes in Medicare fees that occurred during the period of my study (1987 to 1989) were driven largely by physicians' own pricing behavior rather than Medicare payment policy, rendering the interpretation of fee/utilization correlations problematic. Their assertion, however, reflects an incorrect reading of the available data. In 1989, Medicare fees

Reforming graduate medical education. Summary report of the Physician Payment Review Commission.

THE PHYSICIAN Payment Review Commission, created in 1986 to advise the US Congress on reform of Medicare's method of paying physicians, has developed a comprehensive policy designed to limit growth in residencies, shift the balance between subspecialists and generalists, and facilitate training in ambulatory settings.1 During the past 2 years, the commission has devoted considerable attention to physician supply, specialty distribution, and the financing of graduate medical education (GME). The national debate on health system reform offers the potential to structure more effective policies that will include all payers in new GME financing strategies and to develop different systems of service provision for uninsured people who historically have relied on teaching institutions as their source of care. The debate also provides an important opportunity, missing in the past, to coordinate policies regarding physician supply and training with those affecting payment for services, patients' access to care, and cost containment.

Reforming Graduate Medical Education

THE PHYSICIAN Payment Review Commission, created in 1986 to advise the US Congress on reform of Medicare's method of paying physicians, has developed a comprehensive policy designed to limit growth in residencies, shift the balance between subspecialists and generalists, and facilitate training in ambulatory settings.1 During the past 2 years, the commission has devoted considerable attention to physician supply, specialty distribution, and the financing of graduate medical education (GME). The national debate on health system reform offers the potential to structure more effective policies that will include all payers in new GME financing strategies and to develop different systems of service provision for uninsured people who historically have relied on teaching institutions as their source of care. The debate also provides an important opportunity, missing in the past, to coordinate policies regarding physician supply and training with those affecting payment for services, patients' access to care, and cost containment.

Physician Payment Review Commission Sends Recommendations to Capitol Hill

Physician Payment Review Commission Sends Recommendations to Capitol Hill

Physician Response to Fee Changes

THE PHYSICIAN Payment Review Commission, Washington, DC, has a long-standing interest in measuring physicians' response to changes in payment rates (called "behavioral offset"). A summary of our recent empirical work on this subject is included in the commission's 1993 report to Congress.¹ In this issue, Escarce²analyzes Medicare claims before and after the overvalued procedure fee reductions specified in the Omnibus Budget Reconciliation Act of 1987 (OBRA 87). He purports to show that the OBRA 87 cuts generated no net behavioral offset. See also p 2513. We disagree with Escarce's conclusion: we believe the Medicare data provide good evidence of a behavioral offset. We frame herein the policy issue, identify the important methodological differences between Escarce's analysis and our own, and summarize findings from our own studies of the OBRA 87 fee reductions and subsequent policy-driven changes in Medicare fees. The issue of the behavioral offset gained broad

Analysis, advice, and congressional leadership: the Physician Payment Review Commission and the politics of Medicare.

In 1985, Congress established the Physician Payment Review Commission (PPRC) to help formulate changes in the system used by Medicare to pay for physician services. The recommendations of the PPRC and subsequent legislative action led to fundamental reform. As a new type of advisory body, the PPRC enabled Congress to establish an agenda for physician payment reform and set it into law despite initial resistance from the executive branch. Four key factors contributed to the influence of the commission: (1) an institutional design that enhanced and integrated congressional policy formulation; (2) the quality of the information generated for legislative deliberation; (3) the open, consensual process the commission used to translate that information into policy recommendations; and (4) the strategic packaging of the proposals for reform. In the process leading to enactment of the new payment system, the commission skillfully bridged the traditionally segmented roles of neutral analyst and political advisor for legislators pursuing Medicare reform. Implementation of physician payment reform has been largely an administrative responsibility, in which the PPRC has played a minimal role. The complexity and ambiguity of some of the legislative provisions have left room for administrative officials and interest groups to maneuver according to their priorities. Thus, despite congressional efforts to design a tightly controlled system, a considerable amount of work remains to assure its technical and political success.

Incorporating practice costs into the Resource-Based Relative Value Scale.

Practice costs (not including liability insurance costs) account for approximately 41% of the payment for medical and surgical services in the Medicare Fee Schedule. Unlike the portion of the fee schedule that compensates physicians for their work, the practice cost portion of the Medicare Fee Schedule is not resource-based; it is based instead on historical charges. As a result, physicians can recover their practice costs in less time and with less effort (measured in work relative value units) by performing invasive procedures and tests than by providing evaluation and management services. The Physician Payment Review Commission has proposed, in some detail, a method for incorporating practice costs into the Medicare Fee Schedule. The method involves allocating indirect costs on the basis of physician work plus direct costs. We find, using their own analytical framework, that indirect costs should rather be allocated on the basis of time. But to better serve the goal of incentive neutrality, and to make practice cost payments more equitable, the payment a physician receives for practice costs should be based not on service mix and volume, but on characteristics of the physician's practice more closely related to practice costs: for example, whether the physician has an office, or whether the physician practices alone or in a group.

The Medicare assignment controversy: the construction of public-professional conflict.

The conflict between the elderly and organized medicine over "mandatory assignment" and "balance billing" is a significant public policy issue. Considerable ideological importance has been attached to this conflict by both sides, despite the relatively modest proportion of total revenue for physician services received through balance billing in payment for care of Medicare beneficiaries. The positions of these two coalitions are examined as well as the efforts of the Physician Payment Review Commission (PPRC) to craft a public policy response. Three alternative resolutions--those adopted by Congress in 1989 on the recommendation of the PPRC, the Canadian solution, and actions taken on a state level--are then contrasted. The concentrated impact on the elderly of balance billing practices is considered as a problem, especially for elderly of limited income and resources. Justification of the practice is typically provided by the profession on the ideological grounds of preservation of professional autonomy rather than economic gain, which also reflects the current relatively limited use of balance billing; a significant majority of all claims submitted in the United States are now assigned to physicians. A continuation of the gradualist strategy of the PPRC is endorsed as the most appropriate short-range solution to these problems, which diminish in significance with a more comprehensive national health financing scheme.

Impact of the Medicare physician fee schedule.

DataWatch Health AffairsVol. 11, No. 3 Impact Of The Medicare Physician Fee ScheduleDavid C. Colby AffiliationsThe Physician Payment Review Commission in Washington, D.C.PUBLISHED:Fall 1992No Accesshttps://doi.org/10.1377/hlthaff.11.3.216AboutSectionsView articleView Full TextView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions View articleTOPICSPaymentPhysician paymentMedicare Part BMedicareOmnibus Budget Reconciliation Act of 1987Medical specialtiesSurgeryPhysician practicesRelative value unitsResource-based relative value scale Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 5 History Published online 1 January 1992 InformationCopyright © by Project HOPE: The People-to-People Health Foundation, Inc.ACKNOWLEDGMENTSThe views expressed in this DataWatch are those of the author, and no endorsement by the Physician Payment Review Commission is intended or should be inferred. The author thanks Jansen Davis, Paul Ginsburg, Annette Hennessey, Jack Hoadley, Roz Lasker, Lauren LeRoy, David Shapiro, and Jennifer Smith for assistance with various aspects of this DataWatch.PDF downloadCited ByCoding and Reimbursement for Vestibular Tests by the U.S. Centers for Medicare and Medicaid Services (CMS)27 September 2021 | Otology & Neurotology, Vol. 42, No. 10Putting Complex Older Persons First: How the Centers for Medicare and Medicaid Services 2019 Payment Proposal Fails Older Americans4 December 2018 | Journal of the American Geriatrics Society, Vol. 67, No. 1Variation in specialist fees: evidence from New Zealand insurance claims4 December 2016 | Journal of Health Services Research & Policy, Vol. 9, No. 2_supplMonitoring the Impact of the Medicare Fee Schedule on Access to Care for Vulnerable PopulationsJournal of Health Politics, Policy and Law, Vol. 22, No. 1Use of the Resource-Based Relative Value Scale for Private InsurersHenry G. Dove24 July 2017 | Health Affairs, Vol. 13, No. 5

Medicare Physician Payment Reform: implications for nurse practitioners.

In January 1992, the federal government implemented a package of physician payment reforms for use in the Medicare program. Among these reforms is a resource-based fee schedule that replaces the customary, prevailing, and reasonable (CPR) method of payment that has been used since Medicare's inception. This article describes the recommendations of the Physician Payment Review Commission, a Congressional advisory group, concerning the implications of the resource-based fee schedule on nurse practitioners and other non-physician practitioners. Absent changes in current law, services provided by nurse practitioners will be paid based on the same formulas that were used under CPR. This author advises that these payment formulas be revised to reflect the differences in resource costs borne by physicians and nonphysicians. Furthermore, revisions to the payment formulas should be made in the near future before the Medicare fee schedule and the rules governing its use are adopted by other public (e.g., Medicaid) and private payers.