Maloney J V
Department of Surgery, UCLA School of Medicine 90024-1741.
JAMA. 1991 Dec 25;266(24):3453-8.
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.
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.
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.
--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.
背景——人们普遍认为，程序性医疗服务的报销比例高于认知性服务，这种比例是不合理的。根据国会授权，医疗保健财务管理局（HCFA）已被指示制定一项医疗保险费用表，以便在预算中性的假设下，将资金从程序性服务转移到认知性服务。为了给这一变革提供合理依据，萧氏等人（哈佛 - 萧氏）制定了一种基于资源的相对价值尺度（RBRVS），该尺度将一项服务的价值等同于产生该服务所需的资源。方法——本研究并非关注相对价值和费用表（“每项服务的价格”），而是采用标准的商业/工业方法来确定15个医学和外科专业的报销率（收入除以劳动小时数）。来自独立来源的数据用于确定所研究的每个专业的收入和专业工作小时数。哈佛 - 萧氏和HCFA预测了在初始RBRVS和HCFA费用表下每个专业收入的百分比变化。然后，本研究使用预测收入在新提议的支付系统下重新计算报销率。
现行支付系统——医学和外科专业的平均年收入分别为124,500美元和176,600美元，相差42%（P = 0.03）。医学和外科专业的平均每周工作小时数（名义小时数，已根据加班情况调整）分别为70.6小时和87.8小时（P = 0.005）。医学专业（33.90美元）和外科专业（38.80美元）的平均每小时报销率没有显著差异（P值不显著）。年收入的差异是由外科医生每周额外的17.2小时工作时间造成的。认为程序性医疗服务提供者的报销率高于认知性医疗从业者的错误观念，可能源于外科医生将认知工作时间的收费转移到其在手术室花费的18%时间的计费方式差异。
提议的RBRVS和HCFA支付系统——通过改变报销率，使所有专业的收入均衡在约132,500美元的均值（±21,400美元[1个标准差]）左右，从而充分消除工作时间的影响。提议的支付系统下的报销率没有考虑专业工作小时数、研究生专业培训或医生工作性质的假定差异。
——RBRVS以及基于该尺度的HCFA费用表，并非医生报销系统改革的合适依据。
