Revicki D A, Orkin F K, Luce B R, McMenamin P, Weschler J M
Medical Technology and Policy Research Center, Battelle Human Affairs Research Centers, Washington, DC 20024.
Anesthesiology. 1990 Oct;73(4):760-9. doi: 10.1097/00000542-199010000-00022.
We examined the effects of Resource-based Relative Value Scale (RBRVS)- and physician diagnosis-related groups (MDDRG)-based payment for anesthesiology services related to surgery by simulating these physician payment reform options. We merged Medicare Part A (hospital) and Part B (anesthesiology) payment data for 7,770 patients for the MDDRG analysis and examined 10,431 surgical procedures for the RBRVS analysis within 27 diagnosis-related groups (DRGs) during the second half of 1986 in 16 hospitals representing different geographic regions, bed size, and teaching status. Assuming budget neutrality (i.e., constant total expenditure for anesthesiology services) and using the proposed methodologies, we simulated RBRVS and MDDRG payments and compared them to current payments for anesthesiology services. Individual surgical procedures demonstrated a two- to more than four-fold variation in duration, accompanied by a similar variation in anesthesiology payments. Within DRGs, there was a three- to ten-fold variation in duration, and a two- to seven-fold variation in anesthesiology payments. Anesthesiology time was highly correlated with surgical time (r = 0.86-0.96). Compared to the current system, RBRVS and MDDRG systems were associated with systematic variations in payments, such that on average, on each case, anesthesiologists practicing in rural and nonteaching hospitals would gain, whereas those in urban or suburban and teaching facilities would lose. After adjusting for complexity of procedure, the distribution of payment gains and losses was a function of duration of surgery, which is not influenced by the anethesiologist. Longer cases of a given surgical procedure result in payment decreases. The results document the importance of retaining a time factor in the payment methodology for anesthesiology services to maintain equitable payment across practice settings--an objective of physician payment reform.
我们通过模拟这些医师薪酬改革方案，研究了基于资源的相对价值比例（RBRVS）和基于医师诊断相关分组（MDDRG）的支付方式对与手术相关的麻醉服务的影响。我们合并了1986年下半年16家代表不同地理区域、床位规模和教学状况的医院中7770名患者的医疗保险A部分（医院）和B部分（麻醉）支付数据，用于MDDRG分析，并对27个诊断相关分组（DRG）内的10431例外科手术进行了RBRVS分析。假设预算中性（即麻醉服务的总支出不变），并使用提议的方法，我们模拟了RBRVS和MDDRG支付方式，并将其与当前的麻醉服务支付方式进行比较。个体外科手术的持续时间呈现出2倍至4倍以上的差异，麻醉支付也有类似的差异。在DRG内，持续时间有3倍至10倍的差异，麻醉支付有2倍至7倍的差异。麻醉时间与手术时间高度相关（r = 0.86 - 0.96）。与当前系统相比，RBRVS和MDDRG系统在支付方面存在系统性差异，平均而言，在每个病例中，在农村和非教学医院执业的麻醉医师会获利，而在城市或郊区以及教学机构执业的麻醉医师会亏损。在调整手术复杂性后，支付盈亏的分布是手术持续时间的函数，而这不受麻醉医师的影响。给定外科手术的较长病例会导致支付减少。结果证明了在麻醉服务支付方法中保留时间因素对于在不同执业环境中维持公平支付的重要性——这是医师薪酬改革的一个目标。
