McMahon L F
Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor 48109-0376.
Am J Public Health. 1990 Jul;80(7):793-8. doi: 10.2105/ajph.80.7.793.
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.
医生薪酬改革在全国卫生政策辩论中占据了突出地位。这场辩论的一个关键组成部分是哈佛基于资源的相对价值尺度（RBRVS）。哈佛的研究工作依赖于几个必要的方法学假设和妥协，要理解RBRVS的优缺点就必须了解这些。例如，哈佛团队调查的病例太少，无法涵盖一个专科临床实践的范围，在判断专科之间相同或等效的病例选择上投入太少，并且使用了未经证实的外推方法来为未调查的医生服务分配总工作量的最终值。这种方法导致最终的RBRVS出现了一些异常情况，比如某些专科针对新患者的综合服务价值低于老患者，以及内科许多新患者门诊服务的总工作量价值低于家庭医学，这一发现与实证证据不符。哈佛RBRVS做出了重大贡献，增进了我们对医生执业的理解。该系统不应被视为一个成品。需要对这些假设和异常情况进行进一步调查和解释，以构建一个能充分反映医生工作复杂性的系统。
