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Viewpoint
September 9, 2019

The Relative Value Scale Update Committee: Time for an Update

Author Affiliations
  • 1Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
  • 2Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA. 2019;322(12):1137-1138. doi:10.1001/jama.2019.14591

In 1992, the Centers for Medicare & Medicaid Services (CMS) introduced the Resource-Based Relative Value Scale (RBRVS) as a new system for physician payment. Rather than paying physicians their “usual, customary, and reasonable”1 charges, this system was designed to pay physicians based on the time, technical skill, and mental effort required to perform each procedure. Thus, the relative value unit (RVU) was born.

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    2 Comments for this article
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    Surgery vs Oncology
    Richard Reiling, Clinical Professor | Wright State University School of Medicine
    This Viewpoint seeks to show the fallacies of the RUC process for reimbursement using only data on several surgical procedures. The basic error is the time of a procedure as noted from records which would only include the time of the procedure itself, such as time in the operating room! This is a grossly inadequate measure of the actual time which must include the pre-operation discussion with the patient and the family in the hospital/clinic, scrubbing hands (at least 10 minutes), pre-procedure positioning of the patient, post-op order writing, discussion with the family. Initially with the RUC system we were faced with the inguinal hernia as the standard for the whole RUC system and did not include all the time involved - the 30-45 minutes in the OR is about one half of the time usually involved. In addition, there is a global surgical period which would include hospital visits as often as necessary and outpatient care.

    The author of this study is a medical oncologist. In the initiation of the RUC, medical oncologists refused to participate because they were making income on the 'selling' of chemotherapy and didn't rely on time spent with their patients. That nirvana ended with restrictions on drug reimbursement. The medical oncologists then tried to enter the RUC system and push that their services were more important than other internal medicine specialties. This report can be read as a 'lot of hot air' by an author whose specialty was injured by the RUC system.
    CONFLICT OF INTEREST: None Reported
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    Are Primary Care Physicians Overlooked by RVU Changes?
    Edward Volpintesta, MD | 155 Greenwood Avenue Bethel CT
    The changes based on ‘empirical’ evidence ‘ may help with reimbursing for medical and surgical procedures, but for primary care doctors who often spend considerable time dealing with patients’ social and emotional problems, answering questions that consultants may have overlooked or simply didn’t have the time for, it will be impossible to fairly reimburse them.

    This ‘cognitive’ function of primary care, because it does not translate as a ‘procedure,’ is undervalued and the time has come to appraise it accurately and fairly. This may draw criticism from the ‘proceduralists’ because any increases that go to primary
    care will probably cause decreases to them.
    CONFLICT OF INTEREST: None Reported
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