A rational process for the reform of the physician payment system

Analysis of the resource-based relative value scale (RBRVS) for physician payment indicates that in 1996, hourly reimbursement rates will be unrelated to the intensity of work and income will be unrelated to hours worked. A "consensus method" of payment is proposed as an alternative to the RBRVS.

As with the method of the RBRVS study, a pilot survey asked a specialty-representative cohort of physicians to assign dimensionless numbers to the relative value of work in 15 specialties using the Hsiao et al. definition of work intensity as "time modified by, a) mental effort, b) clinical judgment, c) technical skill, and d) physical effort under stress." The consensus method is similar to that of the Hsaio method, except there is no mathematical transformation of the raw data to establish specialty work values once the data are collected. A comparative analysis was then made of work hours, reimbursement rates, and annual income with 1) the customary prevailing and reasonable system (CPR, pre-1992), 2) the RBRVS system (1996), and 3) the proposed consensus system.

The RBRVS intends that physicians be reimbursed on the basis of time and intensity of work. Neither the CPR nor the RBRVS systems accomplish this objective when the data and computational methods of the Physician Payment Review Commission are used with independently determined work intensity to compute hourly reimbursement rates in the specialties. The consensus method shows the desired direct linear correlation of income with both length of the physician's work week and intensity of effort. It rates the primary care specialties as a group more highly than the RBRVS.

The proposed consensus method meets the original intent of the RBRVS to reimburse physicians on the basis of the resource input of time as modified by the criteria of Hsiao et al.