Comparison of Work Relative Value Units Assigned to Urological and Gynecological Surgical Procedures.

INTRODUCTION: We sought to determine if work relative value unit differences exist between analogous, sex-specific procedures. METHODS: Representatives from the AUA and the American College of Obstetricians and Gynecologists independently reviewed the entire procedural code set and identified sex-specific procedures that had an analogous procedure in the opposite sex. These pairs were then evaluated and compared using current American Medical Association Relative Value Scale Update Committee methodology. Comparable code pair values were then examined to determine any systemic bias in the work relative value units assigned between the procedures. Mean differences and 95% confidence intervals were used to determine any differences in procedure or physician time values. The methodology used considered global period, intraservice time, total time, hospital days, postoperative office visits, and the date of the committee review. RESULTS: Of the 10 directly analogous code pairs reviewed, 7 of the female procedures had higher work relative value unit differences (range 0.29-6.47), and 3 of the male procedures had higher work relative value unit differences (range 1.23-2.34). There was no statistical difference between the code pair work relative value units. The work relative value unit per minute of intraservice time and total time were not statistically different. CONCLUSIONS: In this study, we compared operative procedures performed in women with clinically comparable operative procedures performed in men that had similar surgical approaches, global periods, and valuation methodologies. Overall, no statistical differences in work relative value units were demonstrated.

The Optimization Path and Practice of Public Hospital Performance Appraisal System from the Perspective of Value Co-creation / 中国卫生经济

Objective:To improve the public welfare attributes of public hospitals through the optimization of the performance ap-praisal system of public hospitals,stimulate the enthusiasm of medical staff,and continuously improve the quality and level of medi-cal services.Methods:From the perspective of value co-creation,the three-party value subjects of hospitals,patients and depart-ments are considered,and the core indicators of Diagnosis Related Group(DRG)and Resource-based Relative Value Scale(RBRVS)accounting methods are introduced to construct a performance appraisal system at the level of medical departments in public hospi-tals.Results:The sample hospital applied DRG and RBRVS-based medical department performance appraisal system,and found that the equity of performance evaluation,the efficiency of hospital operation ability,and the satisfaction of patients and medical staff were significantly improved.Conclusion:Based on the theory of value co-creation,the performance appraisal system of the case hos-pital is optimized into three dimensions:cost control assessment,KPI index assessment and workload assessment,so as to achieve consistency between performance appraisal work objectives,and the the result variables of value co-creation,promote the balance of service quality and quantity of medical service providers,and promote the optimization of the effect of hospitals,departments and pa-tients.

Optimization of nursing services for percutaneous coronary interventional therapy based on clinical nursing pathway / 中华医院管理杂志

Objective:To optimize the clinical nursing pathway, service program and evaluation parameters of percutaneous coronary intervention(PCI), for references for the cost accounting and compensation mechanism of nursing program in public hospitals.Methods:After literature analysis and group discussion, the initial templates were constructed for the PCI clinical nursing pathway, nursing service projects, and their evaluation parameters. 15 experts were consulted by two rounds of Delphi method to optimize PCI nursing path, nursing service items and their evaluation parameters (basic labor consumption, basic time consumption, technical difficulty and risk degree).Results:Two rounds of Delphi method finally determined the PCI clinical nursing path and 27 nursing service items, and adjusted the evaluation parameters of 10 nursing service items. The new projects for PCI clinical nursing services included adjustment and review of dual antiplatelet therapy plans, postoperative rehabilitation nursing, and key project verification. The three nursing service projects with the highest level of technical difficulty and risk were intravenous blood transfusion, gastric catheterization, and gastrointestinal decompression. The two items with the highest importance assigned were high pump assisted arterial/venous infusion (blood) and invasive continuous arterial blood pressure monitoring.Conclusions:The PCI clinical nursing pathway and nursing service project constructed in this study could closely integrate with clinical practice, highlight the integrated nursing service model, and reflect the labor value of nurses.

Practice of medical technology performance reform in a large public hospital based on resource-based relative value scale theory / 中华医院管理杂志

With the deepening of the comprehensive reform process of public hospitals and the further refinement of high-quality development requirements, the reform of compensation system of public hospitals has also begun. Taking a hospital as an example, the authors deeply analyzed the four-dimensional performance appraisal scheme of medical technology departments based on resource-based relative value scale concept, with workload assessment as the foundation, multi-dimensional cost assessment as the emphasis, work efficiency as the spur and work quality as the foundation, and introduced the process of implementing the distribution scheme guided by knowledge value to the secondary distribution of departments. The performance appraisal scheme could scientifically reflect the work value of medical staff in medical and technical departments, strengthen the department′s awareness of cost control, improve the efficiency and quality of the department′s work, significantly motivate the medical and technical staff, and deepen the modern management of hospitals.

Measuring work complexity for acute care services.

Case weights capture the resource cost by diagnosis-related group (DRG) but may not fully reflect the complexity of the clinical services provided. This study describes the use of a work complexity index (WCI), for assessing acute care services focusing on those provided by physicians in healthcare systems. The services are classified using relative value units (RVUs) and their point value assigned using the resource-based relative value scale. 57,559 acute inpatients from a tertiary hospital were first classified into diagnosis-related groups, which together with the relative value units assigned to services were then used to calculate a work complexity index for 38 departments. A case mix index (CMI) was also compiled as a conventional measure of complexity which had a correlation of 0.676 (p < 0.001) with the WCI. The correlation between the WCI and the RVUs representing the weighted volume of physician activities was 0.342 (p = 0.036). The WCI represents a more output or activity focused measure of complexity whereas the CMI is more patient focused and thus provides better insights into Departments' productivity. Although this paper focuses on physicians, the WCI can be easily extended to include other clinical services.

Realigning the provider payment system for primary health care: a pilot study in a rural county of Zhejiang Province, China.

AIM: This work aimed to evaluate a pre/post-reform pilot study from 2015 to 2018 in a rural county of Zhejiang Province, China to realign the provider payment system for primary health care (PHC). METHODS: Data were extracted from the National Health Financial Annual Reports for the 21 township health centers (THCs) in Shengzhou County. An information system was designed for the reform. Differences among independent groups were assessed using Kruskal-Wallis H-test. Dunn's post hoc test was used for multiple comparisons. Differences between paired groups were tested by Wilcoxon signed-rank test. Two-tailed P < 0.05 indicated statistical significance. Data were processed and analyzed using R 3.6.1 for Windows. FINDINGS: First, payments to THCs shifted from a "soft budget" to a mixed system of line-item input-based and categorized output-based payments, accounting for 17.54% and 82.46%, respectively, of total revenue in 2017. Second, providers were more motivated to deliver services after the reform; total volumes increased by 27.80%, 19.22%, and 30.31% for inpatient visits, outpatient visits, and the National Essential Public Health Services Package (NEPHSP), respectively. Third, NEPHSP payments were shifted from capitation to resource-based relative value scale (RBRVS) payments, resulting in a change in the NEPHSP subsidy from 36.41 to 67.35 per capita among the 21 THCs in 2017. Fourth, incentive merit pay to primary health physicians accounted for 38.40% of total salary, and the average salary increased by 32.74%, with a 32.45% increase in working intensity. A small proportion of penalties for unqualified products and pay-for-performance rewards were blended with the payments. The reform should be modified to motivate providers in remote areas. CONCLUSION: In the context of a profit-driven, hospital-centered system, add-on payments - including categorized output-based payments to THCs and incentive merit pay to primary care physicians (PCPs) - are probably worth pursuing to achieve more active and output/outcome-based PHC in China.

Determination of Health Insurance Fee Schedule and Strengthening Policy for Health Insurance Coverage / 대한내과학회지

The resource-based relative value scale (RBRVS) was introduced in Korea as a payment system in 2001. However, the health insurance fee schedule had many problems. Unbalanced insurance fee schedules still occur, and the relative value was not divided between physicians' work and practice expenses. Furthermore, malpractice fees were not included in the total RBRVS. The first refinement project of the health insurance relative value scales was conducted in 2003 and the second project started in 2010. In the first project, final relative values were calculated under budget neutrality by medical departments, and imbalances within the departments were resolved. However, imbalances still existed between departments. In the second project, final relative values were classified and computed by the type of medical treatment. The final RBRVS has been applied step by step since 2017 and the imbalance problem of the insurance fee schedule has been partially resolved. The government recently announced strengthening the plan for health insurance coverage. The current coverage rate for total medical costs by national health insurance is 63%. The purpose of this plan was to increase the coverage rate by up to 70%. The government has suggested detailed plans but there remain many controversial issues and limitations with regard to the practical aspects. Thus, further research and suggestions are needed.

Influencing factors for operative workload: analysis based on multivariate regression model / 中华医院管理杂志

Objective To establish a multi-regression workload model based on surgical related factors.Methods The routine surgery workload was measured by the RBRVS development process of Hsiao WC,and multiple regression models were established for the operative factors from the surgical project specifications,pricing regulations and the operative workload.Results Top workload factors of an operation were technical difficulty,surgical classification and time cost.Multiple regression equation R2=0.699.One degree increase of technical difficulty would push up workload by 0.034;one level of operation grade would raise workload by 0.793;and every one hour longer of the operation time would increase workload by 1.025. Conclusions Operations of higher level, technical difficulty and longer time cost should deserve more reimbursement in consideration of both pricing and income distribution.

The Korean Spinal Neurosurgery Society ; Are We Reimbursed Properly for Spinal Neurosurgical Practices under the Korean Resource Based Relative Value Scale Service?

OBJECTIVES: The Korean Resource Based Relative Value Scale (K-RBRVS) was introduced in 2001 as an alternative of the previous medical fee schedule. Unfortunately, most neurosurgeons are unfamiliar with the details of the K-RBRVS and how it affects the reimbursement rates for the surgical procedures we perform. We summarize the K-RBRVS in brief, and discuss on how the relative value (RV) of the spinal neurosurgical procedures have changed since the introduction in 2001. METHODS: We analyzed the change of spinal procedure RVs since 2001, and compared it with the change of values in the brain neurosurgical procedures. RVs of 88 neurospinal procedures on the list of K-RBRVS were analyzed, while 24 procedures added during annual revisions were excluded. RESULTS: During the past 15 years, RVs for spinal procedures have increased 62.8%, which is not so different with the cumulative increase of consumer prices during this time period or the increase rate of 92.3% for brain surgeries. When comparing the change of RVs in more complex procedures between spinal and brain neurosurgery, the increase rate was 125.3% and 133%, respectively. CONCLUSION: More effort of the society of spinal surgeons seems to be needed to get adequate reimbursement, as there have been some discrimination compared to brain surgeons in the increase of RVs. And considering the relative underestimation of spinal neurosurgeons' labor, more objective measures of neurospinal surgeons' work and productivity should be developed for impartial reimbursement.

Estimating Surgical Procedure Times Using Anesthesia Billing Data and Operating Room Records.

OBJECTIVE: The median time required to perform a surgical procedure is important in determining payment under Medicare's physician fee schedule. Prior studies have demonstrated that the current methodology of using physician surveys to determine surgical times results in overstated times. To measure surgical times more accurately, we developed and validated a methodology using available data from anesthesia billing data and operating room (OR) records. DATA SOURCES: We estimated surgical times using Medicare 2011 anesthesia claims and New York Statewide Planning and Research Cooperative System 2011 OR times. Estimated times were validated using data from the National Surgical Quality Improvement Program. We compared our time estimates to those used by Medicare in the fee schedule. STUDY DESIGN: We estimate surgical times via piecewise linear median regression models. PRINCIPAL FINDINGS: Using 3.0 million observations of anesthesia and OR times, we estimated surgical time for 921 procedures. Correlation between these time estimates and directly measured surgical time from the validation database was 0.98. Our estimates of surgical time were shorter than the Medicare fee schedule estimates for 78 percent of procedures. CONCLUSIONS: Anesthesia and OR times can be used to measure surgical time and thereby improve the payment for surgical procedures in the Medicare fee schedule.

Considerations on Performance-based Salary Distribution Mechanism for Doctors in County-Level Public Hospitals / 中国医院管理

In order to solve the drawbacks of egalitarianism,induced demand and ineffective incentive in the current distribution mode,the leverage of the salary mobilization and the hospital development is used to put forward the relative value of RBRVS as the theoretical guide to accounting the medical service project,and to establish doctor post value and comprehensive goal assessment system.Finally,a salary distribution model for doctors in county-level hospitals based on doctors' workload post value and comprehensive goals assessment will be formatted,which will reflect public welfare and incentive mechanism.

The Korean Spinal Neurosurgery Society ; Are We Reimbursed Properly for Spinal Neurosurgical Practices under the Korean Resource Based Relative Value Scale Service?

OBJECTIVES: The Korean Resource Based Relative Value Scale (K-RBRVS) was introduced in 2001 as an alternative of the previous medical fee schedule. Unfortunately, most neurosurgeons are unfamiliar with the details of the K-RBRVS and how it affects the reimbursement rates for the surgical procedures we perform. We summarize the K-RBRVS in brief, and discuss on how the relative value (RV) of the spinal neurosurgical procedures have changed since the introduction in 2001. METHODS: We analyzed the change of spinal procedure RVs since 2001, and compared it with the change of values in the brain neurosurgical procedures. RVs of 88 neurospinal procedures on the list of K-RBRVS were analyzed, while 24 procedures added during annual revisions were excluded. RESULTS: During the past 15 years, RVs for spinal procedures have increased 62.8%, which is not so different with the cumulative increase of consumer prices during this time period or the increase rate of 92.3% for brain surgeries. When comparing the change of RVs in more complex procedures between spinal and brain neurosurgery, the increase rate was 125.3% and 133%, respectively. CONCLUSION: More effort of the society of spinal surgeons seems to be needed to get adequate reimbursement, as there have been some discrimination compared to brain surgeons in the increase of RVs. And considering the relative underestimation of spinal neurosurgeons’ labor, more objective measures of neurospinal surgeons’ work and productivity should be developed for impartial reimbursement.

Integration of new technology into clinical practice after FDA approval.

Development of new medical technology is a crucial part of the advancement of medicine and our ability to better treat patients and their diseases. This process of development is long and arduous and requires a significant investment of human, financial and material capital. However, technology development can be rewarded richly by its impact on patient outcomes and successful sale of the product. One of the major regulatory hurdles to technology development is the Food and Drug Administration (FDA) approval process, which is necessary before a technology can be marketed and sold in the USA. Many businesses, medical providers and consumers believe that the FDA approval process is the only hurdle prior to use of the technology in day-to-day care. In order for the technology to be adopted into clinical use, reimbursement for both the device as well as the associated work performed by physicians and medical staff must be in place. Work and coverage decisions require Current Procedural Terminology (CPT) code development and Relative Value Scale Update Committee (RUC) valuation determination. Understanding these processes is crucial to the timely availability of new technology to patients and providers. Continued and better partnerships between physicians, industry, regulatory bodies and payers will facilitate bringing technology to market sooner and ensure appropriate utilization.

Neurosurgeons' responses to changing Medicare reimbursement.

OBJECT: Medicare reimbursement for physician services has been declining even as the number of Medicare enrollees has been increasing. The number of Medicare participants will only continue to grow as the American population ages and the Patient Protection and Affordable Care Act goes into effect. Efforts to increase reimbursement for physician services through Medicare are often met with data showing that most neurosurgeons continue to participate in the program despite these cutbacks. To better understand this dichotomy, practicing neurosurgeons were surveyed to gauge their response to cutbacks in the Medicare program beyond just their participation status. METHODS: An Internet-based survey invitation was emailed to 3469 practicing neurosurgeons. Reminder emails were sent at intervals over several weeks to help increase the response rate. RESULTS: Among respondents, an overwhelming percentage (96.8%) participated in Medicare. The neurosurgeons indicated that about one-third of their patient population was covered by Medicare. They also reported limiting the number of Medicare patients they see through a variety of mechanisms: only seeing Medicare patients with a specific diagnosis or from certain referring physicians or limiting the number of appointment slots for Medicare patients. Many respondents stated that further declines in Medicare reimbursement would lead to a reduction in their participation. CONCLUSIONS: While most responding neurosurgeons do participate in the Medicare program, a substantial proportion modulates their participation through a variety of mechanisms. These barriers to care access for Medicare patients are only expected to become greater if further declines in reimbursement are implemented through the program.

The Measurement Analysis of Doctor Workload Based on the Analytic Hierarchy Process / 中国卫生经济

Objective: To search for the weighting the doctor’s service value and method to give the payment to doctors. Methods:From the hierarchy of medical service items, medical service items are classified, the weight of medical service item are calculated by analytic hierarchy process (AHP) , the Harvard University doctor workload measurement model is established. Results: According to the weight of medical service items, to calculate the workload of doctors integrated with practical work quantity. Conclusion:By applying the theoretical results into practices, the estimation system of doctor workload was smoothly operated in the organization.

A Review of the Classification of the Practice Characteristics and the Physicians' Work in Vascular Surgery

PURPOSE: Since the medical insurance system was started in Korea, there has been an imbalance in the medical charges among the procedural items of special departments. For correcting this problem, the Resource-based Relative Value Scale (RBRVS) was introduced to determine the relative values of physician services and practices. The RBRVS is the prevailing model used today to describe, quantify and reimburse physicians for their services. In this study we attempted to clarify the relative values of the practice characteristics in vascular surgery and evaluate the propriety compared with the relative value unit (RVU) of the American Medical Association (AMA). METHOD: The classification of practice characteristics in vascular surgery was compared with that of the AMA. The propriety of physicians' work was measured according to the Korean and American physicians' work. The rate more than 70, between 50 to 69, and less than 49 were used to decide over-, proper- or under-estimation, respectively. RESULT: The ratio of the number of practice characteristics in Korean and American vascular surgery was 1:3.31 (97:321). The over-, proper- or under-estimated physicians' work among the identical American practice characteristics was 8/46 (17.4%), 19/46 (41.3%) and 19/46 (41.3%) respectively. CONCLUSION: Our results demonstrated that the practice characteristics of Korean vascular surgery are not sorted by detail and a large percentage of physicians' work (41.3%) is under-estimated. Therefore, reasonable payment for physician services or practices can not be determined for Korean vascular surgery.

A Study on the Blood Processing Costs in Hospital Blood Banks / 대한수혈학회지

BACKGROUND: The blood processing works are composed of phlebotomy, donor testing, manufacturing, storage, transportation, and quality control. Among these, storage, transportation and quality control are done partially at the blood collection centers and finally accomplished at the hospital blood banks. We tried to analyze blood processing costs in hospital blood banks. METHODS: Blood processing costs are divided into physician works, practice expenses, and professional liability insurance according to RBRVS (Resource-Based Relative Value Scale). Physician works were analyzed according to the study of the 'Physician work RBRVS committee of the Korean society for laboratory medicine'. For the practice expenses, three university hospital blood banks data were analyzed. The costs for the blood supply of small clinics or hospitals without blood banks were investigated by questionnaire. RESULTS: Comprehensive works of physician were such as laboratory administration, quality control, preparation of procedure manual, education, quality improvement control. Specific works of physician were such as supervision over technologists, analysis of quality control data, management of blood inventory, storage and issue, blood utilization review, management of adverse transfusion reaction, blood return and disposal. As for one unit of blood, the standard labor time of technologists was 28.8 minutes (which is equivalent of 7,680 won) and the mean equipment cost was 592 won. The mean cost of small clinics or hospitals for blood supply was 12,150 won. CONCLUSION: The reimbursement of blood processing cost for the hospital blood bank would contribute to stable blood bank administration, stable blood supply and safe transfusion.

Korean Medical Insurance System in Rheumatic Diseases / 대한류마티스학회지

Korean resource-based relative value scale (RBRVS) was developed first in 1997 for the alternative of the traditional Korean fee-for-service system. The knowledge about the RBRVS-based fee schedule is necessary to understand the physician payment system of Korean medical insurance. Still now, it is considered that a few more issues should be modified for the most balanced and rational fee schedule in specific situation of Korea. In this article, we analyzed the current Korean medical insurance fee schedule, especially the RBRVS related to rheumatic diseases. And we introduced the guide of the medical service for rheumatic diseases in the view of approved limit under the medical insurance. In addition, the new optional medical service system, which was operated recently, was also evaluated briefly. It is suggested that the medical insurance fee schedule be modified to more acceptable and reasonable one for the best medical services. For that purpose, it is necessary for medical committee and its members to make an efforts continuously on the basis of the great insights of the current fee schedule of Korean medical insurance.

Estimation of Psychiatric Nursing Costs by Using the Resource-Based Relative Value Scale(RBRVS) / 간호학회지

This study was conducted to assess the amount of nursing services for psychiatric inpatients and to estimate psychiatric nursing costs by using the RBRVS. Full details of medical services, including physician and nursing services, for psychiatric inpatients were surveyed and data of general characteristics of hospitals and patients were also collected. The cost of nursing activities was estimated by the multiple conversion factor which was drawn from the Korean RBRVS Development Project to the RBRVS score of each nursing activities, which was drawn from the results of Korean Nurses Association (KNA)'s projects about nursing RBRVS development and cost of nursing activities. The data about 89 inpatients from 3 general hospitals with psychiatric departments were analyzed. The total cost of nursing activities for each patient per admission day was from KRW 22,185 to KRW 27,954 by hospital, and KRW 25,220 in average. The percent of nursing cost to the total cost of medical services was from 36% to 48% by characteristics of patients and 41.4% in average. The cost of nursing activities estimated in this study was between the existing NHI fee schedule and the one suggested by KNA. It is considered as appropriate and acceptable level compared to the total amount of medical services. In the process of KNA's activities to get nursing fee in NHI fee schedule, results of additional studies to estimate the cost of nursing activities balanced with total cost of medical services in every departments should be found and utilized.