A method for estimating the preservice and postservice work of physicians' services.

The goal of the Resource-Based Relative Value Scale is to measure the resource costs of physicians' services, or, more centrally, the physicians' total work. This article describes the estimation of relative values for physicians' work before and after the performance of a service (preservice and postservice work). For methodological and practical reasons, we could not obtain direct ratings of preservice and postservice work except for a few services. We therefore developed a systematic process to estimate preservice and postservice time and rate of work per unit of time. Then time and work per unit of time were multiplied to estimate work. The major finding of our investigation is that preservice and postservice work make up a substantial portion of total work. The typical percentages of total work accounted for by preservice and postservice work range from 26% and 33% for imaging services and evaluation and management services, respectively, to 46% for invasive services performed in a hospital inpatient setting.

Cross-specialty linkage of resource-based relative value scales. Linking specialties by services and procedures of equal work.

This article describes methods used to combine into a common scale resource-based relative values from separate specialties. The key to producing a common scale is identifying pairs ("links") of services from different specialties that require approximately equal amounts of intraservice work. We distinguished two kinds of pairs of link services, those judged to be the same and those judged to be equivalent, usually within a narrow category of medical activity. Working with a cross-specialty panel of physicians and with data on time factors from a national survey, we selected sufficient links to connect each specialty to others by at least four links. We then used the weighted least-squares method to locate all the links optimally on a single, common scale. Analyses of the accuracy of this scale showed that the typical disagreement between specialties about where to locate the intraservice work of a given service was only 7%. Other analyses showed that the accuracy of the common scale was not sensitive to different classes of links.

Resource-based relative values for invasive procedures performed by eight surgical specialties.

We surveyed approximately 850 physicians in eight surgical specialties to investigate physicians' work in performing invasive services. Building on our analysis of physician work, we developed a relative value scale of physicians' services based on resource costs. First, we found that physician charges are not set in proportion to the resources required to perform a given procedure: there is a threefold variation, across hospital-based invasive procedures, in the ratio of charges to resource-based relative values. Second, for most procedures, the preoperative and postoperative periods represent 60% to 75% of a physician's total service time, but only 35% to 50% of the total service work. Lastly, intraoperative work per unit of time varies greatly. Work per minute for invasive procedures is two to three times that of medical office visits and is strikingly greater for some specialties. The Resource-Based Relative Value Scale, at a minimum, represents a useful tool for payers to identify procedures with potentially aberrant charges and also offers unique insights into the nature of physicians' work.

Results and policy implications of the resource-based relative-value study.

The resource-based relative-value scale (RBRVS) is a measure of relative levels of resource input expended when physicians produce services and procedures. It is a function of the physician's work input, the opportunity cost of specialty training, and the relative practice costs for each specialty. This paper presents resource-based relative values (RBRVs) for selected procedures of four major specialties--family practice, internal medicine, general surgery, and thoracic and cardiovascular surgery. We compare RBRVs with current charges and find several general patterns. Invasive procedures are typically compensated at more than double the rate of evaluation-and-management services, when both consume the same resource inputs. Imaging and laboratory procedures fall between invasive and evaluation-and-management services. We analyze the financial implications of the RBRVS by developing a simple model and simulating the effects of an RBRVS-based fee schedule on physicians' revenues in various specialties. We use Medicare data to perform the simulation under the "budget-neutral" assumption. Results show that an RBRVS-based fee schedule affects specialties differently. The average family practitioner could receive 60 percent more revenue from Medicare, whereas the average ophthalmologist could lose 40 percent of current revenues. The effects on other specialties fall between these two.

Hemodynamic and platelet response to the bolus intravenous administration of porcine heparin.

There is considerable evidence that under some conditions intravenous heparin infusion may cause or at least enhance platelet aggregation in vivo. Reports of heparin-induced vasodilatation and decreases in arterial blood pressure have not been accompanied by simultaneous observations of the platelet response. In this study both the hemodynamic and platelet response to the bolus administration of porcine intestinal mucosa sodium heparin were monitored in 24 cardiac and 12 vascular surgery patients. Mean arterial blood pressure decreased 7.1 +/- 0.8 mmHg as a result of a 247 +/- 34 dyne X sec/cm5 decrease in systemic vascular resistance. Platelet count, platelet volume distribution, and beta-thromboglobulin levels did not change with heparin infusion. These responses did not differ when comparing the 155 unit/kg group and the 400 unit/kg group or the 400 unit/kg groups treated with different commercial preparations. The single patient who did have a decrease in platelet count and a severe rise in beta-thromboglobulin with heparin died intraoperatively of a massive myocardial infarction. Large increases in platelet factor 4 with heparin administration were not associated with platelet release but were dependent on whether or not the patient was treated with preoperative subcutaneous or intravenous heparin. There was no evidence that heparin-induced vasodilatation was mediated by platelet aggregation and release.