Transforming Health Care Through Evidence and Collaboration
Transforming Health Care Through Evidence and Collaboration
The NIHCM Foundation is a nonprofit, nonpartisan organization dedicated to improving the effectiveness, efficiency and quality of America's health care system.
  • Data Insights

    Mental illness has become more common over the last decade, particularly among 18- to 25-year-olds. This Data Insights looks at trends in mental health and their implications for the future.

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  • Briefing

    NIHCM Foundation led a briefing on Capitol Hill to discuss social determinants of health and the opioid crisis with Founding President and CEO Nancy Chockley, former CMS Administrator Don Berwick, Curtis Barnett of Arkansas Blue Cross Blue Shield, Craig Samitt of Blue Cross and Blue Shield of Minnesota, and Grant Baldwin from the CDC.

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  • Data Insights

    As urbanization increases, an older, sicker and poorer population remains in rural America. Despite the health care challenges posed by these changes, promising initiatives can improve rural health.

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  • Advisory Board

    NIHCM Foundation is pleased to welcome Dr. Scott Gottlieb, Sherry Glied, PhD, and Katherine Baicker, PhD, to its distinguished Advisory Board. Their ideas and insights will advance NIHCM's mission to improve health care for millions of Americans.

    Press Release Advisory Board
  • Awards

    NIHCM Foundation hosted the 25th Annual NIHCM Awards at the Organization of American States in Washington, D.C. to recognize outstanding health care research and journalism.

    Press Release Winners Finalists
  • News

    NIHCM welcomed Secretary Azar to a meeting in March to discuss efforts by the Department of Health and Human Services to transform health care by lowering costs and improving value for patients.

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Events

May 08, 2019
Suicide-webinar-graphic-1

The third part in our Defying Despair series delved deeper into the data on suicides and explored a range of initiatives designed to prevent suicide in different communities.

November 26, 2019
usc-drug-prices

Part of the Health Matters webinar series, this webinar explored the likelihood of drug pricing legislation passing before the end of 2019.

In the News

December 2019
Population Health Spotlight
preterm-births-2019

Valuing Physician Work in Medicare: Time for a Change

Miriam J. Laugesen, Ph.D., Assistant Professor, Department of Health Policy and Management, Mailman School of Public Health, Columbia University
Miriam J. Laugesen
Miriam J. Laugesen

For more than 20 years, Medicare pay-ments to physicians have been based on a Resource Based Relative Value Scale (RBRVS) designed to capture the relative variation in physician work, practice expenses, and medical liability insurance costs for each of the more than 7,000 services provided by physicians. Not only do these valuations affect the relative profitability of specific services and the earnings of the specialties that provide them, their use by many Medicaid programs and commercial payers amplifies their impact well beyond Medicare. Despite the critical need to get the values right, however, there is considerable evidence that the values for many services are inaccurate, with misvaluations potentially encouraging provision of surgical and procedural services over primary care.1

The Centers for Medicare and Medicaid Services (CMS) makes annual updates to the RBRVS to reflect developments in technology and medical practice, which create new services and can change the time and effort required to deliver existing services. In addition, the law requires a comprehensive review of the fee schedule values every five years. Hundreds of annual updates and thousands of fee schedule codes make maintenance of the RBRVS a daunting task.

Since the inception of the fee schedule, CMS has relied on the American Medical Association’s Relative Value Scale Update Committee (RUC) to accomplish this work. The RUC is a non-governmental body with membership from the major specialty societies, primary care physicians, the AMA and the osteopathic and allied health professions. It meets three times a year to develop update recommendations for CMS. Between 1994 and 2010 CMS accepted almost 90 percent of RUC recommendations,2 although increasingly CMS has been more likely to disagree with the RUC.

Recent media reports have drawn attention to the role of the medical profession in the update process.3,4 Specialty societies and RUC leadership respond by emphasizing the unique expertise of the committee. What is the real story? In this essay, I provide insights gained from interviews with current and former RUC participants.* My observations confirm the dedication of the RUC members and staff but also reiterate concerns that have been raised by others5 regarding the reliability of the evidence underpinning the RBRVS.

Questionable Data, Selectively Used

To make its work-value recommendations, the RUC largely relies on specialty society surveys that collect data on the intensity of effort and amount of physician time required to provide specific services. Intended to reflect factors such as technical skill, physical exertion and mental stress, estimates of intensity of effort are necessarily subjective and prone to error. Time should be more easily measured, but as early as 2006 researchers used operating room logs to show RUC time estimates were off base.6,7 My comparison of those measured times to 2014 RUC times shows that RUC times remained longer than actual times for 20 of the 24 services studied (Figure 1).Across all 24 services, RUC times overstate real-world times by an average of 33 percent and by as much as 127 percent in one instance. Several problems with the methodology of the surveys and the way the data are used likely contribute to at least some of these discrepancies.

Small and Non-Random Samples

Until this year, the RUC required societies to survey a minimum of 30 physicians (it is now 50). At times, however, it has accepted even smaller samples and permits use of standing panels of physicians who complete surveys regularly. Such panels may not be broadly representative of physicians or specialty society members. For example, one society has used a panel drawn from its practice management section, whose members are likely to have a better understanding than most physicians of reimbursement policy and how survey results can influence payment rates. The problems introduced by small purposive samples are likely compounded by low response rates.

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Events

May 08, 2019
Suicide-webinar-graphic-1

The third part in our Defying Despair series delved deeper into the data on suicides and explored a range of initiatives designed to prevent suicide in different communities.

November 26, 2019
usc-drug-prices

Part of the Health Matters webinar series, this webinar explored the likelihood of drug pricing legislation passing before the end of 2019.

In the News

December 2019
Population Health Spotlight
preterm-births-2019

Grants

Journalism GrantsJournalism Grant Program

We are no longer accepting letters of inquiry for the 2019-2020 round of grantmaking. NIHCM will notify grant winners in November 2019.

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Investigator-Initiated Research Grant Program

We are no longer accepting letters of inquiry for the 2019-2020 round of grantmaking. A small number of applicants will be invited to submit a full proposal in September.

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Awards

Winners Named in the 25th Annual Research and Journalism Awards

Winners Announcment 2018 1

Congratulations to all of the winners of the 25th Annual NIHCM Foundation Research and Journalism Awards! The winners and finalists were honored at a banquet in Washington, DC, in May.

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