RBRVS the Killer of Basic Health Access

The Resource Based Relative Value Scale has had major impact on the shaping of the US health care workforce since 1990. The effects can only be described as distortions favoring the few doing well and harming most services (basic health access) and most Americans who have little else remaining of local health care other than basic health access.

By devaluing primary care and basics, the workforce is shaped away from primary care and basics. The impact involves MD DO NP PA RN and other delivery team members. Fewer enter basics and those who do enter are more and more likely to leave. For those most valued by RBRVS there are better paychecks, benefits, team members, and salaries.

RBRVS sets up less experience in the workforce and in the other delivery team members. The deficits of experience are a function of the financial design with the most impact on the basics that have lesser financing. The design contributes to lower productivity, higher turnover costs, and a steadily worsening financial design.

Historical Context

Hsaio and others published in JAMA about "...measuring the work (intraservice work) of performing medical services and procedures, estimating preservice and postservice work, comparing work across specialties, measuring practice costs, extrapolating from surveyed services, and establishing an RBRVS for evaluation/management services and for invasive procedures." This was implemented into what became RBRVS.

Note that the 1980s period involved a number of major changes such as Diagnosis Related Groups, Prospective Payments, Graduate Medical Education, managed care focus, and the Resource Based Relative Value Scale.

• These all favored those bigger, academic, subspecialty, and most concentrated in workforce
• Not big, not academic, lowest in concentrations of workforce - fell further behind by design

A Recent Discussion of the History of RBRVS is Useful to Review at Primary Care for America

https://www.youtube.com/watch?v=tJXBmvJZKMI&list=PLH_7_imEUNKU2rLF4Hdn0SAqsTEFd3PDS&index=10

RBRVS is about

1. clinician work and
2. resources involved (mostly 1 and 2)
3. with some liability costs considered.

The 1989 implementation followed the cost cutting designs of the era. This is not surprising as the 1980s involved a period of runaway health care costs.

RBRVS was set in concrete

...by the establishment of budget neutrality. To get any increases even if needed in primary care or basic health access, there must be cuts in other areas to compensate for any increases. The increases for basic health access would have to get past regulatory capture (embedded special interests) and budget neutrality and the most powerful health care lobbies in the nation.

There has always been questionable objectivity.

Those involved in designs are often higher income, most urban, academic, subspecialty, and hospital. Basic health access for most Americans most behind is unlikely to be understood and is most likely to be abused - and this has been the case.

Critique of RBRVS is about being too clinician centric and archaic.

RBRVS fails to consider

• The fact that care is delivered by teams with better and worse teams shaped by the RBRVS design
• Changes in practice over 30 years
• Many areas of effort and cost in primary care that are not covered as they are not a part of the original design (EHR, phone calls, communications, changes in technology)
• A need basis for the service
• A need basis for 40% of Americans facing deficits of workforce and access
• Inequities in the financial design as public and private plan patients are stuck with the worst health plans and limitations in access along with the rest of the population across vast regions where public and private plan finances cause and worsen deficits of workforce and access
• Outcome based - It was great to hear Kevin Hayes in the video presentation question whether innovative payment designs can do anything about the financial design. He questioned this "magical thinking." I also feel that primary care leaders must stop this magical thinking and attitudes of support for the CMS micromanagement fiascos that only get worse. When basic health access is a few hundred billion behind small changes are ridiculous.
• The pecking order that RBRVS sets up

Winners and Losers

The Community Health Centers and practices with higher proportions of Medicaid and other worst paying plans - are the most behind by design. HRSA with a few tens of billions is no match for CMS with 1.4 trillion shaping movement from those least financed to better financed primary care and to procedural, technical, subspecialized and hospital areas. Highest payments and most lines of revenue shape more and better delivery team members to share the load, better salaries, and better environments.

Distortions of health professional workforce are seen with movement to areas with the most lines of revenue and highest payments as MD DO NP PA depart primary care and basics as well as the 2621 counties forever lowest in health care workforce where 41 years of abusive designs combine their impacts.

It was quite sad to hear that it took Barbara Levy and others over 30 years to get improvements in office payments across the specialties.

Serious Flaws

Kevin Hayes pointed out the tiny sum of 93 billion a year spent on the fee schedule,

The panel pointed out the passive decline as the fixed design adds more services and does not consider burdens shifted from hospitals to practices.

Payments 27% less over 35 years can only continue to decline by design