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The Resource-Based Relative Value Scale and Physician Reimbursement PolicyUpdating Medicare Relative Value Units FREE TO VIEW

Miriam J. Laugesen, PhD
Author and Funding Information

From the Department of Health Policy and Management, Columbia University, New York, NY.

CORRESPONDENCE TO: Miriam J. Laugesen, PhD, Department of Health Policy and Management, Columbia University, 600 W 168th St, Sixth Fl, New York, NY 10032; e-mail: ml3111@columbia.edu


FUNDING/SUPPORT: This work was supported by the Robert Wood Johnson Investigator Award in Health Policy Research Program.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(5):1413-1419. doi:10.1378/chest.13-2367
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Published online

Most physicians are unfamiliar with the details of the Resource-Based Relative Value Scale (RBRVS) and how changes in the RBRVS influence Medicare and private reimbursement rates. Physicians in a wide variety of settings may benefit from understanding the RBRVS, including physicians who are employees, because many organizations use relative value units as productivity measures. Despite the complexity of the RBRVS, its logic and ideal are simple: In theory, the resource usage (comprising physician work, practice expense, and liability insurance premium costs) for one service is relative to the resource usage of all others. Ensuring relativity when new services are introduced or existing services are changed is, therefore, critical. Since the inception of the RBRVS, the American Medical Association’s Relative Value Scale Update Committee (RUC) has made recommendations to the Centers for Medicare & Medicaid Services on changes to relative value units. The RUC’s core focus is to develop estimates of physician work, but work estimates also partly determine practice expense payments. Critics have attributed various health-care system problems, including declining and growing gaps between primary care and specialist incomes, to the RUC’s role in the RBRVS update process. There are persistent concerns regarding the quality of data used in the process and the potential for services to be overvalued. The Affordable Care Act addresses some of these concerns by increasing payments to primary care physicians, requiring reevaluation of the data underlying work relative value units, and reviewing misvalued codes.

Figures in this Article

Medicare physician payment policy touches almost all physicians and practices. Medicare’s Resource-Based Relative Value Scale (RBRVS) is used, with adaptations, by most private payers,1 and increasingly, the RBRVS is used in salary-based practices to estimate productivity2 and in new payment models, such as Accountable Care Organizations. Not unexpectedly, most physicians are unfamiliar with the details of the RBRVS and how it affects Medicare Physician Fee Schedule (MPFS) payments. Physicians may also not be aware of the yearly update process where physician organizations provide input on changes to the fee schedule. Finally, many physicians may not fully understand the role of the Centers for Medicare & Medicaid Services (CMS) in relation to the American Medical Association (AMA) organization called the Relative Value Scale Update Committee (RUC). This article explains the origins, underlying rationale, and process by which specialty societies, such as the American College of Chest Physicians (CHEST), are involved in regularly updating the RBRVS. In the concluding section, the fairness and relativity of the RBRVS are discussed alongside three important components of the Affordable Care Act (ACA) that aim to address these concerns.

During the early 1980s, policymakers were concerned about two issues: (1) the persistent growth in Medicare expenditures and (2) low reimbursement rates for primary care physicians. These concerns, which are strikingly similar to those discussed today, prompted the Health Care Financing Administration (HCFA) (now called CMS) to explore new payment models, including the development of a new Medicare fee schedule.3 HCFA awarded a contract to William C. Hsiao, an economist at the Harvard School of Public Health, to develop a new payment model.

Hsiao and colleagues4 suggested three kinds of resource inputs that should determine physician reimbursement levels: a physician’s time or work associated with providing a service, which is relatively consistent with the definition used today (Table 1); the costs of running a practice, including professional liability insurance premiums; and the opportunity cost of training amortized over a career. In the resource model that was actually implemented, training costs were not included.

Table Graphic Jump Location
TABLE 1 ]  Components of Physician Work Used in the American Medical Association Relative Value Scale Update Committee Survey

Study researchers developed resource cost estimates for around 460 services described in the Current Procedural Terminology (CPT) and a method to extrapolate this to other services.4 The CPT coding system was just one of many used by physicians, but HCFA was already using CPT in its nomenclature, the Healthcare Common Procedure Coding System. The Healthcare Common Procedure Coding System and CPT became the standard way of coding and billing for physician services across all payers partly because HCFA began using CPT. In retrospect, neither HCFA nor payment reformers understood the implications of linking RBRVS to the CPT system, which is coordinated and copyrighted by AMA. Procedural and surgical services lend themselves more easily to description as discrete CPT codes, which may have been a disadvantage to primary care services.5

Congress authorized a new resource-based payment system in 1989. The resources in the model would be measured in a new “coin of the realm”5 of relative value units (RVUs), and HCFA implemented RVUs and the MPFS in 1992. Initially, the practice expense and liability insurance RVUs were based on historical costs.

Today, > 7,400 Medicare6 services in the MPFS make up a subset of the larger pool of CPT codes. Some codes in the MPFS do not have RVUs, but for the majority that do, the total RVU comprises work, practice expense, and professional liability insurance units. The Medicare payment equals the total RVU multiplied by a dollar conversion factor, which is adjusted for geographic variations in costs. One can look up relative values and payment information for specific CPT codes on the CMS website.7

CMS publishes a new MPFS every year to account for several hundred new and revised CPT codes, usually with RVUs for each service. Before the ACA was implemented, CMS also asked for nominations of potentially misvalued services every 5 years.8

Specialty societies play a key role in the CPT revision process and subsequent RVU determination (Fig 1). The AMA convened the RUC before the RBRVS was fully implemented, and RUC has provided work RVU recommendations to HCFA and CMS since 1993. The RUC is sponsored by the AMA and has a chair and 31 members.1 The committee comprises specialty society representatives, the chair of the RUC Practice Expense Subcommittee, and one representative each of other (nonphysician) health professions, the AMA CPT Editorial Panel, and the AMA. The chair of the RUC does not vote unless in the case of a tie. The Practice Expense Subcommittee and the CPT Editorial Panel members do not vote. Most of the societies represented on RUC have been members since its inception, although more seats have been added (for example, neurology). In 2011, a seat in geriatrics and a rotating seat in primary care were added to address criticisms that the RUC was inadequately representing primary care organizations. Additionally, > 100 other specialty and subspecialty societies are members of a larger RUC advisory committee.

Figure Jump LinkFigure 1 –  The role of RUC recommendations and CMS decisions used in the Medicare Physician Fee Schedule. Note that if CMS revises a subset of codes in response to public comments, revisions are published around 1 year after the final rule and are not open to public comment. AMA = American Medical Association; CMS = Centers for Medicare & Medicaid Services; CPT = Current Procedural Terminology; RUC = Relative Value Scale Update Committee.Grahic Jump Location

After a new CPT code is developed or an old code is rewritten by the AMA CPT Editorial Panel, both the new and the revised codes are forwarded to the RUC, which asks specialty societies whether they want to develop work relative values. Societies make recommendations to RUC and vote on the change. RUC rules require that increases need a two-thirds majority.

RUC sends its recommendations to CMS. After reviewing RUC recommendations, CMS publishes an interim final rule showing new and revised RVUs, which is the basis for Medicare fees paid in the next calendar year. This is usually published between October and December. Physician groups and others can comment on the time and RVU levels in the interim rule through a process known as refinement. CMS typically publishes its response the following fall. At that point, the CMS decision is final.

Like most other agencies,9 CMS usually publishes proposed rules before it makes a rule change, as it does for issues such as misvalued codes. By contrast, in the annual process of updating the fee schedule, CMS rules are implemented almost immediately on January 1 while the rule is interim. However, CMS’s practice could change. In a letter to CMS in April 2014, House Democrats argued that this practice lacks transparency “at a crucial phase of policy development” and that CMS should issue proposed rules before introducing revised RVUs.10

CMS has consistently accepted RUC’s recommendations over the years,11 although starting in 2011, CMS has made more changes to RUC recommendations. The RUC’s role was originally to provide clinical input regarding the government’s review of work values, but its role has expanded: Practice expenses for a code or a family of codes are now reviewed alongside work values, and the RUC has contributed to the design of professional liability RVUs.

Legislation requires changes in RVUs to be budget neutral, meaning that CMS must offset increases in RVUs. In the past, CMS reduced the conversion factor; decreased RVUs for groups of services; or, less commonly, made across-the-board adjustments in RVUs, but specialty societies and the AMA argued that RVU adjustments were disruptive for private payers using the RBRVS. Congress agreed and directed CMS to make budget neutrality adjustments using the conversion factor in 2008.12 CMS also reduced RVUs within some specific code families and specific providers (eg, chiropractic services).13

The annual fee schedule update determines payments by adjusting the dollar conversion factor from year to year. The update factor will vary based on whether actual Medicare expenditure in past years exceeds or is less than prior year estimates compared with targets. When expenditure exceeds the target growth rate (ie, the sustainable growth rate [SGR]), the update is negative, thus reducing the conversion factor. Since 2002, updates have been negative, however, and Congress has reduced almost all the proposed cuts.14 In 2014, Congress considered replacing the SGR.15 Regardless of changes to the SGR, however, Congress has not indicated that it is moving away from the RBRVS as the basis for fee-for-service payment.

Work RVUs

The physician work RVU accounts for about 50% of the total RVU6 and is defined as the physician time and intensity involved in providing a service.8 The time it takes to provide a service is closely related to the total work RVU, and times are used to calculate practice expense RVUs; time, therefore, is an important variable. Intensity is the mental effort, physical effort, technical skill, and psychologic stress involved in providing the service (Table 1).

Work includes “activities before and after direct patient contact”8 and for surgical procedures, preoperative and postoperative physicians services, also known as global periods of service.8 CMS refers to preservice work as preparation before the physician sees the patient, such as scrub, dress, and wait time. Typically, the most intensive component of physician work is intraservice time or face-to-face patient time (also called “skin to skin”). After the patient encounter, postservice work may include communicating with the patient and family or coordinating further care.

The definition of work has not changed substantially since 1992. Hsiao and his team mainly focused on physician work, and the AMA drew on their broad approach (although the administration of the survey and the methods used by Hsiao were different) to develop a standard survey instrument sent to physicians (Table 1). Physicians are asked to estimate the time and intensity of a service under review, whether the patient vignette represents a typical patient, and how the work of the service compares with the work of other services. With RUC authorization, societies can convene their own expert panels to inform specialty society recommendations, especially when the service is performed infrequently, and these are incorporated into the society’s recommendations on RVUs presented to the RUC. Societies develop RVU recommendations based on these sources, although RUC members may question or disagree with society recommendations or interpretation of the data (as can CMS in the rulemaking process), including the relativity between an existing service and the society’s recommendation or the relativity to services in other specialties. RUC members and individuals appearing before the committee have to make conflict of interest declarations.

Practice Expense RVUs

Practice expense RVUs capture the nonphysician costs of providing services and vary according to whether the service is provided in a facility (eg, hospital) or nonfacility (eg, physician’s office).1 The practice expense RVUs for facility-provided services are lower because facilities receive other Medicare payments to account for their expenses; conversely, services in nonfacility settings have higher RVUs because the practice expenses are borne by the physician. As noted, RUC has contributed to the practice expense policies and in 1998, established its own internal practice expense review committee to make recommendations on practice expense RVUs.

Practice expense RVUs are a composite of both direct and indirect practice expenses; each is calculated very differently.1 Direct practice expenses are costs associated with providing a particular service. Specialty society practice expense RVU recommendations sent to CMS include a detailed spreadsheet listing input types for each code: clinical staff time, invoices for equipment costing > $500, and a list of single-use supplies. These direct expenses are reviewed by the RUC and forwarded to CMS with work RVUs. CMS compares RUC recommendations with independent estimates of costs from other sources and maintains a database of costs.

The second type of practice expense is indirect expenses, which are calculated by CMS for each CPT code. Indirect expenses are those that cannot easily be attributed to providing a particular service but are needed to provide the service, such as office rent, electricity, or office supplies. Indirect practice expenses typically vary across specialties, so CMS uses data from the AMA’s Physician Practice Information Survey to understand practice costs for each specialty. The survey has 3,600 respondents in 51 specialties and nonphysician groups. These data allow CMS to estimate average specialty-specific ratios of indirect to direct costs.1,16 To calculate the indirect practice expense for a specific code, CMS would consult claims data to find out which specialty or specialties mainly bill the code. If, for example, a code is mainly billed by obstetricians and gynecologists, then the indirect cost ratio for this specialty is used in the final calculation.

Professional Liability Insurance RVUs

CMS calculates professional liability insurance RVUs based on the mean of state malpractice insurance premium data across specialties. The professional liability insurance RVU for a particular CPT code is the same for a primary care physician, a pulmonologist, or a general surgeon.

The RBRVS is a complex and evolving system, especially given ongoing changes in CMS policies, new legislation, and changes in RUC procedures. However, understanding the rationale for the RBRVS and its broad features may help physicians to understand reimbursement changes or why various services are reimbursed differently. Furthermore, understanding the RBRVS gives physicians insight into a wide range of current and developing reimbursement models across all organizational settings, including blended and bundled17 payments, Accountable Care Organizations, and productivity payments for salaried physicians, because all base payments on the RBRVS.2 With more information, physicians may experience either reduced or increased confidence in its logic and fairness. Increasingly, the relativity of the RBRVS is being questioned.5 Greater understanding of CMS’s acceptance of RUC recommendations (CMS agrees 87.5% of the time)11 has drawn more scrutiny to the process. In addition, changes under the ACA require CMS to explore alternative sources of data.

First, there are persistent income gaps between primary care and procedural and surgical physicians that may reflect greater proportions of such specialties on the RUC.18 These were partly, albeit indirectly, addressed by the ACA. Congress has been reluctant to directly attribute income gaps or undervalued primary care services to the RBRVS, CMS, or RUC, and legislators may believe that making changes is politically challenging. Instead, the ACA took a different approach and increased dollar payments to primary care physicians providing primary care services. However, the fee schedule in general does not have distinctly primary care service codes other than some new transitional care management codes that facilitate a patient’s transition from the hospital. CPT codes are designed to be specialty blind; that is, primary care and general internal medicine physicians can use the same codes as surgical or procedural specialists. Previous CMS efforts in 2007 to increase evaluation and management (E&M) RVUs proved difficult after increases triggered a budget neutrality adjustment for 2008 because payment increases for E&M visits inadvertently increased payments for all physicians. In contrast, the approach used under the ACA side-stepped the RBRVS through legislation; therefore, a budget neutrality adjustment was not needed. This underscores the potential for targeted payment increases (and reductions) and the limitations of using the RBRVS or RUC process alone to address the differences in specialty and primary care reimbursement.

Second, time estimates for services can lose accuracy because physicians get faster at performing procedural and surgical services, but work values (and fees) do not tend to decrease in tandem. Physicians can provide more services per hour, which ultimately leads to income differences. In contrast, office visit times tend to remain more consistent over time. A related issue is the problematic process RUC uses to determine physician times from self-administered physician surveys. The time estimates drawn from these surveys are inaccurate.1921 RUC rules only require data from a minimum of 30 physicians. Data used by the RUC should be collected robustly (including the best use of existing electronic data), and if the RBRVS is retained, the tools used to assess intensity should be scrutinized by experts on work intensity from medicine and other professions.

The ACA gives CMS the power to address this problem by authorizing the Secretary of Health and Human Services to collect data from other sources.22 CMS launched a national study23 that is collecting time data from physician practices; the findings may bolster claims that the RUC times need revising. By participating in this survey and others (eg, the National Ambulatory Medical Care Survey), physicians can contribute to improving the evidence base underlying payment policy. Whether the RBRVS is retained will at least partly depend on whether the service codes are perceived as accurately and appropriately reflecting the work associated with each service. Thus, E&M service code vignettes and CPT code descriptions need to be brought up to date and then appropriately valued.5

Third, some services may be overvalued. The ACA attempts to address relativity problems caused by overvalued services by requiring CMS to review potentially misvalued services. CMS now calls for nominations of misvalued codes every year and identifies codes for review based on criteria included in the ACA. The ACA essentially extended and formalized CMS and RUC misvalued code initiatives, and CMS and RUC report reviewing > 1,000 codes. However, CMS has also acknowledged that most of the RVU decreases in 2012 were due to reductions in payments for services provided to the same patient on the same day.24 And specialty societies can also ask Congress to dial back decreases, such as those for in imaging service payments.25 In general, however, reviewing misvalued codes represents the ethos of the ACA to target resources more efficiently, which is supported by many physicians. Indeed, CHEST members have called on their colleagues to make practice changes to reduce health-care costs and improve quality.26 CMS has also commissioned research to help it to address misvalued codes.27

The ACA-related changes may ultimately reshape the RBRVS. However, as this overview shows, incremental changes that have immediate and specific impacts occur within the fee schedule on an ongoing basis. CMS posts many of its physician fee schedule proposed rules for comment online28 every year, providing a key opportunity for individual physicians to provide input. Physicians can also submit feedback on rules through committees, such as the CHEST Reimbursement and Regulations Committee and the American Thoracic Society Clinical Practice Committee. These committees draft responses to proposed regulations on behalf of their members.

Policymakers want to know whether they have overlooked important practical issues so that they can prevent implementation problems, and comments do influence agency rules.29 In most policy areas, agency officials find comments based on data, evidence,30 or technical expertise the most helpful.

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

ACA

Affordable Care Act

AMA

American Medical Association

CHEST

American College of Chest Physicians

CMS

Centers for Medicare & Medicaid Services

CPT

Current Procedural Terminology

E&M

evaluation and management

HCFA

Health Care Financing Administration

MPFS

Medicare Physician Fee Schedule

RBRVS

Resource-Based Relative Value Scale

RUC

Relative Value Scale Update Committee

RVU

relative value unit

SGR

sustainable growth rate

Smith SL., ed. Medicare RBRVS: The Physicians’ Guide 2012. Chicago, IL: American Medical Association; 2012.
 
Goldsmith J. Accountable care organizations: the case for flexible partnerships between health plans and providers. Health Aff (Millwood). 2011;30(1):32-40. [CrossRef] [PubMed]
 
Hsiao WC, Braun P, Dunn D, Becker ER. Resource-based relative values. An overview. JAMA. 1988;260(16):2347-2353. [CrossRef] [PubMed]
 
Hsiao WC, Braun P, Dunn DL, et al. An overview of the development and refinement of the Resource-Based Relative Value Scale. The foundation for reform of US physician payment. Med Care. 1992;30(11 suppl):NS1-NS12. [PubMed]
 
Kumetz EA, Goodson JD. The undervaluation of evaluation and management professional services: the lasting impact of Current Procedural Terminology code deficiencies on physician payment. Chest. 2013;144(3):740-745. [CrossRef] [PubMed]
 
Centers for Medicare & Medicaid Services. Medicare Physician Fee Schedule(Payment System Fact Sheet Series). Vol ICN 006814. Baltimore, MD: Centers for Medicare & Medicaid Services; 2013.
 
Center for Medicare & Medicaid Services. Physician fee schedule overview. Centers for Medicare & Medicaid Services website. http://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Accessed July 25, 2013.
 
Social Security Act, USC §1848(c)(1)(A) (2013).
 
Kerwin CM, Furlong SR. Rulemaking: How Government Agencies Write Law and Make Policy.4th ed. Washington, DC: CQ Press; 2011.
 
Levin S, Waxman HA, McDermott J, Pallone F Jr. Letter to Honorable Marilyn Tavenner, Administrator Centers for Medicare & Medicaid Services, April 8. United States Congress. Washington, DC: House Energy and Commerce Committee; 2014.
 
Laugesen MJ, Wada R, Chen EM. In setting doctors’ Medicare fees, CMS almost always accepts the relative value update panel’s advice on work values. Health Aff (Millwood). 2012;31(5):965-972. [CrossRef] [PubMed]
 
Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Pub L No. 110-275.
 
Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; payment policies under the physician fee schedule, five-year review of work relative value units, clinical laboratory fee schedule: signature on requisition, and other revisions to part B for CY 2012. Final rule with comment period. Fed Regist. 2011;76(228):73026-73474. [PubMed]
 
Laugesen MJ. Siren song: physicians, congress, and Medicare fees. J Health Polit Policy Law. 2009;34(2):157-179. [CrossRef] [PubMed]
 
Health Policy Brief: Medicare payments to physicians. Health Policy Brief. 2013;33(5). Health Affairs website. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=85. Accessed March 20, 2013.
 
Centers for Medicare & Medicaid Services. Medicare program; payment policies under the physician fee schedule and other revisions for part B for CY 2010. Fed Regist. 2009;74(226):61737-62188. [PubMed]
 
Landon BE, Roberts DH. Reenvisioning specialty care and payment under global payment systems. JAMA. 2013;310(4):371-372. [CrossRef] [PubMed]
 
Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. 2007;146(4):301-306. [CrossRef] [PubMed]
 
Cromwell J, Hoover S, McCall N, Braun P. Validating CPT typical times for Medicare office evaluation and management (E/M) services. Med Care Res Rev. 2006;63(2):236-255. [CrossRef] [PubMed]
 
McCall N, Cromwell J, Braun P. Validation of physician survey estimates of surgical time using operating room logs. Med Care Res Rev. 2006;63(6):764-777. [CrossRef] [PubMed]
 
Braun P, McCall N. Improving the Accuracy of Time in the Medicare Physician Fee Schedule: Feasibility of Using Extant Data and of Collecting Primary Data. Washington, DC: Medicare Payment Advisory Commission; 2011.
 
Centers for Medicare & Medicaid Services. Medicare program; revisions to payment policies under the physician fee schedule, clinical laboratory fee schedule & other revisions to part B for CY 2014.Fed Regist. 2013;78(237):74229-74823.
 
Department of Health and Human Services Office of the Secretary. Notice: agency information collection activities; proposed collection; public comment request. Fed Regist. 2013;78(30):10174-10175.
 
Centers for Medicare & Medicaid Services. Medicare program; revisions to payment policies under the physician fee schedule, DME face-to-face encounters, elimination of the requirement for termination of non-random prepayment complex medical review and other revisions to part B for CY 2013. Fed Regist. 2012;76(228):73026-73474.
 
American College of Radiology. Multiple procedure payment reduction and H.R. 846/S. 623, the Diagnostic Imaging Services Access Protection Act. American College of Radiology website. http://www.acr.org/Advocacy/Legislative-Issues/MPPR. Accessed September 24, 2013.
 
Collop N, Diamond E, Phillips B, Sessler CN, Simpson SQ. Health-care reform and chest physicians. Chest Physician. 2012;;(August):18-19.
 
Center for Medicare & Medicaid Services. Medicare physician fee schedule (PFS): development of a validation model for work relative value units (RVUs). Centers for Medicare & Medicaid website. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/RVUs-Validation-Model.pdf. Accessed May 27, 2014.
 
E-Rulemaking Program Management Office. Regulations.gov website. http://www.regulation.gov. Accessed September 23, 2013.
 
Shapiro S. Does the amount of participation matter? Public comments, agency responses and the time to finalize a regulation. Policy Sci. 2008;41(1):33-49. [CrossRef]
 
Knight J. Six tips on how to write an effective SEC rulemaking comment letter. Corporate Governance Advisor. 2012;20(6):22-23.
 

Figures

Figure Jump LinkFigure 1 –  The role of RUC recommendations and CMS decisions used in the Medicare Physician Fee Schedule. Note that if CMS revises a subset of codes in response to public comments, revisions are published around 1 year after the final rule and are not open to public comment. AMA = American Medical Association; CMS = Centers for Medicare & Medicaid Services; CPT = Current Procedural Terminology; RUC = Relative Value Scale Update Committee.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Components of Physician Work Used in the American Medical Association Relative Value Scale Update Committee Survey

References

Smith SL., ed. Medicare RBRVS: The Physicians’ Guide 2012. Chicago, IL: American Medical Association; 2012.
 
Goldsmith J. Accountable care organizations: the case for flexible partnerships between health plans and providers. Health Aff (Millwood). 2011;30(1):32-40. [CrossRef] [PubMed]
 
Hsiao WC, Braun P, Dunn D, Becker ER. Resource-based relative values. An overview. JAMA. 1988;260(16):2347-2353. [CrossRef] [PubMed]
 
Hsiao WC, Braun P, Dunn DL, et al. An overview of the development and refinement of the Resource-Based Relative Value Scale. The foundation for reform of US physician payment. Med Care. 1992;30(11 suppl):NS1-NS12. [PubMed]
 
Kumetz EA, Goodson JD. The undervaluation of evaluation and management professional services: the lasting impact of Current Procedural Terminology code deficiencies on physician payment. Chest. 2013;144(3):740-745. [CrossRef] [PubMed]
 
Centers for Medicare & Medicaid Services. Medicare Physician Fee Schedule(Payment System Fact Sheet Series). Vol ICN 006814. Baltimore, MD: Centers for Medicare & Medicaid Services; 2013.
 
Center for Medicare & Medicaid Services. Physician fee schedule overview. Centers for Medicare & Medicaid Services website. http://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Accessed July 25, 2013.
 
Social Security Act, USC §1848(c)(1)(A) (2013).
 
Kerwin CM, Furlong SR. Rulemaking: How Government Agencies Write Law and Make Policy.4th ed. Washington, DC: CQ Press; 2011.
 
Levin S, Waxman HA, McDermott J, Pallone F Jr. Letter to Honorable Marilyn Tavenner, Administrator Centers for Medicare & Medicaid Services, April 8. United States Congress. Washington, DC: House Energy and Commerce Committee; 2014.
 
Laugesen MJ, Wada R, Chen EM. In setting doctors’ Medicare fees, CMS almost always accepts the relative value update panel’s advice on work values. Health Aff (Millwood). 2012;31(5):965-972. [CrossRef] [PubMed]
 
Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Pub L No. 110-275.
 
Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; payment policies under the physician fee schedule, five-year review of work relative value units, clinical laboratory fee schedule: signature on requisition, and other revisions to part B for CY 2012. Final rule with comment period. Fed Regist. 2011;76(228):73026-73474. [PubMed]
 
Laugesen MJ. Siren song: physicians, congress, and Medicare fees. J Health Polit Policy Law. 2009;34(2):157-179. [CrossRef] [PubMed]
 
Health Policy Brief: Medicare payments to physicians. Health Policy Brief. 2013;33(5). Health Affairs website. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=85. Accessed March 20, 2013.
 
Centers for Medicare & Medicaid Services. Medicare program; payment policies under the physician fee schedule and other revisions for part B for CY 2010. Fed Regist. 2009;74(226):61737-62188. [PubMed]
 
Landon BE, Roberts DH. Reenvisioning specialty care and payment under global payment systems. JAMA. 2013;310(4):371-372. [CrossRef] [PubMed]
 
Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. 2007;146(4):301-306. [CrossRef] [PubMed]
 
Cromwell J, Hoover S, McCall N, Braun P. Validating CPT typical times for Medicare office evaluation and management (E/M) services. Med Care Res Rev. 2006;63(2):236-255. [CrossRef] [PubMed]
 
McCall N, Cromwell J, Braun P. Validation of physician survey estimates of surgical time using operating room logs. Med Care Res Rev. 2006;63(6):764-777. [CrossRef] [PubMed]
 
Braun P, McCall N. Improving the Accuracy of Time in the Medicare Physician Fee Schedule: Feasibility of Using Extant Data and of Collecting Primary Data. Washington, DC: Medicare Payment Advisory Commission; 2011.
 
Centers for Medicare & Medicaid Services. Medicare program; revisions to payment policies under the physician fee schedule, clinical laboratory fee schedule & other revisions to part B for CY 2014.Fed Regist. 2013;78(237):74229-74823.
 
Department of Health and Human Services Office of the Secretary. Notice: agency information collection activities; proposed collection; public comment request. Fed Regist. 2013;78(30):10174-10175.
 
Centers for Medicare & Medicaid Services. Medicare program; revisions to payment policies under the physician fee schedule, DME face-to-face encounters, elimination of the requirement for termination of non-random prepayment complex medical review and other revisions to part B for CY 2013. Fed Regist. 2012;76(228):73026-73474.
 
American College of Radiology. Multiple procedure payment reduction and H.R. 846/S. 623, the Diagnostic Imaging Services Access Protection Act. American College of Radiology website. http://www.acr.org/Advocacy/Legislative-Issues/MPPR. Accessed September 24, 2013.
 
Collop N, Diamond E, Phillips B, Sessler CN, Simpson SQ. Health-care reform and chest physicians. Chest Physician. 2012;;(August):18-19.
 
Center for Medicare & Medicaid Services. Medicare physician fee schedule (PFS): development of a validation model for work relative value units (RVUs). Centers for Medicare & Medicaid website. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/RVUs-Validation-Model.pdf. Accessed May 27, 2014.
 
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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543