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There are many statistics that illustrate the flaws of the U.S. health-care system. One in particular stands out. In 2017, Americans spent an average of $10,224 per person on health [...]

AbstractIn 2016, the Flagship Program for improving health systems performance and equity, a partnership for leadership development between the World Bank and the Harvard T.H. Chan School of Public Health and other institutions, celebrates 20 years of achievement. Set up at a time when development assistance for health was growing exponentially, the Flagship Program sought to bring systems thinking to efforts at health sector strengthening and reform. Capacity-building and knowledge transfer mechanisms are relatively easy to begin but hard to sustain, yet the Flagship Program has continued for two decades and remains highly demanded by national governments and development partners. In this article, we describe the process used and the principles employed to create the Flagship Program and highlight some lessons from its two decades of sustained success and effectiveness in leadership development for health systems improvement.

China's 3 year, CN¥850 billion (US$125 billion) reform plan, launched in 2009, marked the first phase towards achieving comprehensive universal health coverage by 2020. The government's undertaking of systemic reform and its affirmation of its role in financing health care together with priorities for prevention, primary care, and redistribution of finance and human resources to poor regions are positive developments. Accomplishing nearly universal insurance coverage in such a short time is commendable. However, transformation of money and insurance coverage into cost-effective services is difficult when delivery of health care is hindered by waste, inefficiencies, poor quality of services, and scarcity and maldistribution of the qualified workforce. China must reform its incentive structures for providers, improve governance of public hospitals, and institute a stronger regulatory system, but these changes have been slowed by opposition from stakeholders and lack of implementation capacity. The pace of reform should be moderated to allow service providers to develop absorptive capacity. Independent, outcome-based monitoring and evaluation by a third-party are essential for mid-course correction of the plans and to make officials and providers accountable.

Discusses the state of the health care system in China, as of April 2004. Strategy used by China regarding rural health services; Comparison of urban and rural health conditions, including infant mortality; Impact of two economic policies implemented in the country on the rural health sector.

In the Spring 1995 issue of Health AffairsMark Pauly and John Goodman outlined their proposal for medical savings accounts (MSAs) supplemented with tax credits to purchase insurance and encourage cost-effective consumer behavior. This proposal has been widely debated, both in Washington and across the nation. To further enlighten the debate, Health Affairspresents two accounts of the experience with MSAs in Singapore, which differ over how successful Singapore has been at controlling health spending using MSAs. In part, this difference reflects a divide in the broader debate over the outcomes by which MSAs should be evaluated. It is clear that there is ample room here to sustain a debate between honest, serious parties. The result of the exchange is an enriched discussion that will prepare the reader to reach an informed judgment.

On January 1,1992, the Health Care Financing Administration implemented the 1989 legislation reforming the Medicare payment system for physicians' services. The cornerstone of the new payment reform is the Medicare Fee Schedule (MFS), which is based on the Resource-Based Relative Value Scale (R6RVS). In this article, the major findings of the R6RVS study and its impacts on physician payment are summarized. The authors report the impacts of a RBRVS-based fee schedule on Medicare fees and physicians' income if it were fully implemented, assuming budget neutrality and absence of volume changes in services. Under this scenario, fees for evaluation and management services increase by 15% to 45%, while fees for invasive services and diagnostic tests decrease by 20% to 30%. These changes increase the Medicare income of family practitioners by more than 30% while decreasing the income of most surgical specialties by 10% to 20%.

Responding to distortions in payment rates between services, policymakers in the United States have sought a systematic and rational foundation for determining physician fees. One such approach to paying physicians, the Resource- Based Relative Value Scale (RBRVS), determines fees by measuring the relative resource costs required to produce them. On January 1,1992, the Medicare program implemented a new payment system for physician services based on the RBRVS. This article provides a brief history of the RBRVS and a summary of the methods and data used to derive it. This overview represents the culmination of 6 years of research by the Harvard RBRVS study team and provides a road map to the study's concepts and definitions. The overview also provides a context for the articles in this issue that describe five major studies undertaken since 1988. The study's overall results are presented in the last article of the series.

This article presents the overall results of the Resource-Based Relative Value Scale (RBRVS) study. We present resource-based relative values for selected services in each of the 18 specialties we studied. We found that preservice and postservice work represents close to 50% of total work for invasive services and 33% of total work for evaluation/management services. We also found that the work per unit time (a measure of intensity) for invasive services is about three times that of evaluation/management. We developed a simple model and simulated an RBRVS-based fee schedule for the Medicare program under a "budget-neutral" assumption. Results for 30 commonly performed services show that office visit fees for evaluation/management services could rise by 70%, while some surgical fees could drop by 60%. We also simulated what the Medicare outlays would have been in 1986 for categories of medical services under an RBRVS-based fee schedule. We found that total Medicare payments for evaluation/management services would have increased by about 56%. Invasive, imaging, and laboratory services would have decreased by 42%, 30%, and 5%, respectively. We also discuss implementation issues related to an RBRVS-based fee schedule, such as the determination of a monetary conversion factor, practice costs, billing codes, and the need to evaluate the potential impacts of an RBRVS-based payment system on the cost and quality of health care.(JAMA 1988;260:2429-2438)

A national survey of physicians produced detailed data on the work involved in performing 372 different services. This article describes methods developed to extrapolate the study data to a larger universe of services, defined by the Physicians' Current Procedural Terminology, edition 4. Because data measuring work inputs for nonsurveyed services presently are unavailable, we devised an extrapolation method that makes use of available charge data without building their inherent distortions into the extrapolated scale. To neutralize the effect of these distortions, we used small, homogeneous families of services as the basic units for the extrapolations and assumed that charges are reasonable indicators of relative work within such families. To produce extrapolated work values within each family, we multiplied an estimate of work based on survey data for a benchmark procedure by charge-based ratios that represent the relationships between surveyed and nonsurveyed services. These extrapolations can be used in constructing a Resource-Based Relative Value Scale.(JAMA 1988;260:2379-2384)

Practice costs, defined as those costs of medical practice that exclude the physician's own time and effort, represent a substantial portion of the resources necessary to perform a service. In this article we describe the development of the practice cost index used in constructing the Resource-Based Relative Value Scale (RBRVS). We derived the practice cost index value for each specialty, using specialty-specific practice costs and gross revenue data. The index values for all other specialties are standardized to the value for general surgery, and these are used to adjust the resource-based relative values for services performed by each specialty; in this way, the RBRVS incorporates practice cost variations. The data used in the construction of the practice cost index are the 1983 Physician Practice Cost and Income Survey data, adjusted to reflect the relative levels of 1986 professional liability insurance. Our findings show that, among most specialties, the range of relative difference in practice costs as a percentage of gross revenue is approximately 15%. Four specialties fall outside this range: pathology, psychiatry, rheumatology, and orthopedic surgery. We discuss problems with the available data on practice costs as these relate to their use in the RBRVS and conceptual issues in applying practice costs to the construction of the RBRVS.(JAMA 1988;260:2397-2402)

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.(JAMA 1988;260:2418-2424)

Studies have been conducted over the past decade to develop a Resource-Based Relative Value Scale (RBRVS) for physicians' services. Policymakers view an RBRVS as a potential tool to pay physicians. The Physician Payment Review Commission, under a congressional mandate, has endorsed the general concept of a fee schedule based on resource costs for physician payment under Medicare. In this overview article, we present the policy context in which the RBRVS may play a role and describe the approach taken to develop this scale, specifically consultation with clinicians, researchers, and insurers and data gathering, including a national survey of physicians. We discuss underlying elements that are necessary to constructing an RBRVS, each of which is described more fully in subsequent articles: 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. Overall results are presented in a companion article.(JAMA 1988;260:2347-2353)

The goal of the Resource-Based Relative Value Scale is to measure the resource costs of physicians' services, or, more centrally, the physician's 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.(JAMA 1988;260:2371-2378)

The work that physicians perform represents a major resource input to medical services and procedures. In this article we describe the concepts of work and its dimensions, as well as the methods developed to measure them. We also describe the design and results of a national probability survey of physicians in 18 specialties. We present the results—estimated values of work and its dimensions—for selected services. Our findings indicate that physicians can give reliable and valid ratings of work and that we can model this work as a function of four dimensions: time, mental effort and judgment, technical skill and physical effort, and stress. Analyzing the complex functional relationship between work and these four dimensions shows that all four dimensions are important and statistically significant in predicting work. Time is a more important dimension in predicting work for medical specialties than for surgical specialties, with the estimated regression coefficients between.3 and.5 and.2 and.3, respectively. In contrast, technical skill is a more important dimension in predicting work in surgical specialties than for medical specialties, with the estimated regression coefficients between.3 and.5 and.2 and.3, respectively. Finally, we found that an exponential equation of the four dimensions precisely describes total work.(JAMA 1988;260:2361-2370)

Evaluation and management (E/M) services, which include making diagnoses, counseling and educating, developing strategies of care, and following up on treatment, are common to all medical specialties. Surveys of a variety of specialists using the magnitude-estimation method show that physicians agree closely in rating the work of particular E/M services. Regardless of the type of E/M service, the site at which it is performed, or the specialty performing it, work per unit of time varies only slightly. Comparison of work and time for services to which experts assigned billing codes in our consultative process indicates, however, that there may be large differences in the way different specialties use these billing codes. In some instances, work entailed by some of the E/M billing codes within specialties also appears to vary substantially. If empirical studies of physicians' coding and billing practices support our findings, possible responses might include (1) developing specialty-specific resource-based relative values for E/M services and (2) redefining the Physicians' Current Procedural Terminology, edition 4, codes for these services in terms that include time specifications.(JAMA 1988;260:2409-2417)

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 zzclasses of links.(JAMA 1988;260:2390-2396)

Prologue:In many respects, New Jersey's state-regulated hospital payment scheme served as a prototype for Medicares prospective payment system. New Jersey';s model served, in the political realm, as evidence that prospective payment could he implemented without causing an upheaval in the hospital world. At the time of congressional enactment, of course, there was not a lot of empirical evidence regarding the impact that prospective payments based on diagnosis-related groups (DRGs) would have on the cost of medical care. In this essay, the authors report for the first time the initial phase of an extensive evaluation of New Jersey's experience with reimbursing hospitals based on DRGs. William Hsiao is a professor of economics at the Harvard School of Public Health. An actuary who has a deep understanding of how insurance works and how the insurance industry operates, Hsiao is a frequent congressional witness and consultant. Hsiao currently is engaged in a closely watched exercise that is funded by the Health Care Financing Administration to develop a relative fee scale for possible use in reforming Medicares current physician payment method. Harvey Sapolsky is a professor of public policy and organization at the Massachusetts Institute of Technology (MIT). Sapolsky, whose interest in health policy issues evolved from a fascination with technology (he served on the National Heart and Lung Institutes committee on the artificial heart in the early 1970s), has delved into a wide variety of subjects over the last decade, including the medical care system of the Veterans Administration, private employer attitudes on health care costs, blood banking, and, most recently, the health effects of common consumer products, which is the subject of a soon-to-be-released book he has authored. Daniel Dunn is an economist who works with Hsiao at the Harvard School of Public Health. Sanford Weiner, a political scientist, is a research associate at MIT's Whitaker College of Health Science, Technology, and Management.

This article describes the design and methods of a study currently under way to develop a Resource-Based Relative Value Scale (RBRVS); an alternative basis for establishing the payment rate for the services and procedures (S/Ps) of physicians in medical and surgical specialties. Physician resource inputs to be measured include (1) S/P time, (2) pre-S/P and post-S/P times, (3) intensity, (4) practice costs, including malpractice premiums, and (5) the cost of specialty training. These five factors will be combined to produce an RBRVS denominated in nonmonetary units. In the initial phase of the study, data on time and intensity will be obtained through a national survey of physicians who perform these S/Ps. In the second, consensus phase of the project, the investigators will convene a panel of representatives of the medical profession, third-party payers, consumers, and other interested parties to examine areas of agreement and disagreement as to how an RBRVS should be used for policy purposes. The final results of this study are expected by the summer of 1988.(JAMA 1987;258:799-802)

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In Reply.—Dr Janower has expressed views on several aspects of the Resource-Based Relative Value Scale that are incorrect or that indicate misunderstanding of the design of the project.Most important, the intensity of a procedure or service cannot only be measured, but can be measured quite accurately. Unlike measurement of time, practice costs, and the opportunity costs of training, intensity cannot be measured by objective means. Subjective assessments are, however, neither unscientific nor arbitrary. During the past 25 years, measurement psychologists have developed methods and demonstrated that one can obtain, using subjective judgments, reproducible and valid measurements of previously unquantified matters when assessments are obtained in carefully designed studies.1With the aid of experts in the field of measurement psychology, we have designed studies, using the method of magnitude estimation, of the relative work of physicians' services and have subjected this methodology to extensive validation trials. The methods