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Changes that are the consequences of the transformation of health care into an industry are reviewed. The primary focus is on the effects of this transformation and government finding policies on physician reimbursement for cardiac surgery. Also addressed are Relative Values Scales as the basis for physician reimbursement, physician payment reform under the Omnibus Budget Reconciliation Act of 1989, impact of Medicare policy on surgical volume and surgeon income over recent years, provisions of the Medicare plan under current consideration, and impact of the Congressional-mandated resource-based practice expense relative value scale study currently under way.

This system determines Medicare reimbursement in the USA but also may provide information to help analyze your practice. Since being implemented in 1992, the Resource- Based Relative Value Scale (RBRVS) has been the basis of all physician reimbursement from Medicare and increasingly is being used by other third-party payers to determine physician payments. The development of the RBRVS dates back to the 1980s and has evolved to the current system. Besides its use in physician reimbursement, by virtue of its nationwide usage, RBRVS has become a tool by which physicians can compare practice volume and efficiency, both with respect to other practices and within a single practice, to compare individual physicians. Although seemingly complex, the RBRVS provides a useful tool for physicians to understand their productivity, contracting, and reimbursement.

Benefits of sequential surgery include assessment of the outcome of the first surgery to tailor the surgical technique, intraocular lens (IOL) power, and choice of IOL for the second surgery. Additionally, recovery may be prolonged from corneal edema, anterior chamber inflammation, or cystoid macular edema. Allowing the patient to maintain visual function in one eye during the recovery of the other eye can be important. Therefore, the few benefits of simultaneous surgery are greatly outweighed by risks of bilateral complications, inability to foresee refractive outcome, inability to alter IOL choice, potential loss of physician reimbursement, and possible increased legal ramifications.

INTRODUCTION AND OBJECTIVES: Since the introduction of PSA, the diagnosis and treatment of prostate cancer (CaP) has increased and continues to evolve. We determined the treatment patterns for CaP utilizing a longitudinal database involving a community urology practice over a 16 year period (1995-2010). METHODS: A total of 10,684 patients were diagnosed with CaP by needle biopsy in a single urology practice during the study period. Over 97% of the patients chose to have treatment done by urologists in the practice. The treatment choices of the patients were tracked related to events occurring in physician ownership of treatment services and advances in medical knowledge/technology. Patients were grouped by time of service per year and choice of initial treatment. The treatment categories were: Surgery, Radiation, Androgen Ablation (ADT), and Active Surveillance (AS). The treatment events evaluated were: Physician owned surgery center for brachytherapy (RASI); least costly alternative (LCA)pricing for LHRH agonists; introduction of robotic radical prostatectomy (RoRP); and ownership of EBRT facility. Trends in treatment selection over time were evaluated. RESULTS: The majority of the 10,684 CaP patients in the group, 51.8% (5534), chose radical prostatectomy (RP) as their primary treatment. The remaining patients were divided among other treatments: 25.5% (2719) radiation (12.6% EBRT and 12.9% RASI); 10.3% (1105) active surveillance and 2.0% unknown. Over time the RP group remained consistent at 50%, however the number of open RP decreased with the introduction of RoBP by 2010 (100% to 36%). Although the percentage of patients choosing radiation remained relatively unchanged over time, there was an increase in RASI associated with the availability of the physician owned surgery center and a corresponding decrease in EBRT. After the ownership of EBRT services there was an increase in the EBRT group and a decrease in the RASI group maintaining the overall percentage of patients choosing radiation. The introduction of LCA payment for LHRH did not impact the number of patients selecting ADT as their primary treatment. During the study period, AS was stable at 7-8% per year until 2006 when there was an increase to 15-20% per year. CONCLUSIONS: The management of CaP has evolved in the PSA period as have urologist’s reimbursement. The utilization of RP has remained constant over time while variations are evident in other treatment modalities subject to changes in physician reimbursement and clinical standards of care.

We study the effects of 'balance billing', i.e., allowing physicians to charge a fee from patients in addition to the fee paid by Medicare. First, we show that on pure efficiency grounds the optimal Medicare fee under balance billing is zero. An active Medicare policy thus can only be justified when distributional concerns are accounted for. Extending the analysis by Glazer and McGuire, we therefore analyze the optimal policy from the patients' point of view. We demonstrate that, from the patients' perspective, a positive fee can be superior under balance billing. Furthermore, patient welfare can be lower if balance billing is prohibited. In particular, this is the case if the administrative costs of Medicare are large. However, we cannot rule out that prohibiting balance billing may be superior. Finally, we show that payer fee discrimination increases patient welfare if Medicare's administrative costs are high or if Medicare's optimal fee under balance billing implies lower quality for fee-only patients. JEL-classification: I11, I18, H51

It is found that health maintenance organizations (HMOs) initially increase, but will eventually significantly decrease, a population's health care costs. Thus, HMOs appear to require a significant amount of time to control effectively physician and patient behaviour and achieve reductions in costs. Unlike health care costs, HMOs are found to have no significant impact on a population's aggregate health in either the short- or the long-run. Thus, HMOs are found to achieve savings in health care costs in the long-fun and they apparently do so with no resultant decline in health. The paper also has important implications for the National Health Service (NHS) in Great Britain given the similarities that exist between HMO physician reimbursement and NHS funding of its general practitioners.

The Patient Protection and Affordable Care Act will not prove to be the reform for which physicians were long hoping. Private insurance rates will climb sharply, forcing people onto government programs; physician reimbursement will plummet; the physician shortage will worsen; rationing in the form of waiting lists is certain; health care as a whole will worsen; and once fully engaged, nationalization of health care will be irreversible.

Background Nephrologists are often thwarted in their attempts to grow their peritoneal dialysis programs because of suboptimal surgeon performance in placing catheters. A rallying call is heard among nephrologists to step up to the role of dialysis access providers. Objective What factors influence the practicability of nephrologists becoming primary dialysis access providers? Why have surgeons failed their task and can anything motivate them to change their performance and improve outcomes? Methods While the issues are universal, this analysis focuses on current practice data from the United States. Evidence reviewed includes dialysis center size and annual new starts, profile of specialties performing catheter placement, nephrology workforce capacity, catheter implantation methodology, resource utilization for peritoneal access, and surgeon performance. Results The current nephrology workforce is running at maximum capacity and fellowship training programs will struggle to meet additional demands. Nephrology training programs are often deficient in providing adequate experience in peritoneal dialysis management. Only 2.3% of peritoneal catheters are placed by nephrologists. The best catheter outcomes are produced by laparoscopic methods used by surgeons. Compared to other catheter placement techniques, laparoscopy enables a larger candidate pool of patients. Nonetheless, suboptimal surgical performances are related to inadequate training, low procedure volume, and poor reimbursement. Conclusions It is improbable that nephrologists can expand the scope of their practice to assume the additional role of dialysis access providers. The performance of the existing surgical workforce can be enhanced through medical society-sponsored educational activities, channeling access procedures to designated surgeons, and improved remuneration through outcomes-based incentive programs.

States have implemented a number of strategies to provide services, pay providers, and control Medicaid spending. We test the effects of some differences in state Medicaid policies on program enrollees' access to and use of health care services. Logistic and OLS regression analyses of cross-sectional data indicate that these policies exert significant influences on enrollees' access to health services but have a weaker direct effect on their use of them. However, we find evidence that utilization is affected indirectly (through increased access) by state policy decisions. Somewhat surprisingly, Medicaid policies designed to contain costs by limiting utilization appear to affect neither access nor utilization. Medicaid enrollees have greater access to a private physician in states with higher physician reimbursement and additional Medicare insurance for their enrollees. Other nonpolicy variables with pronounced impacts on access to private office physicians include race and the availability of private insurance.

Reform is coming to U.S. health care. A sense of urgency regarding the redesign of policies prevailed well before Barack Obama was elected president under the banner of change. A debate is now raging over a wide span of topics, including prescription plans, physician reimbursement, and solutions for the medical liability problem. But thought leaders have been remarkably reticent with respect to one aspect of the health care system: end-of-life care. Given that patients with terminal illness require a disproportionate concentration of expenditures, the silence is deafening. Sure, the summer's controversy over “death panels” provided fodder for late-night comedians, but . . .

Pay-for-performance has become increasingly common to complement physician reimbursement. We designed a quality framework to measure family physicians' performance in a managed care setting in Buenos Aires. We aimed to assess the effectiveness of a multimodal intervention based on pay-for-performance, teamwork, continuous education, and audit and feedback to improve quality. After 2 years, a significant improvement was observed in most of the indicators measuring clinical effectiveness and some improvements were observed in other domains. Despite these results, a better performance matrix is needed to capture not only specific conditions but also other aspects like integrating, prioritizing, and personalizing care.

This paper examines how changes in reimbursement fees influence the service production of laboratory tests among Norwegian primary care physicians. The data represent a panel of 2,083 physicians paid on a fee-for-service basis for the period 2001–04. We construct a variable that measures the exogenous effect of changes in reimbursement fees on physician income. We measure service production by the number of laboratory tests per consultation, the relative change in the composition of laboratory tests, and the number of tests per consultation ordered from clinical laboratories. There are three main findings. First, physicians reduce the number of laboratory tests per consultation when fees decrease. Second, physicians change the composition of laboratory tests to tests that are more expensive when fees decrease. Finally, there is a spillover effect to the specialist health care sector because physicians who experience an income loss for tests analysed at the office laboratory order more tests from clinical laboratories. The results imply that fee regulation may be a simple means of controlling government expenditure. However, it is important to note the change in composition along with the potential spillover effects to other parts of the health care sector to obtain a complete picture of the influence of fee regulation on physician behaviour

Physician involvement in home care has declined markedly over the past 50 years. By contrast, the renaissance in home care in the US over the last decade has created a pressing need for greater physician participation and new roles for physicians as members of the home care team. This article reviews these developments and identifies the need for improved medical education and physician reimbursement if the desired physician involvement in home care is to become a reality.

In response to a reader's question, Dr. Philipsen examines the possibilities of conflict of interest in various methods of physician reimbursement.

Presuming that the standard of care reflected in the physician reimbursement scheme harms patients, German and US courts enforce their traditional legal standard of care in malpractice lawsuits. This paper summarizes the literature, evaluates the legal standard in microeconomic terms and determines the insurers' and courts' impact on patient welfare. The legal standard proves to be inefficiently high. By contrast, patient welfare is maximized when insurers apply a two-part reimbursement scheme that induces physicians not to comply with the legal standard. If this is infeasible, another reimbursement scheme is suggested.

Objectives To describe consultation with an arthritis specialist because of suspected new-onset juvenile rheumatoid arthritis (JRA) and to determine factors associated with prompt consultation. Design Retrospective cohort study. Setting Physician reimbursement administrative data were obtained for all children aged 16 years or younger in the Province of Quebec (Canada). Participants Suspected new-onset cases of JRA in 2000 were defined by a physician visit because of JRA, providing there had been no such claims in the preceding 3 years. Main Exposure First JRA diagnosis made by a non–arthritis specialist. Main Outcome Measures First consultation with an arthritis specialist subsequent to diagnosis by a non–arthritis specialist and time to first consultation with an arthritis specialist. Results Of 352 children and adolescents with suspected new-onset JRA identified by non–arthritis specialists, 159 (45.2%) were subsequently seen by an arthritis specialist. Mean (SD) time to consultation for those seen was 115.3 (213.8) days (median, 28 days). Younger children were more likely to obtain care from an arthritis specialist compared with those having JRA first diagnosed by a general practitioner. Conclusion Most patients with suspected new-onset JRA do not obtain prompt care from an arthritis specialist. Further research and action should focus on this issue so that outcomes may be optimized.

Within a rapidly changing political and economic environment lies the fundamental need to provide continuity of patient care to decrease morbidity and mortality. Not all women need the same care and an attempt should be made by the clinician to focus on issues specific to high-risk categories and age-related variables (Tables 1.1-1.5). Additionally, scientific and economic documentation of the effectiveness of medical care has become an important issue in both clinical settings and policy-making situations. These concepts will also dictate physician reimbursement.

This article assesses the situation that led to the development of the Resource-Based Relative-Value Scale (RBRVS), describes the scale and how it might be applied, and compares it to other reimbursement schemes. Potential weaknesses of the RBRVS are also discussed.

Based on an analysis of the fee schedule update process in France, the Federal Republic of Germany and Canada, this article draws a number of inferences and interpretations and concludes with a discussion of the major weaknesses and strengths of the United States.

This study provides empiric confirmation of the widely held belief that coronary artery bypass graft (CABG) surgery has become quicker over time as clinical and organizational improvements diffuse across hospitals. Based on a two-stage cluster sample of 74 hospitals performing CABG surgery in 1984, data on skin-to-skin procedure and pump times were analyzed for 2,784 Medicare-eligible cases over the 1972-84 period. Using multivariate regression analysis to adjust for patient characteristics and number of grafts, we found that CABG skin-to-skin times fell an average of 36.5% during the first 12 years of hospital experience while cardiopulmonary pump times fell 28.2%. Rates of decline averaged 4.5-5.4% annually initially, but tapered off to 1.5% by the twelfth year of experience. Extrapolating over a 20-year period, gains in skin-to-skin times are projected to reach 42%, resulting in nearly a halving of surgical times. Our findings have implications both for physician reimbursement and patient outcomes. Medicare CABG prevailing fees do not reflect these gains in efficiency and could be reduced substantially. Alternatively, efficient, high-volume hospitals could be identified for inclusion in a Medicare "CABG PPO" so that society might share in the productivity gains. Finally, recent research showing better outcomes in high-volume institutions may be partially explained by their shorter procedure times, which should reduce operative complications.

The Affordable Care Act (ACA) is shifting physician reimbursement from volume to value. Academic medical centers (AMCs) are responsible for educating future physicians so that they will acquire the skills to practice valuebased care. However, the linkages between the leaders of health systems and leaders of residency education may be tenuous, primarily because these leaders exist in separate silos in AMCs.

As Medicaid reaches its 40th birthday, the future of the program is less certain than it has been for years. Congress recently passed the Budget Reconciliation Act, which could signal the beginning of a restructuring and retrenchment of the Medicaid program. Under this act, individual states will have the option of reducing benefits and imposing significant costs on Medicaid recipients, including copayments. New procedural barriers such as a rigid demand for a birth certificate to establish eligibility will make it harder for eligible people to access the program. These provisions will likely result in fewer enrollees. Yet, at the same time that Congress is allowing or requiring states to make these changes that may result in drastic reductions in their Medicaid programs, Illinois has enacted the All Kids program, which is a major expansion of Illinois' publicly supported health coverage programs. Under All Kids, Illinois will offer Medicaid-type benefits to all children who are currently uninsured. Illinois is bucking the trend by increasing its eligible populations but not increasing its spending. Illinois' All Kids program is designed to expand access to health care while offsetting the costs of expansion through cost savings. Illinois intends to generate those cost savings by implementing primary care case management and disease management programs, all based on physician payment on a fee-for-service basis. Illinois will also require that families who are currently uninsured and not currently covered by a public program make … Address correspondence to Mark Rosenberg, MD, MA, Children's Healthcare Associates, 2835 N Sheffield Ave, #501, Chicago, IL 60657. E-mail: markrosenbergmd{at}aol.com

The Medicare program, enacted in 1965, is a federally funded health care coverage plan for people aged 65 years and older, for those who are disabled, and for those needing renal dialysis or kidney transplants for the treatment of end-stage renal disease. Today, nearly 40 million Americans rely on Medicare for their health care services. The purpose of the Medicare program is to increase access to quality care for the elderly while maintaining a financially viable federal fund from which health care reimbursements can be appropriately and efficiently allocated to health care providers. This paper has three main objectives: (1) introduce the functioning of the Medicare payment system, (2) explain in more detail how the program currently reimburses physicians, and (3) discuss the current challenges facing the physician reimbursement system.

A cross-sectional anonymous postal survey was carried out in a Department of Internal Medicine in order to assess physicians' knowledge about and attitudes towards clinical practice guidelines and to evaluate the role of age in determining their use and opinions. The study took place in a Swiss University Hospital where exposure to guidelines had been limited. The questionnaire was sent to the 174 physicians of the Department. The response rate was 67% (116/174). The spontaneous definitions of guidelines were heterogeneous and referred to information of uncertain validity. Most participants, especially the younger groups of junior and senior residents, reported using guidelines and were favourable to their development. Less favourable attitudes were observed among senior staff physicians and consultants. For instance, the latter more often held the opinion that guidelines are too rigid to apply to individual patients, were likely to decrease physician reimbursement and to hamper research (respectively, 32% vs 24%, 50% vs 31% and 18% vs 7% when compared with the opinions of residents). In conclusion, in a non-prescriptive hospital setting, where the development, dissemination and implementation of guidelines are emerging, the concept of 'guideline' was heterogeneous. Despite generally positive attitudes towards guidelines, the opinion of senior staff physicians constitute a barrier to their dissemination and implementation.

✓ The President of the American Association of Neurological Surgeons (AANS) discusses the present socioeconomic milieu, which has created anxiety in the neurosurgical community. The underlying factors are technological advances, hospital-physician relationships, medical liability, quality assurance reviews, and physician reimbursement. It is proposed that neurosurgeons be proactive in the development of health-care reform.

Adoption of resource-based relative value units (RVU) for physician reimbursement is the standard method for determining professional payment. RVUs are intended to determine compensation primarily on the “work” involved in performing various procedures. Present RVU assignment for pediatric

Physician payment under Medicaid has been a cause of growing concern among physicians because of the low levels of reimbursement in relation to private payors and the Medicare program in many states. This is particularly important to physicians caring for children because of the growing dependence of poor children on Medicaid and the evolution of Medicaid policies since the mid 1980s. Beginning in the mid 1980s Congress began legislating a series of laws that expanded Medicaid eligibility for poor and near poor children. This series of legislation culminated with the Omnibus Budget Reconciliation Acts of 1989 and 1990. These acts required all states to establish minimum Medicaid income eligibility thresholds at 133% of the federal poverty level for children less than 6 years of age and then subsequently to phase-in coverage, 1 year at a time, for all children through 18 years of age with family incomes less than 100% of poverty level.

With numerous medical groups and individual practice associations (IPAs) in California now reporting operating losses--and many approaching financial insolvency--the question arises why physician organizations are in such a tenuous situation. One line of thinking is that the problem is attributable to the market dominance of the major health plans and their ability to impose actuarially unsound low capitation rates on professional providers. This article describes four other reasons for the current plight of physician organizations: (1) a physician-centric approach to IPA governance, (2) lack of qualified staff within key operating units, (3) management reporting that is insufficient to support utilization analysis and health plan negotiations, and (4) a highly charged political process for determining physician reimbursement. IPA survival will ultimately depend upon whether IPAs are perceived by their physician members and leaders as true business operations or just as another income source.

One hundred twenty stratified nonselected cases of primary and revision total joint arthroplastics performed between 1990 and 1992 in which complete financial and clinical data were available were reviewed. All cases were performed at a single university hospital. Compared with primary total joint arthroplasty, revision surgery involved significantly more operative time, greater blood loss, increased length of stay, and a much higher complication rate. The actual physician reimbursement was not significantly more than for primary procedures. Physician reimbursement constituted 18% of the total fees collected compared with 24% for the actual prosthesis cost. Surgeons performing revision surgery devote significantly more time and are at a higher liability than when performing primary total joint arthroplasty.

Medicare's resource-based relative value scale (RBRVS) fee schedule dramatically restructures physician reimbursement; providers of cognitive-based services are projected to gain at the expense of those with procedure-based services. In this study, we computed the impact of the new payment system for Medicare comparing trauma surgery to four other surgical specialties. Plastic surgery will see a 4% increase in revenue, but the other specialties will experience a cut (trauma, minus 14%; general, minus 4%; vascular, minus 5%; cardiothoracic, minus 10%). As expected, with the exception of plastic surgery, there was a decrease in procedure reimbursement (trauma, minus 13%; general, minus 12%; vascular, minus 8%; cardiothoracic, minus 10%). However, when analyzing cognitive services, trauma is the only group that will sustain a reduction. This is largely explained by the fact that trauma cognitive services are inpatient based, whereas the RBRVS fee schedule is biased toward outpatient cognitive services. In conclusion, the RBRVS fee schedule will challenge the economic stability of trauma surgeons. Because Medicare reform will set future standards for other forms of physician reimbursement, trauma system planners need to take a proactive role in this evolving process.

The origin of the term “general surgery” is uncertain, but it is known that it has been in the lexicon of surgical parlance for more than a century. Although specialization began at least 150 years ago, it became a major trend at the end of World War I. The potential fragmentation of the specialty is the most significant problem currently faced by general surgeons. Other areas affecting the future of general surgery are discussed, including residency requirements, manpower analyses, and physician reimbursement. Because of rapid technologic changes and the aging of the population, surgeons need to incorporate those features that will improve patient care into their practices to meet the needs of the future.

We use a model of horizontal and vertical differentiation to study physicians´incentives to provide quality in the physician-patient relationship under price regulation. If the price is the only regulatory variable, the social planner cannot implement the first-best policy. Moreover, the second-best policy is time-inconsistent. Excess entry and first-best efficient total quality provision are observed in the game without commitment. Allowing physicians to compete in prices does not solve the commitment problem, since the competitive solution coincides with the time-consistent outcome. In the median-voter equilibrium the time-consistency problem is more severe.

To the Editor. —Dr Maloney 1 compared data on specialty-specific physician incomes 2 and working hours 3 and concluded on the basis of his calculations that "Hourly reimbursement rates for surgical and nonsurgical specialties are not substantially different" and that "The 42% higher income of surgeons is explained by their longer working hours." He asserted that RBRVS, which is expected to alter income differentials by specialty, "is an inappropriate basis for reform of the physician reimbursement system." Recalling the observation of Spodick 4 that "too often, the 'Conclusions' giveth, but the 'Materials and Methods' taketh away," I reviewed Maloney's "Analytic Methods and Assumptions" and found them inappropriate in the following areas: He calculates from a table of reported working hours for institution-based physicians (reference 3 [Levy et al], Table 3.4) rather than one for all physicians (reference 3 [Levy et al], Table 3.1). If he had used the latter, he

This is a well-written compilation of practice information for the physician who wants to understand reimbursement options and how to evaluate practice options, to establish and manage a medical practice successfully using advisers, and to survive the frustrations and stresses of a physician's life. Gary Gitnick, MD, professor of medicine at UCLA School of Medicine at Los Angeles, has brought together a team of 53 experts who provide a wealth of information in a well-organized text.The first of five sections is an overview of the changing market forces impacting on the physician's practice. It reviews the changes in physician reimbursement patterns since 1900. Accompanying the changes from fee-for-service to the various third-party mechanisms of payment is the involvement of hospitals, government, group practices, the American Medical Association, and the recent alphabet soup of managed care. This trend analysis, primarily from the physician reimbursement standpoint, gives the reader a basis