Primary Care, Physician Payment - Nonintendo and Hardening of the Categories.

Nonintendo and Hardening of the Categories

An article in the December 5 JAMA, “Unintended Consequences of Resource-Based Relative Value Scale,” from the department of medicine at Massachusetts General Hospital, prompts this blog.


Its author, Dr. John Goodson, argues RBRVS is responsible for the impending collapse of primary care in America.


Here is how Dr. Goodson puts it:


Medicine's generalist base is disappearing as a consequence of the reimbursement system crafted to save it—the resource-based relative value scale. The US physician workforce is unique among developed economies of the world. Virtually all European countries have a broad generalist foundation comprising 70% to 80% of practicing physicians. The United States is the opposite. Starfield has summarized the benefits of a generalist workforce as access to health service for relatively deprived populations; care equal to specialists in most situations (recognizing the invaluable contribution of the specialist physicians but acknowledging that the diffusion of knowledge increases the ability of the non-specialist to provide up-to-date care); improved preventive service delivery; efficient management of multiple simultaneous medical, surgical, and mental health problems in active and fully functional patients; provision of continuity in the health care experience, advice, and counsel where appropriate and access to appropriate diagnostic, consultative, and specialty.


And here is what Goodson sees as a solution:

The medical profession needs to reformulate the way the value of clinical services and the infrastructure expenses of practice are determined, needs to make the process open and accountable, and needs to solicit input and oversight from those who have the health of individuals, the nation, and the economy as their highest priorities. The resource-based relative value scale system originally developed to achieve full value for cognitive services currently threatens the sustainability of the generalist base. As a result, a large portion of the population will lose access to the continuous and personalized care provided by generalist physicians whose repertoire of clinical skills and interventions coupled with access to specialty and diagnostic services are essential for ensuring efficient and effective health care delivery.

I agree with Dr. Goodson, and I’m reminded of the law of unintended consequences. It refers to situations where an action results in an outcome not intended. The unintended consequences may be foreseen or unforeseen, and may fall into three categories.

1. A positive unexpected benefit, usually referred to as serendipity or a windfall.
2, A potential source of problems, according to Murphy’s Law ro system engineering
3. A negative or a perverse effect, which is the opposite result of what is intended
RBRVS falls into the third category, and to me it indicates the government and other creators and enforcers of RBRVS are suffering from a dire disorder known as “hardening of the categories, “ which, in the case of Medicare, may be irreversible.