Gender bias suspected in RBRVS
Gender bias suspected in RBRVS
Do men-only procedures warrant higher pay?
Is there a gender bias in Medicare’s Resource-Based Relative Value Scale (RBRVS)?
Yes, say some OB/GYN physicians and reimbursement experts, who say they can prove physician payments are lower for women’s services than they are for comparable men’s surgeries and comparable general services.
Specialists at the University of Vermont College of Medicine stumbled across the possibility several years ago when one of their physicians was submitting documentation to create new codes for several new urological surgical techniques they had developed, says Peter Cherouny, MD, an OB/GYN specialist at the Burlington campus. Both urologists and OB/GYN specialists work together on certain invasive procedures and research within the 175-physician academic group practice, as do other specialists.
"In trying to develop some of these we noticed that these urology codes seemed to be specifically higher," says Cherouny. Colleen Nadolski, MS, the faculty practice’s reimbursement analyst, was brought in to review the codes also. Acting on intuition, Cherouny and Nadolski decided to perform a more exhaustive study.
In brief, Cherouny contends that their analysis shows that the "work" component of RBRVS weights for comparative procedures is undervalued for women-only procedures compared to work values assigned to male-only and general surgical procedures. RBRVS values are composed of three components physician work, practice costs, and malpractice costs. Work is not specific to specialty, while the other two components reflect specialty-specific differences.
History repeats itself
The bias, he says, stems largely from the historical undervaluing of key women-only procedures embedded in the old usual, reasonable, and customary (URC) fee system upon which much of RBRVS' data were based. Cherouny presented his and Nadolski’s findings at the Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco in 1995, and in 1996 he submitted them to the HCFA/AMA national RBRVS review committee formed to revamp aspects of RBRVS. That committee is expected to make its final revisions later this year. Here are Cherouny’s main points:
• When RBRVS was first designed, 5% of all CPT codes were manually measured for their work value, based on time and cognitive skills. From the 5% sample, all the other work components were extrapolated from existing charge-based data.
• Therein lies several problems, they argue:
Biases originally in the charge-based environment were transferred to RBRVS.
Extrapolated values were not validated because they were not measured against the same standard criteria as the 5% sample taken for RBRVS.
Work components for similar specialties that were overvalued were adopted across CPT codes, as were those that were undervalued.
• RBRVS values used in the study were obtained from HCFA, and geographic practice costs indices for Vermont were used.
Specialists seek answers to two key questions
Cherouny and Nadolski sought answers to these specific questions:
• Is the ratio of the work component of the RBRVS unit to the total RBRVS units for OB/GYN invasive services (female-only) comparable with those for urologic procedures performed exclusively for men? As an index from which to make the comparison, they used comparable general surgery invasive services as the "gender-neutral" denominator for the ratios.
• Is the McGraw-Hill (MGH) relative value scale similarly skewed? Because the MGH relative value scale is still the most widely used pay scale for non-Medicare, private-payer insurance claims, they compared MGH values to RBRVS values.
"Overall, our hypothesis or feeling is that when they [HCFA researchers] developed RBRVS, they brought an old bias right into the new system," says Cherouny. HCFA researchers had time and financial restraints within which to work. "They had to make a significant number of assumptions, but if there was a historical bias it would have been continued in this new supposedly non-biased scale. It was as good as they were able to do.
"They only had so much money and they had to make some assumptions up front. They relied on questionnaires and they had to limit the number they had to send. They used a low percentage of universal procedures."
The payment disparities are glaring, according to Cherouny’s analysis. For example, an incision and drainage (I&D) of the penis pays five times more than an I&D for the vulva (work RVU is 5.22, compared to 1.41); a prostate drainage pays almost double what an ovarian drainage pays (work RVU is 7.62, compared to 4.0). McGraw-Hill’s scale has a similar pattern for the drainage procedure, but not for the I&D procedure. There are more details on these comparisons in the chart for the top ten most common gender-related procedures. (See chart on p. 27.)
"OB/GYN codes appeared grossly undervalued," he says. "We were trying to confirm this and get the information as non-biased as possible."
Ratios of work component to total RVU units also reflect the disparity, Cherouny says. When combining the values of these top 10 procedures he analyzed, he found that OB/GYN was the "outlier" lower-valued group.
For example, the ratio of the work component to the total RVU for urology is 55.1, compared to 49.1 for OB/GYN and 53.2 for overall surgery. In Vermont dollars, he found that urology pays an average of 67.3 for the average RVU, compared to 44.5 for OB/GYN services and 57.5 for general surgery.
OB/GYNs can be sued till child is 21
"I’ve always thought this was the case, but I haven’t done any of my own statistical analysis," says Bobbye B. Hinson, administrator for Women’s Clinic in Jackson, TN, and past president of the OB/GYN assembly of the Medical Group Management Association in Englewood, CO. At the same time, some experts argue that OB/GYN is overpriced, she points out. "When you think about what we pay for malpractice insurance, I don’t think we’re overpaid, especially when you realize we can be sued up until the child reaches 21 years of age. We’re responsible for the life of a mother and a newborn."
Hinson expresses reserved confidence that changes will be made in the OB/GYN-related RBRVS formulas. "Once the proper calculations are done, and all the information is collected, perhaps those people with vision can see the need to make some changes." This is important, she notes, because not only do other third-party payers tend to adopt Medicare’s fee schedule, but they also use RBRVS as a cost mechanism in setting capitation payment levels. Collectively, the impact of RBRVS is widespread, she says.
Reference
1. Cherouny P, Nadolski C. Underreimbursement of obstetric and gynecologic invasive services by the resource-based relative value scale. Obstet Gynecol 1996; 87:328-331.
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