In 2012, the US National Quality Forum (NQF) endorsed the Total Cost of Care and Resource Use (TCOC) measure which was developed by HealthPartners in Minnesota. The TCOC measure uses the Total Care Relative Resource Values (TCRRVs) which are relative resource values designed to evaluate resource use across all types of medical services, procedures and places of service. The values are independent of price and therefore can be used to evaluate providers, hospitals, physicians and health plans against their peers on their efficiency of resource use in treating like conditions and in overall care of a population. You will find documentation and download information for the TCOC toolkit at www.healthpartners.com/public/tcoc/

Thank you very much Klaus; apart from this link is there any publication that is considered gold standard or really original regarding this issue ? I remember the articles of Hsiao but perhaps nowadays there exist a review of methods or another influencial author

Thanks in advance

As a practicing emergency physician I have significant concerns with the use of RVUs. Many emergency physicians are paid based on RVU generation, but unlike an internist or surgeon, they have little to no control over the number of patients that present or the types of problems they see. However, because RVUs value procedures more highly than patient management, the simple laceration may pay better than the patient with multiple medical and social issues. So what happens to the complex patient? Some are just admitted to the hospital, where they are warehoused for a few days, receiving some treatment for the superficial medical issues but little treatment for the core social issues. Others are given a bus pass or a cab voucher back to wherever it is that they live. Those people often are labeled "frequent flyers," since they return to the ED over and over again, never having resolution of the root causes of their medical and social problems.

The RVU issue also drives the medical workforce. A primary care physician spends his or her day seeing patients, doing examinations, and writing prescriptions, none of which are high RVU activities. A surgeon, however, may spend the same amount of time performing laparoscopic cholecystectomies, a procedure that has 8 times as many RVUs as an intermediate office visit. An experienced surgeon can perform a lap chole in less than an hour. An intermediate office visit takes about half an hour. For a student looking at a large student loan bill, the choice is pretty simple.

Clearly there has to be a better way to value the work of physicians which will produce better allocation of both the clinical work and the workforce.

Thanks David !!

I think that all depends on which parameters we decide to include in the RVU function and most importantly on how we ponderate them. Parameters I have read about are: Effort level (always a discretional dimension), educational level (school years and degrees achieved), time to do the practice, the risk management and others.

I understand that behind your comments you are trying to say that it is "unfair" that a primary care physician get paid less than a surgeon because the former spend a lot of time doing his/her job with a lot of effort and similar educational level. But what about the risk management ? here we can find different oppinions and how he finally decide to ponderate them will define tha way we pay, so this conduct us to another question ... What would be the best methods to create and elicit these value judgements ? isn't it ?

I am quoting Uwe Reinhardt: "In a nutshell, for a particular service (e.g., a routine office revisit or an appendectomy or a heart transplant) that we shall call Z, Medicare pays a fee calculated with this formula:

FeeZ = (Work RVUZ x Work GPCI + PE RVUZ x PE GPCI + PLI RVUZ x PLI GPCI) x CV

FeeZ is the dollar amount of the fee paid for the service, Work RVUZ denotes the relative value units for the physicians’ work going into the production of service Z, PEZ denotes the relative value units of the physician’s practice expenses allocated to service Z and PLIZ denotes the relative value units for the professional liability insurance premium allocated to service Z." The liability insurance component accounts for 4% of an RVU. I think this may represent a way to put a value on risk.

It is still not clear to me what you want to measure. Perhaps all of the participants in this discussion are part of the same narrow subfield where that goes without saying, but no one has made it explicit.

As a safety economist, I am tasked, among other things, with estimating the medical costs of injuries. In our usual method, we begin with case-level data with actual hospital charges. We multiply these charges times facility-specific cost-to-charge ratios estimated from CMS data. These ratios vary widely from state to state (from ca. 90% in Maryland and Iowa to 40% in some other states), and also to some extent from hospital to hospital within a given state. This gives us a good estimate of the actual payments to hospitals.

Unfortunately, hospital charges in our datasets generally do not include professional payments to specialists who bill separately from the hospital. Our ratios of professional fees to hospital payments are based on samples that are small and dated (1996-97), but in principle there is no reason they could not be updated if our funding agencies requested it and wanted to pay for it.

Dear Bruce,

Thank your very much for your answer; I'm involved in a literature review regarding methodologies to meausure costs for health care resources, specially in laboratory (i.e. total cholesterol) and image practices (i.e. Rx or nuclear magnetic resonance). In our country there exist a small debate regarding methods to assign a value and calculate a cost and then a price/tariff for each. In Argentina, there isn't a consensus or a regulation regarding this issue so each producer calculate them in different ways, tipically we have an insurance company that could be a leader setting up prices/tariffs and in certain circunstances this price/tariff isn't enough to cover the costs for many health care producer.

I'm interested in generating alternative values for many practices to dilucidate this issue.

Many thanks for all contributions !!

Joaquín

Joaquin, I would not recommend RVU's for you at all. While the RELATIVE resource use for procedures and imaging studies may be somewhat useable, RVU's are particularly not great for lab tests. In addition, there is a huge political component to the RBRVS which tends to over-value procedures and some specialities (e.g. cardiology) and undervalue others.

It is not easy, but I would assert that you are better off measuring resource use as directly as possible. Value as a concept has to do with the contribution of the test or procedure to improved health outcomes divided by the resource use.

If you have not already, please check out articles by Kaplan and Porter from the Harvard Business School on Time-dependent activity based costing in health care.

Good luck!