兰德-Practice-Expense-Methodology-and-Data-Collection-Research-and-Analysis_154页_3mb

Summary of Practice Expense Methodology and Data Collection Research and Analysis

Core Content

This report evaluates the Medicare Physician Fee Schedule (MPFS) practice expense (PE) valuation methodology and explores potential refinements to improve accuracy and fairness in payment rates. The study was commissioned by the Centers for Medicare & Medicaid Services (CMS) to address concerns that the current PE RVU (Relative Value Unit) allocation process may lead to misvalued payments. The focus is on the PE component, which constitutes about 45% of total MPFS payments and includes both direct and indirect costs associated with providing medical services.

The current PE valuation methodology is based on data from the Physician Practice Information Survey (PPIS), which is over a decade old and may not reflect recent changes in the U.S. healthcare system. The report suggests that the data used for indirect cost allocation may be outdated and insufficiently representative of all specialties. As a result, there is a need for updated and more accurate data sources to inform the PE RVU calculations.

Main Points

• PE Components: The MPFS includes three components: physician work, PE, and malpractice liability. PE covers direct costs (clinical labor, medical supplies, equipment) and indirect costs (administration, rent, overhead).
• Incentive Neutrality: CMS aims to ensure that PE RVUs are incentive neutral, meaning payment rates should be proportional to the resources required for each service, not influence practitioners to favor certain services or settings.
• Current Methodology: The PE RVU calculation involves an 18-step process and uses PPIS data. However, this data may not be current or comprehensive enough to capture changes in the healthcare landscape.
• Alternative Data Sources: The Medical Group Management Association (MGMA) survey data is more recent and detailed, but not fully representative of all specialties. It shows that indirect costs have increased over time, which may affect the accuracy of PE valuation.
• Specialty Adjustments: The current PE algorithm includes specialty-specific inputs, which may reflect market conditions rather than true resource usage. Reducing the number of distinct specialty inputs could simplify the process and reduce survey burden.
• Facility vs. Non-Facility Settings: Indirect costs in facility-based settings are often covered by facility fees, while non-facility-based services still require indirect PE payments. This discrepancy may lead to misvaluation of services.
• OPPS-Based Cost Data: The report explores the feasibility of using hospital outpatient prospective payment system (OPPS) cost data to inform or replace the current PE valuation process. OPPS data could provide more accurate and regularly updated cost estimates.
• Methodological Challenges: Several challenges exist in integrating OPPS data into the MPFS system, including aligning cost classifications, estimating APC-level costs, and scaling data into relative values.

Key Findings

• Practice Size and Ownership: There is weak evidence of scale efficiencies in practice size, but hospital-owned practices tend to report lower indirect PE, suggesting that ownership structure may influence cost allocation.
• Cognitive Services: These services, such as counseling, have low direct costs and are currently allocated minimal indirect PE. Adjusting their indirect PE to match the ratio of E&M visits (HCPCS 99213) could lead to significant payment changes for the specialties that provide them.
• OPPS Data Feasibility: While using OPPS-based cost data is feasible, it would require addressing several methodological issues to ensure consistency and accuracy. A consistent data source and methodology for both payment systems would allow for more explicit differentials in payment rates.
• Policy Recommendations: The report recommends moving toward using OPPS-based relative values for total PE, updating data collection methods, and reducing the number of specialty-specific inputs to streamline the valuation process.

Recommendations

• Adopt OPPS-Based Relative Values: This would improve the accuracy of PE valuation, reduce financial incentives for certain service settings, and simplify Medicare payment policy.
• Update Data Collection: Replace PPIS with more current and representative data sources, such as MGMA surveys, and consider collecting PE per work RVU (wRVU) rather than per hour (PE/HR).
• Group Specialties: Group specialties into fewer categories based on clinical and cost similarities to reduce survey burden and improve the feasibility of regular updates.
• Identify Misvalued Services: Use OPPS data to identify services with potentially misvalued PE and consider extending OPPS caps to these services if necessary.
• Refine Indirect Cost Allocation: Improve the allocation of indirect costs by considering practice characteristics, such as size and ownership, and using more accurate cost data.

Conclusion

The current PE valuation system requires significant refinement to ensure accurate and fair payment rates. The use of OPPS-based cost data presents a promising alternative, though it comes with methodological challenges. Updating data sources, simplifying specialty adjustments, and improving the allocation of indirect costs are key steps toward achieving a more accurate and sustainable PE valuation process. These changes would support CMS's strategic goals of moving toward alternative payment models and improving the overall efficiency and equity of Medicare payments.

Key Information

• Authors: Lane F. Burgette, Jodi L. Liu, Benjamin M. Miller, Barbara O. Wynn, Stephanie Dellva, Rosalie Malsberger, Katie Merrell, PhuongGiang Nguyen, Xiaoyu Nie, Joseph D. Pane, Nabeel Shariq Qureshi, Teague Ruder, Lan Zhao, Peter S. Hussey
• Funding: CMS under contract HHSM-500-2014-0036I, Task Order HHSM-500-T0004
• Organization: RAND Health, a division of the RAND Corporation
• Publication: RAND Corporation, Santa Monica, Calif. (2018)
• Study Objectives: Assess potential improvements in PE valuation methodology, develop alternative methodologies using updated data sources, and explore the feasibility of using OPPS-based cost data to inform or replace the current system.

Structure Overview

• Preface: Introduces the purpose of the study and the context of Medicare payment rates.
• Study Objectives: Outlines the goals of the research, including updating input data and refining the PE valuation process.
• Updating Data Sources: Reviews PPIS and MGMA data, highlights their limitations, and proposes new data collection strategies.
• Refining Indirect Cost Allocation: Examines the relationship between practice characteristics and PE, and suggests improvements to the current allocation methodology.
• Specialty Adjustments: Evaluates the impact of specialty-specific inputs and recommends reducing the number of categories.
• Facility-Based Indirect PE: Discusses the differences in cost allocation between facility and non-facility settings and the implications for payment accuracy.
• Using OPPS Costs: Explores the feasibility and challenges of using hospital outpatient cost data for PE valuation.
• Recommendations and Conclusion: Summarizes policy options and concludes that refining the PE valuation process is essential for CMS's strategic goals.

This report provides a comprehensive analysis of the current PE valuation system and offers actionable recommendations to improve its accuracy and fairness.