A critique of the Harvard Resource-Based Relative Value Scale

Physician payment reform has assumed a prominent place in the national health policy debate. A key component in this debate is the Harvard Resource-Based Relative Value Scale (RBRVS). The Harvard research effort relied upon several necessary methodologic assumptions and compromises that must be understood to appreciate the RBRVS's strengths and weaknesses. For example, the Harvard group surveyed too few cases to cover the range of clinical practice in a specialty, had too little input in the selection of cases that were judged to be the same or equivalent between specialties, and used an unproven extrapolation methodology to assign final values for total work to non-surveyed physician services. This methodology led to a number of anomalies in the final RBRVS, such as values for comprehensive services for some specialties that were lower for new than for established patients, and total work values for many new patient office services that were lower for Internal Medicine than for Family Practice, a finding inconsistent with empiric evidence. The Harvard RBRVS represents a significant contribution that increases our understanding of physician practice. The system should not be viewed as a finished product. Further investigation and explanation of the assumptions and anomalies are needed to construct a system that reflects adequately the complexity in physician work.