NEJM Highlights April 2016: Value and values: RBRVS, ACA and readmissions, E-cigs


RBRVS: an acronym we ought to think more about

RBRVS stands for the Resource Based Relative Value Scale, and codifies the time and effort involved for a comprehensive set of physician activities on which Medicare payments are based. In this perspective, the authors highlight that most value-based payment (VBP) systems currently under development are essentially built as modifiers on top of the RBRVS. But the RBRVS has two major issues with it: it is “downward sticky” and has not evolved to take into account increased efficiency (e.g. automation), and it underestimates E/M (Evaluation/Management) activities which have become more and more complex and important as patient complexity has increased. In a nutshell, the end result is that care coordination is undervalued relative to procedural care. And if the RBRVS does not reflect cost and value, a derivative VBP system won’t either.  Currently, updates to the RBVRS are dependent on an AMA-sponsored committee which is dominated by medical specialists – so unless this process changes, we are unlikely to see a major evolution anytime soon.  Finding Value in Unexpected Places — Fixing the Medicare Physician Fee Schedule (free access)


Impact of the ACA’s hospital readmissions reduction program

An important innovation of the ACA was to penalize hospitals with high rates of 30-day readmissions with decreased CMS reimbursements – essentially a way to enhance discharge planning for better patient outcomes and lesser medical costs. In this analysis of data from 3387 hospitals from 2007 to 2015, the authors found that:

  1. For conditions targeted by the penalties, readmission rates dropped by about 2% (absolute, 20% to 18%) over trend in a way that was temporally correlated with passage of the ACA;
  2. There was a spill-over effect in non-targeted conditions for an additional readmission drop of about 1.5% over trend;
  3. While it has been hypothesized that this was the result of a shift toward observations stays, there was no correlation between change in readmission rate and change in rate of observation service use (r=-0.03).

In addition, we note that this policy mechanism has enabled an innovative ecosystem of service providers (post-acute care monitoring, population health analytics, etc.) whose value proposition has been centered on readmission reduction. Readmissions, Observation, and the Hospital Readmissions Reduction Program (subscriber access)


Are E-cigarettes good for population health?

A perspective on E-cigarettes highlighting the divide between British and US approaches to tobacco addiction, and possibly more.  Whereas the British view has emphasized the benefits of e-cigarettes as a harm reduction tool (for smokers trying to quit), the US approach to tobacco control emphasizes abstinence.  Who is right? It does appear that there is more than evidence at play here given that this is a difference that percolates in other areas of substance abuse and in reproductive health.  Evidence, Policy, and E-Cigarettes — Will England Reframe the Debate? (free access)


The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer a brief overview of highlights that might be of interest to our clients and others.