An examination of cross-specialty linkage applied to the resource-based relative value scale.

Objectives: Analyses were performed to reproduce and examine the sensitivity of the cross-specialty linkage algorithm used by Hsiao et al(1) to obtain the currently implemented resource-based relative value scale for Medicare physician reimbursement.

Methods: The cross-specialty linkage procedure designed and implemented in Hsiao et al is an important component of the resource-based relative value scale underlying current Medicare Fee Schedule. This linkage procedure aligns independent intraspecialty relative value scales onto a common scale, and therefore determines the level of reimbursement accruing to each specialty.

Profiling primary care physicians for a new managed care network.

We developed methods for comparing physicians who would be selected to participate in a major employer's self-insurance program. These methods used insurance claims data to identify and profile physicians according to deviations from prevailing practice and outcome patterns, after considering differences in case-mix and severity of illness among the patients treated by those providers. The discussion notes the usefulness and limitations of claims data for this and other purposes.

Estimating increases in outpatient dialysis costs resulting from scientific and technological advancement.

The Medicare program's base payment rate for outpatient dialysis services has never been adjusted for the effects of inflation, productivity changes, or scientific and technological advancement on the costs of treating patients with end-stage renal disease. In recognition of this, Congress asked the Prospective Payment Assessment Commission to annually recommend an adjustment to Medicare's base payment rate to dialysis facilities. One component of this adjustment addresses the cost-increasing effects of technological change--the scientific and technological advances (S&TA) component.

Using claims data to select primary care physicians for a managed care network.

An insurance claims databased profiling system was developed to help select new primary care physicians (PCPs) for a managed care network. PCPs (family practitioners, internists, and pediatricians) were ranked based on how closely their actual use of outpatient services conformed to the predictions of a mathematical model that adjusted for differences in age, sex, and case mix.