“To Each What She Deserves”: an Early Analysis
Would-be reformers of the Medicare payment system have resuscitated an old idea. The concept
of a relative value scale, the “comparable worth” of medicine, was described and demolished in
1928 by George Bernard Shaw.
In his book The Intelligent Woman’s Guide to Socialism, Capitalism, Sovietism, and
Fascism, Shaw deplored an economic system that rewarded prizefighters so much more
handsomely than others of presumed higher social value. “But to suppose that it could be changed
by any possible calculation that an ounce of archbishop or three ounces of judge is worth a pound of
prizefighter would be sillier still” (1).
Analyzing an example involving cognitive versus procedural skills, Shaw wrote: “Well think it
out. The clergyman…is able to read the New Testament in Greek; so that he can do something the
blacksmith cannot do. On the other hand, the blacksmith can make a horseshoe, which the parson
cannot. How many verses of the Greek Testament are worth one horseshoe? You have only to ask
the silly question to see that nobody can answer it” (1).
Objective vs Subjective Value:
an Economic Analysis
The absurdity of trying to convert social value into an objective unit of measure such as ounces or
horseshoes seems apparent from Shaw’s examples. The resource-based relative value scale
(RBRVS) attempts to circumvent this difficulty by expressing the value of a service in objective
terms related to the cost of its production.
The method used by William Hsiao and colleagues at Harvard University considers four dimen-
sions of physician work, including the time required to perform a service, the mental effort, the
degree of technical skill, and stress (2). The cost of production also includes the overhead expenses
such as liability insurance. Although the Harvard study has been called “a significant new source of
independent information from which to design a new Medicare payment system” (3), it is based on
an old idea: the objective theory of value, one of the fundamental tenets of Marxist
economics.
This theory, which is sometimes accepted as axiomatic, was subjected to critical scrutiny in the
late nineteenth century by Austrian economists Carl Menger and Eugene von Böhm-Bawerk (4). A
simple example may serve to illustrate its fallacy:
Consider two diamonds of equal size and quality. Suppose that one was simply found by chance,
with no effort or danger in its discovery, while the second one was recovered from a mine, repre-
senting a large investment by the owners, and significant danger to the workers. Although one
diamond cost little or nothing, and the second was produced at enormous cost, both might be sold at
the same auction for a similar price. In other words, there is no necessary connection between the
value of an object and the cost of its production (5).
In fields characterized by rapid technologic advance, the fallacy of the objective theory of value
is even more apparent. The theory would assign a higher value to one of the early mainframe com-
puters, which occupied a large room, than to a far more powerful modern desk-top computer,
because the former cost far more to produce. Similarly, a lengthy cataract operation performed with
great intensity of effort using old techniques should be valued more highly than a modern operation
with lens implantation.
The objective theory of value considers only the producer and completely neglects the
consumer. Nowhere does the calculation of “relative value” consider the most important
factor: the benefit to the person who purchases the goods or services.
In contrast, the subjective theory of economic value proposes that the value of an
object is not inherent in the thing itself, but exists in the mind of the person who values it.
As Bettina Bien Graves pointed out, this theory “represented a completely new, revolutionary
approach to economics. For the first time, the individual actor himself became the unit with which
economics was concerned. His actions, his responses . . ., were recognized as the key to explaining
market phenomena” (6).
The ranking of values varies with each individual, depending on personal circumstances and
expectations. A person may be willing to make great sacrifices to obtain certain services, but will
purchase others only if they are very cheap. For example, to one person cancer chemotherapy or
surgery may seem a burden so great that the expectation of benefit may not be worth the price (either
in money or suffering). To another, a small chance of cure may be worth any amount of pain and all
of his worldly possessions. No third person can make a determination of the value of the service,
even though its cost to the persons providing it may be exactly the same in the two instances.
According to the subjective theory of value, costs are basically opportunity costs
incurred by a decision-maker, i.e. the value of the other goods or services he is willing to forego in
order to obtain the goods or services under consideration. Such must be borne exclusively by the
person making the decision; they cannot be shifted to others. Nor can they be measured by others,
since subjective mental experience cannot be directly observed. (However, the subjective value is
reflected in the price that an individual is willing to pay.) Further, costs are dated at the moment of
final decision or choice (7). A recalibration of the relative value scale every five years is far too slow
to account for changes in the personal circumstances of the actors in any economic transaction.
The objective theory of value must be assumed by those who believe in central planning by
omniscient planners. The subjective theory of value is espoused by those who believe in economic
freedom, in the rights of individuals to engage in voluntary transactions that they perceive to be of
mutual benefit.
The Harvard Study: Specific Critiques
Although the Harvard study superficially appears to be objective, with its standard deviations,
equations, and lists of numerical rankings expressed to three or four significant figures, it is based on
physicians’ judgments, which are inherently subjective. A study garbed in the statistical trappings of
science tends to be highly impressive to policymakers. However, when “judgments take the form of
assigning fixed numerical weights and restrictive and arbitrary mathematical formulas to vaguely
defined and unmeasurable concepts such as skill, intensity of effort, complexity, opportunity cost,
and the allocation of overhead expenses, the results are castles built on sand” (8).
If the judgments are made by those with a consistent preexisting bias, then the results are
probably built on quicksand. The group chosen by the Health Care Financing Administration
(HCFA) to do the $2 million study had previously done work on this subject, with results that were
procognitive and antiprocedural with respect to fee evaluations (9, 10). It is possible that HCFA
determined in advance what it wanted, and got what it was paying for.
After obtaining a consensus from various specialists about the ranking of various procedures in
order of difficulty, the researchers needed to normalize the results (i.e. rescale, compress and expand
the rankings for different types of procedures so that they could be interlocked properly). The
methodology to be used for this procedure was not specified. Dr. Robert Reinecke of Thomas
Jefferson University Hospital thought that Hsaio’s group might have withheld the details so as to
prevent some specialists from jury-rigging the rankings to beat the system. However, in response to
queries at an informational meeting in Dallas, Edmond Becker, Ph.D., Project Director for the Hsaio
study, stated that the methodology had not been worked out, and that they planned to try different
formulae until the data looked right. This violates one of the most fundamental principles of
research design, that the methodology must be specified before the data are collected. It
allows the researchers to manipulate the methodology until the data support their predetermined con-
clusions (11).
After all the sophisticated manipulations, some of the results defied common logic. For example,
the same relative value was obtained for a superficial lobectomy of the parotid gland as for a
pharyngolaryngectomy for cancer. The latter procedure is far more exacting and requires much more
postoperative care than the former. Another result that met statistical standards of reliability but
failed the common sense test was equating the intensity per unit time spent doing a diagnostic D&C
with that spent performing a vaginal hysterectomy or managing a difficult labor (12).
Who Favors the RBRVS?
Physicians who believe that their services are undervalued, and that they would therefore benefit
from the RBRVS, are more likely to support the concept. The American Society of Internal
Medicine (ASIM), the American Academy of Family Physicians (AAFP), the American Society of
Anesthesiologists (ASA) and the American Academy of Pediatrics have been among the biggest
boosters of an RVS.
The American Association of Retired Persons (AARP) is also promoting a change in the
Medicare payment system based on the RBRVS. This strange ally of the ASIM and AAFP has a
different long-range objective: forcing all physicians to accept assignment. At the present time,
AARP concedes that there are certain inequities in the payment system. Once these are “corrected,”
there is no impediment to forcing the doctors to accept a payment that is certified to be “fair.”
The concept of the RBRVS has long been promoted by labor unions, directors of health and
welfare funds, and Blue Cross and other third party payers, as discussed by former AAPS President
Robert J. Moorhead in 1961 (13). The RBRVS would be a means of keeping fees in line, thus
helping to save actuarially unsound policies that offer first-dollar coverage.
The third parties themselves had difficulty developing an RVS for all medical procedures
because of the obvious nonrelationship of so many procedures. They could not standardize the
procedures when performed by more than one physician. Furthermore, they could not standardize
patients. Thus, it was necessary to enlist physicians themselves to meet the “challenge” to relate,
economically, all medical, surgical, x-ray, and laboratory procedures.
The American Society of Anesthesiologists set up a voluntary RVS in 1962. After it was in wide use
for many years, the US Department of Justice entered suit in December, 1975, charging violation of
Section 1 of the Sherman Antitrust Act. In June, 1979, the suit was dismissed. Ironically, now
another unit of the federal bureaucracy is on the brink of instituting a mandatory RVS!
Pitfalls in Acceptance of the RBRVS
-
Disunity in the profession. Pitting one group against another (the “procedural” vs
the “cognitive” or “nonprocedural” specialties) is an example of the time-honored technique of
divide and conquer. Furthermore, the pursuit of financial self-interest can be self-destructive in the
long term. Since the actual payment to the physician will be determined by the multiplier, not
exclusively by the relative value, internists may find themselves worse off than before, despite a
narrower gap between themselves and “proceduralists.” -
Interference with the physician-patient relationship. With the RBRVS, a collective
tells every physician what his services are worth, and abolishes his right to contract with the
individual patient. The RBRVS contradicts the basic principle of private medicine, that the unit of
practice is the individual patient, and that the medical service is personal and unstandardized. (Note
the critical difference between the RBRVS, which dictates the worth of a service, and
an indemnity, which simply states what a particular insurer is willing to pay to its subscriber.)
The patients’ values are completely excluded from the equations. -
Next step: mandatory assignment. Acceptance of the RBRVS transfers the onus of
inadequate coverage to the physician, who is easily portrayed as a capitalistic gouger (13). Members
of the Physicians’ Payment Review Commission have acknowledged that the RBRVS was likely to
be followed by a nationwide ban on balance billing. While using terms like “equity,” Congress is
primarily interested in cost containment (i.e. a reduction in Medicare expenditures), which includes
“controlling the inappropriate volume of care” (i.e. rationing) (14). An increase in the fee could
easily be offset by disallowing more services as “medically unnecessary.” -
Distortion in the medical marketplace. Like all previous examples of wage and price
controls, the RBRVS will predictably cause distorted market incentives, resulting in excesses and
shortages. One proposed remedy is to maintain a dual system of fee schedule amounts and
physicians’ charges, so that average charges can serve as a continuous monitor of how closely the fee
schedule reflects market conditions (8). As all centrally planned economies have discovered, price
information from a free market is absolutely essential to permit rational economic calculations.While attributing undesirable incentives in the health care system to “distortions in the price of
physicians’ services” (caused by current third party payment schedules), Hsaio proposes that his fee
schedule would serve as a corrective measure. Specifically, he suggests that central planners could
use the RBRVS to encourage or discourage certain types of practice or behavior, to motivate physi-
cians to serve in regions or specialties with shortages, and to identify outlying charges for closer peer
review (15). -
Encouragement of dishonesty. Under the RBRVS, the physician would benefit from
practices such as removing one wart at a time and filing a separate claim for each. This is to the
patient’s disadvantage and cannot be condoned. Neither can the establishment of the RVS, which
precipitates this situation (13). -
Irreversibility. Like many steps on the road to collectivized medical practice, the
RBRVS will be almost impossible to retract, once it is made public.
Conclusions
Because it is based on fallacious economics and flawed science, the RBRVS cannot correct
inequities and distortions in the medical marketplace, but can only cause new ones. Its support is
based on the politics of envy, which threatens to split the medical profession. While “proceduralists”
and “nonproceduralists” war with each other over questions of short-term financial gain, the
collectivization of medicine can proceed. The RBRVS gives would-be commissars a powerful tool
for controlling the practice of medicine by controlling physicians’ livelihoods. Its acceptance by
physicians implies assent to the role of interchangeable servants of the collective, and a disavowal of
responsibility to their patients as individuals.
References
- Shaw, GB: The Intelligent Woman’s Guide to Socialism, Capitalism, Sovietism, and
Fascism. Harmondsworth, Middlesex, England, Penguin Books, 1982 (first published
1928). - Hsiao, WC, et al. Resource-based relative values for invasive procedures performed
by eight surgical specialties. JAMA 1988;260:2418-2424. - Center for Health Policy Research, American Medical Association: The Impact of
Medicare Payment Schedule Alternatives on Physicians. AMA, 1988. - Böhm-Bawerk. Value and Price: an Extract, ed. 2. South Holland, IL, Libertarian
Press, 1973. - Nash, R: The subjective theory of economic value. Presented at the Foundation for Economic
Education, July, 1988. - Greaves, BB: Free Market Economics. Irvington-on-Hudson, NY, Foundation for
Economic Education, 1975. - Nash, R: Poverty and Wealth. Westchester, IL, Crossway Books, 1986.
- Hadley, J and Berenson, RA: Seeking the just price: constructing relative value scales and fee
schedules. Ann Intern Med////1987;106:461-466. - Hsiao, WC, Stasson, W: Toward developing a relative value scale for medical and surgical
services. Health Care Finance Rev 1979;1:23-38. - Hsiao, WC, Braun, P, Goldman, P et al.: Resource Based Relative Values of Selected
Medical and Surgical Procedures in Massachusetts: Final Report on Research Contract for
Rate Setting Commission, Commonwealth of Massachusetts. Boston, Harvard School of
Public Health, 1985. - Reinecke, RD: A better mousetrap? Flawed research should not be the basis of public policy.
AAPS News 1988;44(4):1. - Kirchner, M: Will this formula change the way you get paid? Medical Economics
April 4, 1988, pp. 138-152. - Moorhead, R: Here’s what’s wrong with the relative value scale. Presented at the 18th annual
meeting of AAPS, Asheville, NC, October 12-14, 1961. - Orient, JM: Physicians’ pay targeted for “cost containment.” AAPS News
1987;43(12):1. - Hsaio, WC, Braun, P, Becker, ER, and Thomas, SR: The resource-based relative value scale:
toward the development of an alternative physician payment system. JAMA
1987;258:799-802.
