Am J Psychiatry 1992; 149:1654-1659
Copyright © 1992 by American Psychiatric Association
Measuring the determinants of work values for psychiatrists' services in the resource-based relative value scale study
RA Dorwart, E Rodriguez, J Dernburg and P Braun
Department of Health Policy and Management, Harvard School of Public Health, Cambridge, Mass.
OBJECTIVE: As part of the Harvard resource-based relative value scale
study, the authors investigated how well the codes in the Physician's
Current Procedural Terminology, 4th edition, or CPT-4, match psychiatric
services to the work involved in evaluating and managing patients and how
patient care characteristics affect different levels of psychiatric work.
METHOD: A random sample of over 200 psychiatrists and subspecialists was
asked to use 68 typical clinical examples or vignettes to evaluate services
described by CPT codes. Data were analyzed by multivariate statistical
methods. RESULTS: The survey showed that the existing coding system does
not adequately describe the work that psychiatrists do. Within a single
code (e.g., 90844, individual medical psychotherapy), there was wide (more
than twofold) variation in the estimates, from multiple measurements based
on different vignettes, of the amount of work represented. Estimates of
work values varied significantly according to treatment setting and patient
characteristics: psychiatric services in the hospital showed an average
work value 25% greater than that for office services; treating new patients
involved 18% more effort than treating established patients; and treating
patients described as at risk of harming self or others increased the
psychiatrists' work effort by 36%. CONCLUSIONS: Revisions in coding
evaluation and management services in the new Medicare fee schedule for
psychiatric services should be further refined and then implemented. These
revisions would bring the coding system into line with psychiatric
practice, making it a better way of accounting for the relative work
involved in treating patients of varying difficulty.
