South Carolina on Fee Schedules; What's the Value?

Just when it seemed that I could get away from the topic of medical fee schedules, South Carolina has to come along in the headlines with a debate about the repeal of that state's RVRBS schedule.

The state's seven-member Workers' Compensation Commission (WCC), after months of debate, voted in January 2010 to update its 2003 Medicare-based schedule to include current values and to lower the South Carolina conversion factor from $52 to $50.

Since then the WCC has come under fire from specialists to scrap its current Medicare-based fee schedule and apply multiple conversion factors to cover medical specialties. Physicians argue that the fee schedule favors general practitioners and has reduced payments to specialists.

In response, WCC has scheduled a public hearing for Aug. 15 to consider language that would give it the authority to eliminate use of Medicare's Resource-Based Relative Value Scale (RBRVS).

The WCC relies upon NCCI monitoring to determine affects on system costs.

According to NCCI, the state's average medical costs are low compared to neighboring states and since the adoption of the fee schedule total medical spending has decreased by nearly 40%. Observers indicate this was primarily due to adjustments to hospital charges.

But, as with many other states that have adopted an RVRBS system, there is minimal statistical evidence of the impact on injured worker access to care. There is evidence, as with many other states, that physicians may reduce their acceptance of workers' compensation patients.

Opponents of California's proposed RVRBS schedule have labeled that state's reimbursement level at 125% Medicare "low". Hawaii had a reimbursement schedule that was 110%, but has since amended it to a higher value. Studies have indicated that specialists are less willing to take on work comp  patients at that level of payment. Oregon apparently pays over 200% and studies reflect good specialist acceptance - though the sampling in the studies I have seen is very small and likely not statistically valid.

Regardless, the debate over how much to pay physicians misses the mark. The question is not how much, but how should services be valued. 

Does the work comp system want specialists? If so, at what level of the care equation? 

These are difficult questions that require evidence, analysis and debate, and ultimately, someone won't be happy.