Healthcare payment in the United States operates on a fascinating contradiction that few people outside the industry recognize. Private insurance companies base their reimbursement rates on Medicare's Resource-Based Relative Value Scale (RBRVS), a system meticulously designed by the AMA to objectively measure the time, skill, intensity, and resources required for every medical service. Yet these same insurers routinely pay specialists vastly different amounts for performing identical procedures. A cardiologist might receive 175% of Medicare rates for a standard office visit (CPT 99213), while a pediatrician, on a good day, may get 95% for the exact same service. This practice fundamentally contradicts the very system it claims to follow.
The RBRVS was created specifically to eliminate arbitrary payment differences by establishing objective valuations based on actual resource consumption. When Medicare assigns Relative Value Units to a procedure code, those values already account for physician work, practice expenses, and malpractice costs, adjusted for geographic variations. The CPT code itself defines the work being performed. A 99213 office visit requires the same physician time, documentation, and cognitive effort whether performed by an internist, a neurologist, an endocrinologist, or a pediatrician. The system already compensates for procedure complexity through higher RVU assignments for more intensive services. If the RBRVS methodology is sound enough to serve as the foundation for healthcare payment, then its valuations should be consistently applied.
What insurers are actually doing through differential rates has nothing to do with resource consumption and everything to do with market leverage. Specialists are normally part of large healthcare systems that are much more aggressive with negotiations than typical independent primary care pediatric practices. Network adequacy requirements force insurers to pay more for certain specialties to maintain adequate provider panels. These are business decisions driven by supply constraints and competitive dynamics, not objective assessments of the resources required to deliver care. The problem isn't that market forces exist; it's that insurers obscure these market-based adjustments by wrapping them in the veneer of a resource-based payment system. They're selectively accepting RBRVS valuations when convenient, while overriding them based on criteria that have nothing to do with the work being performed.
This contradiction matters because it perpetuates payment inequities that affect care access and healthcare costs. Pediatricians, who perform the bulk of preventive and chronic disease management for children, often receive the lowest percentage of Medicare rates despite performing the same evaluation and management services as highly-paid specialists. The system essentially double-counts specialty differences—once through the RVU structure that already assigns higher values to complex procedures, and again through arbitrary percentage multipliers. If we're going to use RBRVS as our payment foundation, we should follow its logic consistently. Otherwise, we should be honest that we're operating in a market-negotiated system and stop pretending that objective resource measurement drives payment decisions.