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Comment on "Toward Understanding Healthcare Value".

In Reply: We sincerely thank Dr. Bruce L. Hall, MD, PhD, MBA, FACS for his thoughtful commentary on our work in the recently published Annals Editorial ‘‘Toward Understanding Healthcare Value.’’ The editorial provides timely and excellent insight regarding the implications of our study assessing Medicare reimbursement in general surgery. The editorial summarizes our study findings that Medicare fee-for-service reimbursement has failed to keep pace with inflation, and contextualizes these findings in an expert manner. We agree that as the editorial postulates, it is important that readers of our work avoid reflexively assuming that the findings of our study are ‘‘bad.’’ Although they might be, as Dr. Hall argues we need to realize that some, or all, of the adjusted decline to reimbursement demonstrated in our study may be the result of rational and necessary adjustments made to optimize limited resource utilization and allocation. To further assess the driving factors associated with our findings, the editorial goes on to review a critical limitation of our original study. As the editorial addresses, the fee-for-service Medicare reimbursements which supplied the data for our study are generated via the resource-based relative value scale system. Under the resource-based relative value scale, total reimbursement is calculated by generating relative value units (RVUs) for 3 summative components of each procedure, which include physician work, practice expense, and malpractice expense. Our study did not originally assess changes to these individual underlying components, which prevented our ability to assess the degree to which individual RVU components were driving decreased adjusted reimburse-