A basic change in the way physicians were paid for services for Medicare patients, mandated by the Omnibus Budget Reconciliation Act of 1989 (OBRA 89), effective 1 January 1992. Prior to that date, payment had been based on customary, prevailing, reasonable charges (CPR). Replacing that method, the new method was based on a resource-based relative value scale (RBRVS). One intent of the change was to reduce the premium (high fees) put on procedures, typically done by specialists, and increase the reimbursement for cognitive services, such as evaluation and diagnosis and patient management, services provided mainly by primary care physicians. A second component of the reform was application of Medicare Volume Performance Standards (MVPS), targets against which physician’s spending is measured. If a physician’s standard is exceeded, the next year his or her rate of fee increase is reduced. A third component of the reform is a cap on the out-of-pocket charges which may be made to beneficiaries.