Does relative value unit-based compensation shortchange the acute care surgeon?

Addressing the Urgent Need For Clinical Nutrition Education in Post-Graduate Medical Training: New Programs and Credentialling

The importance of nutrition in the development of disease, and in the recovery from illness, is among the most fundamental tenets in human biology and optimal health. Nutrition was fundamental in many traditional forms of medicine, until its role in medical care experienced a rapid decline over the last century. We believe a key cause of the decline in nutrition's essential role in healthcare and preventative medicine is the escalating crisis of inadequate nutrition education in medical training. Recent data shows 75% of US medical schools have no required clinical nutrition classes and only 14% of residency programs have required nutrition curriculum. More troubling, only 14% of current healthcare providers feel comfortable discussing nutrition with their patients. The purpose of this paper is to present the evidence illustrating the distinct lack of nutrition education in medical training. Further, we will present key examples of existing formal nutrition curricula to incorporate nutritional science into all healthcare providers' education and practices. We will discuss existing nutrition fellowships and training programs, including the new Duke Online Clinical Nutrition Fellowship. We will also cover a physician nutrition certification allowing for physicians to pursue clinical nutrition as a career path. Finally, recent financial incentives and quality measures incentivizing healthcare provider nutrition education will be discussed. Thus, in conclusion, we advocate inclusion of nutrition education curricula must be a priority in medical schools, graduate medical education and continuing medical education. Formal clinical nutrition training should be required by hospital leadership and administrators for all Parenteral Nutrition and Nutrition Team Physician Directors in hospitals worldwide, and this key clinical role must become an essential position in all hospitals. In addition, we desperately need to address the critical shortage in physician nutrition specialists who will serve as the next generation of leaders in clinical nutrition care and research.

For the Love of the Game: Calculating the Premium Associated With Academic Surgical Practice

OBJECTIVE

We sought to determine the premium associated with a career in academic surgery, as measured by compensation normalized to the work relative value unit (wRVU).

BACKGROUND

An academic surgical career embodying innovation and mentorship offers intrinsic rewards but is not well monetized. We know compensation for academic surgeons is less than their nonacademic counterparts, but the value of clinical effort, as normalized to the wRVU, between academic and nonacademic surgeons has not been well characterized. Thus, we analyzed the variations in the valuation of academic and nonacademic surgical work from 2010 to 2022.

METHODS

We utilized Medical Group Management Association Provider Compensation data from 2010, 2014, 2018, and 2022 to compare academic and nonacademic surgeons. We analyzed raw total cash compensation (TCC), wRVU, TCC per wRVU (TCC/wRVU), and TCC to collections (TCCtColl). We calculated collections per wRVU (Coll/wRVU). We adjusted TCC and TCCtColl for inflation using the Consumer Price Index. Linear modeling for trend analysis was performed.

RESULTS

Compared with nonacademic, academic surgeons had lower TCC (2010: $500,415.0±23,666 vs $631,515.5±23,948.2, -21%; 2022: $564,789.8±23,993.9 vs $628,247.4±15,753.2, -10%), despite higher wRVUs (2022: 9109.4±474.9 vs 8062.7±252.7) and higher Coll/wRVU (2022: 76.68±8.15 vs 71.80±6.10). Trend analysis indicated that TCC will converge in 2038 at an estimated $660,931.

CONCLUSIONS

In 2022, academic surgeons had more clinical activity and superior organizational revenue capture, despite less total and normalized clinical compensation. On the basis of TCC/wRVUs, academia charges a premium of 16% over nonacademic surgery. However, trend analysis suggests that TCC will converge within the next 20 years.

Defining the acute care surgeon: American Association for the Surgery of Trauma (AAST) panel discussion on full-time employment, compensation and career trajectory

Since its inception, the specialty of acute care surgery has evolved and now represents a field with a broad clinical scope and large variations in implementation and practice. These variations produce unique challenges and there is no consistent definition of the scope, intensity or value of the work performed by acute care surgeons. This lack of clarity regarding expectations extends to surgeons and non-surgeons outside of our specialty, compounding difficulties in advocacy at the local, regional and national levels. Coupled with a lack of clarity surrounding the definition of full-time employment, these challenges have prompted surgeons to develop initiatives within acute care surgery in collaboration with the American Association for the Surgery of Trauma (AAST). A panel session at the AAST 2023 annual meeting was held to discuss the need to define a full-time equivalent for an acute care surgeon and how to consider and incorporate non-clinical responsibilities. Experiences, perspectives and propositions for change were discussed and are presented here.

Does Work Relative Value Unit Measure Surgical Complexity for Risk Adjustment of Surgical Outcomes?

INTRODUCTION

The purpose of this study was to determine whether the work relative value unit (workRVU) of a patient's operation can be useful as a measure of surgical complexity for the risk adjustment of surgical outcomes.

METHODS

We retrospectively analyzed the American College of Surgeon's National Surgical Quality Improvement Program database (2005-2018). We examined the associations of workRVU of the patient's primary operation with preoperative patient characteristics and associations with postoperative complications. We performed forward selection multiple logistic regression analysis to determine the predictive importance of workRVU. We then generated prediction models using patient characteristics with and without workRVU and compared c-indexes to assess workRVU's additive predictive value.

RESULTS

7,507,991 operations were included. Patients who were underweight, functionally dependent, transferred from an acute care hospital, had higher American Society of Anesthesiologists class or who had medical comorbidities had operations with higher workRVU (all P < 0.0001). The subspecialties with the highest workRVU were neurosurgery (mean = 22.2), thoracic surgery (mean = 21.1), and vascular surgery (mean = 18.8) (P < 0.0001). For all postoperative complications, mean workRVU was higher for patients with the complication than those without (all P < 0.0001). For eight of 12 postoperative complications, workRVU entered the logistic regression models as a predictor variable in the 1st to 4th steps. Addition of workRVU as a preoperative predictive variable improved the c-index of the prediction models.

CONCLUSIONS

WorkRVU was associated with sicker patients and patients experiencing postoperative complications and was an important predictor of postoperative complications. When added to a prediction model including patient characteristics, it only marginally improved prediction. This is possibly because workRVU is associated with patient characteristics.

National Undervaluation of Cleft Surgical Services: Evidence from a Comparative Analysis of 50,450 Cases

BACKGROUND

Relative value units (RVUs) are broadly used for billing and physician compensation; however, the accuracy of RVU assignments has not been scientifically evaluated for craniofacial surgery. The authors hypothesize that unbalanced RVU allocation creates inappropriate disparities in value among procedures performed by cleft and craniofacial surgeons.

METHODS

The National Surgical Quality Improvement Program Pediatric database was queried to identify all cleft and craniofacial surgery cases performed by plastic surgeons from 2012 to 2019 based on CPT code. Microsurgical cases and CPT codes with a case count of fewer than 10 were excluded. Efficiency was defined as total RVUs divided by total operative time (ie, RVUs/hour). Mean efficiency per CPT code was ranked and compared by quartile using t tests.

RESULTS

The sample consisted of 69 CPT codes with 50,450 cases. In the top quartile, most CPT codes were craniofacial procedures including frontofacial procedures (23.53%) and craniectomies for craniosynostosis or bony lesions (35.29%) (mean, 15.65 ± 4.22 RVUs/hour). The lowest quartile was composed mainly of CPT codes for cleft procedures including operations for velopharyngeal insufficiency (17.65%), cleft palate repair (23.53%), and cleft septoplasty (5.88%) (mean, 7.39 ± 0.98 RVUs/hour; P < 0.001). It was 2.5 times more efficient for a cleft and craniofacial surgeon to perform a local skin flap (15.18 RVUs/hour) than a secondary palatal lengthening for cleft palate (6.09 RVUs/hour).

CONCLUSIONS

The current RVU allocation to cleft and craniofacial procedures creates arbitrary disparities in physician efficiency, with cleft procedures disproportionately negatively affected. RVU assignments should be reevaluated to avoid disincentivizing cleft surgical care.

Are Foot & Ankle Surgeons Being Adequately Compensated for Ankle Fractures? - An Analysis of Relative Value Units

The current relative value units (RVU)-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs bi-malleolar vs tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation for uni-malleolar versus bi-malleolar versus tri-malleolar ankle fractures. The 2012 to 2017 American College of Surgeons - National Surgical Quality Improvement Program files were queried using current Procedural Terminology (CPT) codes for patients undergoing open reduction internal fixation for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814), and tri-malleolar (CPT-27822,CPT-27823) ankle fractures. A total of 7830 (37.2%) uni-malleolar, 7826 (37.2%) bi-malleolar and 5391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71 and 3) Tri-malleolar = 12.87 (p < .001). A statistically significant difference was noted in mean operative time (uni-malleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p < .001) between the 3 groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p < .001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

Value-based surgery physician compensation model: Review of the literature

BACKGROUND

In recent history, healthcare payment reform and legislative initiatives have drastically altered the practice environment for many physicians. Individual providers have migrated from self-managed smaller practices toward employed positions with larger entities, in which provider productivity is tracked. In academic institutions, surgical departments are tasked with meeting clinical productivity metrics while maintaining research and education missions. The objective was to review the current literature regarding the status of physician compensation.

METHODS

A narrative review of the literature with a defined search strategy using Pubmed and MEDLINE was performed. Using keywords of physician reimbursement, physician compensation, performance-based incentives, relative value unit, RVU, searches were completed and subsequently reviewed by the authors for inclusion. Subsequently, all review articles had their included studies hand searched by the research team and any relevant articles were included in our review.

RESULTS

In total, fifteen papers were deemed to meet inclusion criteria. Articles were then divided into 7 domains (Origins of the Work Relative Value Unit, Adjusting for Clinical Complexity, Alternative Compensation Strategies, Aligning Compensation with Department Goals, Individual versus Group Incentives, Minimizing Complexity, Maximize Efficiency, Minimize Loss).

CONCLUSION

As external powers continue to apply pressure to surgeon compensation, leaders have had to increasingly focus on clinical productivity, while the missions of research and education become more neglected. One solution could be the development of metrics to best align incentives for clinical, research, and education activities with institutional goals.

A Retrospective Review of Relative Value Units in Revision Total Knee Arthroplasty: A Dichotomy Between Surgical Complexity and Reimbursement

BACKGROUND

Revision total knee arthroplasties (TKA) are costly, time-intensive, and technically demanding procedures. There are concerns regarding the valuation of Current Procedural Terminology (CPT) codes and the assigned relative value units (RVU) as a potential disincentive to perform revision TKAs. This study evaluated the labor and time investment for each component-specific revision and assessed the disparities between procedural value billed and reimbursement.

METHODS

A retrospective review of 154 primary and revision TKA cases were thoroughly vetted using operative notes and internal billing data. Revision TKAs were stratified by single femoral component, single tibial component, polyethylene liner only, all-component, and spacer placement for prosthetic infection. Operative time, RVUs billed, total charges, deductions, and reimbursements were recorded. Mann-Whitney U tests compared final reimbursement per minute and per RVU between revision and primary TKAs.

RESULTS

There were 28 primary TKAs, 11 femoral component revisions, 25 tibial component revisions, 25 liner exchanges, 37 all-component revisions, and 28 spacer placements. Revisions involving the tibial component, all-components, and placement of spacers were reimbursed less dollars per minute than primary TKAs (P < .05). Controlling for RVUs, liner exchanges and all-component revisions had fewer dollars per RVU than primary TKAs (P < .05).

CONCLUSION

As revision complexity increases, physicians face less reimbursement per minute and per RVU. With reductions set by CMS and private insurers, revisions may be financially unfavorable and lead to restrictions and access to care problems. Our data supports the need for reevaluating RVU allocation amongst revision procedures with potential updates to the CPT coding system.

Does seasonal variation in orthopaedic trauma volume correlate with adverse hospital events and burnout?

INTRODUCTION

Assessing workload and mitigating burnout risk should be a constant goal within training programs. By using work relative value unit (wRVU) data in a non-elective orthopaedic trauma practice, we investigated seasonal variation in workload on an orthopaedic trauma service at a level I trauma centre. We also investigated whether there was a correlation in seasonal preventable adverse patient safety events (PSEs) and resident Epworth Sleepiness Scale (ESS) scores.

MATERIALS AND METHODS

Data on wRVUs were collected over an 8-year period for a single orthopaedic trauma surgeon with a non-elective practice. Monthly wRVU totals were tabulated over this 8-year period and compared with total hospital orthopaedic surgical trauma volume. The total number of wRVUs and surgical cases analysed were 80,955 and 9,928 respectively. A total of 1,560 PSEs and four years of resident ESS scores were analysed. Data on seasonal variations was evaluated for significance utilizing the Kruskal-Wallis test. WRVUs were then compared to total case volume, PSEs, and resident ESS scores using Spearman's correlation coefficients.

RESULTS

We found that wRVUs significantly differed by month (P-value < 0.001) and season (P-value < 0.001) with the highest volume occurring in the summer months. Seasonal variation in wRVUs demonstrated a positive linear correlation with total surgical volume (P-value <0.001) and resident reported ESS scores (P-value = 0.001). PSEs were highest in the summer (P = 0.026), but were not correlated with our findings of seasonal variations in orthopaedic volume (P-value = 0.741).

CONCLUSION

WRVUs of our single surgeon's orthopaedic trauma practice had a seasonal variation with significantly higher volume during the summer. These findings were representative of seasonal variations in total hospital orthopaedic trauma volume and also demonstrated correlation with objective resident sleepiness scores. PSEs were more frequent in the summer but not correlated with seasonal variation in volume. Burnout poses a risk to patient safety and has been shown to be correlated with increased work volume. These topics are important and applicable to various specialties involved in the care of patients with orthopaedic trauma injuries.

Relative Value Units Underestimate Reimbursement for Revision Shoulder Arthroplasty

INTRODUCTION

Relative value units (RVUs) have been fundamental to reimbursement calculations in payment models for arthroplasty surgeons. RVUs are based on various factors, including physician work, and have been higher for increased complexity, such as revision arthroplasty. The purpose of this study was to compare RVUs and estimated reimbursement differences between primary and revision shoulder arthroplasty.

METHODS

The National Surgical Quality Improvement Program database was used to collect primary and revision shoulder arthroplasty cases in 2017. Data variables collected included age at the time of surgery, surgical time, and RVU for each shoulder arthroplasty.

RESULTS

A total of 4,948 shoulder arthroplasty patients (4,657 primary and 291 revision) were included in this study. The mean age was 69.1 years (9.6 SD) for primary shoulder arthroplasty and 67.8 years (10.4 SD) for revision shoulder arthroplasty, P = 0.02. RVU for primary shoulder arthroplasty was 22.1 (0 SD) compared with 26.4 (1.1 SD) for revision shoulder arthroplasty (P = 0.0001). Surgical time was significantly higher in revision versus primary cases, 131.5 minutes (89.0 SD) versus 109.3 minutes (42.5 SD) (P = 0.0001). RVUs per minute were near equivalent for primary and revision arthroplasty at 0.20 (0.1 SD) and 0.20 (01 SD), respectively. However, owing to the difference in surgical time and cases per day, this translates to an estimated reimbursement difference of $174,554.4 per year more for primary shoulder arthroplasty over revision cases.

CONCLUSION

The current RVU model does not adequately factor surgical time for revision shoulder arthroplasty and translates to a notable yearly reimbursement difference that favors primary shoulder arthroplasty.

Does Complexity Always Correlate With Compensation? An Analysis of Work Relative Value Units in 3 Common Nerve Decompression Syndromes

BACKGROUND

Work relative value units (wRVUs) are part of Resource Based Relative Value Scale system. It is expected that a more difficult and time-consuming procedure would yield higher wRVUs. Brachial plexus nerve decompression surgery is a more time-consuming procedure compared with carpal and cubital tunnel procedures. The aim of this study was to analyze physician reimbursement in upper limb decompression procedures by comparing mean operative times, wRVUs per minute, and dollars per minute.

METHODS

A retrospective cohort study was conducted from June 2016 to June 2019, including all patients who underwent carpal tunnel, cubital tunnel, and brachial plexus release procedures. Operating time was collected, and calculations of mean operative time, wRVUs per minute, and dollars per minute were performed and compared between groups.

RESULTS

A total of 209 cases were included. Carpal tunnel accounted for 75.1% of the cases, followed by cubital tunnel and brachial plexus releases. Brachial plexus release had the highest median operative time (147 minutes), followed by cubital tunnel (57 minutes) and carpal tunnel release (16 minutes, P < 0.0001). Carpal tunnel release procedures had a significantly higher wRVUs per minute (0.310) when compared with cubital tunnel and brachial pleaxus release procedures, 0.127 and 0.077, respectively (P < 0.0001). Same was true for dollars per minute; carpal tunnel procedures yielded significantly more compensation than cubital tunnel and thoracic outlet procedures (P < 0.0001).

CONCLUSIONS

More complex and time-consuming procedures yielded a lower reimbursement for physicians. The current work relative unit system does not account adequately for the time spent in each procedure.

Primary versus revision total shoulder arthroplasty: comparing relative value and reimbursement trends

Background

Total shoulder arthroplasty (TSA) has been demonstrated to be an effective treatment for multiple shoulder pathologies. The purpose of our study was to compare the relative value units (RVUs) per minute of surgical time for primary and revision TSA.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients that underwent primary TSA, one-component revision TSA, and two-component revision TSA between January 1, 2015 and December 31, 2017 using current procedure terminology codes. RVUs were divided by mean operative time for each procedure to determine the amount of revenue generated per minute. Rates were compared between the groups using a one-way analysis of variance with post-hoc Tukey test. Statistical significance was set at p<0.05.

Results

When dividing compensation by surgical time, we found that two-component revision generated more compensation per minute compared to primary TSA (0.284±0.114 vs. 0.239±0.278 RVU per minute or $10.25±$4.11 vs. $8.64±$10.05 per minute, respectively; p=0.001).

Conclusions

The relative value of revision TSA procedures is weighted to account for the increased technical challenges and time associated with these procedures. This study confirms that reimbursement is higher for revision TSA compared to primary TSA.

Association of Surrogate Objective Measures With Work Relative Value Units

Background: The determination of accurate measures of evaluating surgeon work for reimbursement is poorly characterized. This study defines the correlation of surgical work relative value units (work RVUs) with several surrogate objective measures for otolaryngologic work. The defined surrogate objective measures evaluated in this study are length of hospital stay (LOS), operative time, 30-day mortality, 30-day unplanned readmission, 30-day reoperation, and 30-day morbidity.

Methods: We collected data on otolaryngologic cases from 2016 to 2018 from the American College of Surgeons National Surgical Quality Improvement Program. Pearson correlation coefficient was used to associate work RVUs with objective measures of surgeon work. Linear regressions were used to identify predictors of work RVUs from the surrogate objective measures. Studentized residuals were used to identify outlying procedures.

Results: Work RVUs correlated strongly with operative time (R=0.6775), 30-day readmission (R=0.6100), and LOS (R=0.6083); moderately with 30-day reoperation (R=0.5257) and 30-day morbidity (R=0.4842); and very weakly with 30-day mortality (R=0.1383). The best predictors for work RVUs based on multivariable linear regression analysis were morbidity, reoperation, and operative time. Analysis revealed that the projected work RVU is 12.23 units higher than the current value for excision of bone, mandible (Current Procedural Terminology [CPT] code 21025) and 19.48 units lower than the current value for resection/excision of lesion infratemporal fossa space apex extradural (CPT code 61605).

Conclusion: Using objective surrogate measures for time and intensity of physician work in head and neck cases may improve work RVU assignment accuracy compared to the current system of physician survey. Future investigation with additional objective parameters may be beneficial to make work RVU assignments less subjective.

General surgeon involvement in the care of patients designated with an American Association for the Surgery of Trauma-endorsed ICD-10-CM emergency general surgery diagnosis code in Wisconsin

BACKGROUND

The current national burden of emergency general surgery (EGS) illnesses and the extent of surgeon involvement in the care of these patients remain largely unknown. To inform needs assessments, research, and education, we sought to: (1) translate previously developed International Classification of Diseases (ICD), 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes representing EGS conditions to ICD 10th Revision, CM (ICD-10-CM) codes and (2) determine the national burden of and assess surgeon involvement across EGS conditions.

METHODS

We converted ICD-9-CM codes to candidate ICD-10-CM codes using General Equivalence Mappings then iteratively refined the code list. We used National Inpatient Sample 2016 to 2017 data to develop a national estimate of the burden of EGS disease. To evaluate surgeon involvement, using Wisconsin Hospital Association discharge data (January 1, 2016 to June 30, 2018), we selected adult urgent/emergent encounters with an EGS condition as the principal diagnosis. Surgeon involvement was defined as a surgeon being either the attending provider or procedural physician.

RESULTS

Four hundred and eighty-five ICD-9-CM codes mapped to 1,696 ICD-10-CM codes. The final list contained 985 ICD-10-CM codes. Nationally, there were 2,977,843 adult patient encounters with an ICD-10-CM EGS diagnosis. Of 94,903 EGS patients in the Wisconsin Hospital Association data set, most encounters were inpatient as compared with observation (75,878 [80.0%] vs. 19,025 [20.0%]). There were 57,780 patients (60.9%) that underwent any procedure. Among all Wisconsin EGS patients, most had no surgeon involvement (64.9% [n = 61,616]). Of the seven most common EGS diagnoses, surgeon involvement was highest for appendicitis (96.0%) and biliary tract disease (77.1%). For the other five most common conditions (skin/soft tissue infections, gastrointestinal hemorrhage, intestinal obstruction/ileus, pancreatitis, diverticular disease), surgeons were involved in roughly 20% of patient care episodes.

CONCLUSION

Surgeon involvement for EGS conditions ranges from highly likely (appendicitis) to relatively unlikely (skin/soft tissue infections). The wide range in surgeon involvement underscores the importance of multidisciplinary collaboration in the care of EGS patients.

LEVEL OF EVIDENCE

Prognostic/epidemiological, Level III.

Development of a local model for measuring the work of surgeons

Objective: The Relative Value Unit (RVU) is the main method of calculating surgeons’ reimbursements and a tool for measuring the work of surgeons. Existing evidence shows that the work Relative Value Unit (wRVU) does not accurately represent surgeon’s work. Therefore, the current study attempted to develop a local model to measure surgeons’ work.

Material and Methods: This study was conducted in two main phases of determining the metrics and model development using quantitative and qualitative approaches from December 2019 to April 2021. Literature review, focused group discussions, and interviews were used to collect data. Con- tent analysis and Exploratory Data Analysis techniques were applied to analyze data.

Results: The findings demonstrated that patient’s conditions (age, severity of disease at referring time, and comorbidities), disease specifications (time, complexity, physical effort, and risk), and provider characteristic (surgeon’s willingness, imposed stress, and surgeon’s skill) were important by 17, 51, and 32%, respectively, in determining surgeons’ work.

Conclusion: Determining a fixed value for each procedure does not accurately estimate the amount of required surgeon’s work for any procedure. Many factors, such as the patient’s condition, surgeon’s characteristics, and disease specification affect surgeons’ work in the operation room. Proper measurement of the surgeon’s work is an important step towards establishing equity in payment in the health system.

Comparing Relative Value Units among Shoulder Arthroplasty, Hemiarthroplasty, and ORIF for Proximal Humerus Fractures in the Elderly: Which is Most Worth Your Time?

Background

Relative value units (RVUs) are assigned to Current Procedural Technology (CPT) codes and give relative economic values to the services physicians provide. This study compared the RVU reimbursements for the surgical options of proximal humerus fractures in the elderly, which include arthroplasty (reverse [RSA] and total [TSA]), hemiarthroplasty (HA), and open reduction and internal fixation (ORIF).

Methods

Using the National Surgical Quality Improvement Program, a total of 1,437 patients of at least 65 years of age with proximal humerus fractures between 2008 and 2016 were identified. Of those, 259 underwent RSA/TSA (CPT code 23472), 418 underwent HA (CPT codes 23470 and 23616), and 760 underwent ORIF (CPT code 23615). Univariate analysis compared RVU per minute, reimbursement rate, and the average annual revenue across cohorts based on respective operative times.

Results

RSA/TSA generated a mean RVU per minute of 0.197 (SD 0.078; 95%CI [0.188, 0.207]), which was significantly greater than the mean RVU per minute for 23470 HA (0.156; SD 0.057; 95%CI [0.148, 0.163]), 23616 HA (0.166; SD 0.065; 95%CI [0.005, 0.156]), and ORIF (0.135; SD 0.048; 95%CI [0.132, 0.138]; P<0.001). This converted to respective reimbursement rates of $6.97/min (SD 2.78; 95%CI [6.63, 7.31]), $5.48/min (SD 2.05; 95%CI [5.22, 5.74]), $5.83/min (SD 2.28; 95%CI [5.49, 6.16]) and $4.74/min (SD 1.69; 95%CI [4.62, 4.87]). After extrapolation, respective average annual revenues were $580,386, $456,633, $475,077, and $395,608.

Conclusion

RSA/TSA provides significantly greater reimbursement rates compared to HA and ORIF. Orthopaedic surgeons can use this information to optimize daily procedural cost-effectiveness in their practices.

Evaluation of the Relationship Between Aspects of Medical Complexity and Work Relative Value Units (wRVUs) for Foot and Ankle Surgical Procedures

Work relative value units (wRVUs) have been assigned to current procedural terminology codes in an effort to help establish physician compensation. However, the ability of these to accurately and efficiently capture the time, technical, and perioperative managerial aspects required of various procedures has recently been called into question for several surgical subspecialties. Therefore, the objective of this investigation was to evaluate various measures of medical complexity against wRVUs for foot and ankle surgical procedures. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify and extract data related to the perioperative medical complexity of 16 foot and ankle surgical current procedural terminology codes. We observed a "weak" positive relationship between wRVUs and operation time as defined by a correlation coefficient of 0.234 (p < .001). Other variables associated with medical complexity in the perioperative period were found to significantly vary between wRVUs categories, but these differences were neither consistently nor directly associated with assigned relative values. We conclude that wRVUs might not always represent an efficient means for determining compensation for foot and ankle surgical procedures.

Underrepresentation of pediatric operations in the relative value unit updating process

BACKGROUND

The Relative Value Unit (RVU) system was designed and implemented by Medicare to standardize physician payments for a given service. Because Medicare primarily cares for older adults, RVU assignments and updates may not consider pediatric-specific procedures, despite the fact that private insurers and Medicaid often base their payments on these RVU valuations.

METHODS

The CPT codes of index pediatric operations were retrieved from the ACGME. We categorized these procedures into "Peds-specific" (eg, Ladd Procedure) versus those that could be performed in both children and adults, or "Non-specific" (eg, fundoplication). We merged these codes with RVU information from publicly available CMS files and the Resource-based Relative Value Scale Data Manager. Variables included were the date of last RVU update and the vignette used by survey respondents when asked to update the RVU valuation.

RESULTS

Among 85 procedures, nearly three-quarters were Peds-specific (74%), with the remainder Non-specific. Approximately half of the 85 procedures (52%) had never been updated. Compared to Non-specific CPT codes, Peds-specific CPT codes were less likely to have been updated (38% vs. 91%, p < 0.001) and, among those that were updated, were updated more remotely (median year 2000 vs. 2005, p = 0.02). Among updated Non-specific CPT codes, the vignette written to justify the valuation was based on an adult patient in 85% of cases.

CONCLUSIONS

Peds-specific surgical CPT codes have either never been updated or have not been updated in decades. Procedures performed in both children and adults have been updated more often and more recently, but the vignette on which this valuation is based on is typically an adult patient. In order to remain relevant and reimburse pediatric surgeons accurately, the RVUs for pediatric procedures need to also be prioritized for revision and updating.

The Importance of Financial Metrics in Physician Funding and Performance Evaluation

BACKGROUND

Financial key performance indicators are often used to evaluate performance. Understanding of key performance indicators can be crucial for career advancement and bargaining leverage in resource negotiations. This study aimed to identify the most important key performance indicators used in surgical funding requests and understand how to use these metrics in clinical practice.

METHODS

In two tertiary medical centers, funding requests for surgeon gap support (2019 to 2020) and equipment (2017 to 2019) within departments of surgery were reviewed. The requesting department, approval status, and amount allotted were recorded. In requests for gap support, projections for contribution margin, operating room volume, charges, collections, and relative value units were tracked. Projected contribution margin and cost savings were recorded for equipment funding requests.

RESULTS

There were 40 gap support and 24 equipment requests, and all were approved. Most gap support requests included collections (90.0 percent), charges (87.5 percent), operating room cases (80.0 percent), relative value units (77.5 percent), and hospital contribution margin (77.5 percent). The most represented departments were general surgery (37.5 percent), neurosurgery (22.5 percent), and plastic surgery (15.0 percent). The departments that submitted the most equipment requests were general surgery (28.0 percent) and neurosurgery (28.0 percent). Most requests included projections for contribution margin (95.8 percent) and cost savings (87.4 percent). Projected hospital contribution margin correlated with the amount of funds allotted for surgeon support (r = 0.409; p = 0.022).

CONCLUSIONS

This multicenter study identified the importance of using key performance indicators for a successful financial outcome in funding requests. In addition, the authors demonstrate the need for surgeons to understand their own key performance indicators. Surgeons should advocate for increased transparency to better understand their financial contributions and performance.

Reassessment of Relative Value in Shoulder and Elbow Surgery: Do Payment and Relative Value Units Reflect Reality?

BACKGROUD

Many U.S. health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. A major determinant of payment and wRVU assignments is operative time. We sought to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common shoulder/elbow procedures.

METHODS

We collected data on wRVUs, payments, and operative times from CMS for 29 types of isolated arthroscopic and open shoulder/elbow procedures. Using regression analysis, we compared relationships between these variables, in addition to median operative times reported by NSQIP (2013-2016). We then determined the relative valuation of each procedure based on operative time.

RESULTS

Seventy-nine percent of CMS operative time were longer than NSQIP time (R2 = 0.58), including, but not limited to, shoulder arthroplasty and arthroscopic shoulder surgery. The correlation between payments and operative times was stronger between CMS data (R2 = 0.61) than NSQIP data (R2 = 0.43). Similarly, the correlation between wRVUs and operative times was stronger when using CMS data (R2 = 0.87) than NSQIP data (R2 = 0.69). Nearly all arthroscopic shoulder procedures (aside from synovectomy, debridement, and decompression) were highly valued according to both datasets. Per NSQIP, compensation for revision total shoulder arthroplasty ($10.14/min; 0.26 wRVU/min) was higher than that for primary cases ($9.85, 0.23 wRVU/min) and nearly twice the CMS rate for revision cases ($5.84/min; 0.13 wRVU/min).

CONCLUSIONS

CMS may overestimate operative times compared to actual operative times as recorded by NSQIP. Shorter operative times may render certain procedures more highly valued than others. Case examples show that this can potentially affect patient care and incentivize higher compensating procedures per operative time when less-involved, shorter operations have similar patient-reported outcomes.

Physician Compensation in the United States - Through the Lens of the MS Neurologist

PURPOSE OF REVIEW

To explore the elements that are typically considered when determining physician compensation in the United States and to examine if the compensation of neurologists with expertise in multiple sclerosis (MS) care is commensurate with that for other neurological specialists and medical specialists that also employ complex therapies, e.g., oncology.

RECENT FINDINGS

The complexity in the diagnosis and management of MS requires increasing specialization. Additionally, changing models for the delivery of MS care has resulted in the MS neurologist generating significant contribution margins. In fact, the revenue to compensation ratio for the MS neurologist may be significantly higher than that of any other discipline in neuroscience service lines. However, while the contribution margin is often a key justification of compensation of interventional and intensive care practitioners in neuroscience service lines, it is generally not considered in the MS neurologist's compensation. Compensation models for MS neurologists typically depend heavily on the absolute number of relative value units associated with evaluation and management (E&M) codes making other fields of neurology financially more attractive to trainees.

SUMMARY

In considering the shortage of MS specialists, the demands of their discipline, and the revenue to compensation ratios, the MS neurologist is significantly undercompensated relative to other neurological specialists and to physicians in other disciplines. Compensating the MS neurologist appropriately and supporting the necessary infrastructure for MS care will likely attract more trainees to this discipline and help reverse the current scarcity of MS neurologists in the United States.

Trends in reimbursement for primary and revision total elbow arthroplasty

BACKGROUND

Relative value units (RVUs) are an essential component of reimbursement calculations from the Centers for Medicare & Medicaid Services. RVUs are calculated based on physician work, practice expense, and professional liability insurance. Procedures that are more complex, such as revision arthroplasty, require greater levels of physician work and should therefore be assigned a greater RVU. The purpose of this study is to compare RVUs assigned for primary and revision total elbow arthroplasty (TEA).

METHODS

The National Surgical Quality Improvement Program database was used to collect all primary and revision total elbow arthroplasties performed between January 2015 and December 2017. Variables collected included age at time of surgery, RVUs assigned for the procedure, and operative time.

RESULTS

A total of 359 cases (282 primary TEA, 77 revision TEA) were included in this study. Mean RVUs for primary TEA was 21.4 (2.0 standard deviation [SD]) vs. 24.4 (1.7 SD) for revision arthroplasty (P < .001). Mean operative time for primary TEA was 137.9 minutes (24.4 SD) vs. 185.5 minutes (99.7 SD) for revision TEA (P < .001). The RVU per minute for primary TEA was 0.16 and revision TEA was 0.13 (P < .001). This amounts to a yearly reimbursement difference of $71,024 in favor of primary TEA over revision TEA.

CONCLUSION

The current reimbursement model does not adequately account for increased operative time, technical demand, and pre- and postoperative care associated with revision elbow arthroplasty compared with primary TEA. This leads to a financial advantage on performing primary TEA.

Reimbursement for Hip Fractures: The Impact of Varied Current Procedural Terminology Coding Using Relative Value Units

BACKGROUND

Many orthopedic practices routinely code hip fracture hemiarthroplasty as Current Procedural Terminology (CPT) 27125 even though 27236 is the correct CPT code. Our objective is to determine the financial impact this simple mistake has on surgeon reimbursement.

METHODS

Our data comprised cases assigned International Classification of Diseases, Tenth Revision code S72.001A through S72.035A and CPT code 27125 or 27236 within the American College of Surgeons National Surgical Quality Improvement Program 2016-2017 database. Relative value units (RVUs) per CPT code and the Centers for Medicare and Medicaid Services reported that RVU conversion factor of $36.0896 per 1 RVU was used to calculate reimbursement per case. The dollar difference and percent difference per case was then calculated between cases assigned CPT code 27125 and those assigned 27236.

RESULTS

Our total sample consisted of 12,287 National Surgical Quality Improvement Program cases. Of those, 4185 (34%) were cases of a hip fracture treated with hemiarthroplasty that were incorrectly coded as CPT code 27125. That error in coding results in a decrease in reimbursement of $35.01 per case, a 5.51% difference.

CONCLUSION

Since the current healthcare reimbursement model relies solely on CPT codes to determine RVUs, it is imperative that orthopedic surgeons understand the financial impact of incorrect coding. Although correct coding of hemiarthroplasty procedures for hip fractures is an easy task to fix in the future, we hope that through this study a greater emphasis is placed on coding in orthopedic surgery.

Laparoscopic Inguinal Hernia Repair: Undervalued by the Relative Value Unit System

Work relative value units (wRVUs) serve as a proxy of surgeon's effort, technical skill, and time to determine reimbursement. The aim of this study is to determine how accurately wRVUs reflect the work effort of surgeons performing laparoscopic inguinal hernia repair (LIHR) as compared to open repair (OIHR). Within the National Surgical Quality Improvement Program database, 40 099 patients who underwent LIHR and 99 176 patients who underwent OIHR between 2012 and 2017 were identified. Mean wRVUs, wRVUs per minute, and operative times were compared between 8 groups based on clinical factors (unilateral vs. bilateral; obstructed vs. non-obstructed; primary vs. recurrent; 2 × 2 × 2 = 8). In both aggregate and matched cohorts, wRVUs for LIHR were significantly lower than OIHR in all 8 categories (P < .001). On regression analysis, the mean difference in assigned vs. calculated relative value units (RVUs) was most divergent among unilateral, recurrent, obstructed IHR (3.12 mean RVUs, P < .001). Despite the rising utilization of LIHR, current wRVUs significantly undervalue this technique across all categories and consequently the work of surgeons who perform laparoscopic procedures. This RVU discrepancy in an increasing minimally invasive, value-driven surgical environment calls for more objective criteria to assign RVUs, whereby the value is measured by operative complexity-patient clinical factors and severity of the hernia itself-not solely operative technique.

Health care disparity exists among those undergoing emergent hernia repairs in New York State

INTRODUCTION

Socioeconomic factors predispose certain populations to an increased exposure to emergent operative procedures. The aim of this study is to evaluate the role socioeconomic factors play in emergent repairs of inguinal, ventral and umbilical hernias.

METHODS

The SPARCS database was used to identify all patients undergoing emergent ventral hernia repair (EVR), emergent inguinal hernia repair (EIR), and emergent umbilical hernia repair (EUR) between 2008 and 2015. Chi-square test with exact p values from Monte Carlo simulation determined marginal associations between repairs (elective vs. emergent), and patient characteristics and comorbidities. Multivariable logistic regression models were further utilized to examine socioeconomic disparity.

RESULTS

107,887 ventral hernias, 66,947 inguinal hernias, and 63,515 umbilical hernias (total 238,349) were noted. African Americans were most likely to undergo an EVR compared to Caucasians (OR 1.55, 95% CI: 1.48-1.61), Asians (OR 1.31, 95% CI: 1.15-1.5), and Hispanics (OR 1.3, 95% CI: 1.23-1.37). African Americans were most likely to undergo EIR compared to Caucasians (OR 2.2, 95% CI: 2.06-2.36), Asians (OR 1.74, 95% CI: 1.49-2.02), and Hispanics (OR 1.22, 95% CI: 1.12-1.34). African Americans were most likely to undergo EUR compared to whites (OR 1.29, 95% CI: 1.22-1.36), Asians (26.62%, OR 1.21, 95% CI: 1.01-1.46) and Hispanic (28.03%, OR 1.08, 95% CI: 1.01-1.16). Medicaid patients were also more likely to undergo EVR (OR 1.31, OR 1.73), EIR (OR 2.92, OR 4.55) and EUR (OR 1.63, OR 2.31) compared to Medicare and commercial insurance.

CONCLUSION

Race is a contributing factor in who undergoes an emergent hernia repair in New York State. A significantly larger proportion of the African American population is undergoing hernia repair in the emergent setting. Socioeconomic status, as indicated by the significant number of Medicaid patients undergoing emergent hernia repairs, also plays a role.

Surgeon as Double Agent: Perception of Conflicting Expectations of Patient Care and Stewardship of Resources

BACKGROUND

Physicians must satisfy 2 competing expectations: advocate for patients and serve as stewards of resources. No guidelines exist for surgeons on resolving this conflict. We surveyed surgeons' perceptions about these dual obligations.

STUDY DESIGN

We conducted our study at 2 large university hospitals in 3 distinct steps, each built on the previous one. First, we surveyed 40 surgery residents and medical students using a 10-question assessment tool as the quantitative portion of our analysis. Next, a focus group of attending surgeons was surveyed to identify themes for the qualitative part of our study. Based on these, 5 attending surgeons from varying specialties were interviewed in a semi-structured format. We used the Wilcoxon signed rank test for quantitative analysis and content analysis to report our qualitative findings.

RESULTS

Students and residents did not think that they faced resource allocation decisions; however, they observed attending surgeons face them regularly (p = 0.0003). Attending surgeons from various specialties agreed that they thought they were obligated to both provide excellent care and serve as a steward of resources. All surgeons agreed these obligations can conflict. Individual practices varied with all erring on the side of patient care. Concern about being an outlier in one's section was a greater motivator to alter practice than was fear of litigation. No surgeon thought that patients had an adequate understanding of surgeons' dual agency.

CONCLUSIONS

Surgeons balance the responsibilities of patient care and stewardship of resources with great variability. Diverse practices likely add to inequalities in healthcare delivery and increase mistrust. Surgeons' social contract with patients calls for transparent strategies to address their dual agency.

Patient complexity by surgical specialty does not correlate with work relative value units

BACKGROUND

Understanding the differences in how patient complexity varies across surgical specialties can inform policy decisions about appropriate resource allocation and reimbursement. This study evaluated variation in patient complexity across surgical specialties and the correlation between complexity and work relative value units.

STUDY DESIGN

The 2017 American College of Surgeons National Surgical Quality Improvement Program was queried for cases involving otolaryngology and general, neurologic, vascular, cardiac, thoracic, urologic, orthopedic, and plastic surgery. A total of 10 domains of patient complexity were measured: American Society of Anesthesiologists class ≥4, number of major comorbidities, emergency operation, major complications, concurrent procedures, additional procedures, length of stay, non-home discharge, readmission, and mortality. Specialties were ranked by their complexity domains and the domains summed to create an overall complexity score. Patient complexity then was evaluated for correlation with work relative value units.

RESULTS

Overall, 936,496 cases were identified. Cardiac surgery had the greatest total complexity score and was most complex across 4 domains: American Society of Anesthesiologists class ≥4 (78.5%), 30-day mortality (3.4%), major complications (56.9%), and mean length of stay (9.8 days). Vascular surgery had the second greatest complexity score and ranked the greatest on the domains of major comorbidities (2.7 comorbidities) and 30-day readmissions (10.1%). The work relative value units did not correlate with overall complexity score (Spearman's ρ = 0.07; P < .01). Although vascular surgery had the second most complex patients, it ranked fifth greatest in median work relative value units. Similarly, general surgery was the fifth most complex but had the second-least median work relative value units.

CONCLUSION

Substantial differences exist between patient complexity across specialties, which do not correlate with work relative value units. Physician effort is determined largely by patient complexity, which is not captured appropriately by the current work relative value units.

Misvaluation of Hospital-Based Upper Extremity Surgery Across Payment, Relative Value Units, and Operative Time

BACKGROUND

Many US health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. Among other factors, a major determinant of payment and wRVU assignments is operative time. Our objective was to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common hospital-based hand and upper extremity procedures.

METHODS

Data on wRVUs, surgeon payment, and estimated operative times were collected from CMS for 53 procedures. We used regression models to compare relationships between these variables, in addition to actual median operative times as reported in the NSQIP database, from 2011 to 2016. We then determined the relative valuation of each procedure based on operative time.

RESULTS

There was a wide discrepancy between CMS and NSQIP operative times (R²=0.49), with 60% of CMS times being longer than NSQIP times. Payment correlated more strongly with CMS operative times (R²=0.55) than with NSQIP operative times (R²=0.24). Similarly, wRVUs more strongly correlated with CMS operative times (R²=0.84) than with NSQIP operative times (R2=0.51). In general, for trauma-related procedures, any distal radius open reduction internal fixation (ORIF) had the highest valuation while any ORIF proximal to the distal radius had lower valuation in analysis of both databases. While 61% of trauma procedures were highly valued, 70% of elective procedures had a low valuation, including nearly all elective tendon procedures. Notable compensation differences were found between trapeziectomy versus ligament reconstruction and tendon interposition, epicondyle debridement with tendon repair versus denervation, proximal row carpectomy versus four corner fusion, and distal radius open versus percutaneous fixation.

CONCLUSIONS

CMS may misvalue payment and wRVU rates of hospital-based hand procedures due to inaccurate operative time estimates. By identifying which procedures are misvalued in terms of payment and wRVU per operative time, providers and payors may be able to address these imbalances and maximize appropriate care delivery incentives.Level of Evidence: III.

Compensation models in emergency medicine: An ethical perspective

There is considerable diversity in compensation models in the specialty of Emergency Medicine (EM). We review different compensation models and examine moral consequences possibly associated with the use of various models. The article will consider how different models may promote or undermine health care's quadruple aim of providing quality care, improving population health, reducing health care costs, and improving the work-life balance of health care professionals. It will also assess how different models may promote or undermine the basic bioethical principles of beneficence, non-maleficence, respect for autonomy, and justice.

Not all primary total hip arthroplasties are equal-so is there a difference in reimbursement?

Background

Relative value units (RVUs) are a physician reimbursement model based on the effort required, or value, in providing a procedure or service for a patient. Procedures such as conversion total hip arthroplasties (THAs) can be compared to primary THAs, but many studies have revealed increased difficulties in conversion cases. Despite the increased time and effort for conversion THA, it is unknown if this is reflected in the RVU compensation model. Therefore, the purpose of this study was to compare the: (I) mean operative times; (II) mean RVUs; (III) RVU/minute for primary and conversion THAs; and (IV) perform an individualized idealized surgeon annual cost difference analysis.

Methods

A total of 103,702 primary THA patients were identified using CPT code 27130 and 2,986 conversion THA patients were identified using CPT code 27132 using the National Surgical Quality Improvement Program (NSQIP) database. The mean RVUs, operative times (minutes), and RVU/minute were calculated and compared. An annualize cost analysis of dollar amounts per case, day, and the year was also performed.

Results

The mean operative times for the primary and conversion THA cohorts were 94 vs. 146 minutes (P<0.001) and mean RVUs were 21.24 vs. 25.68 (P<0.001). Interestingly, the mean RVU per minute was higher for the primary THA compared to the conversion THA groups (0.26 vs. 0.21, P<0.001). Annualized cost analysis revealed a potential $173,529 difference from performing primary vs. conversion THAs.

Conclusions

Even though conversion THA can be considered to a more complex and demanding procedure, based on RVUs per minute of surgery, orthopaedic surgeons are reimbursed better for primary THA cases. This data could be used by orthopaedic surgeons to administer their practices better to yield the highest return on time.

A comparison of relative value units in revision hip versus revision knee arthroplasty

The purpose of this study was to compare the: 1) RVUs; 2) lengths-of-surgery; 3) RVU per minute between revision hip (THA) and knee (TKA) arthroplasties; and 4) perform an annualized surgeon cost analysis. Using the ACS-NSQIP from 2008 to 2015, 8081 revision TKAs, 7233 THAs were compared. Revision THA had greater mean RVUs (30.27 vs. 27.10 RVUs, p < 0.001), operative times (152 vs. 149 min, p < 0.001), and RVU/minute (0.3 vs. 0.2 RVUs per minute, p < 0.001). Cost analysis yielded and annual $89,922.73 difference. Revision THA, therefore, is reimbursed at a significantly higher "hourly rate," when compared to revision TKA.

What provides a better value for your time? The use of relative value units to compare posterior segmental instrumentation of vertebral segments

BACKGROUND CONTEXT

Relative value units (RVUs) are a compensation model based on the effort required to provide a procedure or service to a patient. Thus, procedures that are more complex and require greater technical skill and aftercare, such as multilevel spine surgery, should provide greater physician compensation. However, there are limited data comparing RVUs with operative time. Therefore, this study aims to compare mean (1) operative times; (2) RVUs; and (3) RVU/min between posterior segmental instrumentation of 3-6, 7-12, and ≥13 vertebral segments, and to perform annual cost difference analysis.

METHODS

A total of 437 patients who underwent instrumentation of 3-6 segments (Cohort 1, current procedural terminology [CPT] code: 22842), 67 patients who had instrumentation of 7-12 segments (Cohort 2, CPT code: 22843), and 16 patients who had instrumentation of ≥13 segments (Cohort 3, CPT code: 22844) were identified from the National Surgical Quality Improvement Program (NSQIP) database. Mean operative times, RVUs, and RVU/min, as well as an annualized cost difference analysis, were calculated and compared using Student t test. This study received no funding from any party or entity.

RESULTS

Cohort 1 had shorter mean operative times than Cohorts 2 and 3 (217 minutes vs. 325 minutes vs. 426 minutes, p<.05). Cohort 1 had a lower mean RVU than Cohorts 2 and 3 (12.6 vs. 13.4 vs. 16.4). Cohort 1 had a greater RVU/min than Cohorts 2 and 3 (0.08 vs. 0.05, p<.05; vs. 0.08 vs. 0.05, p>.05). A $112,432.12 annualized cost difference between Cohorts 1 and 2, a $176,744.76 difference between Cohorts 1 and 3, and a $64,312.55 difference between Cohorts 2 and 3 were calculated.

CONCLUSION

The RVU/min takes into account not just the value provided but also the operative times required for highly complex cases. The RVU/min for fewer vertebral level instrumentation being greater (0.08 vs. 0.05), as well as the $177,000 annualized cost difference, indicates that compensation is not proportional to the added time, effort, and skill for more complex cases.

A Comparison of Relative Value Units in Primary Versus Revision Total Knee Arthroplasty

BACKGROUND

In total knee arthroplasty (TKA), revision cases are often technically more challenging, and require more operative time and aftercare than primary cases. These time and effort differences should therefore be appropriately compensated for when using the relative value unit (RVU) system. Therefore, the purpose of this study is to compare the mean (1) RVUs; (2) operative times; and (3) RVU/min; and (4) perform an individualized idealized surgeon annual cost difference analysis for primary vs revision TKA.

METHODS

Current Procedural Terminology code 27447 identified 165,439 primary TKA patients, while Current Procedural Terminology code 27487 identified 8081 revision TKA patients from the National Surgical Quality Improvement Program database. The mean RVUs, operative times, and RVU/min were calculated. Dollar amount per minute, per case, per day, and year were also calculated. Student's t-test, with a cut-off P-value of <.05, was used in order to identify any statistical differences in mean RVUs, operative times, and RVU/min.

RESULTS

The mean RVUs for primary TKA was 22, while for revision TKA was 27 (P < .001). The mean operative time for primary TKA was 94 minutes, while for revision TKA was 149 minutes (P < .001). The mean RVU/min for primary TKA was 0.26, while for revision TKA was 0.22 (P < .001). The dollar amounts calculated for primary vs revision TKA were per minute ($9.33 vs $7.90), per case ($877.12 vs $1176.43), per day ($4385.60 vs $3529), and projected a $137,008.70 annual cost difference.

CONCLUSION

Orthopedic surgeons are reimbursed at a higher rate per minute for primary cases compared to revision TKA (0.26 vs 0.22, P < .001). The annual difference can amount to nearly $140,000. Orthopedic surgeons can use this information to better understand the dynamics of their time, compensation, and ultimately, their practice. Furthermore, it can be argued that there needs to be a shift to increase the RVU per unit time for revision TKAs.

Are We Appropriately Compensated by Relative Value Units for Primary vs Revision Total Hip Arthroplasty?

BACKGROUND

Relative value units (RVUs) are used to evaluate the effort required for providing a service to patients in order to determine compensation. Thus, more complicated cases, like revision arthroplasty cases, should yield a greater compensation. However, there are limited data comparing RVUs to the time required to complete the service. Therefore, the purpose of this study is to compare the (1) mean RVUs, (2) mean operative times, and (3) mean RVU/minute between primary and revision total hip arthroplasty (THA) and (4) perform an individualized idealized surgeon annual cost difference analysis.

METHODS

A total of 103,702 patients who underwent primary (current procedural terminology code 27130) and 7273 patients who underwent revision THA (current procedural terminology code 27134) were identified using the National Surgical Quality Improvement Program database. Mean RVUs, operative times (minutes), and RVU/minute were calculated and compared using Student t-test. Dollar amount per minute, per case, per day, and year was calculated to find an individualized idealized surgeon annual cost difference.

RESULTS

The mean RVU was 21.24 ± 0.53 (range, 20.72-21.79) for primary and 30.27 ± 0.03 (range, 30.13-30.28) for revision THA (P < .001). The mean operative time for primary THA was 94 ± 38 minutes (range, 30-480 minutes) and 152 ± 75 minutes (range, 30-475 minutes) for revision THA (P < .001). The mean RVU/minute was 0.260 ± 0.10 (range, 0.04-0.73) for primary and 0.249 ± 0.12 (range, 0.06-1.0) for revision cases (P < .001). The dollar amounts calculated for primary vs revision THA were as follows: per minute ($9.33 vs $8.93), per case ($877.12 vs $1358.32), per day ($6139.84 vs $5433.26), and a projected $113,052.28 annual cost difference for an individual surgeon.

CONCLUSION

Maximizing the RVU/minute provides the greatest "hourly rate." The RVU/minute for primary (0.260) being significantly greater than revision THA (0.249) and an annualized $113,052.28 cost difference reveal that although revision THAs are more complex cases requiring longer operative time, greater technical skill, and aftercare, compensation per time is not greater.

"Halo effect" in trauma centers: does it extend to emergent colectomy?

BACKGROUND

Trauma centers (TCs) have been demonstrated to improve outcomes for some nontrauma surgical conditions, such as appendicitis, but it remains unclear if this extends to all emergency general surgery procedures. Using emergent colectomy in patients with diverticulitis as index condition, this study compared outcomes between TCs and nontrauma centers (NTCs).

MATERIALS AND METHODS

The Nationwide Emergency Department Sample (2006-2011) was queried for patients ≥16 y with diverticulitis who underwent emergency surgical intervention. Outcomes included mortality, total charges, and length of stay (LOS). Mortality in TC and NTC was compared using logistic regression, controlling for patient, procedure, and hospital-level characteristics. Adjusted total charges and LOS were analyzed using generalized linear models with gamma and Poisson distributions, respectively.

RESULTS

A total of 25,396 patients were included, 5189 (20.4%) were treated at TC and 20,207 (79.6%) at NTC. Median age and sex distribution were similar. Unadjusted proportional in-hospital mortality did not differ between TC and NTC; median charges and LOS were greater in TC. After adjusting, the odds of mortality were significantly higher in TC (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.02-1.51; P = 0.003) as were mean charges and LOS (P < 0.001).

CONCLUSIONS

The improved outcomes reported for other nontrauma conditions in TC were not observed for patients undergoing an emergent colectomy for diverticulitis after accounting for patient, procedure, and hospital-level characteristics. Future research is needed to assess differences in case mix between TC versus NTC and possible case-mix effects on outcomes to elucidate potential benefit of surgical care in a TC across the breadth of emergency general surgery conditions.

Determinants of Resource Utilization in a Tertiary Pediatric and Congenital Echocardiographic Laboratory

We sought to determine the relation between technical charges for transthoracic echocardiograms (TTE) and total time for study completion (TT), identify factors associated with high TT, and create a scoring system to predict high TT studies. We analyzed a quality improvement database that prospectively tracked patient flow through TTEs in our laboratory for 3 consecutive months. The performing sonographer or fellow recorded TT and its components for every study. Patient and scan characteristics were abstracted from the clinical database and technical charges from the financial database. Factors independently associated with high TT (top quartile ≥85 minutes) were identified in 1,686 studies and validated in the remaining 847 studies. Median age was 7.8 years (0 to 77.9) and median TT was 65 minutes (14 to 370 minutes). Charges correlated poorly with TT (r = 0.2). Multivariate analysis identified several independent factors associated with high TT. The final model had an area under the curve of 0.78 in the development sample and 0.75 in the validation sample. On the basis of the final model, we developed a risk score for TT ≥85 minutes. The prevalence of high TT was 15% in low-score studies, 51% in medium-score studies, and 81% in high-score studies. In conclusion, this is the first study to demonstrate poor correlation between technical charges for pediatric/congenital echocardiography and TT, identify risk factors for high TT, and develop a high TT risk scoring system. These data may assist in resource allocation for pediatric/congenital echocardiograms and inform reimbursement systems.

A method to account for variation in congenital heart surgery charges

BACKGROUND

In response to societal pressure to reduce expenditures and increase quality, we sought to develop a methodology to predict hospital charges related to congenital heart surgery.

METHODS

Patients undergoing congenital heart surgery at Boston Children's Hospital in fiscal years 2007 to 2009 comprised the derivation cohort. Clinical data, including Current Procedural Terminology coding of the primary surgical intervention, were collected prospectively and linked to total hospital charges for an episode of care. Surgical charge categories were developed to group surgical procedure types using empiric data and expert consensus. A multivariable model was built using surgical charge categories and additional patient and procedural characteristics to predict the outcome, total hospital charges. A contemporary cohort for fiscal years 2010 to 2012 was used to validate surgical charge categories and the multivariable model.

RESULTS

In the derivation cohort, 2,105 cases met inclusion criteria. One hundred three surgical procedure types were categorized into seven surgical charge categories, yielding a grouper variable with an R(2) explanatory value of 47.3%. Explanatory value increased with consideration of patient age, admission status, and preoperative ventilator dependence (R(2) = 59.4%), as well as weight category, noncardiac abnormality, and genetic syndrome other than trisomy 21 (R(2) = 61.5%). Additional variability in charge was explained when extracorporeal membrane oxygenation utilization and greater than one operating room visit during the episode of care were added (R(2) = 74.3%). The contemporary cohort yielded an R(2) explanatory value of 67.7%.

CONCLUSIONS

The combination of clinical data with resource utilization information resulted in a statistically valid predictive model for total hospital charges in congenital heart surgery.

Development of a charge adjustment model for cardiac catheterization

A methodology that would allow for comparison of charges across institutions has not been developed for catheterization in congenital heart disease. A single institution catheterization database with prospectively collected case characteristics was linked to hospital charges related and limited to an episode of care in the catheterization laboratory for fiscal years 2008-2010. Catheterization charge categories (CCC) were developed to group types of catheterization procedures using a combination of empiric data and expert consensus. A multivariable model with outcome charges was created using CCC and additional patient and procedural characteristics. In 3 fiscal years, 3,839 cases were available for analysis. Forty catheterization procedure types were categorized into 7 CCC yielding a grouper variable with an R (2) explanatory value of 72.6%. In the final CCC, the largest proportion of cases was in CCC 2 (34%), which included diagnostic cases without intervention. Biopsy cases were isolated in CCC 1 (12%), and percutaneous pulmonary valve placement alone made up CCC 7 (2%). The final model included CCC, number of interventions, and cardiac diagnosis (R (2) = 74.2%). Additionally, current financial metrics such as APR-DRG severity of illness and case mix index demonstrated a lack of correlation with CCC. We have developed a catheterization procedure type financial grouper that accounts for the diverse case population encountered in catheterization for congenital heart disease. CCC and our multivariable model could be used to understand financial characteristics of a population at a single point in time, longitudinally, and to compare populations.

Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities?

BACKGROUND

We hypothesize that lack of access to care results in propensity toward emergent operative management and may be an important factor in worse outcomes for the uninsured population. The objective of this study is to investigate a possible link to worse outcomes in patients without insurance who undergo an emergent operation.

METHODS

A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample (NIS) 2005-2011 dataset. Patients who underwent biliary, hernia, and colorectal operations were evaluated. Multivariate analyses were performed to assess the associations between insurance status, urgency of operation, and outcome. Covariates of age, sex, race, and comorbidities were controlled.

RESULTS

The uninsured group had greatest odds ratios of undergoing emergent operative management in biliary (OR 2.43), colorectal (3.54), and hernia (3.95) operations, P < .001. Emergent operation was most likely in the 25- to 34-year age bracket, black and Hispanic patients, men, and patients with at least one comorbidity. Postoperative complications in emergencies, however, were appreciated most frequently in the populations with government coverage.

CONCLUSION

Although the uninsured more frequently underwent emergent operations, patients with coverage through the government had more complications in most categories investigated. Young patients also carried significant risk of emergent operations with increased complication rates. Patients with government insurance tended toward worse outcomes, suggesting disparity for programs such as Medicaid. Disparity related to payor status implies need for policy revisions for equivalent health care access.