Work relative value units undervalue the clinical effort associated with teaching cases: An ACS-NSQIP analysis

PURPOSE

Work-relative-value-units (wRVUs) are a core metric of faculty effort but do not account for the additional work associated with intraoperative teaching. This study introduces and assesses an indexed effort, wRVU per minute (wRVU index). We hypothesize that there is a significant decrease in the calculated wRVU index among teaching cases.

METHODS

We queried the ACS-NSQIP database for 7 core Emergency General Surgery procedures and records were stratified into teaching vs non-teaching, and emergent vs non-emergent procedures. We utilized multivariable generalized linear models to determine factors associated with increased operative time and decreased wRVU index.

RESULTS

Data were available for 953,967 cases from 2005 to 2010. For all cases, teaching vs non-teaching, the median wRVU index was 0.16 vs 0.21 (p ​< ​0.001). There was a positive association between teaching cases and decreased wRVU index for all cases.

CONCLUSION

The wRVU index was 24% lower for teaching cases when compared to non-teaching cases despite controlling for patient-specific factors. This finding highlights the need for further evaluation of the current wRVU framework.

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.

The financial and employment effects of coronavirus disease 2019 on physicians in the United States

Although the coronavirus disease 2019 (COVID-19) pandemic has created havoc with the U.S healthcare system and physicians, the financial and contractual implications for physicians are now beginning to come to the forefront. Financial assistance from the federal government has mainly been received by hospitals, which have borne the brunt of the COVID-19 illness. Some physician groups have, or are, receiving assistance through a few programs, although the accelerated and advance payments have been suspended. Employed surgeons are now being furloughed, terminated, or persuaded to agree to a significant cut in pay, forego bonuses, or take leave without pay as healthcare systems and some physician groups have started to experience the consequences of halting elective procedures. Newly hired surgeons might be forced in a few cases to agree to delays in starting their employment, new amendments, changes in employment status, and other terms for fear of losing their employment. In the present report, we have explained some agreement terminology and options available to allow physicians to understand the terms of their employment agreement and make their decisions after consulting with an expert healthcare attorney.

Medical oncologists' willingness to participate in bundled payment programs

Background

Bundled payment programs play an increasingly important role in transforming reimbursement for oncologic care. We assessed determinants of oncologists’ willingness to participate in bundled payment programs for breast cancer. We hypothesized that providers would be more likely to participate in bundled payment programs if offered higher levels of reimbursement for each episode of care.

Methods

Oncologists from Florida, New Jersey, New York, and Pennsylvania were identified in the AMA database or by patients listed in state cancer registries. Providers were randomized to receive one of four versions of a survey describing bundled payment programs offering different levels of compensation for the first year of localized breast cancer treatment ($5000, $10,000, $15,000, or $20,000). Physicians rated their likelihood of participation in a bundled program on a Likert scale. Logistic regression was used to analyze determinants of likelihood of participation in bundling.

Results

Among 460 respondents, only 17% of oncologists were highly likely to participate in a bundled program paying $5000 for the first year of care, rising to 41% for the $15,000 program, but falling to 34% for the $20,000 program. Likelihood of participation was higher among oncologists who were male, older, and believed that cancer patients should not be offered high-cost drugs with minimal survival benefit.

Conclusion

Our results suggest that medical oncologists have limited enthusiasm for bundled payments, and higher payments may not overcome resistance to bundling among a substantial proportion of physicians.

Assessing the relationship between patient satisfaction and clinical quality in an ambulatory setting

Purpose The purpose of this paper is to assess the relationship between patient satisfaction and a variety of clinical quality measures in an ambulatory setting to determine if there is significant overlap between patient satisfaction and clinical quality or if they are separate domains of overall physician quality. Assessing this relationship will help to determine whether there is congruence between different types of clinical quality performance and patient satisfaction and therefore provide insight to appropriate financial structures for physicians. Design/methodology/approach Ordered probit regression analysis is conducted with overall rating of physician from patient satisfaction responses to the Clinician and Groups Consumer Assessment of Healthcare Providers and Systems survey as the dependent variable. Physician clinical quality is measured across five composite groups based on 26 Healthcare Effectiveness Data and Information Set (HEDIS) measures aggregated from patient electronic health records. Physician and patient demographic variables are also included in the model. Findings Better physician performance on HEDIS measures are correlated with increases in patient satisfaction for three composite measures: antibiotics, generics, and vaccination; it has no relationship for chronic conditions and is correlated with decrease in patient satisfaction for preventative measures, although the negative relationship for preventative measures is not robust in sensitivity analysis. In addition, younger physicians and male physicians have higher satisfaction scores even with the HEDIS quality measures in the regression. Research limitations/implications There are four primary limitations to this study. First, the data for the study come from a single hospital provider organization. Second, the survey response rate for the satisfaction measure is low. Third, the physician clinical quality measure is the percent of the physician's relevant patient population that met the HEDIS measure rather than if the measure was met for the individual patient. Finally, it is not possible to distinguish if the significant coefficient estimates on the physician age and gender variables are capturing systematic differences in physician behavior or capturing patient bias. Practical implications The results suggest patient satisfaction and physician clinical quality may be complementary, capturing similar aspects of overall physician quality, across some clinical quality measures but for other measures satisfaction and clinical quality are unrelated or negatively related. Therefore, for some clinical quality metrics, it will be important to separately compensate clinical quality and satisfaction and understand the relationship between metrics. Finally, the strong relationship between the level of patient satisfaction and physician age, physician gender, and patient age are important to consider when designing a physician compensation package based on patient satisfaction; if these differences reflect patient bias they could increase inequality among medical staff if compensation is based on patient satisfaction. Originality/value This study is the first to use physician organization data to examine patient satisfaction and physician performance on a variety of HEDIS quality metrics.

The differential effect of compensation structures on the likelihood that firms accept new patients by insurance type

Adequate access to primary care is not universally achieved in many countries, including the United States, particularly for vulnerable populations. In this paper we use multiple years of the U.S.-based Community Tracking Survey to examine whether a variety of physician compensation structures chosen by practices influence the likelihood that the practice takes new patients from a variety of different types of insurance. Specifically, we examine the roles of customer satisfaction and quality measures on the one hand, and individual physician productivity measures on the other hand, in determining whether or not firms are more likely to accept patients who have private insurance, Medicare, or Medicaid. In the United States these different types of insurance mechanisms cover populations with different levels of vulnerability. Medicare (elderly and disabled individuals) and Medicaid (low income households) enrollees commonly have lower ability to pay any cost sharing associated with care, are more likely to have multiple comorbidities (and so be more costly to treat), and may be more sensitive to poor access. Further, these two insurers also generally reimburse less generously than private payors. Thus, if lower reimbursements interact with compensation mechanisms to discourage physician practices from accepting new patients, highly vulnerable populations may be at even greater risk than generally appreciated. We control for the potential endogeneity of incentive choice using a multi-level propensity score method. We find that the compensation incentives chosen by practices are statistically and economically significant predictors for the types of new patients that practices accept. These findings have important implications for both policy makers and private health care systems.