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.

Relative Value Units and Operative Time in Plastic and Reconstructive Surgery

BACKGROUND

Work relative value units (wRVUs) are linked to clinical reimbursements and physician compensation in the USA and thus should consider the time of the physician providing care. The primary goal of this study is to assess whether wRVUs appropriately consider operative time in plastic and reconstructive surgery.

METHODS

The 2015-2018 National Surgical Quality Improvement Program was queried for the 50 most performed plastic surgery cases with assigned wRVUs and a recorded operative time. Linear regressions were used to assess the relationships between operative time, assigned wRVUs, and wRVUs per hour. The procedures with the highest and lowest assigned wRVUs relative to their operative time were identified.

RESULTS

A total of 31,156 cases were included in this analysis. Among the 50 most performed procedures, the median (range) for assigned wRVUs was 10.0 (1.0-42.6), operative time was 61 min (21-441), and wRVUs per hour was 8.7 (2.2-16.2). There was a strong positive linear correlation between assigned wRVUs and median operative time (R²=0.78), with each additional operative hour being associated with an increase of 5.3 wRVUs (p<0.001). The procedures earning the most wRVUs relative to their operative times were breast reconstruction with other techniques and tissue expander placement in breast reconstruction. However, excisional debridements of the muscle/fascia and subcutaneous tissue had the lowest earned wRVUs relative to their operative times.

CONCLUSION

Although wRVUs and operative time are correlated in plastic surgery, numerous outliers from this trend exist. This suggests that wRVUs may not be optimally assigned across the range of plastic surgery procedures.

Understanding value and patient complexity among common inpatient vascular surgery procedures

OBJECTIVE

Vascular surgery patients are highly complex, second only to patients undergoing cardiac procedures. However, unlike cardiac surgery, work relative value units (wRVU) for vascular surgery were undervalued based on an overall patient complexity score. This study assesses the correlation of patient complexity with wRVUs for the most commonly performed inpatient vascular surgery procedures.

METHODS

The 2014 to 2017 National Surgical Quality Improvement Program Participant Use Data Files were queried for inpatient cases performed by vascular surgeons. A previously developed patient complexity score using perioperative domains was calculated based on patient age, American Society of Anesthesiologists class of ≥4, major comorbidities, emergent status, concurrent procedures, additional procedures, hospital length of stay, nonhome discharge, and 30-day major complications, readmissions, and mortality. Procedures were assigned points based on their relative rank and then an overall score was created by summing the total points. An observed to expected ratio (O/E) was calculated using open ruptured abdominal aortic aneurysm repair (rOAAA) as the referent and then applied to an adjusted median wRVU per operative minute.

RESULTS

Among 164,370 cases, patient complexity was greatest for rOAAA (complexity score = 128) and the least for carotid endarterectomy (CEA) (complexity score = 29). Patients undergoing rOAAA repair had the greatest proportion of American Society of Anesthesiologists class of ≥IV (84.8%; 95% confidence interval [CI], 82.6%-86.8%), highest mortality (35.5%; 95% CI, 32.8%-38.3%), and major complication rate (87.1%; 95% CI, 85.1%-89.0%). Patients undergoing CEA had the lowest mortality (0.7%; 95% CI, 0.7%-0.8%), major complication rate (8.2%; 95% 95% CI, 8.0%-8.5%), and shortest length of stay (2.7 days; 95% CI, 2.7-2.7). The median wRVU ranged from 10.0 to 42.1 and only weakly correlated with overall complexity (Spearman's ρ = 0.11; P < .01). The median wRVU per operative minute was greatest for thoracic endovascular aortic repair (0.25) and lowest for both axillary-femoral artery bypass (0.12) and open femoral endarterectomy, thromboembolectomy, or reconstruction (0.12). After adjusting for patient complexity, CEA (O/E = 3.8) and transcarotid artery revascularization (O/E = 2.8) had greater than expected O/E. In contrast, lower extremity bypass (O/E = 0.77), lower extremity embolectomy (O/E = 0.79), and open abdominal aortic repair (O/E = 0.80) had a lower than expected O/E.

CONCLUSIONS

Patient complexity varies substantially across vascular procedures and is not captured effectively by wRVUs. Increased operative time for open procedures is not adequately accounted for by wRVUs, which may unfairly penalize surgeons who perform complex open operations.