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Background It has been speculated that women's productivity decreases after maternity leave. In this study, we measured if surgeon clinical productivity decreases after a maternity leave or other types of leave. Methods Data from a large medical center was used to measure surgeon productivity before (pre) and after (post) a leave of absence. Post-to-pre productivity ratios were calculated for each leave based on operative volumes and Relative Value Units (RVUs). Multivariate linear regression analysis was performed for the post/pre productivity ratios, adjusting for surgeon characteristics. Results Fifty leaves of absence, from 30 surgeons, were analyzed. There was no significant difference between post and pre leave productivity for maternity leave or other types of leave. There was also no significant difference when comparing post/pre productivity ratios between maternity leaves versus other types of leave (volume: 0.06, p = 0.52; RVU: 0.08, p = 0.58). Conclusion Surgeons do not significantly reduce clinical productivity after maternity or other types of leaves.

Rationale and Objectives While radiology training programs aim to prepare trainees for clinical practice, the relationship between trainee, and national radiology workforce demands is unclear. This study assesses changing radiology trainee neuroimaging workloads nationwide for neuroimaging studies. Materials and Methods Using aggregate Medicare claims files from 2002 to 2018, we identified all computed tomography (CT) and magnetic resonance (MR) examinations of the brain, head and neck, and spine (hereafter “neuroimaging”) in Medicare fee-for-service beneficiaries nationwide. Using separate Medicare files, we calculated population utilization rates, and work relative value unit (wRVU) weights of all diagnostic neuroradiology services. Using claims modifiers, we identified services rendered by radiology trainees. Using separate national trainee enrollment files, we calculated mean annual per trainee wRVUs. Results Between 2002 and 2018, total Medicare neuroimaging claims increased for both radiologists overall (86.1%) and trainees (162.5%), including increases in both CT (102.9% vs 196.8%), and MR (59.9% vs 106.6%). The national percentage of all radiologist neuroimaging wRVUs rendered by trainees increased 46.1% (3.8% of all wRVUs nationally in 2002 to 5.6% in 2018). National trainee increases were present across all neuroimaging services but greatest for head and neck CT (+86.5%). Mean annual per radiology trainee neuroimaging Medicare wRVUs increased +174.9% (42.1 per trainee in 2002 to 115.70 in 2018). Mean per trainee wRVU increases were greatest for spine CT (+394.2%) but present across all neuroimaging services. Conclusion As neuroimaging utilization in Medicare beneficiaries has grown, radiology trainee neuroimaging workloads have increased disproportionately.

Considerable variability exists between surgeons' assessments of a patient's individual pre-operative surgical risk. Surgical risk calculators are not routinely used despite their validation. We sought to compare thoracic surgeons' prediction of patients' risk of postoperative adverse outcomes versus a surgical risk calculator, the Surgical Risk Preoperative Assessment System (SURPAS). We developed vignettes from 30 randomly selected patients who underwent thoracic surgery in the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database. Twelve thoracic surgeons estimated patients' preoperative risks of postoperative morbidity and mortality. These were compared to SURPAS estimates of the same vignettes. C-indices and Brier scores were calculated for the surgeons' and SURPAS estimates. Agreement between surgeon estimates was examined using intraclass correlation coefficients (ICCs). Surgeons estimated higher morbidity risk compared to SURPAS for low-risk patients (ASA classes 1-2, 11.5% vs. 5.1%, p=

Introduction COVID-19 has resulted in decreases in absolute imaging volumes, however imaging utilization on a per-patient basis has not been reported. Here we compare per-patient imaging utilization, characterized by imaging studies and work relative value units (wRVUs), in an emergency department (ED) during a COVID-19 surge to the same period in 2019. Methods This retrospective study included patients presenting to the ED from April 1–May 1, 2020 and 2019. Patients were stratified into three primary subgroups: all patients (n = 9580, n = 5686), patients presenting with respiratory complaints (n = 1373, n = 2193), and patients presenting without respiratory complaints (n = 8207, n = 3493). The primary outcome was imaging studies/patient and wRVU/patient. Secondary analysis was by disposition and COVID status. Comparisons were via the Wilcoxon rank-sum or Chi-squared tests. Results The total patients, imaging exams, and wRVUs during the 2020 and 2019 periods were 5686 and 9580 (−41%), 6624 and 8765 (−24%), and 4988 and 7818 (−36%), respectively, and the percentage patients receiving any imaging was 67% and 51%, respectively (p

BACKGROUND With increasing complexity of our aging inpatient population, we implemented an interprofessional geriatric and palliative care intervention on a hospitalist service. This study aimed to measure the intervention's impact on length of stay (LOS), 30-day readmission, and the daily intensity of inpatient services utilization. METHODS Using a nonrandomized controlled intervention at a 1000-bed U.S. academic quaternary medical center, we studied 13,941 individuals admitted to a general medicine hospitalist service (of which 5644 were age > =65 years); 1483 were on intervention teams (576 age > =65 years), 5413 concurrent controls, and 7045 historical controls. On 2 of 11 hospitalist teams, a geriatrician, palliative care physician and social worker attended multidisciplinary discharge rounds twice weekly, to recommend inpatient geriatric or palliative care consult (GPCC), postacute nursing or home care, versus postdischarge outpatient consultation. We measured the difference in improvement over time between intervention and control team patients for the following: (1) LOS adjusted for case-mix index, (2) 30-day readmissions, and (3) intensity of hospital service utilization (mean services provided per patient per day). RESULTS Adjusted LOS (in hospital days) was decreased by 0.36 days (p = 0.039) for the 1483 patients in the intervention teams, with greater LOS reduction of 0.55 days per admission (p = 0.022) on average among the subset of 576 older patient admissions. Readmissions were unchanged (-1.17%, p = 0.48 for all patients; 1.91%, p = 0.46 for older patients). However, the daily relative value unit (RVU) utilization was modestly increased for both the overall and older subgroup, 0.35 RVUs (p = 0.041) and 0.74 RVUs (p

Background Medicare and Medicaid are 2 of the largest government-run health care programs in the United States. Although Medicare reimbursement is determined at the federal level by the Centers for Medicare & Medicaid Services, Medicaid reimbursement rates are set by each individual state. The purpose of this study is to compare Medicaid reimbursement rates with regional Medicare reimbursement rates for 12 orthopedic procedures performed to treat common fractures of the upper extremity. Methods Twelve orthopedic procedures were selected and their Medicare reimbursement rates were collected from the 2020 Medicare Physician Fee Schedule. Medicaid reimbursement rates were obtained from each state’s physician fee schedule. Reimbursement rates were then compared by assessing the ratio of Medicaid to Medicare, the dollar difference in Medicaid to Medicare reimbursement, and the difference per relative value unit. The range of variation in Medicaid reimbursement and Medicare wage index–adjusted Medicaid reimbursement was calculated. Comparisons in reimbursement were calculated using coefficient of variation and Student t tests to evaluate the differences between the mean Medicaid and Medicare reimbursements. Two-sample coefficient of variation testing was used to determine whether dispersion in Medicare and Medicaid reimbursement rates differed significantly. Results There was significant difference in reimbursement rates between Medicare and Medicaid for all 12 procedures, with Medicare reimbursing on average 46.5% more than Medicaid. In 40 states, Medicaid reimbursed less than Medicare for all 12 procedures. Regarding the dollar difference per relative value unit, Medicaid reimbursed on average $18.03 less per relative value unit than Medicare. The coefficient of variation for Medicaid reimbursement rates ranged from 0.26-0.33. This is in stark contrast with the significantly lower variability observed in Medicare reimbursement, which ranged from 0.06-0.07. Conclusion Our findings highlight the variation in reimbursement that exists among state Medicaid programs for 12 orthopedic procedures commonly used to treat fractures of the upper extremity. Furthermore, average Medicaid reimbursement rates were significantly lower than Medicare rates for all 12 procedures. Such discrepancies in reimbursement may act as a barrier, impeding many Medicaid patients from accessing timely orthopedic care.

Background Total shoulder arthroplasty (TSA) procedures performed for proximal humerus fractures are considered to have higher complications rates and longer operative time than TSA performed for osteoarthritis (OA). However, there exists only one current procedural terminology (CPT) code for TSA, which may not accurately capture the increased work and complexity required for fracture cases. The purpose of this study was to compare TSA work relative value unit (RVU) rates per operative time performed for osteoarthritis and fracture care. Methods Data were collected through the National Surgical Quality Improvement Program (NSQIP) database for the years 2006 to 2018 to identify all patients who underwent primary TSA for either OA or fractures. Work RVU, operation time (skin incision to closure), work RVU per minute, and payment per minute were compared between the osteoarthritis and fracture TSA cohorts. Bivariate and multivariate analyses controlling for patient demographics and comorbidity were utilized to determine whether there existed a reimbursement differential between the two groups. Results The mean operation times for primary TSA for osteoarthritis and fracture were 109 minutes and 122 minutes, respectively (P Conclusion On average, TSA performed for fracture care is associated with longer operative times and may require more work compared to elective TSA for OA. These results highlight the need for more precise procedural coding to accurately capture the added effort and operative time required for TSA in the setting of fracture care. Level of Evidence Level III

Objective: The goal of this research was to evaluate trends in gynecologic surgical reimbursement and to determine the factors affecting compensation. Materials and Methods: Procedure codes represe...

Child neurology programs can be net margin generators for children's hospitals. The relative value unit (RVU) expectations for child neurologists are heavily influenced by proceduralists (neurophysiologists, Botox injectors, and so forth) and means in most RVU data sets are not realistic expectations for Evaluation and Management coding, outpatient neurologists. Yet each neurologist has a net revenue/expense ratio of 1.97 for a hospital neurology enterprise, so each of the neurologists generates nearly twice their salary for the hospital. Downstream revenue is even more impressive. Each neurologist generates about $2,000,000.00 in downstream revenue per year.

The work relative value unit (wRVU) is a commonly cited surrogate for surgical complexity; however, it is highly susceptible to subjective interpretation and external forces. Our objective was to evaluate whether wRVU is associated with perioperative outcomes, including complications, after brain tumor surgery. The 2006–2014 American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients ≥ 18 years who underwent brain tumor resection. Patients were categorized into approximate quintiles based on total wRVU. The relationship between wRVU and several perioperative outcomes was assessed with univariate and multivariate analyses. Subgroup analyses were performed using a Current Procedural Terminology code common to all wRVU groups. The 16,884 patients were categorized into wRVU ranges 0–30.83 (4664 patients), 30.84–34.58 (2548 patients), 34.59–38.04 (3147 patients), 38.05–45.38 (3173 patients), and ≥ 45.39 (3352 patients). In multivariate logistic regression analysis, increasing wRVU did not predict more 30-day postoperative complications, except respiratory complications and need for blood transfusion. Linear regression analysis showed that wRVU was poorly correlated with operative duration and length of stay. On multivariate analysis of the craniectomy subgroup, wRVU was not associated with overall or respiratory complications. The highest wRVU group was still associated with greater risk of requiring blood transfusion (OR 3.01, p

OBJECTIVE To demonstrate discrepancies between operative times in the ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Project) and self-reported operative time from the American Medical Association's Relative Value Scale Update Committee (RUC) and their effect on relative value units (RVU) determination. METHODS This is a cross-sectional review of registry data using the ACS NSQIP 2016 Participant User File and the Centers for Medicare & Medicaid Services physician procedure time file for 2018. We analyzed total RVUs for surgeries by operative time to calculate RVU per hour and stratified by specialty. Multivariate regression analysis adjusted for patient comorbidities, age, length of stay, and ACS NSQIP mortality and morbidity probabilities. The surgeon self-reported operative times from the Centers for Medicare & Medicaid Services physician were compared with operative times recorded in the ACS NSQIP, with excess time from RUC estimates termed "overreported time." RESULTS Analysis of 901,917 surgeries revealed a wide variation in median RVU per hour between specialties. Orthopedics (14.3), neurosurgery (12.9), and general surgery (12.1) had the highest RVU per hour, whereas gynecology (10.2), plastic surgery (9.5), and otolaryngology (9) had the lowest (P

Advanced interventional pulmonary procedures of the airways, pleural space, and mediastinum continue to evolve and be refined. Health care, finance, and clinical professionals are challenged by both the indications and related coding complexities. As the scope of interventional pulmonary procedures expands with advanced technique and medical innovation, program planning and ongoing collaboration among clinicians, finance executives, and reimbursement experts are key elements for success. We describe advanced bronchoscopic procedures, appropriate Current Procedural Terminology coding, valuations, and necessary modifiers to fill the knowledge gap between basic and advanced procedural coding. Our approach is to balance the description of procedures with the associated coding in a way that is of use to the proceduralist, the coding specialist, and other nonclinical professionals.

Practicing neurosurgery in 2021 requires a detailed knowledge of the vocabulary and mechanisms for coding and reimbursement, which should include general knowledge at the global level and fluency at the provider level. It is specifically of interest for the neurosurgeon to understand conceptually the nuances of hospital reimbursement. That knowledge is especially germane as more neurosurgeons become hospital employees. Here we provide an overview of the mechanics of coding. We illustrate the formula to generate physician reimbursement through the current relative value unit structure. We also seek to explain hospital-level reimbursement through the diagnosis-related group structure. Finally, we expand about different and ancillary income streams available to neurosurgeons and provide a realistic assessment including the opportunities and challenges of those entities.

Surgeon providers and billing professionals use Current Procedural Terminology (CPT) codes to specify patient treatment and associated charges. In the present study, coding discrepancies between surgeons' first pass coding and employed coders' final codes were investigated. A total of 500 patients over 3 months were retrospectively analyzed for coding discrepancies. To quantify the impact of change, codes with the most accumulated discrepancies were studied and change to annual relative value unit (RVU) was determined. Final submission of codes to billing demonstrated a 161% increase in total codes by the professional coders, versus original surgeon-derived codes (1594 vs 987 CPT codes). The most common source of change between the surgeon and coder was the addition of distinct codes by the billing professional (270 patients, 54.51%). These results demonstrate the existence of coding discrepancies. Future investigation will evaluate the communication between surgeons and billing professionals.

Oncology nurse practitioners (ONPs) are essential providers of oncology care who work in a variety of practice settings. ONPs add to productivity in practice, but the way in which productivity is measured may not capture their full contributions and value. A greater understanding of productivity measures can empower ONPs to communicate and demonstrate their full value in practice.

Conventional measures of radiologist efficiency, such as the relative value unit, fail to account for variations in the complexity and difficulty of a given study. For lumbar spine MRI (LMRI), an ideal performance metric should account for the global severity of lumbar degenerative disease (LSDD) which may influence reporting time (RT), thereby affecting clinical productivity. This study aims to derive a global LSDD metric and estimate its effect on RT. A 10-year archive of LMRI reports comprising 13,388 exams was reviewed. Objective reporting timestamps were used to calculate RT. A natural language processing (NLP) tool was used to extract radiologist-assigned stenosis severity using a 6-point scale (0 = “normal” to 5 = “severe”) at each lumbar level. The composite severity score (CSS) was calculated as the sum of each of 18 stenosis grades. The predictive values of CSS, sex, age, radiologist identity, and referring service on RT were examined with multiple regression models. The NLP tool accurately classified LSDD in 94.8% of cases in a validation set. The CSS increased with patient age and differed between men and women. In a univariable model, CSS was a significant predictor of mean RT (R2 = 0.38, p p R2 = 0.83, p 25, R2 = 0.15, p = 0.05). Individual radiologist study volume was negatively correlated with mean RT (Pearson’s R = − 0.35, p

Background Periprosthetic infection (PJI) remains a challenging complication in total shoulder arthroplasty. Surgical treatment options can include 1 or 2-stage revision procedures, temporizing articulating spacers, and resection arthroplasty, with many cases resulting in transfer of patient care to a tertiary care center. While these cases can impose significant cost and clinical burden for both surgeons and hospital systems, there is limited data about the operative time investment and reimbursement compared to aseptic revision cases. The purpose of the current study was to compare work relative value units and operative times for aseptic and septic shoulder arthroplasty revision procedures. We hypothesize that staged, PJI-related revision shoulder arthroplasty is associated with significant differences in operative time and work relative value units assigned as compared to aseptic revisions. Methods This study utilized data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Inclusion criteria included all patients that underwent a revision total shoulder arthroplasty between January 1, 2010 and December 31, 2018. Procedures were grouped as either aseptic or septic revisions and further stratified into 1 stage and each stage of a 2-stage revision for septic cases. The RVU-to-dollar conversion factor was provided by the United States Centers for Medicare and Medicaid Services (CMS). This was used to obtain total reimbursement and reimbursement per minute estimates. Results When assessing the ratio of RVUs per minute of operative time across the groups, we found that the second stage of a 2-stage septic revision had a significantly lower RVU per minute operative time ratio (0.25) when compared to both the aseptic 2-component revision (0.34) and the first stage of a 2-stage septic revision (0.29). This translated to a significantly lower dollar per minute operative time value. Conclusion The current study found that the second stage of a 2-stage septic revision was undervalued in the number of RVUs per minute of operative time when compared to an aseptic revision or even its first stage counterpart. An adjustment or redistribution of relative value units for these procedures may offset the disproportionate clinical burdens encountered with definitive treatment of these complications. Level of Evidence Level III.

INTRODUCTION The purpose of this study was to compare surgeon professional fee reimbursement and trends from Medicare versus commercial payors for inpatient orthopaedic surgeries: total knee arthroplasty (TKA), total hip arthroplasty (THA), total shoulder arthroplasty (TSA), anterior cervical diskectomy and fusion (ACDF), and posterior lumbar fusion (PLF). METHODS Patients undergoing TKA, THA, TSA, single-level ACDF, and single-level PLF from 2010 to 2018 were queried in a commercially insured claims database. Medicare reimbursements and the work relative value unit (wRVU) of each procedure were obtained from the Medicare Physician Fee Schedule. All costs were adjusted for inflation and reported in 2018 real dollars. Compound annual growth rates were calculated to assess the mean growth rate for each procedure. Linear regression was done to assess trends. RESULTS On average, payments from Medicare were 57% less than payments from commercial payors. From 2010 to 2018, both Medicare and commercial payments decreased significantly for each surgery (P < 0.05 for all). Compared with inflation-adjusted commercial payments, Medicare payments decreased 2.1 times faster for TKA (-2.1% versus -1.0%), 2.8 times faster for THA (-1.4% versus -0.5%), 1.3 times faster for TSA (-1.0% versus -0.8%), and 1.9 times faster for ACDF (-1.1% versus -0.6%). PLF was the only procedure for which Medicare payments declined slower than commercial payments (-0.6% versus -1.21%). Medicare payments per wRVU markedly declined for TKA (-0.83%), THA (-0.80%), TSA (-0.75%), and ACDF (-1.10%), whereas commercial payments per wRVU for those surgeries showed no notable change. For PLF, there was a notable decrease in both Medicare (-0.63%) and commercial (-1.21%) payments per wRVU. CONCLUSION Over the past decade, both commercial and Medicare surgeon payments for commonly performed inpatient orthopaedic surgeries decreased markedly, with Medicare payments decreasing an average of 1.5 times faster than commercial payments. The impact of declining reimbursements on access and quality of care merits additional investigation.

Background There has been 25-year trend of decreasing value for orthopedic surgical work based on the Resource-Based Relative Value Scale (RBRVS) for Medicare reimbursement. This study was undertaken to estimate the time that Medicare payment rates for time spent in the office doing cognitive work will equal time dedicated in the operating room to performing procedural work based on long-term negative payment trends. Methods The RBRVS Update Committee database was accessed to extract the time elements for 2 procedures, total knee arthroplasty and total hip arthroplasty (27447 and 27130), on the day of surgery. The evaluation and management code mix for 2 mid-sized orthopedic practice was averaged to create an amalgamated rate for the reimbursement of office work on an hourly rate. A graph of the 25-year trend line in Medicare reimbursement for arthroplasty procedures was used to create a trend line. The trend line was then extrapolated to estimate the time in the future that the hourly rate for office work would equal the hourly rate for surgery. Results Time inputs and the Medicare conversion factor for 2021 were used in this analysis. Total procedural time for both 27447 and 27130 was 204 minutes (3.4 hours) on the day of surgery. An amalgamated hourly office rate of 7.9 relative value unit was calculated from the average of the 2 mid-sized private practices for an overall in office Medicare reimbursement of $318.89/h, with $1083.04 for the 3.4 hours allowed in the RBRVS Update Committee database for a joint replacement. When the trend line for reimbursement was extrapolated to the $1083.04 price point, the year corresponding to the point where hourly office reimbursement would equal hourly surgical work was 2024. Conclusion Policymakers in Washington and practicing orthopedic surgeons need to consider the looming economic parity of surgical and cognitive work for Medicare. Continued negative reimbursement rates are likely to decrease patient access to necessary surgical care and result in de facto rationing of arthroplasty services for Medicare patients. The deployment of the orthopedic workforce is likely to change to accommodate the decreases in the value of surgical work. This trend will have significant impact on the practice of musculoskeletal medicine and patient access to orthopedic services.

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.

Purpose To create a new list of medical procedures in ophthalmology based on the International Classification of Diseases ICD-9-CM. To establish the general principles that define criteria, quantitative indicators, and scales. To develop the algorithms needed to calculate fees for medical procedures. Methods The out-of-date processes were removed from the list, and new techniques were added, descriptors were modified, procedures with similar descriptions were grouped together, and others were relocated to other group according to surgical complexity conditions. The criteria to calculate the medical fees were defined: training and complexity (U), proficient responsibility (R), and health value (V), with their respective quantitative indicators: period of training necessary to master a technique, frequency of complications that worsen the preoperative situation, and days of incapacity for work due to the process. The Relative Value Unit (RVU) was defined as the score sum of R, V and U. The final fee per medical procedure was calculated as the product of the RVU by its unit cost and by the weighting coefficient (WC). Results A new catalogue was prepared with 161 medical procedures, grouped into consultations, diagnostic procedures (DX.PR), therapeutic procedures (TX.PR), and surgical interventions, increasing in complexity from group 0 to group 8. The following characters were described for each one of the procedures: OMC and ICD-9-MC code, descriptor term, group, proposed modification: no changes or minimums in the descriptors, grouping of acts by similar definitions, change of origin group, new procedures, and procedures removed. The indicators for assessment were also scored: U between 1−4 points, and R and V between 0−3 points. Using their sum, the number of RVUs per medical procedure (between 1 and 10) was calculated which, together with the unit cost of the RVU and the WC (between 0.05 and 1), will determine the final rate. Conclusions The new standardised ophthalmological nomenclature updates and improves the old classification, adapting the procedures to the descriptors included in the ICD-9-CM, and incorporating all the new techniques. Additionally, the declaration of the general principles allows defining new criteria, quantitative indicators, rating scales, and algorithms to calculate fees for medical procedures.

OBJECTIVE To compare the complexity of operations performed by female versus male surgeons. BACKGROUND Prior literature has suggested that female surgeons are relatively underemployed when compared to male surgeons, with regards to operative case volume and specialization. METHODS Operative case records from a large academic medical center from 1997 to 2018 were evaluated. The primary end point was work relative value unit (wRVU) for each case with a secondary end point of total wRVU per month for each surgeon. Multivariate linear analysis was performed, adjusting for surgeon race, calendar year, seniority, and clinical subspecialty. RESULTS A total of 551,047 records were analyzed, from 131 surgeons and 13,666 surgeon-months. Among them, 104,424 (19.0%) of cases were performed by female surgeons, who make up 20.6% (n = 27) of the surgeon population, and 2879 (21.1%) of the surgeon months. On adjusted analysis, male surgeons earned an additional 1.65 wRVU per case, compared to female surgeons (95% confidence interval 1.57-1.74). Subset analyses found that sex disparity increased with surgeon seniority, and did not improve over the 20-year study period. CONCLUSIONS Female surgeons perform less complex cases than their male peers, even after accounting for subspecialty and seniority. These sex differences are not due to availability from competing professional or familial obligations. Future work should focus on determining the cause and mitigating this underemployment of female surgeons.

Although relative value units are used to measure physician productivity, research has demonstrated incongruencies between relative value units and actual surgeon work effort. We sought to determine whether this variation extends across surgical specialties.A retrospective review of surgical cases was conducted using the 2017 American College of Surgeons National Surgical Quality Improvement Program database. For each case, we identified the primary Current Procedural Terminology, surgical specialty, total relative value units, and 5 alternative measures of work effort. We then examined the correlation between a Current Procedural Terminology's mean total relative value unit and work effort. Finally, we constructed a multivariable linear regression model to evaluate the association between surgical specialty and the expected mean total relative value unit adjusting for work effort and patient characteristics.A total of 876,515 cases met the inclusion criteria. Overall, median operative time correlated well with mean total relative value unit (R = 0.85), though it was lowest for cardiac surgery (R = 0.51) and highest for otolaryngology (R = 0.97). Neurosurgery had the greatest increase in mean total relative value unit per hour of operative time (12.9/h). Mean total relative value unit correlated modestly with length of stay (R = 0.58) and serious adverse events (R = 0.61) and weakly with readmission (R = 0.42) and mortality (R = 0.29). When holding these metrics constant, the multivariable model showed mean total relative value units differed according to surgical specialty alone. Compared with general surgery, neurosurgery and cardiac surgery earned 3.41 to 3.61 additional mean total relative value units (P.05), while orthopedics, otolaryngology, thoracic, urology, and vascular surgery received fewer mean total relative value units (-1.84 to -4.43, P.05).Surgeon productivity is increasingly measured using relative value units. While mean total relative value units correlate well with operative time, they may not reflect other aspects of work effort. Differences in mean total relative value units by surgical specialty demonstrate potential inequities in the determination of physician productivity.

Wound care accounts for more than $6 billion of health expenditure in the United States annually. In addition, Medicare reimbursement per relative value unit has remained flat with respect to inflation over the past 20 years. Yet, physicians face increasing operating costs. The economic effects of declining inflation-adjusted Medicare physician reimbursement on the use of wound debridement procedures have yet to be elucidated. This study describes trends in Medicare reimbursement, utilization, and total Medicare expenditure for wound debridement procedures. Using Medicare claims data, we aggregated the volume of services and average Medicare reimbursement for wound debridement procedures over the calendar years 2012 to 2017. For each billing code, we estimated inflation-adjusted total Medicare expenditure by multiplying the average inflation-adjusted Medicare reimbursement by the aggregate volume of services. The average inflation-adjusted payment for wound debridement procedures decreased by 6% from 2012 to 2017. Over this time period, the utilization of wound care procedures increased 32%. Total inflation-adjusted annual Medicare expenditure on wound care increased 24% from 2012 to 2017. Therefore, despite declining physician reimbursement rates, total Medicare expenditure on wound debridement increased from 2012 to 2017. This increase in total Medicare expenditure was driven by higher utilization of wound debridement procedures.

Purpose Burnout is a psychological syndrome in response to chronic occupational stressors. The prevalence of burnout among medical professionals has been increasing, and recent studies have shown that radiologists are among those affected. We investigated the prevalence of burnout and assessed associated factors among cardiothoracic radiologists. Materials and methods Society of Thoracic Radiology members were invited to complete an anonymous cross-sectional survey that included an adapted Maslach Burnout Inventory and questions about demographics, work place characteristics, and stressors. Results The survey response rate was 33.1% (290/874). Per-item response rate ranged from 94% to 100% with a median of 99%. The prevalence of emotional exhaustion was 66.8% (186/283), depersonalization was 79% (223/283), and low personal accomplishment was 23% (65/280). There were no statistically significant differences between academic and private practice. There was a trend toward worse burnout in women, but this was not statistically significant. Being in early career (0 to 10 y since fellowship) was associated with low personal accomplishment [odds ratio (OR): 2.07, 95% confidence interval (CI): 1.08-3.99]. Those working fewer than 51 hours per week were significantly less likely to report emotional exhaustion (OR: 0.55, 95% CI: 0.33-0.90). The odds of emotional exhaustion for those producing fewer than 7500 work relative value units per year were approximately half of those exceeding that number (OR: 0.46, 95% CI: 0.22-0.95). Conclusions The prevalence of burnout among cardiothoracic radiologists is comparable to that reported for radiologists in other subspecialties such as musculoskeletal and interventional radiology. High work relative value unit productivity and longer work hours are associated with higher prevalence of burnout.

Objective. The total relative value unit (TRVU) of surgery reflects surgical complexity. However, its impact on mortality after noncardiac surgery has not been identified. This study aimed to investigate the association of TRVUs for surgery with postoperative 90-day mortality in adult patients who received planned, elective noncardiac surgery. We hypothesized that higher TRVU was associated with an increase in 90-day mortality after noncardiac surgery. Method. This retrospective cohort study analyzed medical records of adult patients admitted to a single tertiary academic hospital between January 2012 and December 2018 for planned elective noncardiac surgery. The primary end point was 90-day mortality. Results. A total of 112 606 patients were included. Among them, 561 patients (.5%) exhibited mortality within 90-days. In the multivariable model, an increase of 10 000 points of TRVUs was not significantly associated with 90-day mortality (odds ratio: .98, 95% confidence interval: .93 to 1.04; P = .536). Additionally, when it was divided into 4 quartile groups (Q1, Q2, Q3, and Q4), Q2, Q3, and Q4 group of TRVUs were not associated with 90-day mortality compared to the Q1 group of TRVUs ( P = .058, .984, and .237, respectively). In receiver-operating characteristic analysis, the area under the curve of TRVUs for a 90-day mortality rate was .61. Conclusions. In conclusion , TRVUs were not associated significantly with a 90-day mortality rate after noncardiac surgery and have a low predictive ability for 90-day mortality after noncardiac surgery alone.

Changes in our health care system have posed challenges for the patient-provider relationship (PPR) and may have negative consequences. For the clinician, due to lower reimbursements from third party payers, and increased administrative tasks such as the electronic medical record (EMR) and certification requirements, clinic visit time is now one-fifth that of decades ago. Clinicians may order diagnostic studies and imaging as a substitute for face to face time as it is seen to save time and increase relative value units (RVUs). As a result, the medical interview is very abbreviated, and the physical examination is disappearing. This occurs at the expense of the physician-patient relationship. Now there is limited time to gather relevant information, to understand the context of the illness, and address patient needs. For the clinician there is reduced satisfaction, loss of the meaningfulness of caring for patients, and possibly increased risk for burnout, and malpractice. This may lead to negative attitudes and behaviors toward patients, particularly for those with nonstructural diagnoses (eg, disorders of gut-brain interaction) which are given lower priority than those with acute or structural illness. In turn, patients experience a diminution in their role in the relationship and respond to adverse clinician behaviors with a lack of connection, frustration, and at times self-blame and stigmatization. To reverse this downward trend and re-establish an effective PPR changes are needed: 1) improving educational methods to provide skills to enhance patient-centered care, 2) incentivizing educators who teach and clinicians who practice patient-centered care, and 3) research support to demonstrate successful outcomes in satisfaction, adherence and clinical outcomes.

BACKGROUND Although smoking is associated with several postoperative complications, a possible association with surgical bleeding remains unclear. We examined if smoking is associated with a higher risk of surgical bleeding. STUDY DESIGN AND METHODS We included patients from the American College of Surgeons National Surgical Quality Improvement Program 2007-2016 from 680 hospitals across the United States. Patients with information on age, sex, surgical specialty, and smoking status were included. Surgical bleeding was defined as 1 or more red blood cell (RBC) units transfused intraoperatively to 72 hours postoperatively. The association between smoking and surgical bleeding was examined using logistic regressions adjusted for age, sex, body mass index, ethnicity, comorbidities, laboratory values, American Society of Anesthesiologists score, type of anesthesia, duration of surgery, work relative value unit (surrogate for operative complexity), surgical specialty, and procedure year. RESULTS A total of 5,452,411 cases were recorded, of whom 19% smoked and 6% received transfusion. Odds ratios for transfusion were 1.06 (95% confidence interval [CI], 1.05-1.07) for smokers versus nonsmokers and 1.06 (95% CI, 1.04-1.09) for current smokers versus never-smokers. Odds ratios for cumulative smoking were 0.97 (95% CI, 0.95-1.00) for greater than 0 to 20 versus 0 pack-years, 1.04 (95% CI, 1.01-1.07) for greater than 20 to 40, and 1.12 (95% CI, 1.09-1.15) for greater than 40 (p for trend

Work relative value unit (wRVU) - based fee schedules are predominantly used by both the Center for Medicare and Medicaid Services (CMS) and private payers to determine the payments for physicians' clinical productivity. However, under the Affordable Care Act, CMS is transitioning into value-based payment structure that rewards patient-oriented outcomes and cost savings. Moreover, in the context of solid organ transplantation, physicians and surgeons conduct many activities that are neither billable nor accounted for in the wRVU models. New compensation models for transplant professionals must (i) justify payments for non-billable work related to transplant activity/procedures; (ii) capture the entire academic, clinical, and relationship-building work effort as part of RVU determination, and (iii) move towards a value-based compensation scheme that aligns the incentives for physicians, surgeons, transplant center, payers, and patients. In this review, we provide an example of redesigning RVUs to address these challenges in compensating transplant physicians and surgeons. We define a customized RVU (cRVU) for activities that typically do not generate wRVUs and create an outcome value unit (OVU) measure that incorporates outcomes and cost savings into RVUs to include value-based compensation.

Purpose Because children cannot reliably remain immobile during radiation therapy (RT) for cancer anatomy targeting requiring millimeter precision, daily anesthesia plays a large role in each RT session. Unfortunately, anesthesia is a source of financial burden for patients' families and is invasive and traumatic. This study attempts to assess the cost-savings benefit of audiovisual-assisted therapeutic ambiance in radiation therapy (AVATAR)-aided omission of pediatric anesthesia in RT. Methods and Materials The baseline time of anesthesia during RT was derived from documented anesthesia billing time during RT simulation at our institution and from the published literature. Current Procedural Terminology and relative value unit codes encompassing anesthesia-related charges from radiation oncology and anesthesia were analyzed in concert with this value to calculate the total cost of pediatric anesthesia per RT session. Results The mean number of RT fractions administered per patient with AVATAR-directed anesthesia omission at our institution was 19.0, similar to the 17.6 previously reported. At a mean anesthesia time exceeding 30 minutes (with mean RT duration of 4 weeks), the cost of pediatric anesthesia per RT fraction in non-AVATAR sessions was $1,904.35, yielding a total RT treatment anesthesia cost of $38,087.00 per patient (including simulation). Patients at our institution were not billed for AVATAR-assisted RT. Conclusions The ability of AVATAR to obviate the need for daily anesthesia in pediatric RT provides substantial cost-savings. These findings argue for increased utilization of AVATAR and for analyses of RT targeting the accuracy of AVATAR versus conventional anesthesia-guided treatment of pediatric malignancies.

The finances of academic medical centers (AMCs) are complex and rapidly evolving. This financial environment can have important effects on faculty expectations, compensation, and the work environment. This article describes the commonly used concepts and models related to financial decision-making in Pulmonology and Critical Care divisions across AMCs in the United States. Faculty clinical productivity is often measured by work relative value units, which are set nationally for a discrete piece of physician work and attempt to equilibrate aspects of care across specialties. The expected clinical productivity and salary for a given faculty member are often determined relative to one or more national benchmarks developed from data submitted by departments and schools across the country. The most commonly used benchmarks include those from the Association of American Medical Colleges and the Medical Group Management Association. Changes to the paradigm of fee for service reimbursement are beginning to change physician compensation and incentive structures. In addition, research and education are key academic missions for faculty. It is important to understand the limitations of extramural research funding and implications for the support of research infrastructure. Measurements of productivity within education have been less codified, but some centers are attempting to create educational relative value units similar to those used in clinical productivity. In summary, faculty should understand basic concepts of finances. This knowledge includes a common set of terms and concepts that can help all faculty understand basic financial considerations in their work and lead to success for their divisions.

INTRODUCTION AND OBJECTIVE:The work relative value unit or wRVU is an often controversial measurement of productivity used in many academic medical centers (AMC). The interests at AMCs including ca...

Background/Purpose Improvements in patient care are directly affected by scientific discovery, and surgeons have historically played a vital role in this process. However, increasing clinical demands and incentivization for pure clinical productivity present challenges for promoting academic productivity. The objective of this work was to analyze the effects of adding an academic relative value unit (aRVU) scoring system to an existing work RVU (wRVU)-based incentivization plan on academic productivity in a Department of Pediatric Surgery. Methods Prior to 2012, incentive bonuses in our Department were mainly based on clinical wRVU activities. A weighted scoring system for 30 specific aRVUs was established in 2012. Incentivization for wRVUs vs. aRVUs was based on the clinical full-time equivalent (cFTE) of each faculty member. Academic activities incentivized included grant submissions/funding, peer reviewed publications, national presentations, Study Section participation, education and mentoring activities, receipt of research or teaching awards, initiation of Institutional Review Board (IRB) protocols, new academic society committee memberships/chairpersons, and patents. Academic progress was analyzed from 2012 to 2020. Results During the study period, annual external federal funding increased from $750,168 to $5,768,243 (7.7-fold increase); annual peer-reviewed publications increased from 24 to 140 (5.8-fold increase); annual national presentations accepted for oral/poster presentations nearly doubled; and faculty members and their trainees received 41 competitive research awards including 8 American Pediatric Surgical Association Awards, 9 American Academy of Pediatrics Section on Surgery Awards, and 3 American College of Surgeons Awards. During the same study period, wRVUs increased by 8%. Conclusions Incentivization based on the addition of an aRVU system to a pre-existing wRVU system was associated with a significant increase in academic productivity, while still maintaining clinical productivity. Implementing an aRVU program is an important means of increasing academic productivity in Pediatric and other Surgery Departments.

BACKGROUND Plastic surgeons are evaluated not only by the number of patients served but also by relative value, quantified by the Medicare relative value unit system, which can affect advancement and compensation. Procedures that demand a high operative time without an increase in relative value units are, by definition, inefficient. The purpose of this study was to determine whether the number of relative value units actually corresponds to operative time. METHODS The National Surgical Quality Improvement Program data sets over a 9-year period were queried for plastic surgery operations. The primary CPT codes representing the 100 most common operations were compared for operative time and total relative value units. RESULTS A total of 53,701 cases were included. There was a high degree of correlation between operative time and number of relative value units (Pearson correlation coefficient, 0.82). The average efficiency was 10.201 ± 3.386 relative value units per hour. Pressure ulcer excisions and breast reconstruction were among the most efficient (e.g., Excision, sacral pressure ulcer, CPT 19357, generated 20.819 relative value units per hour). Skin excisions, debridements, and flap delays were among the least efficient (e.g., Excision, excessive skin and subcutaneous tissue, CPT 15847, generated 1.752 relative value units per hour). CONCLUSIONS As a general trend, the most common plastic surgical procedures requiring longer operative times are associated with more relative value units. Cases with higher relative value units assigned tended to be more efficient. For the 100 most common procedures, relative value units and operative time are not evenly distributed. These data suggest modifications to the current relative value unit designation system to more equally allocate these units based on effort and time.

On August 3, 2020, the Centers for Medicare and Medicaid Services (CMS) released the 2021 Medicare Physician Fee Schedule (MPFS) Proposed Rule. The MPFS is used by CMS to calculate physician reimbursement, generating relative value unit (RVU) numbers that are adjusted for geography. The 2021 edition entailed reducing the RVU conversion factor (CF) from $36.09 to $32.26, (a -10.61% change). Due to budget neutrality requirements, the reduction is mainly due to increased expenditures for evaluation and management (E/M) services. Using neurosurgery and interventional radiology (IR) as predicates for NeuroInterventional (NI) practice, were the 2021 MPFS Proposed Rule to be implemented, we would predict reimbursement decreases of approximately 7%–9% from CMS. To understand why the 2021 CMS proposed rule results in this substantial decrease for neurointerventionalists, we must recognize how physicians are compensated by CMS and the impetuses for change in payment for office/outpatient services that have been brewing over the past few years. In brief, payment for physician services by the CMS is correlated to the number of RVUs allocated for that service, which takes into account physician work (professional component), practice expense (technical component), and professional liability insurance. The RVU is multiplied by a conversion factor, set by CMS to maintain budget neutrality, resulting in the eventual dollar amount paid for a service.1 To consistently describe medical services, a unique and billable Current Procedural Terminology (CPT) code are assigned. Codes are allocated RVUs by CMS based on input from the AMA Relative Value Scale Update Committee (RUC).2 3 CMS updates and publishes payment for physician services annually in the Medicare Physician Fee Schedule (MPFS). New codes are periodically added to the MPFS, and the number of RVUs assigned can also be adjusted to more accurately reflect the value of that service.4 5 The MPFS must be …

Objective Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions. Summary of background data Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity. Methods Using National and Veterans Affairs Surgical Quality Improvement Programs (2015-2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score). Results Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [ρs = 0.587 (95% confidence interval, 0.586-0.587)], but negligible with frailty ρ = 0.177 (95% confidence interval, 0.176-0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases. Conclusions Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients.

Upper extremity surgeons perform diverse operations, including hand surgery, microsurgery, and shoulder/elbow arthroscopy and arthroplasty. Declining orthopedic reimbursement rates may encourage surgeons to adjust their case mix, favoring a shift toward procedures with higher compensation. To determine whether upper extremity surgeons and hand-fellowship trainees may be financially incentivized to perform more shoulder/elbow procedures than hand procedures in a hospital-based setting, relative value unit (RVU) compensation rates were compared for these 2 fields. Using Centers for Medicare & Medicaid Services–assigned work RVUs (wRVU) and National Surgical Quality Improvement Program operative time data, wRVU compensation rates per minute of operative time were determined for common shoulder/elbow surgeries. Overall nonweighted and weighted wRVU/min averages were calculated for hospital-based shoulder/elbow and hand surgery. A total of 27 shoulder/elbow procedures and 53 hand surgery procedures were analyzed. Nonweighted comparison showed shoulder/elbow surgery had a higher wRVU/min (0.19±0.03 vs 0.14±0.05, P P Orthopedics . 2021;44(3):e373–e377.]

In the United States, the most widely used measure of clinical productivity is the relative value unit (RVU) system, which calculates compensation on the basis of relative physician resource costs. Before its implementation, payers for health care services based compensation on the historical

We established the Primary Care for Cancer Survivor (PCCS) Clinic in 2015 to address transition and care delivery challenges unique to cancer survivors. We describe the clinical program, detail patients from the first 4 years of implementation, and discuss lessons learned during the process. We abstracted relevant patient information from the electronic medical record, administered a needs assessment survey at initial visits, and collected relative value unit (RVU) data. Between August 2015 and May 2019, we saw 230 PCCS patients with an increasing number of referrals yearly; nearly half were breast cancer survivors. At the initial visit, patients reported a median of 9 needs, with emotional needs most prevalent; over a third received at least one referral. PCCS patients generated higher billing codes and average RVUs compared with general patients. In its first 4 years, the PCCS program has thrived as a unique model of cancer survivorship centered in primary care. PCCS patients reported numerous needs, emphasizing the critical need for a multi-disciplinary approach in this population. With increasing referrals, we have considered different risk stratification and staffing models for capacity and expansion. By generating more RVUs per visit compared with the general clinic, PCCS has demonstrated financial sustainability. Buy-in from our oncology colleagues, divisional support from general medicine, along with our collaboration of like-minded internists have allowed us to be a robust program. Models of survivorship care embedded in primary care can provide meaningful, patient-centered care for cancer survivors.

Background and purpose Escalating health care costs have led to greater efforts directed at measuring the cost and benefits of medical treatments. The aim of this study was to estimate the costs of 5-year local control and overall survival benefits of radiotherapy for the cancer population in Australia. Materials and Methods The local control and overall survival benefits of radiotherapy at 5-years and optimal number of fractions per course have been estimated for 26 tumour sites for which radiotherapy is indicated. For this study, a hybrid approach that merges features from activity based costing (ABC) and relative value units costing (RVU) were used to provide cost estimates. ABC methodology was used to allocate costs to all radiotherapy activities associated with each patient’s treatment course, while the RVUs represent the cost of each radiotherapy activity relative to the average cost of all activities and were used to achieve a weighted cost allocation. A patient’s journey for the financial year was constructed by consolidating all the radiotherapy activities and their associated costs, and the average cost per activity (fraction) was determined. The cost of radiotherapy per 5-year overall survival and local control was then estimated. Results The estimated population 5-year local control and overall survival benefits of radiotherapy for all cancer were 23% and 6%, respectively. The optimal number of fractions per treatment course if guidelines were followed was 19.4 fractions. The average cost per fraction for all cancer was AU$276. The estimated cost of radiotherapy was AU$23,585 per 5-year local control and AU$86,480 per 5-year overall survival (equivalent to 5 life years) for all cancer. Conclusion The cost of AU$86,480 per 5-year overall survival would translate to AU$17,296 1-year overall survival. Therefore, the cost of radiotherapy is inexpensive if delivered optimally. Policy implications from this study include knowledge about cost to deliver radiotherapy to allow one to quantify the expected benefit at a population level.

Aims Revision total knee arthroplasty (rTKA) accounts for approximately 5% to 10% of all TKAs. Although the complexity of these procedures is well recognized, few investigators have evaluated the cost and value-added with the implementation of a dedicated revision arthroplasty service. The aim of the present study is to compare and contrast surgeon productivity in several differing models of activity. Materials and Methods All patients that underwent primary or revision TKA from January 2016 to June 2018 were included as the primary source of data. All rTKA patients were categorized by the number of components revised (e.g. liner exchange, two or more components). Three models were used to assess the potential surgical productivity of a dedicated rTKA service : 1) work relative value unit (RVU) versus mean surgical time; 2) primary TKA with a single operating theatre (OT) versus rTKA with a single OT; and 3) primary TKA with two OTs versus rTKA with a single OT. Results In total, 4570 procedures were performed: 4128 primary TKAs, 51 TKA liner exchanges, and 391 full rTKAs. Surgical time was significantly different between the primary TKA, liner exchange, and rTKA cohorts (100.6, 97.1, and 141.7 minutes, respectively; p < 0.001). Primary TKA yielded a mean of 7.1% more RVU/min per procedure than rTKA. Our one-OT model demonstrated that primary TKA (n = 4) had a 1.9% RVU/day advantage over rTKA (n = 3). If two OTs are used for primary TKA (n = 6), the outcome strongly favours primary TKA by an added 34.6% RVUs/day. Conclusion Our results suggest that a dedicated rTKA service would lead to lower surgeon remuneration based on the current RVU paradigm. Revision arthroplasty specialists may need additional or alternative incentives to promote the development of a dedicated revision service. Through such an approach, healthcare organizations could enhance the quality of care provided, but surgeon productivity measures would need to be adjusted to reflect the burden of these cases. Cite this article: Bone Joint J 2019;101-B:675–681.

Study objective We examine the effect of Medicaid expansion on reimbursement for emergency physicians' professional services. Methods We conducted a retrospective study using data from a national emergency medicine group in a sample of 50 emergency departments (EDs) from July 1, 2012, to June 30, 2015. We categorized facilities in 14 states into full-expansion (23), partial-expansion (17), and nonexpansion (10) categories based on pre-expansion Medicaid eligibility criteria for all adults. We used a difference-in-differences design to assess the effect of Medicaid expansion on provider reimbursement per visit. Secondary outcomes included reimbursement per relative value unit and relative value units per visit, both overall and by payer type, controlling for age, sex, billing codes, and health system relationship. Results We studied greater than 6.7 million ED visits during July 2012 to December 2015, 3.0 million pre-expansion and 3.7 million postexpansion. After adjusting for covariates, reimbursement per visit increased 6.3% (95% confidence interval 1.4% to 11.1%) in full-expansion relative to nonexpansion states and did not change significantly in partial-expansion versus nonexpansion states. Reimbursement per visit for commercial insurance increased 17.1% (95% confidence interval 9.9% to 24.2%) in full-expansion versus nonexpansion states. Reimbursement for self-pay visits increased 9.7% (95% confidence interval 3.7% to 15.7%) in full-expansion versus nonexpansion states. Changes in payments were driven by higher reimbursement per relative value unit; relative value units per visit declined slightly in full-expansion compared with nonexpansion states. Conclusion In this sample, full Medicaid expansion increased payments for emergency physicians' professional services compared with reimbursement in nonexpansion states. Higher reimbursement was driven primarily by lower proportions of uninsured patients and increased reimbursement per visit for both commercially insured and self-pay patients in states with full Medicaid expansion.

To determine the effects an incentive-based physician compensation model has on safety outcomes related to outpatient otolaryngology surgical procedures.A retrospective analysis of a prospectively maintained database assessing the difference in outpatient surgical volume and postoperative adverse outcomes before and after the implementation of a relative value unit (RVU)-based payment structure.Single-center academic otolaryngology practice operating at a hospital-owned ambulatory surgery center.Data prospectively collected from outpatient otolaryngology surgical cases performed at the surgery center from April 2013 to April 2018 were retrospectively reviewed. Equal pre-RVU and post-RVU study periods were calculated for 4 surgeons based on their chronological transition in payment structure (range, 46-56 months). Case volume and incidence rates of adverse outcomes, including postoperative infections, emergency department visits, unplanned hospital admissions, and returns to the operating room, were compared between the pre-RVU and post-RVU study periods at both the surgeon and group levels.At the group level, the post-RVU period was associated with a higher volume of surgical cases ( P = .001). No significant differences were observed in the overall incidence of adverse outcomes ( P = .21) or among the specific rates of postoperative hospitalizations ( P = .39), infections ( P = .45), unplanned returns to the operating room ( P = 1.00), or emergency department visits ( P = .39). Comparable results were observed at the individual surgeon level.The implementation of an incentive-based salary was not associated with a change in the incidence of adverse safety outcomes in the setting of increased outpatient otolaryngology procedures.

Purpose To assess whether reimbursement for orthopaedic sports procedures adequately compensates for operative time and surgical complexity. Methods The National Surgical Quality Improvement Program (NSQIP) database was queried for all orthopedic sports medicine procedures performed greater than 150 times from 2016 to 2018 with regard to operative time, preoperative risk factors, morbidity, and mortality data. Physician work relative value units (wRVU) data were obtained from the 2020 Centers for Medicare & Medicaid Services (CMS) fee schedule. The primary outcome was wRVU per minute operative time (wRVU/min). Linear regressions were used to assess wRVU, operative time, and wRVU/min. Results A total of 42 CPT codes, including 84,966 cases, were stratified into the top and bottom 50%, according to mean operative time, complications, mortality, reoperations, and readmissions. Mean wRVU/min was significantly lower for longer procedures (.153 vs .187; P = .02), and comparable with regard to ASA score, complications, mortality, readmissions, and reoperations. Arthroscopy reimbursed more (.187 vs .148 wRVU/min; P = .008), with lower complications (1.5 vs 2.6%; P = .115) and operative time (56.1 vs 82.8 min; P = .001) compared to open. Multivariate linear regression revealed that after adjusting for complication rate, there was a decrease of .054 wRVU/h (P = .026) and $116.90/hour less for every additional hour of operative time. Conclusion The current 2020 RVU scale does not fairly compensate sports procedures with longer operative times. When examining the hourly reimbursement rates for the most commonly performed sports procedures, there is a significant trend toward lower reimbursement for longer procedures even after accounting for complication rates. Furthermore, procedures of the knee reimbursed at higher rates relative to the general pool of sports procedures and open procedures are compensated at a lower rate compared to arthroscopic procedures.

BACKGROUND The physician work relative value unit (wRVU) scale is the primary determinant of compensation. Operative time, technical skill, effort, and surgical complexity contribute to wRVU allocation. The aim of this study was to identify the relationship between these factors and reimbursement for trauma procedures. METHODS The National Surgical Quality Improvement Program database was queried for orthopaedic trauma procedures from 2016 to 2018. Physician wRVU data were obtained from the 2020 Centers for Medicare & Medicaid Services fee schedule. The primary outcome measured was mean wRVU per minute of operative time (wRVU/min). Wilcoxon rank sum test and quantile regression were used to determine the association between wRVU, operative time, complication rate, upper or lower extremity procedure, and wRVU/min. RESULTS Sixty-three current procedural terminology codes or 107,171 cases were queried. Median wRVU/min was significantly lower for longest 50% of procedures (0.119 vs. 0.160, P < 0.001) and higher for the top 50% with regard to complication rate (0.161 vs. 0.124, P < 0.001). Upper extremity procedures were reimbursed less than lower extremity (0.110 vs. 0.145, P < 0.001). Quintile regression showed that adjusted for complication rate, median wRVU/min decreased by 0.0005 (95% confidence interval: 0.0007-0.0003, R1 = 0.27, P < 0.001) for every additional minute of operative time. CONCLUSIONS The 2020 wRVU scale does not allocate sufficient wRVUs to orthopaedic trauma procedures with longer mean operative time or to procedures performed on the upper extremity. There is a negative correlation between operative time and hourly reimbursement, equating to a decrease of $64.96/h per hour of operation.

Objectives: Discrepancies in the reimbursement of gender-specific procedures have been reported since the beginning of the fee-for-service model. Procedure-based reimbursement is mediated by both work relative value unit (wRVU) and a specialty-specific compensation rate. Whether gender-based discrepancies in reimbursement have improved over time and which of these factors, wRVUs assigned per procedure or dollars per RVU, are the driver of these discrepancies in unknown. We aim to describe how wRVUs for gender-specific procedures have changed over time and to compare time-based compensation for gender-specific procedures. Methods: Using the National Surgical Quality Improvement Program (NSQIP) 2015-2018 we compared operative time and wRVUs for twelve pairs of gender-specific procedures. Only cases with a primary current procedural terminology (CPT) code and without any other procedure or concurrent procedure CPT codes were included in the analysis. Procedures were matched to be anatomically and technically similar. We further compared procedure assigned RVUs in 2015 to those assigned in 1997. We also evaluated procedure-based compensation. Procedure compensation was determined using median dollars per RVU for Urology and Gynecology provided in SullivanCotter's 2018 Physician Compensation and Productivity Survey. This was compared with specialty-specific McGraw-Hill per RVU data from 1994. Wilcoxon rank sum test was used to examine associations. Results: A total of 12,120 patients underwent 6,217 male-specific procedures and 5,903 female-specific procedures between 2015-2018. Male-specific procedures had a median wRVU of 25.2 (IQR 21.4-25.2), significantly higher than the median wRVU of 7.5 (IQR 7.5-23.4) for female-specific procedures (p Download : Download high-res image (216KB) Download : Download full-size image Conclusions: Over the past two decades increases in wRVUs for female-specific procedures and specialty-specific per RVU reimbursement have resulted in more equitable reimbursement for female-specific procedures compared with male-specific procedures. However, even with these changes, our findings support an overall lower relative value of work and reimbursement for procedures performed for women-only when compared with equivalent procedures performed for men-only.

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.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.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.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.

Rationale and Objectives This study seeks to quantify the financial impact of COVID-19 on radiology departments, and to describe the structure of both volume and revenue recovery. Materials and Methods Radiology studies from a large academic health system were retrospectively studied from the first 33 weeks of 2020. Volume and work relative value unit (wRVU) data were aggregated on a weekly basis for three periods: Presurge (weeks 1–9), surge (10–19), and recovery (20–33), and analyzed compared to the pre-COVID baseline stratified by modality, specialty, patient service location, and facility type. Mean and median wRVU per study were used as a surrogate for case complexity. Results During the pandemic surge, case volumes fell 57%, while wRVUs fell by 69% relative to the pre-COVID-19 baseline. Mean wRVU per study was 1.13 in the presurge period, 1.03 during the surge, and 1.19 in the recovery. Categories with the greatest mean complexity declines were radiography (−14.7%), cardiothoracic imaging (−16.2%), and community hospitals overall (−15.9%). Breast imaging (+6.5%), interventional (+5.5%), and outpatient (+12.1%) complexity increased. During the recovery, significant increases in complexity were seen in cardiothoracic (0.46 to 0.49), abdominal (1.80 to 1.91), and neuroradiology (2.46 to 2.56) at stand-alone outpatient centers with similar changes at community hospitals. At academic hospitals, only breast imaging complexity remained elevated (1.32 from 1.17) during the recovery. Conclusion Reliance on volume alone underestimates the financial impact of the COVID-19 pandemic as there was a disproportionate loss in high-RVU studies. However, increased complexity of outpatient cases has stabilized overall losses during the recovery.