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Background The Center for Medicare and Medicaid Services (CMS) quantifies the total work associated with procedures based on recommendations from the Relative Value Scale Update Committee (RUC). To determine the amount of work for a procedure, the RUC relies on data gathered via surveys from practicing physicians. Investigation of the accuracy of the RUC’s estimates of physician work have shown that there are discrepancies between the RUC times used to calculate work and times determined objectively. The purpose of this study was to determine the accuracy of the RUC/CMS’s current times and work relative value units (wRVU) for the perioperative work involved regarding shoulder arthroplasty. Methods The RUC was contacted to obtain a list of perioperative tasks for shoulder arthroplasty surgeries. The tasks that occurred outside of the OR were timed as the event occurred, while times for tasks performed inside the OR were determined from the EMR. Each task’s time was then multiplied by its respective CMS assigned intensity coefficient to calculate the wRVU. Results The tasks timed in this study were allotted 105 minutes by the RUC and a total wRVU of 2.1. Our study found that these same tasks took 119.5 minutes and had a total wRVU of 2.4. The overall time it takes to perform perioperative tasks in shoulder arthroplasty surgeries is underestimated by 14.5 minutes resulting in an undervaluation of the wRVUs by 0.3. Conclusion The perioperative work associated with shoulder arthroplasty surgeries is underestimated by the CMS/RUC. The RUC and CMS should consider using prospective, empiric times when calculating physician work as it is a more accurate measurement than the current method used. This discrepancy is expected to be amplified with increased preoperative templating and utilization of technological advancements in arthroplasty. Further study is needed on a broader national or international level to determine if this discrepancy exists systemically.

Background The number of primary and revision shoulder arthroplasties performed each year continues to increase. Relative value units (RVUs) are currently used by the Centers for Medicare and Medicaid Services (CMS) to determine physician reimbursement based on time, effort, and complexity of services rendered. Compared to primary shoulder arthroplasty, revision shoulder arthroplasties are often more technically challenging, have longer operative times, and pose a greater risk of intraoperative and postoperative complications. This study aims to compare surgeon reimbursement between primary and revision shoulder arthroplasty. Methods Utilizing a single institution shoulder arthroplasty database, we identified patients who underwent primary or revision shoulder arthroplasty between February 2011 and December 2013 by a single shoulder and elbow fellowship trained surgeon with over 20 years of experience at the time of data collection. The RVUs for primary and revision shoulder arthroplasty were obtained from the CMS Physician Fee schedule. Physician reimbursement for primary and revision shoulder arthroplasty was calculated using the CMS RVU to dollar conversion factor of $34.8921 per RVU. The RVU was divided by operative time to calculate an RVU/min for primary and revision shoulder arthroplasty. Monetary reimbursement per minute, case, day, and year was subsequently calculated. Results A total of 190 primary and 100 revision shoulder arthroplasties were performed during the study period. Mean RVU for primary shoulder arthroplasty was 22.13 ± 0.00 vs. 26.24 ± 1.10 for revision shoulder arthroplasty (P Conclusion While the RVU/case is higher for revision shoulder arthroplasty, the difference does not account for the additional operative time and complexity compared to primary shoulder arthroplasty. In light of this data, the current RVU reimbursement model should be reevaluated to account for these differences between primary and revision shoulder arthroplasty. Level of Evidence Level III; Retrospective Comparative Study

We consider the problem of allocating procurement quantities for a required input to multiple suppliers in advance of a selling season with uncertain demand. Planning complexity is compounded by uncertainty in whether each supplier will deliver on time, in addition to the existence of an option for reserving capacity with a perfectly reliable supplier and the presence of a spot market for the input with an uncertain price. We apply analytical methods including two-stage stochastic programming with recourse, nonlinear optimization, and exact and efficient model-based heuristic solution methods. We show that for a selected supplier, the newsvendor’s conditional service level, given that the supplier delivers on time, equals a critical ratio value determined by the supplier’s cost and reliability parameters. Post-optimality analysis reveals interesting insights on the way reliability and cost parameters interact to determine whether a supplier receives a positive order allocation, as well as the impact of payment schemes on supplier selection decisions. The analysis clarifies an insightful relationship between the conditional service level and a critical ratio value for each selected supplier. The results also sharpen insights on the way relative supplier reliability and cost parameter values interact to determine an optimal supply portfolio. Furthermore, the ability to interpret a perfectly reliable supplier with a capacity reservation cost as an equivalent unreliable supplier reveals additional insights on the relative value of capacity reservation and facilitates direct comparison among seemingly disparate supply options.

Work relative value units (wRVUs) are part of Resource Based Relative Value Scale system. It is expected that a more difficult and time-consuming procedure would yield higher wRVUs. Brachial plexus nerve decompression surgery is a more time-consuming procedure compared with carpal and cubital tunnel procedures. The aim of this study was to analyze physician reimbursement in upper limb decompression procedures by comparing mean operative times, wRVUs per minute, and dollars per minute.A retrospective cohort study was conducted from June 2016 to June 2019, including all patients who underwent carpal tunnel, cubital tunnel, and brachial plexus release procedures. Operating time was collected, and calculations of mean operative time, wRVUs per minute, and dollars per minute were performed and compared between groups.A total of 209 cases were included. Carpal tunnel accounted for 75.1% of the cases, followed by cubital tunnel and brachial plexus releases. Brachial plexus release had the highest median operative time (147 minutes), followed by cubital tunnel (57 minutes) and carpal tunnel release (16 minutes, P0.0001). Carpal tunnel release procedures had a significantly higher wRVUs per minute (0.310) when compared with cubital tunnel and brachial pleaxus release procedures, 0.127 and 0.077, respectively (P0.0001). Same was true for dollars per minute; carpal tunnel procedures yielded significantly more compensation than cubital tunnel and thoracic outlet procedures (P0.0001).More complex and time-consuming procedures yielded a lower reimbursement for physicians. The current work relative unit system does not account adequately for the time spent in each procedure.

We would like to explain our concrete plans on the pre-service of mathematics education methodology in teacher training course of university. It is difficult for many pupils at elementary school to understand on Relative Value in Japan. Students at university, who want to be teachers, don’t understand Relative Value, sufficiently, too. We have taught the new teaching methods to students. They understood the meaning of Relative Value and learned how to teach it to pupils.

Almost two decades ago, Asia Pacific Journal of Management, 19(2/3): 251–267 Peng (2002) called attention to the promise of institution-based strategy research. The puzzle was to explain differences in strategies around the globe. Building on the work accomplished so far, I ask: Can institution-based strategy succeed when embedded in inappropriate social networks? Institutions and networks are usually studied as separate phenomena, yet each also defines the capabilities of the other. Institutions shape social network contacts and structures because institutions define opportunities for affiliation and the relative value of distinct contacts and network structures. At the same time, social networks shape institutions and organizations’ capabilities for institutional innovation. Thus, the social network in which a manager or organization is embedded can either amplify or counteract success in implementing institution-based strategy. After I review the co-constitutional nature of institutions and networks and discuss a number of sample studies using China as a productive research site, I sketch questions that need to be answered to more tightly integrate network behavior into institutional strategy research, and discuss four emerging areas of research into how network-strategy fit affects performance: (1) network fit to adaptive strategy, (2) network fit to change strategy, (3) institutional dynamics and network-strategy fit, and (4) institutional distance and network-strategy fit.

In this article, the authors propose a systematic approach for pricing and trading municipal bonds, leveraging the feature-rich information available at the individual bond level. Based on the proposed pricing framework, they estimate several models using ridge regression and Kalman filtering. In their empirical work, they show that the models compare favorably in pricing accuracy to those available in the literature. In addition, the models can quickly adapt to changing market conditions. Incorporating the pricing models into relative value trading strategies, the authors demonstrate that the resulting portfolios generate significant excess returns and positive alpha relative to the Vanguard Long-Term Tax-Exempt Fund, one of the largest mutual funds in the municipal space.

The COVID-19 pandemic has increased demand for physicians, leading to widespread redeployment of specialty physicians to care for patients with COVID-19. These redeployments highlight an important question: How do physicians balance competing obligations to their own health, their own patients, and society during a public health crisis? How can physicians, specifically subspecialists, navigate this tension? In this article, we analyse a clinical scenario in which an orthopaedic sports surgeon is redeployed to care for patients with COVID-19. This case raises questions about physicians’ obligations to their own patients compared with society at large, the relative value of specialty physicians during a global pandemic, and the ethical permissibility of compulsory redeployment. Using the orthopaedic surgery specialty as a model, we build a redeployment framework for surgical specialists that is both ethical and equitable. We argue that although orthopaedic surgeons have a moral obligation to participate in physician redeployment schemes, the scope of this obligation is limited and contingent on the following conditions: (1) the number of local COVID-19 cases is high; (2) obligations to their own patients or orthopaedic patients requiring urgent or emergency care have been fulfilled; (3) their value as physicians exceeds their value as specialists because of the pandemic climate; (4) voluntary redeployments are exhausted before compulsory redeployments are implemented; and (5) redeployment would not put the physicians at unreasonable risk of harm.

Type-safe languages improve application safety by eliminating whole classes of vulnerabilities–such as buffer overflows–by construction. However, this safety sometimes comes with a performance cost. As a result, many modern type-safe languages provide escape hatches that allow developers to manually bypass them. The relative value of performance to safety and the degree of performance obtained depends upon the application context, including user goals and the hardware upon which the application is to be executed. Since libraries may be used in many different contexts, library developers cannot make safety-performance trade-off decisions appropriate for all cases. Application developers can tune libraries themselves to increase safety or performance, but this requires extra effort and makes libraries less reusable. To address this problem, we present NADER, a Rust development tool that makes applications safer by automatically transforming unsafe code into equivalent safe code according to developer preferences and application context. In end-to-end system evaluations in a given context, NADER automatically reintroduces numerous library bounds checks, in many cases making application code that uses popular Rust libraries safer with no corresponding loss in performance.

Relative value units (RVUs) are utilized to evaluate physician productivity in many fields, including radiology. The goal of this paper is to use the electronic medical record (EMR) to evaluate whether the current RVU system allows for fair comparison between radiologists' time effort.The study was approved by the local Institutional Review Board (IRB). Over 600,000 radiology studies with unique current procedural terminology (CPT) codes were evaluated, and after exclusion of studies interpreted in conjunction with trainees or interpreted using other software systems, a total of 241,627 studies remained. The median 25%ile, 50%ile, 65%ile, 75%ile and modal study ascribable times (SATs) for each CPT code was calculated across all radiologists. To evaluate the potential bias incurred using the current RVU system, the number of days required to achieve the Association of Administrators in Academic Radiology AAARAD 65%ile were calculated.RVU values were positively correlated with SATs (r = 0.69-0.71, p 0.001). The variability in the radiologists' time to achieve the AAARAD 65%ile benchmark was highest for musculoskeletal imaging, and lowest for thoracic imaging. The discrepancy in the number of days of work required to achieve the AAARAD 65%ile benchmark was 141.1% (197.7 days) for musculoskeletal imaging, 107.5% (161.9 days) for neuroimaging, 89.6% (185.9 days) for body imaging, and 72.2% (84.0 days) for thoracic imaging.The current RVU system is not strongly correlated with radiologist effort measured by radiologists' time. A time-based metric is more representative of radiologist work. However, there is no perfect method to measure radiologists' work.

Self-determination theory proposes that the satisfaction of basic psychological needs is equally beneficial for everyone – the Universal Hypothesis. Equally, there are intra-individual differences in how the satisfaction of differentially important needs might be differentially beneficial, which we term the Intra-individual Hypothesis. We aimed to reconcile these positions. Across four cross-sectional studies (ns = 300 rock climbers, 323 sportspeople, 394 UK and Chinese adults, 320 UK adults), we investigated the needs of individuals with varying dimensions to their identity, and their motivation and self-esteem. In Studies 1, 2, and 4, when individuals strongly related their sense of identity to investment in a specific activity, the association between need satisfaction and self-esteem (and motivation in Studies 1–2) depended on their intra-individual need importance, supporting the Intra-individual Hypothesis. In Studies 3 and 4, for individuals with a multidimensional identity, the association between need satisfaction and self-esteem did not depend on the importance of each need, supporting the Universal Hypothesis. The satisfaction of basic psychological needs is not always uniform in its link with motivation and well-being. The degree to which individuals have a unidimensional or multidimensional self-concept appears fruitful in predicting the relative value of the Universal Hypothesis and the Intra-individual Hypothesis.

PurposeThis article is devoted to conditions and examples of how theories may be applied as methods in the fields of management research and organization studies.Design/methodology/approachAn introduction to minimum requirements for a successful refunctionalization of theory as method as well as to nine contributions to a special issue of the Journal of Organizational Change Management on “Theory as method” is provided.FindingsThe review of these nine cases suggests that the use of theories as methods is not necessarily harmful for the former, and particularly not for the more robust among them.Originality/valueThis article sheds new light on the value of theoretical monism or loyalty and calls for a reassessment of the relative value of expertise in a specific research field, method and or theory.

This contribution argues that BRICS is designed to manage inner‐group tensions indirectly by endorsing a number of pragmatic operating principles. However, these principles seem to work best at smaller scale conflicts but not larger armed confrontation. The article breifly discusses the internal operating procedures of the BRICS group followed by a discussion of their relative value vis‐a‐vis inner group conflict. The article finishes by exploring the role of smaller group members such as South Africa and their ability to dissipate political tensions.

Academic interest in ecosystem services has been growing in the past ten years or more with an increasing number of research studies and papers being dedicated to this complex and diverse field of enquiry. However, Cultural Ecosystem Services have been relatively under-researched, especially in terms of their value to landscapes. The Millennium Ecosystem Assessment (2005) argued that cultural services and values were not recognised enough in landscape planning and management, therefore the implications for rural landscape development are considered in this paper. This paper focuses on the value of Cultural Ecosystem Services in two rural landscapes in Hungary (Őrseg and Kalocsa) using in-depth interviews with a range of local stakeholders. The research analyses the relative value of different categories of Cultural Ecosystem Services focusing mainly on social, symbolic and economic values. The findings reveal the central importance of cultural heritage in relation to other categories of CES, especially its social and symbolic values.

The increasing demand for energy accounts for an alternative energy source. The search for biomass being abundant in an agricultural country is a suitable option to power a community. This paper used Analytical Hierarchy Process (AHP), which includes the organized hierarchy of various selection criteria, the assessment of the relative value of criteria, the comparison and an aggregate rating of the alternatives for each criterion. Specifically, the methodology used was the combination of multi-criteria and weighted-overlay analysis in a Geographical Information System (GIS) environment to provide a spatial overview of the sustainable location for sugarcane residues production in Medellin, Cebu. The study was able to identify Caputatan Sur and Canhabagat as sustainable locations for sugarcane residue production with respect to topography, cultivation area and accessibility. These locations represent 26% of the total cultivation area and average sugarcane production of the locality. The result of this study is an initial step in the support for the utilization of sugarcane residues to answer energy demand in remote areas and further promote the use of indigenous resources for energy generation.

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

The drift diffusion model (DDM) provides a parsimonious explanation of decisions across neurobiological, psychological, and behavioral levels of analysis. Although most DDM implementations assume that only a single value guides decisions, choices often involve multiple attributes that could make separable contributions to choice. Here, we fit incentive-compatible dietary choices to a multi-attribute, time-dependent drift diffusion model (mtDDM), in which taste and health could differentially influence the evidence accumulation process. We found that these attributes shaped both the relative value signal and the latency of evidence accumulation in a manner consistent with participants’ idiosyncratic preferences. Moreover, by using a dietary prime, we showed how a healthy choice intervention alters mtDDM parameters that in turn predict prime-dependent choices. Our results reveal that different decision attributes make separable contributions to the strength and timing of evidence accumulation – providing new insights into the construction of interventions to alter the processes of choice.

Value investing has been one of the cornerstones of equity investment strategies. This article provides a new methodology to select value stocks using the concept of relative value across firms. Results show that using multiple value ratios as foundation blocks provides better risk-adjusted returns than using a single ratio, as used by the Fama–French HML factor. The use of trends in fundamental ratios helps capture value in a stock portfolio in a new way. The trend in value metrics ranks firms that are not just cheap compared to the cross section but also those that have become cheaper over time. The results show that this relative value method proves effective for individual value parameters and when combined to create a composite value model. Trends carry incremental information not captured by common factor models and control variables. The authors construct a composite value model that uses trends in six value ratios. Momentum when combined with value generates enhanced return performance, as documented in various academic literatures. The authors extend the discussion on the combination of momentum with value using three different methods. TOPICS:Fundamental equity analysis, analysis of individual factors/risk premia, statistical methods, performance measurement Key Findings ▪ The authors use trends in value ratios to generate high risk-adjusted returns. ▪ Incremental information in trends in fundamentals is difficult to capture using common factor models. ▪ Combining a value model with momentum enhances the returns of the strategy.

Background Since the Patient Protection and Affordable Care Act was signed into law, there has been a push away from fee-for-service payment models. The rise of bundled payments has drastically impacted plastic surgeons' incomes, especially nonsalaried surgeons in private practice. As a result, physicians must now attempt to optimize contractual reimbursement agreements (carve-outs) with insurance providers. The aim of this article is to explain the economics behind negotiating carve-outs and to offer a how-to guide for plastic surgeons to use in such negotiations. Methods Based on work relative value units, Medicare reimbursement, overhead expenses, physician workload, and desired income, the authors present an approach that allows surgeons to evaluate the reimbursement they receive for various procedures. The authors then review factors that influence whether a carve-out can be pursued. Finally, the authors consider relevant nuances of negotiating with insurance companies. Results Using tissue expander insertion (CPT 19357) as an example, the authors review the mathematics, thought process required, and necessary steps in determining whether a carve-out should be pursued. Strategies for negotiation with insurance companies were identified. The presented approach can be used to potentially negotiate a carve-out for any reconstructive procedure that meets appropriate financial criteria. Conclusions Understanding practice costs will allow plastic surgeons to evaluate the true value of insurance reimbursements and determine whether a carve-out is worth pursuing. Plastic surgeons must be prepared to negotiate adequate reimbursement carve-outs whenever possible. Ultimately, by aligning the best quality patient care with insurance companies' financial motivations, plastic surgeons have the opportunity to improve reimbursement for some reconstructive procedures.

Analytic power has always been a key consideration in adjudicating between analytic frameworks, but the political effects of frameworks have never been unimportant in assessing their relative value...

I provide empirical evidence that patent value indicators can identify technological innovation among inventors and small- and medium-sized enterprises in Sweden. Survey data on the commercialization of patents are related to patent value indicators (patent renewal, patent family size and forward citations) from archival sources. Among the patent value indicators, both the length of patent renewal and the size of the patent family indicate that a patent has been commercialized. Patent renewal for at least 6 years is sufficient to predict an accurate probability of commercialization. Furthermore, patent renewal is the only indicator revealing whether commercialization is successful. Forward citations have a moderate relationship with both commercialization and successful innovation, which may reflect the fact that citations are outside the control of the patentees or that forward citations measure spillovers rather than the private value. Although the correlations of the patent value indicators with technological innovation are noisy, this study provides stronger empirical support for the true relative value of different indicators with respect to innovation.

Background: Relative value units (RVUs) are the measure of value used in US Medicare reimbursement. Medicare determines physician work RVUs (wRVUs) from the Relative Value Update Committee (RUC) for a procedure based on operative time, technical skill and effort, mental effort and judgment, and stress. In theory, work RVUs should account for the complexity and operative time involved in a procedure. The aim of this study was to assess whether major procedures for treatment of benign prostatic enlargement (BPE) are fairly compensated based on complexity and operative time in the RVU system and compare them with the intended reimbursement. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and the Centers for Medicare and Medicaid Services (CMS) Medicare Physician Fee Schedule were queried from 2015 to 2017. Single, current, procedural terminology codes associated with BPE treatments were included: transurethral resection of the prostate (TURP), photovaporization of the prostate (PVP), holmium laser enucleation of the prostate (HoLEP), retropubic simple prostatectomy (RSP), and suprapubic simple prostatectomy (SSP). The CMS operative times and the NSQIP real data were used in turn to calculate separate values for wRVUs per hour (wRVUs/hr) of operative time. The wRVUs/hr derived from CMS operative times represent RUC-estimated wRVUs/hr and wRVUs/hr derived from NSQIP represent actual wRVUs/hr. Results: A total of 27,664 cases were included from the NSQIP dataset. Median wRVU was 15.3 (interquartile range [IQR] 12.2-15.3), median operative time 50 minutes (IQR 33-74), and median wRVUs/hr 17.0 (IQR 11.6-26.2). RUC-estimated wRVUs/hr were TURP 12.2, PVP 12.2, RSP 9, SSP 9.3, and HoLEP 7.3. The actual wRVUs/hr were TURP 19.1, PVP 15.5, RSP 10.2, HoLEP 9.4, and SSP 7.6. Conclusions: Laser enucleation and simple prostatectomy are highly complex and efficacious procedures for treating BPE, yet the current payment schedule assigns these procedures the least amount of wRVUs/hr. Financial incentives for performing BPE surgeries are clearly misaligned.