The Medicare Physician Fee Schedule and Unethical Behavior.

This Viewpoint discusses the Medicare Physician Fee Schedule and its flaws, including how they might be remedied by severing CMS dependence on Relative Value Update Committee estimates of time and intensity.

Optimizing Physician Payment for a Single-Payer Healthcare System.

Current forms of payment of independent physicians in U.S. health care may incentivize more care (fee-for-service) or less care (capitation), be inequitable across specialties (resource-based relative value scale [RBRVS]), and distract from clinical care (value-based payments [VBP]). Alternative systems should be considered as part of health care financing reform. We propose a "Fee-for-Time" approach that would pay independent physicians using an hourly rate based on years of necessary training applied to time for service delivery and documentation. RBRVS overvalues procedures and undervalues cognitive services. VBP shifts insurance risk onto physicians, introducing incentives to game performance metrics and to avoid potentially expensive patients. The administrative requirements of current payment methods introduce large administrative costs and undermine physician motivation and morale. We describe a Fee-for-Time payment scenario. A combination of single-payer financing and payment of independent physicians using the Fee-for-Time proposal would be simpler, more objective, incentive-neutral, fairer, less easily gamed, and less expensive to administer than any system with physician payment based on fee-for-service using RBRVS and VBP.

Comparative Analysis of Three Workload Measurement Methodologies in Surgical Pathology: Conclusions and Implications on Public Health Care and Costing of Pathology Services.

OBJECTIVES: To carry out a comparative analysis between 3 different workload measurement systems in surgical pathology: the Resource-Based Relative Value Scale (RBRVS), the Level 4 Equivalent (L4E), and the Automatable Activity-Based Approach to Complexity Unit Scoring (AABACUS). The RBRVS is one of the most widely used systems in terms of attempting to measure workload, whereas it has been proposed as a means of costing (and thus setting reimbursement rates) of surgical pathology services in Greece, despite being widely criticized for its inaccurate design. METHODS: Surgical pathology workload for 1 representative month at Evaggelismos General Hospital was assessed using both the RBRVS and the 2 newer methods. RESULTS: Pearson correlation showed a high level of correlation (0.902, P < .01) between the L4E and AABACUS but less so between either of those and the RBRVS (0.712 and 0.626, respectively; P < .01). The highest level of discrepancy was observed in the subspecialties of genitourinary, breast, dermatopathology, and gastrointestinal pathology. In addition, total and average working hours as calculated by the RBRVS were significantly lower compared with the other 2 systems. CONCLUSIONS: The RBRVS tends to underestimate actual workload as a result of its inability to take specific workload parameters into account, such as slide count or the need for intradepartmental consultation.

Correlation of Relative Value Units With Surgical Complexity and Physician Workload: A Contemporary Nationwide Analysis of Orthopaedic Procedures.

INTRODUCTION: Although previous studies have demonstrated inconsistencies between surgeon work and reimbursement, no previous study has calculated expected relative value units (RVUs) based on procedure-specific variables. Our study aimed to evaluate how measures of physician workload and surgical complexity correlate with the work RVUs (wRVUs) assigned to orthopaedic procedures and compare our predicted wRVUs with actual wRVUs. METHODS: The National Surgical Quality Improvement Program was used to identify orthopaedic surgeries with the highest procedural volume in 2019. For each Current Procedural Terminology (CPT) code, variables related to surgical complexity and postoperative management were retrieved. A multivariable linear regression was conducted, and R 2 values were calculated. RESULTS: A total of 229,792 cases from the top 20 CPT codes by frequency in 2019 were identified. Base RVU values ranged from 7.03 mRVUs for arthroscopic meniscectomy to 30.28 mRVUs for revision total hip arthroplasty. A total of 15 (75%) of the projected mRVUs were lower than the actual mRVU of the procedure. For the 5 (25%) procedures with mRVU projections higher than actual values, the largest differences were seen for CPT codes 29,888 (arthroscopic anterior cruciate ligament [ACL] repair; difference: 7.81), 22,630 (posterior arthrodesis of the lumbar interbody; difference: 7.75), and 27,487 (revision total knee arthroplasty; difference: 4.04). CONCLUSION: Our analysis demonstrates that current orthopaedic wRVUs do not appropriately compensate for objective measures of overall complexity as it relates to each procedure. Significant undercompensation in projected RVUs was noted for several high-volume orthopaedic procedures including arthroscopic ACL repair and revision total knee arthroplasty.

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

BACKGROUND: Relative value units (RVUs) are broadly used for billing and physician compensation; however, the accuracy of RVU assignments has not been scientifically evaluated for craniofacial surgery. The authors hypothesize that unbalanced RVU allocation creates inappropriate disparities in value among procedures performed by cleft and craniofacial surgeons. METHODS: The National Surgical Quality Improvement Program Pediatric database was queried to identify all cleft and craniofacial surgery cases performed by plastic surgeons from 2012 to 2019 based on CPT code. Microsurgical cases and CPT codes with a case count of fewer than 10 were excluded. Efficiency was defined as total RVUs divided by total operative time (ie, RVUs/hour). Mean efficiency per CPT code was ranked and compared by quartile using t tests. RESULTS: The sample consisted of 69 CPT codes with 50,450 cases. In the top quartile, most CPT codes were craniofacial procedures including frontofacial procedures (23.53%) and craniectomies for craniosynostosis or bony lesions (35.29%) (mean, 15.65 ± 4.22 RVUs/hour). The lowest quartile was composed mainly of CPT codes for cleft procedures including operations for velopharyngeal insufficiency (17.65%), cleft palate repair (23.53%), and cleft septoplasty (5.88%) (mean, 7.39 ± 0.98 RVUs/hour; P < 0.001). It was 2.5 times more efficient for a cleft and craniofacial surgeon to perform a local skin flap (15.18 RVUs/hour) than a secondary palatal lengthening for cleft palate (6.09 RVUs/hour). CONCLUSIONS: The current RVU allocation to cleft and craniofacial procedures creates arbitrary disparities in physician efficiency, with cleft procedures disproportionately negatively affected. RVU assignments should be reevaluated to avoid disincentivizing cleft surgical care.

The Cost of Doing Business: An Appraisal of Relative Value Units in Plastic Surgery and Other Surgical Subspecialties.

BACKGROUND: The relationship between procedural complexity and relative value units (RVUs) awarded has been studied within some specialties, but it has not yet been compared across different surgical disciplines. This study aims to analyze the association of RVUs with operative time as a surrogate for complexity across surgical specialties, with a focus on plastic surgery. METHODS: A retrospective review of surgical cases was conducted with the 2019 National Surgical Quality Improvement Program database. The top 10 most performed procedures per surgical specialty were identified based on case volume. Only cases with a single CPT code were analyzed. A subanalysis of plastic surgery procedures was also conducted to include unilateral and bilateral procedures with a frequency greater than 20. RESULTS: Overall, operative time correlated strongly with work RVUs (R = 0.86). Orthopedic surgery had one of the shortest average operative times with the greatest work RVUs per hour, in contrast to plastic surgery, with the greatest average operative time and one of the lowest work RVUs per hour. Of the plastic surgery procedures analyzed, only five were valued on par with the average calculated from all other specialties. The most poorly rewarded procedure for time spent is unilateral free flap breast reconstruction. CONCLUSIONS: Of all the surgical specialties, plastic surgery has the lowest RVUs per hour and the highest average operative time, leading to severe potential undervaluation compared with other specialties. This study suggests that further reevaluation of the current RVU system is needed to account for complexity more equitably as well as encourage value-based care.

Education Value Units in Medical Education: A Scoping Review.

PURPOSE: On the basis of the tripartite mission of patient care, research, and education, a need has arisen to better support faculty in non-revenue-generating activities, such as education. As a result, some programs have developed education value unit (EVU) systems to incentivize these activities. The purpose of this scoping review is to analyze the existing literature on EVUs to identify current structures and future directions for research. METHOD: The authors conducted a literature search of 5 databases without restrictions, searching for any articles on EVU systems published from database inception to January 12, 2022. Two authors independently screened articles for inclusion. Two authors independently extracted data and all authors performed quantitative and qualitative synthesis, consistent with best practice recommendations for scoping reviews. RESULTS: Fifty-eight articles were included. The most common rationale was to incentivize activities prioritized by the department or institution. Of those reporting funding, departmental revenue was most common. The majority of EVU systems were created using a dedicated committee, although composition of the committees varied. Stakeholder engagement was a key component for EVU system development. Most EVU systems also included noneducational activities, such as clinical activities, scholarship activities, administrative or leadership activities, and citizenship. Incentive models varied widely but typically involved numeric- or time-based quantification. EVUs were generally seen as positive, having increased equity and transparency as well as a positive impact on departmental metrics. CONCLUSIONS: This scoping review summarizes the existing literature on EVU systems, providing valuable insights for application to practice and areas for future research.

Correlation between Relative Value Units and Operative Time for Flap-Based Reconstruction Procedures.

BACKGROUND: Procedures performed by plastic surgeons tend to generate lower work relative value units (RVUs) compared to other surgical specialties despite their major contributions to hospital revenue. The authors aimed to compare work RVUs allocated to all free flap and pedicled flap reconstruction procedures based on their associated median operative times and discuss implications of these compensation disparities. METHODS: A retrospective analysis of deidentified patient data from the American College of Surgeons National Surgical Quality Improvement Program was performed, and relevant CPT codes for flap-based reconstruction were identified from 2011 to 2018. RVU data were assessed using the 2020 National Physician Fee Schedule Relative Value File. The work RVU per unit time was calculated using the median operative time for each procedure. RESULTS: A total of 3991 procedures were included in analysis. With increased operative time and surgical complexity, work RVU per minute trended downward. Free-fascial flaps with microvascular anastomosis generated the highest work RVUs per minute among all free flaps (0.114 work RVU/minute). Free-muscle/myocutaneous flap reconstruction generated the least work RVUs per minute (0.0877 work RVU/minute) among all flap reconstruction procedures. CONCLUSIONS: Longer operative procedures for flap-based reconstruction were designated with higher work RVU. Surgeons were reimbursed less per operative unit time for these surgical procedures, however. Specifically, free flaps resulted in reduced compensation in work RVUs per minute compared to pedicled flaps, except in breast reconstruction. More challenging operations have surprisingly resulted in lower compensation, demonstrating the inequalities in reimbursement within and between surgical specialties. Plastic surgeons should be aware of these discrepancies to appropriately advocate for themselves.

Reductions in Reimbursement and Relative Value Units for Interventional Radiology Procedures: Trends from 2011 to 2021 Compared with Those for Other Physician Specialties.

PURPOSE: To compare recent trends in Medicare reimbursement and relative value units (RVUs) for interventional radiology (IR) procedures similar to those performed by non-IR specialties. MATERIALS AND METHODS: Data from the Centers for Medicare and Medicaid Services Physician Fee Schedule for facility reimbursement and RVU component values for 23 commonly performed single Current Procedural Terminology IR procedures were compared with similar procedures or procedures for similar indications performed by non-IR specialties between 2011 and 2021. RESULTS: The work RVU component decreased in 18 of 23 (78.3%) IR procedures compared with 6 of 23 (26.1%) similar procedures performed by non-IR specialties. The largest change in single RVU component was a 19.2% reduction in practice expense RVU for IR compared with a 16.5% reduction for similar procedures performed by non-IR specialties. CONCLUSIONS: As a specialty, IR experienced a disproportionately greater reduction in reimbursement and RVU valuation for a range of comparable procedures performed by non-IR specialties.

Nurses' critical role in CPT code valuation.

ABSTRACT: Relative value units (RVUs) are a measurement of practice efficiency and patient complexity. RVUs are reviewed by the Centers for Medicare and Medicaid Services through the Resource-Based Relative-Value Scale Update Committee, which determines recommendations regarding the Current Procedural Terminology code valuations for the Medicare Physician Fee Schedule. This article discusses the importance of nurses' participation in the accurate valuation of their work and in the process of developing and revising RVUs.