11. NATIONAL UNDERVALUATION OF CLEFT SURGICAL SERVICES: EVIDENCE FROM A COMPARATIVE ANALYSIS OF 50,450 CASES

Abstract

PURPOSE: 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. We hypothesize that unbalanced RVU allocation creates inappropriate disparities in value amongst procedures performed by cleft and craniofacial surgeons. METHODS: The Pediatric NSQIP database was queried to identify all cleft and craniofacial surgery cases performed by plastic surgeons from 2012-2019 based on Current Procedural Terminology (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 (i.e. RVUs/hour). Mean efficiency per CPT code was ranked and compared by quartile using Student’s 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 comprised mainly of CPT codes for cleft procedures including surgeries 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). CONCLUSION: 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.