Work Relative Value Units Research Articles

Elective surgery growth at Florida hospitals accrues mostly from surgeons averaging 2 or fewer cases per week: A retrospective cohort study

Study objectiveHospital administrators often seek to increase operating room (OR) elective caseload. Previous studies from Iowa demonstrated that surgical growth is mostly from low-caseload surgeons (ie, ≤2 cases per week). We repeated that study using data from Florida, a much more populous state, to confirm the generalizability of the findings. DesignRetrospective cohort study. SettingAll hospitals in the state of Florida. PatientsAll patients undergoing elective surgery during 2018 and 2019. MeasurementsWe determined growth between 2018 and 2019 in regular-workday elective surgical caseload and intraoperative work relative value units (wRVU) at hospitals. Using the two-sided, one group Student t-test, we compared the fractions of those increases attributable to low-caseload surgeons vs. 50% to assess if they accounted for most surgical growth. We used the exact binomial test to compare the fraction of hospitals where most growth (>50%) occurred from low-caseload surgeons to half (50%). Main resultsWe studied the 1,629,879 elective cases from 202 hospitals. Surgeons averaging ≤2.0 cases per week accounted for 73.3% (P < 0.0001 compared to 50%) of caseload growth and 68.7% (P < 0.0001 compared to 50%) of wRVU growth. The corresponding overall pooled growth estimates among hospitals were 70.8% for caseload and 65.0% for wRVU. There were 76.2% of the N = 202 hospitals with more than half their growth in cases from surgeons performing, on average, ≤2.0 cases per week (P < 0.0001 compared to 50% of hospitals). The vast majority of surgical growth at hospitals accrued from the contributions of low-caseload surgeons. ConclusionsSurgical growth in elective surgery at Florida hospitals accrued mostly from the increased activity of low-caseload surgeons averaging ≤2.0 cases per week during the preceding year, confirming the generalizability of the previous Iowa study. If growth in caseload is desired, surgical governance committees should ensure that low-caseload surgeons have access to the OR schedule.

Does Complexity Always Correlate With Compensation? An Analysis of Work Relative Value Units in 3 Common Nerve Decompression Syndromes.

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, P < 0.0001). 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 (P < 0.0001). Same was true for dollars per minute; carpal tunnel procedures yielded significantly more compensation than cubital tunnel and thoracic outlet procedures (P < 0.0001). 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.

Similarities Between Pediatric and General Hospitals Based on Fundamental Attributes of Surgery Including Cases Per Surgeon Per Workday.

IntroductionOperating room (OR) management decision-making at both pediatric and adult hospitals is determined, in large part, by the same fundamental attributes of surgery and other considerations related to case duration prediction. These include the non-preemptive nature of surgeries, wide prediction limits for case duration, and constraints to moving or resequencing cases on the day of surgery. Another attribute fundamentally affecting OR management is the median number of cases a surgeon performs on their OR days. Most adult surgeons have short lists of cases (i.e., one or two cases per day). Similarly, at adult hospitals, growth in caseloads is mostly due to the subset of those surgeons who also operate just once or twice per week. It is unknown if these characteristics of surgery apply to pediatric surgeons and pediatric hospitals as well.MethodsOur retrospective cohort study included all elective surgical cases performed at the six pediatric hospitals in Florida during 2018 and 2019 (n = 71,340 cases). We calculated the percentages of combinations of surgeon, date, and hospital (lists) comprising one or two cases, or just one case, and determined if the values were statistically >50% (i.e., indicative of “most”). We determined if most of the growth in caseload and intraoperative work relative value units (wRVUs) at the pediatric hospitals between 2018 and 2019 accrued from low-caseload surgeons. Results are reported as mean ± standard error of the mean.ResultsAveraging among the six pediatric hospitals, the non-holiday weekday lists of most surgeons at each facility had just one or two elective cases, inpatient and/or ambulatory (68.1%; p = 0.016 vs. 50%, n = 27,557 lists). Growth in surgical caseloads from 2018 to 2019 was mostly attributable to surgeons who in 2018 averaged ≤2.0 cases per week (76.3% ± 5.4%, p = 0.0085 vs. 50%). Similarly, growth in wRVUs was mostly attributable to these low-caseload surgeons (73.8% ± 5.4%, p = 0.017 vs. 50%).ConclusionsLike adult hospitals, most pediatric surgeons’ lists of cases consist of only one or two cases per day, with many lists containing a single case. Similarly, growth at pediatric hospitals accrued from low-caseload surgeons who performed one or two cases per week in the preceding year. These findings indicate that hospitals desiring to increase their surgical caseload should ensure that low-caseload surgeons are provided access to the OR schedule. Additionally, since percent-adjusted utilization and raw utilization cannot be accurately measured for low-caseload surgeons, neither metric should be used to allocate OR time to individual surgeons. Since most adult and pediatric surgeons have low caseloads, this is a fundamental attribute of surgery.

Implementation and early experience of a pediatric electrophysiology telehealth program

BackgroundTelehealth (TH) visits have been growing with exponential increased utilization during the COVID-19 pandemic. The aim of this manuscript is to describe the implementation and early experience of a pediatric electrophysiology (EP) TH program implemented during the pandemic, assessing patient satisfaction, patient equity and inclusion (measured by geographical outreach), and sustainability.MethodsA retrospective chart review study was performed and data were collected from the medical record, including demographic, testing, and billing data from scheduled TH encounters between March and August 2020 of a single pediatric EP group in the Midwest. Patients were called to complete satisfaction surveys.ResultsPatients with diverse pathologies were seen in TH, with supraventricular/atrial tachycardias (n = 41, 35%) and inherited arrhythmia syndromes (n = 23, 20%) being most common. The mean distance from clinic was 95 miles (range 2.8–320 miles), with 43% of patients living more than 100 miles away from clinic. A total of 172 tests were performed previsit (n = 102, 59%), during the visit (n = 17, 10%), or postvisit (n = 53, 31%), including 15 EP studies. Time-based Current Procedural Terminology codes were predominantly used for billing purposes (n = 92, 78%). There was generation of work relative value units (wRVU) for visits (220.5 wRVU) and testing (325.1 wRVU). Survey data demonstrated that 98% of patients were satisfied with their telehealth appointment and 99% had a clear understanding of their diagnosis.ConclusionPediatric EP TH clinics can provide care for a geographically and pathologically heterogeneous group of patients who had positive attitudes toward TH. Our study shows significant downstream testing and subsequent wRVU generation, suggesting financial sustainability.

Hip and Knee Arthroplasty Alternative Payment Model Successes and Challenges.

Hip and Knee Arthroplasty Alternative Payment Model Successes and Challenges.

Are Orthopedic Hand Surgeons Undercompensated for Time Spent in the Operating Room? A Study of Relative Value Units.

This study aims to investigate whether compensation is equitable among the most commonly performed orthopedic hand surgeries and when compared with general orthopedic procedures. The National Surgical Quality Improvement Program database was queried for all orthopedic procedures, from 2016 to 2018, performed more than 150 times using Current Procedural Terminology (CPT) codes. Physician work relative value unit (wRVU) data were obtained from the 2020 US Centers for Medicare and Medicaid Services fee schedule. Linear regressions were used to determine whether there was an association among wRVU, operative time, and wRVU per hour (wRVU/h). Reimbursement for hand surgery CPT codes was compared with that of nonhand orthopedic CPT codes. The CPT codes were stratified into quartile cohorts based on mean operative time, major complication rate, mortality rate, American Society of Anesthesiologists class, reoperation rate, and readmission rate. Student t tests were used to compare wRVU/h between cohorts. Forty-two hand CPT codes were identified from 214 orthopedic CPT codes, accounting for 32 333 hand procedures. The median wRVU/h was significantly lower for procedures in the longest operative time quartile compared with the shortest operative time quartile (P < .001). Compared with hand procedures, nonhand procedures were found to have significantly higher mean operative time (P < .001), mean complication rate (P < .001), mean wRVU (P = .001), and mean wRVU/h (P = .007). The 2020 Physician wRVU scale does not allocate proportional wRVUs to orthopedic hand procedures with longer mean operative times. There is a decrease in mean reimbursement rate for hand procedures with longer mean operative time. When compared with general orthopedic procedures, hand procedures have a lower mean wRVU/h and complication rate.

Extensive Preoperative Work Is Required for Revision Hip and Knee Arthroplasty

BackgroundDetermining the clinical effort associated with preparing for revision total hip and knee arthroplasty is necessary to maintain the appropriate work relative value unit rating. We have investigated the work done by the orthopedic surgical team in the days and weeks prior to revision hip and knee arthroplasty using a count of time by team members in the electronic medical record (EMR). MethodsEMR audit logs were generated, and preoperative work (POW) was calculated for members of the surgical team for 200 sequential revision cases. Independent samples t-tests were conducted to compare total POW for procedure, age, gender, insurance, and health literacy; significance threshold was set at P = .05. ResultsPOW was 97.7 minutes (standard deviation [SD] 53.1). Surgeon POW accounted for 10.5 minutes (SD 9.3), nurses for 29.9 minutes (SD 34.2), mid-level providers for 22.1 minutes (SD 17.0), and office technicians for 34.1 minutes (SD 35.2). There was no difference in total POW based on procedure (hip vs knee), age, gender, insurance type, or health literacy. ConclusionRevision arthroplasty requires substantial preoperative preparation from the surgical team. Most of this is by nurses, mid-level providers, and office staff. This does not seem to be different for hip or knee revisions or by age and gender. EMR audit logs capture the bare minimum POW required to prepare a patient for revision arthroplasty.

Trends in Medicare Physician and Facility Fee Reimbursement in Orthopaedic Foot and Ankle

Category:Ankle; Ankle Arthritis; Arthroscopy; Bunion; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:The purpose of the study was to examine the trends in physician and facility reimbursement for the orthopaedic foot and ankle subspecialty utilizing the 23 most common foot and ankle surgeries based on national payment amounts.Methods:The Current Procedural Terminology (CPT) codes and corresponding Medicare Severity - Diagnosis Related Group (MS-DRG) codes for the 23 most common orthopaedic foot and ankle surgeries were identified. With the CPT codes, physician reimbursement was obtained through querying the Medicare Physician Fee Schedule (MPFS) for the work, malpractice, and practice expense relative value units (RVU) and then multiplying the total RVUs by the yearly conversion factor. CPT codes were also utilized to gather hospital outpatient reimbursement data from the Hospital Outpatient Prospective Payment System (OPPS) database. Hospital inpatient reimbursement rates were obtained from the Hospital Inpatient Prospective Payment System (IPPS) database utilizing the MS-DRG codes. All amounts were then adjusted for inflation using the Consumer Price Index (CPI).Results:From 2008 to 2021, physician reimbursement for the 23 most common orthopaedic foot and ankle surgeries decreased by 20%, with a mean Compound Annual Growth Rate (CAGR) of -1.7%. Hospital inpatient reimbursement increased by 34.7% with a mean CAGR of 2.3%; while outpatient hospital reimbursement increased by 97.2% with a mean CAGR of 5.1%.Conclusion:Over the past 13 years, physician reimbursement for common orthopaedic foot and ankle surgeries has declined while hospital reimbursement has increased. The larger increase in outpatient reimbursement compared to inpatient reimbursement highlights how CMS aims to transition surgeries from the inpatient setting to the more efficient and less expensive outpatient setting. This downward pressure on physician reimbursement while incentivizing outpatient services could have many unintended consequences on the landscape of foot and ankle practice in the US.

Reimbursement for Complex Carpal Trauma

Objectives: To compare Relative Value Unit (RVU)-based reimbursement of operative fixation of complex carpal trauma versus primary operative fixation of distal radius fractures. Design: Database review. Setting: National Surgical Quality Improvement Program (ACS-NSQIP) database Intervention: Surgical treatment of complex carpal trauma and distal radius fracture. Main outcome measurement: Mean and median total work Relative Value Unit (wRVU), surgical time, wRVU/minute, reimbursement/minute, reimbursement/surgical case. Results: The 139 patients who underwent fixation of complex carpal trauma and 222 patients who underwent fixation of distal radius fractures were included in this study. The mean wRVUs were 10.56 for the complex carpal trauma group and 12.46 for the distal radius fracture group. Complex carpal trauma cases were an average of 31 minutes longer than distal radius fracture cases. Mean wRVU/minute (0.19 vs 0.14) and median wRVU/minute (0.18 vs 0.11) were higher for distal radius fracture cases than for complex carpal trauma cases (percent difference: mean 34%, median 62%). Lastly, the mean ($378.85) and median reimbursement ($383.29) per surgical case for complex carpal trauma was lower than that of the mean ($447.19) and median reimbursement ($516.08) of distal radius fractures. Conclusions: Despite longer operative times and increased procedural complexity, surgical treatment of complex carpal trauma is reimbursed significantly less than surgical treatment of distal radius fractures. The authors advocate a threefold plan. First, the ACS may consider developing more clear guidelines on the definition of a hand surgeon. Second, hand surgeons must insert themselves into hospital policy making, particularly with call and consult management discussions. Finally, considering the three components of the RVU calculation (physician work, physician expertise, and liability), the management of complex carpal trauma is under-recognized and reimbursed. As such, the authors recommend consideration of these injuries to be recompensed commiserate with arthroplasty and orthopaedic trauma. Level of Evidence: IV; Economic Analysis Keywords: Complex carpal trauma, relative value unit, wRVU, reimbursement, distal radius fracture (J Ortho Business 2022; Volume 1, Issue 1:pages 19-23)

Economic value of podiatry service in limb salvage alliance.

Over the past decade, multidisciplinary "toe and flow" programs have gained great popularity, with proven benefits in limb salvage. Many vascular surgeons have incorporated podiatrists into their practices. The viability of this practice model requires close partnership, hospital support, and financial sustainability. We intend to examine the economic values of podiatrists in a busy safety-net hospital in the Southwest United States. An administrative database that captured monthly operating room (OR) cases, clinic encounters, in-patient volume, and total work relative value units (wRVUs) in an established limb salvage program in a tertiary referral center were examined. The practice has a diverse patient population with >30% of minority patients. During a period of 3years, there was a significant change in the number of podiatrists (from 1 to 4) within the program, whereas the clinical full-time employees for vascular surgeons remained relatively stable. The limb salvage program experienced >100% of growth in total OR volumes, clinic encounters, and total wRVUs over a period of 4years. A total of 35,591 patients were evaluated in a multidisciplinary limb salvage clinic, and 5535 procedures were performed. The initial growth of clinic volume and operative volume (P< .01) were attributed by the addition of vascular surgeons in year one. However, recruitment of podiatrists to the program significantly increased clinic and OR volume by an additional 60% and >40%, respectively (P< .01) in the past 3years. With equal number of surgeons, podiatry contributed 40% of total wRVUs generated by the entire program in 2019. Despite the fact that that most of the foot and ankle procedures that were regularly performed by vascular surgeons were shifted to the podiatrists, vascular surgeons continued to experience an incremental increase in operative volume and >10% of increase in wRVUs. This study shows that the value of close collaboration between podiatry and vascular in a limb salvage program extends beyond a patient's clinical outcome. A financial advantage of including podiatrists in a vascular surgery practice is clearly demonstrated.

Effect of Resident and Fellow Involvement on Outcomes of Sarcoma Surgery: A NSQIP Database Cross-Sectional Study.

Background The complexity of sarcoma surgery often justifies surgical assistants of higher levels of academic training: senior residents, fellows, or co-surgeons. The association between the level of training of assistants and outcomes of these procedures has yet to be studied. Methods The Current Procedural Terminology (CPT) codes comprising the “core” procedures for musculoskeletal oncology fellowships were gathered. After CPTs primarily capturing nononcologic procedures were excluded, the National Surgical Quality Improvement Program (NSQIP) database was used to find procedures with these CPTs. The severity of complications was assessed using the Severity Weighting of Postoperative Adverse Events in Orthopedic Surgery (SWORD) score. Resident/fellow presence was analyzed both as a binary variable and stratified by level of training. Results In 159 cases meeting inclusion criteria, higher-level assistants were associated with increased rate of any complication (p=0.006) and greater need for transfusion (p=0.001) but also tended to be used in cases of longer duration (p=0.001) and with higher total work relative value units (wRVUs) (p=0.001). Multivariate analysis showed that while higher-wRVU procedures persisted as an independent predictor of increased complications (OR 1.028 per RVU unit, p=0.002), neither the presence nor level of training of assistants had an independent effect on complication rates. Other independent predictors of 30-day complications were treatment comorbidity (OR 3.433, p=0.010) and lower extremity location of the tumor (OR 4.393, p=0.006). Severity of complications did not differ between any of the groups on either univariate or multivariate analysis. Conclusions Trainees of higher levels of academic training tend to be present for longer, higher-complexity musculoskeletal oncology cases, but the overall severity of complications from these do not significantly differ from lower-risk cases without trainees. Orthopedic oncologists may reassure patients that the presence of trainees and co-surgeons is not only safe but it may also help reduce the severity of complications in more complex procedures.

Impact of an ambulatory care pharmacist on provider relative value units in a rural clinic

IntroductionCollaborative team-based care models have been shown to improve the quality of care provided to patients and may increase productivity along with patient access to care. Productivity is often tracked via work relative value units (wRVU). The primary objective of this project was to evaluate how a collaborative practice model affects tracked productivity. MethodsData regarding wRVU were retrospectively extracted from the electronic medical record from a single center. De-identified data points included total number of patients seen and level of service billed for the visit. Visits were grouped as collaborative (physician-pharmacist) or independent (physician alone). Relative value unit totals were calculated separately for individual physicians and pharmacy visits and also combined for collaborative team wRVU totals. Wilcoxon and descriptive statistics were used for analysis. All statistical analyses were performed using SAS v 9.4 (Cary, NC). ResultsA total of 624 patient visits were reviewed. Total number of patients seen by physicians working in collaboration was on average 19.25 per day versus 12.9 per day for those working independently. When evaluating only the average per encounter wRVU for each provider removing collaborative patients, the three providers who worked in the collaborative model averaged 1.45, 1.48, and 1.55 wRVU per patient respectively, compared to those who worked singularly (1.37 and 1.30). This was found to be statistically significant in the unadjusted mixed model (P = 0.0476), but not maintained once adjusted. ConclusionPhysicians working in collaboration with a pharmacist were able to bill at a higher level on average suggesting more productivity.

Procedures With Longer Intraoperative Times Undervalue Surgeon Work in Total Joint Arthroplasty: A Large, Nationwide Database Study.

Work relative value units (wRVUs) measure a surgeon's time and intensity required to perform the pre-service, intra-service, and post-service work of a surgical procedure and are commonly used to compare a physician's work between different procedures. Previous literature across multiple specialties report that longer, often revision, operations are undervalued when compared to primary procedures. Our study aims to analyze the differences in intra-operative time, and its corresponding wRVU/h between the Medicare benchmarks and real-world time-stamped data for total joint arthroplasty procedures. Thirteen primary and revision hip and knee arthroplasty procedures were identified, and intra-operative times were collected using the National Surgical Quality Improvement Program databases from 2014 to 2019. The Relative Value Scale Update Committee's (RUC) estimated median intra-operative times for each procedure was compared to the calculated median intra-operative times from National Surgical Quality Improvement Program, as were their corresponding wRVU/h. Procedures were additionally stratified by "long" (>110minutes) and "short" (≤110minutes) intra-operative times. The RUC over-estimated intra-operative time by 35.24% on average and this overestimation was more profound in longer operations than shorter operations (47.75% vs 15.22%, P= .011). The RUC intensity per unit time values (wRVU/h) between "long" and "short" procedures were significantly different (P<.001) and showed the undervaluation of intensity for the longer procedures by an average of 3.47 wRVU/h. Our study provides further evidence that physician work is undervalued in revision total hip and knee surgeries.

Development of a local model for measuring the work of surgeons.

The Relative Value Unit (RVU) is the main method of calculating surgeons' reimbursements and a tool for measuring the work of surgeons. Existing evidence shows that the work Relative Value Unit (wRVU) does not accurately represent surgeon's work. Therefore, the current study attempted to develop a local model to measure surgeons' work. This study was conducted in two main phases of determining the metrics and model development using quantitative and qualitative approaches from December 2019 to April 2021. Literature review, focused group discussions, and interviews were used to collect data. Con- tent analysis and Exploratory Data Analysis techniques were applied to analyze data. The findings demonstrated that patient's conditions (age, severity of disease at referring time, and comorbidities), disease specifications (time, complexity, physical effort, and risk), and provider characteristic (surgeon's willingness, imposed stress, and surgeon's skill) were important by 17, 51, and 32%, respectively, in determining surgeons' work. Determining a fixed value for each procedure does not accurately estimate the amount of required surgeon's work for any procedure. Many factors, such as the patient's condition, surgeon's characteristics, and disease specification affect surgeons' work in the operation room. Proper measurement of the surgeon's work is an important step towards establishing equity in payment in the health system.

Are Orthopaedic Trauma Surgeons Adequately Compensated for Longer Procedures? An Analysis of Relative Value Units and Operative Times From the American College of Surgeons National Surgical Quality Improvement Program Database.

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. 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. 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. 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.

Shhhhhh … AHPs can improve charge capture and reimbursement for evaluation and management services even in the global service package

Shhhhhh … AHPs can improve charge capture and reimbursement for evaluation and management services even in the global service package

Abstract 11828: Productivity Targets and Performance Reviews for Cardiology Practices in the Veterans Health Administration: Do They Work?

Introduction: The optimal mode of promoting physician productivity in integrated healthcare systems is unknown. In 2013, the Veterans Health Administration (VHA) introduced a program setting productivity targets for specialty practices based on the ratio of total work Relative Value Units (wRVUs) to clinical full-time equivalents (FTEs). Practices with productivity less than 1.25 SDs below the mean for their complexity group were required to undergo annual performance reviews and develop remediation plans. Hypothesis: We hypothesized that performance reviews were associated with increased cardiology practice productivity and clinical volume. Methods: We extracted productivity metrics for 125 cardiology practices from fiscal year 2012-2019 reports. We used linear regression to assess the association of reviews with changes in productivity, clinical volume, and access measures, controlling for practice-level trends. Results: Performance reviews were associated with a 38% (95% CI 29 to 47%) relative increase in cardiology practice productivity in the year following review. In the year before review, these practices experienced a relative productivity decrease of 24% (95% CI -35 to -14%), suggesting the observed effect was not due to regression to the mean alone. Reviews were associated with a relative annual increase in practice wRVUs of 29% (95% CI 15 to 44%), a decrease in reported clinical FTEs of 12% (95% CI -24 to -1%), an increase in clinical encounters of 32% (95% CI 16 to 49%), and an increase in the total number of patients receiving care of 23% (95% CI 9 to 36%). There was no significant association between reviews and the annual change in the percentage of new or established patients waiting more than 30 days for an appointment. Conclusions: A program of productivity targets and reviews of low-performing practices was associated with increased cardiologist productivity and total wRVUs, clinical encounters, and number of patients receiving care at reviewed practices. Programs setting productivity targets for groups of specialist physicians may be an effective way to increase care efficiency in integrated healthcare systems. Future research should investigate the impact of these programs on care utilization, appropriateness, and quality.

The Impact of Coronavirus Disease 2019 Restrictions on an Academic Hand Surgery Practice

PurposeThe impact of the severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019) has been felt worldwide. We examined the quantitative impact during the first 4 weeks of hospital system and state-mandated restrictions on an academic, urban hand surgery practice. We hypothesized that the volume of clinic encounters, office procedures, and surgical cases would decrease and that the volume of nonelective care would remain unchanged.MethodsWe retrospectively reviewed all encounters at a hand surgery practice from March 16, 2020, through April 12, 2020 and compared those to two 4-week control time periods. Weekly encounter volumes and work relative value units (RVUs) were obtained for clinic encounters, office procedures, and surgical cases. The type of ambulatory visit was also identified. Surgical cases were categorized into 4 types (fracture or dislocation, acute soft tissue or nerve injury, infection, or elective/nonurgent) for the most recent time periods. We performed t tests to compare weekly volumes and RVUs between time periods.ResultsAfter the implementation of mandated restrictions on elective health care, ambulatory hand surgery clinic encounters decreased 72% to 73%, clinic procedures decreased by 87% to 90%, and surgical cases decreased by 87% to 88%. The percentage of ambulatory visits performed via telemedicine increased from 0.06% to 74%. Similar impacts on RVUs were seen. Surgeries for fractures and dislocations declined by 58% and those for acute soft tissue or nerve injury declined by 40%; the number of surgical procedures for infection remained unchanged.ConclusionsThe coronavirus restrictions on elective healthcare led to an immediate, substantial impact on hand surgery practice. There were significant decreases in the volumes of ambulatory encounters, office procedures, and surgical cases. The long-term financial impact of this change in practice is still to be determined but, based on the quantitative impacts seen, is likely to be significant.Type of study/level of evidenceEconomic/Decision Analysis IV.

Perioperative work in shoulder arthroplasty is undervalued by Relative Value Scale Update Committee methodology: quantifying shoulder arthroplasty workload in a single surgeon’s practice

BackgroundThe 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 has 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 and CMS’s current times and work relative value units (wRVUs) for the perioperative work involved regarding shoulder arthroplasty. MethodsThe RUC was contacted to obtain a list of perioperative tasks for shoulder arthroplasty surgeries. The tasks that occurred outside of the operating room were timed as the event occurred, whereas times for tasks performed inside the operating room were determined from the electronic medical record. Each task’s time was then multiplied by its respective CMS-assigned intensity coefficient to calculate the wRVU. ResultsThe 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 wRVU by 0.3. ConclusionThe perioperative work associated with shoulder arthroplasty surgeries is underestimated by the RUC and CMS’s. 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.

Current Relative Value Unit Scale Does Not Appropriately Compensate for Longer Orthopedic Sports Surgeries

PurposeTo assess whether reimbursement for orthopaedic sports procedures adequately compensates for operative time and surgical complexity.MethodsThe 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.ResultsA 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.ConclusionThe 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.