Patient complexity by surgical specialty does not correlate with work relative value units

Abstract

Background: Understanding the differences in how patient complexity varies across surgical specialties can inform policy decisions about appropriate resource allocation and reimbursement. This study evaluated variation in patient complexity across surgical specialties and the correlation between complexity and work relative value units. Study design: The 2017 American College of Surgeons National Surgical Quality Improvement Program was queried for cases involving otolaryngology and general, neurologic, vascular, cardiac, thoracic, urologic, orthopedic, and plastic surgery. A total of 10 domains of patient complexity were measured: American Society of Anesthesiologists class 4, number of major comorbidities, emergency operation, major complications, concurrent procedures, additional procedures, length of stay, non-home discharge, readmission, and mortality. Specialties were ranked by their complexity domains and the domains summed to create an overall complexity score. Patient complexity then was evaluated for correlation with work relative value units. Results: Overall, 936,496 cases were identified. Cardiac surgery had the greatest total complexity score and was most complex across 4 domains: American Society of Anesthesiologists class 4 (78.5%), 30-day mortality (3.4%), major complications (56.9%), and mean length of stay (9.8 days). Vascular surgery had the second greatest complexity score and ranked the greatest on the domains of major comorbidities (2.7 comorbidities) and 30-day readmissions (10.1%). The work relative value units did not correlate with overall complexity score (Spearman's r ¼ 0.07; P < .01). Although vascular surgery had the second most complex patients, it ranked fifth greatest in median work relative value units. Similarly, general surgery was the fifth most complex but had the second-least median work relative value units. Conclusion: Substantial differences exist between patient complexity across specialties, which do not correlate with work relative value units. Physician effort is determined largely by patient complexity, which is not captured appropriately by the current work relative value units.

Challenges of the Relative Value Unit Experience in Iran: A Qualitative Study

“…The result of a study done in Korea illustrated that there is still a debate between different medical specialties over the unfair value structure (21). Sadeghi et.al concluded that the professionals in the health system is not completely satisfied with the RVU's book, they thought the new book has failed to establish interdisciplinary justice (9) It is expected that the health systems will face a shortage of specialist staff in some critical specialties in the next few years (23).Sigsbee shows that physician's income gap in the United States made it hard to attracting volunteer physician for some medical specialties, therefore, it is necessary to pay attention to RVU as the basis for physician reimbursement system (24) Of course, injustice is inherent in the structure of RVU. Although this study focused on the challenges of relative value in Iran, it is necessary to note some of the RVU's challenges are inherent.…”

“…As a result, the existing RVU method can include inaccuracies due to the surgeon's work calculation (25) According to experts, the RVUs do not differentiate between acute and elective surgeries, while it is obvious, acute surgeries require time and surgeon's effort more. Unfairly reimbursement for acute care surgery can discourage trainees from pursuing as acute care surgeons or accepting emergency general surgery calls, possibly leading to a shortage of acute care surgeons (23,26). The evidence shows that physicians' dissatisfaction can result in induced demand and illegal payments (27).…”

“…The wrong structure let surgeons perform several procedures in the operating room for just a patient to increase the income sometimes" experts asserted. (p. 23) Experts opined that "Dependence of technical and professional components of the RVU in Iran, causes a serious problem in the health system. MoHME has not been able to measure technical components of surgeries accurately yet, therefore the amount of the technical component is based on the percentage of the professional component.…”

Developing an Integrated Evaluation Model for Physician Comprehensive Workload Tethered to Outpatient Practice: An Empirical Study From China

“…Given that it is difficult to quantity the complexity of the patient serviced by physicians in outpatient clinics in the diagnosis and treatment also with no accepted measures, patient difficulty served by a physician in the diagnosis and treatment could be simply measured based on the question that “did you have any patients that you perceived as difficult?” reported in previous research ( 23 ) and another study reported some domains such as number of major comorbidities, major complications, and operation could be used as a measure of patient complexity by surgical specialty ( 40 ). And accordingly, we used the ratio of the number of outpatients serviced per day admitted to the hospital by a physician for further diagnosis or treatment to the number of outpatients seen per day by the physician as the measure of served patient complexity in this study; and to avoid that the ratio was zero, we normalized this ratio and added 1, that is, 1 represents the reference value.…”

How to maintain the readiness of forward deployed caregivers

“…Surgical patient complexity has no agreed upon definition, but generally increases with the number of patient comorbidities and medications, the need for an emergent operation or additional procedures and an American Society of Anesthesiologists physical classification of IV or greater. [17][18][19] A patient with a "high acuity" generally implies a severe physiologic status in terms of vital signs or laboratory data, a high mortality risk, intense resource needs including nursing care, medications, or blood products and includes high patient complexity. 20 In trauma or critical illness, a high-acuity patient is resource intensive and requires multiple lifesaving interventions in a short period.…”