Trends in reimbursement for primary and revision total elbow arthroplasty

Abstract

Background: Relative value units (RVUs) are an essential component of reimbursement calculations from the Centers for Medicare & Medicaid Services. RVUs are calculated based on physician work, practice expense, and professional liability insurance. Procedures that are more complex, such as revision arthroplasty, require greater levels of physician work and should therefore be assigned a greater RVU. The purpose of this study is to compare RVUs assigned for primary and revision total elbow arthroplasty (TEA). Methods: The National Surgical Quality Improvement Program database was used to collect all primary and revision total elbow arthroplasties performed between January 2015 and December 2017. Variables collected included age at time of surgery, RVUs assigned for the procedure, and operative time. Results: A total of 359 cases (282 primary TEA, 77 revision TEA) were included in this study. Mean RVUs for primary TEA was 21.4 (2.0 standard deviation [SD]) vs. 24.4 (1.7 SD) for revision arthroplasty (P < .001). Mean operative time for primary TEA was 137.9 minutes (24.4 SD) vs. 185.5 minutes (99.7 SD) for revision TEA (P < .001). The RVU per minute for primary TEA was 0.16 and revision TEA was 0.13 (P < .001). This amounts to a yearly reimbursement difference of $71,024 in favor of primary TEA over revision TEA. Conclusion:The current reimbursement model does not adequately account for increased operative time, technical demand, and preand postoperative care associated with revision elbow arthroplasty compared with primary TEA. This leads to a financial advantage on performing primary TEA.

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

“…The more complicated revision surgery is valued no more than the simpler index operation. 20 This exemplifies another critique of the current RVU system, which is its failure to address the learning curve. As physicians perform more of a procedure and technology improves, the operative time usually goes down.…”

Total elbow arthroplasty cases involving orthopaedic residents do not affect short-term postoperative complications

“…It is possible that larger cohort evaluations or the inclusion of revisions may demonstrate longer procedural times, as reported in other studies. 29 Generally, within an academic medical center, attending surgeons are tasked with the responsibility of balancing resident education and providing safe care to patients. These conflicts are additionally complicated by external pressures from health care systems, patients, and family members.…”

“…An increased productivity with limiting hospital costs is a driving force in many orthopaedic surgery procedures including TEA. 29 These pressures, coupled with patient and family members becoming increasingly more aware of trainee participation, make training the next generation of surgeons difficult. The findings in the present study are reassuring that trainee participation does not appear to be compromising efficiency for attendings during elbow replacement.…”

“…Although prior literature has described utilization trends and complication rates for primary and revision TEA broadly, the influence of trainee participation during these procedures is limited. [27][28][29][30][31][32][33][34][35][36][37] In light of a lack of evaluation regarding resident participation during TEA procedures, we sought to use a national surgical database to answer our primary research questions: (1) does resident participation increase shortterm complication risk and surgical complications following TEA and (2) does resident participation have an opportunity cost with regard to increased operative times? To accomplish this, we utilized a national surgical database to compare TEA cases with and without resident participation.…”

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

“…Several recent studies in the field of orthopaedic surgery have suggested that the current RVU system fails to adequately consider the perioperative work and complexity related to various surgical procedures. [5][6][7][8][9] For example, revision surgeries are reimbursed less than their primary counterpart across subspecialties despite the added complexities that are associated with revision procedures. These findings raise concern that inadequate reimbursement may limit access to orthopaedic care among medically complex patients.…”