The John Hopkins University, Department of Orthopedics and Rehabilitation, Baltimore, MD.
Curtis National Hand Center, Union Memorial Hospital, Baltimore, MD.
Iowa Orthop J. 2020;40(1):173-183.
Many US health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. Among other factors, a major determinant of payment and wRVU assignments is operative time. Our objective was to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common hospital-based hand and upper extremity procedures.
Data on wRVUs, surgeon payment, and estimated operative times were collected from CMS for 53 procedures. We used regression models to compare relationships between these variables, in addition to actual median operative times as reported in the NSQIP database, from 2011 to 2016. We then determined the relative valuation of each procedure based on operative time.
There was a wide discrepancy between CMS and NSQIP operative times (R=0.49), with 60% of CMS times being longer than NSQIP times. Payment correlated more strongly with CMS operative times (R=0.55) than with NSQIP operative times (R=0.24). Similarly, wRVUs more strongly correlated with CMS operative times (R=0.84) than with NSQIP operative times (R2=0.51). In general, for trauma-related procedures, any distal radius open reduction internal fixation (ORIF) had the highest valuation while any ORIF proximal to the distal radius had lower valuation in analysis of both databases. While 61% of trauma procedures were highly valued, 70% of elective procedures had a low valuation, including nearly all elective tendon procedures. Notable compensation differences were found between trapeziectomy versus ligament reconstruction and tendon interposition, epicondyle debridement with tendon repair versus denervation, proximal row carpectomy versus four corner fusion, and distal radius open versus percutaneous fixation.
CMS may misvalue payment and wRVU rates of hospital-based hand procedures due to inaccurate operative time estimates. By identifying which procedures are misvalued in terms of payment and wRVU per operative time, providers and payors may be able to address these imbalances and maximize appropriate care delivery incentives..
许多美国医疗机构采用以工作相对价值单位（wRVU）为基础的薪酬模式，以标准化支付并激励医疗服务提供者。在其他因素中，支付和 wRVU 分配的主要决定因素是手术时间。我们的目标是确定医疗保险和医疗补助服务中心（CMS）和国家外科质量改进计划（NSQIP）之间手术时间估计的差异是否导致最常见的基于医院的手部和上肢手术的支付和 wRVU 估值错误。
从 CMS 收集了 53 项手术的 wRVU、外科医生薪酬和估计手术时间数据。我们使用回归模型来比较这些变量之间的关系，此外还比较了 2011 年至 2016 年 NSQIP 数据库中实际的中位数手术时间。然后，我们根据手术时间确定了每个手术的相对估值。
CMS 和 NSQIP 的手术时间存在很大差异（R=0.49），其中 60%的 CMS 时间长于 NSQIP 时间。支付与 CMS 手术时间的相关性（R=0.55）强于与 NSQIP 手术时间的相关性（R=0.24）。同样，wRVU 与 CMS 手术时间的相关性（R=0.84）强于与 NSQIP 手术时间的相关性（R2=0.51）。一般来说，对于创伤相关手术，任何桡骨远端切开复位内固定术（ORIF）的估值最高，而任何桡骨远端近端的 ORIF 则估值较低，这两种数据库的分析结果均如此。虽然 61%的创伤手术具有高估值，但 70%的择期手术具有低估值，包括几乎所有的择期肌腱手术。在桡骨远端切开术与经皮固定术之间发现了明显的补偿差异，在桡骨远端切开术与经皮固定术之间发现了明显的补偿差异，在三角骨切除术与韧带重建和肌腱置入术之间，在伸肌止点清创与神经切断术之间，在桡骨近端切除术与四角融合术之间，以及在桡骨远端切开术与经皮固定术之间。
由于手术时间估计不准确，CMS 可能会错误地评估基于医院的手部手术的支付和 wRVU 率。通过确定哪些手术在支付和 wRVU 方面按手术时间进行错误估值，提供者和支付者可能能够解决这些失衡问题，并最大限度地提高适当的护理提供激励。
