Orenstein Lauren A V, Barbieri John S, Siira Meron, Borre Ethan, Supapannachart Krittin J, Viera Eric, Prestwood Courtney Ann, Swerlick Robert, Patzer Rachel E, Chen Suephy C
Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia.
Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Dermatol. 2025 Mar 1;161(3):274-280. doi: 10.1001/jamadermatol.2024.5286.
Clinical productivity measures may incentivize clinical care to specific patient populations and thus perpetuate inequitable care. Before the 2021 Medicare physician fee schedule changes, outpatient dermatology encounters for patients who were younger, female, and races other than White systematically generated fewer work relative value units (wRVUs).
To examine the association of patient race, age, and sex with wRVUs generated by outpatient dermatology encounters after 2021.
DESIGN, SETTING, AND PARTICIPANTS: This multi-institutional cross-sectional study evaluated demographic and billing data for outpatient dermatology encounters across 3 academic dermatology practices. The study compared wRVUs generated by outpatient general dermatology encounters in 6-month periods before and after the 2021 fee schedule updates (March 1 to August 31, 2019, and March 1 to August 31, 2021). Eligibility required an age of 18 years or older and available age, race, and sex data. Data analysis was performed from September 2022 to March 2024.
The primary outcome was wRVUs generated per encounter.
This study included 89 656 encounters (47 607 before the 2021 Medicare physician fee schedule update and 42 049 after the update). Across all encounters, the mean (SD) patient age was 56.3 (17.8) years; 55 460 encounters (61.9%) were with female patients and 34 196 (38.1%) were with male patients; and 3457 encounters (3.9%) were with Asian patients, 10 478 (11.7%) with Black patients, 72 894 (81.3%) with White patients, and 2287 (3.2%) with patients of other race or ethnicity (Latino and multiracial). The mean (SD) wRVUs per outpatient dermatology encounter was 1.44 (0.88) before the update and 1.80 (0.99) after (P < .001). After 2021, adjusted analyses demonstrated significantly fewer wRVUs per encounter for female (β, -0.11; 95% CI, -0.13 to -0.10) compared with male patients, and for younger (β, 0.04 [95% CI, 0.04 to 0.05] per 10-year increase in age) compared with older patients. After the update, compared with White patients, visits with Asian patients generated fewer wRVUs (β, -0.12; 95% CI, -0.17 to -0.08) as did visits with Black patients (β, -0.14; 95% CI, -0.17 to -0.11), both statistically significant reductions compared with prior comparisons (P < .001 for both). After 2021, mediation analysis identified that premalignant destructions and biopsies mediated many of the remaining differences in wRVU generation by patient age, race, and sex.
This study found that after the 2021 Medicare fee schedule updates, there was a persistent, albeit reduced, gap between wRVU productivity in outpatient dermatology visits for Asian and Black compared with White patients. These persisting differences were attributable to skin biopsies and cryotherapy of premalignant lesions.
临床生产力指标可能会促使针对特定患者群体提供临床护理，从而使不公平护理长期存在。在2021年医疗保险医师费用表变更之前，年龄较小、女性以及非白人种族患者的门诊皮肤科诊疗所产生的工作相对价值单位（wRVU）系统性地较少。
研究2021年后患者种族、年龄和性别与门诊皮肤科诊疗所产生的wRVU之间的关联。
设计、设置和参与者：这项多机构横断面研究评估了3家学术皮肤科诊所门诊皮肤科诊疗的人口统计学和计费数据。该研究比较了2021年费用表更新前后6个月期间门诊普通皮肤科诊疗所产生的wRVU（2019年3月1日至8月31日和2021年3月1日至8月31日）。入选要求年龄在18岁及以上且有可用的年龄、种族和性别数据。数据分析于2022年9月至2024年3月进行。
主要结局是每次诊疗产生的wRVU。
本研究包括89656次诊疗（2021年医疗保险医师费用表更新前47607次，更新后42049次）。在所有诊疗中，患者的平均（标准差）年龄为56.3（17.8）岁；55460次诊疗（61.9%）是与女性患者，34196次（38.1%）是与男性患者；3457次诊疗（3.9%）是与亚洲患者，10478次（11.7%）是与黑人患者，72894次（81.3%）是与白人患者，2287次（3.2%）是与其他种族或族裔（拉丁裔和多种族）患者。更新前门诊皮肤科每次诊疗的平均（标准差）wRVU为1.44（0.88），更新后为1.80（0.99）（P <.001）。2021年后，调整分析显示，与男性患者相比，女性患者每次诊疗的wRVU显著减少（β，-0.11；95%置信区间，-0.13至-0.10），与老年患者相比，年轻患者（每增加10岁β为0.04 [95%置信区间，0.04至0.05]）每次诊疗的wRVU显著减少。更新后，与白人患者相比，亚洲患者的诊疗产生的wRVU较少（β，-0.12；95%置信区间，-0.17至-0.08），黑人患者的诊疗也是如此（β，-0.14；95%置信区间，-0.17至-0.11），与之前的比较相比，两者均有统计学意义的减少（两者P <.001）。2021年后，中介分析确定，癌前病变切除和活检介导了患者年龄、种族和性别在wRVU产生方面的许多剩余差异。
本研究发现，2021年医疗保险费用表更新后，亚洲和黑人患者与白人患者门诊皮肤科诊疗的wRVU生产力之间存在持续（尽管有所缩小）差距。这些持续存在的差异归因于皮肤活检和癌前病变的冷冻治疗。
