Disparities between Operative Time and Relative Value Units for Plastic Surgery Procedures

Abstract

In 1989, the U.S. House of Representatives introduced the Omnibus Budget Reconciliation Act that was passed in the same year. The law established the "relative value unit," meant to quantify medical services. The relative value unit consists of three parts: the work relative value, the practice expense relative value, and the malpractice relative value. The work relative value unit is "based on the relative resources incorporating physician time and intensity required in furnishing the service." 1 The practice expense relative value unit takes into account "the nonphysician clinical and nonclinical labor of the practice, as well as expenses for building space, equipment, and office supplies." The malpractice relative value unit considers "the cost of malpractice insurance premiums." Of all three, the work relative value unit constitutes the largest component of the total relative value unit. For every service, the relative value units are calculated and then multiplied by a dollar conversion factor (approximately $35). This value became the metric for Medicare payments to physicians. 2 The concept of using a relative value scale of medical services to determine cost of care is not new. In 1978, a major study introduced this idea for surgery, where cost was determined with a formula that used the variables of time, complexity, investment in professional training, and overhead expenses. 3 Time was determined by adding the

National Undervaluation of Cleft Surgical Services: Evidence from a Comparative Analysis of 50,450 Cases

“…8 In addition, our estimate for total RVUs and operative time for a given primary CPT code involves the respective RVU and operative time contributions from any other or concurrent procedures that may have been performed during the same anesthetic session. As Blau et al discuss, this summation practice is thought to offer a more realistic and practical representation of services and billing 8 yet nonetheless does not allow for an isolated analysis of a given CPT code. Lastly, our definition of efficiency (RVUs per hour of operative time) and the subsequent quartile ranking system does not capture other measures of complexity that contribute to work effort within the global period.…”

“…Efficiency was defined as total work RVUs for an encounter divided by total operative time in hours (ie, RVUs/hour), based on previously published methodology. 8 Total RVUs equaled the work RVUs for the primary procedure, in addition to RVUs for any concurrent procedures (ie, additional procedures performed by the same surgical team under the same anesthetic) and other procedures (ie, additional procedures performed by a different surgical team, such as a different specialty/service, during the same anesthetic). Total operative time encompassed the time from surgery start to stop, not including additional anesthesia time.…”

“…6,7 Private insurers largely model the Medicare fee schedule, making the RVU the basis of insurer payments for physician services throughout the United States. 8…”

“…6,7 Private insurers largely model the Medicare fee schedule, making the RVU the basis of insurer payments for physician services throughout the United States. 8 In addition to its use as a metric for reimbursement, the RVU has taken on an additional role as a key indicator of physician productivity and determinant of compensation. In many health care settings, including group practices, integrated health systems, and academic medical centers, the work RVU is the predominant measure used to quantify physician productivity, particularly in procedure-based specialties.…”

Immediate Lymphatic Reconstruction and the Current Value Problem

“…Using 2008 to 2020 data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), we compared the efficiency of surgery involving mastectomy or lumpectomy and ALND with and without ILR. Though RVUs encompass the time and effort provided within the full 90-day global period, efficiency was approximated by total wRVUs per case (wRVUs for primary and other procedures performed during a single anesthetic) divided by total operative time (ie, RVU rate), as established in previous methodology 10. The cohort consisted of 117,475 patients.…”