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Purpose The operational and financial impact of the widespread COVID-19 curtailment of imaging services on radiology practices is unknown. We aimed to characterize recent COVID-19 related community practice non-invasive diagnostic imaging professional work declines. Methods Using imaging metadata from nine community radiology practices across the United States between January 2019 and May 2020, we mapped work relative value unit (wRVU) weighted stand-alone non-invasive diagnostic imaging service codes to both modality and body region. Weekly 2020 vs. 2019 wRVU changes were analyzed by modality, body region, and site of service. Practice share Chi-square testing was performed. Results Aggregate weekly wRVUs ranged from a high of 120,450 (February 2020) to a low of 55,188 (April 2020). During that -52% wRVU nadir, outpatient declines were greatest (-66%). All practices followed similar aggregate trends in the distribution of wRVUs between each 2020 vs. 2019 week (p=0.96-0.98). As a percentage of total all-practice wRVUs, declines in CT (20,046/63,992; 31%) and radiography/fluoroscopy (19,196; 30%) were greatest. By body region, declines in abdomen/pelvis (16,203; 25%) and breast (12,032; 19%) imaging were greatest. Mammography (-17%) and abdominal/pelvic CT (-14%) accounted for the largest shares of total all-practice wRVU reductions. Across modality-region groups, declines were far greatest for mammography (-92%). Conclusions Substantial COVID-19 related diagnostic imaging work declines were similar across community practices and disproportionately impacted mammography. Decline patterns could facilitate pandemic second wave planning. Overall implications for practice workflows, practice finances, patient access, and payment policy are manifold., Substantial COVID-19 related diagnostic imaging work declines were similar across community practices and disproportionately impacted mammography; decline patterns could facilitate pandemic second wave planning.

Introduction: High-quality, experiential learning in outpatient settings is indispensable for medical student education; however these settings are difficult to recruit and retain. The majority of primary care physicians are employed by organizations and are under pressure to increase their relative value unit (RVU) production. Although the common perception that teaching medical students decreases productivity is unproven, it is likely a barrier for primary care physicians pursuing clinical teaching. We sought to investigate whether medical student teaching affects clinical productivity. Methods: We recruited 15 family medicine (FM) clerkship sites to participate in our study via email and at an in-person meeting. For each preceptor, we collected billing data in the form of current procedural terminology (CPT) codes for all patient encounters and the number of patients seen per half-day for when the preceptor had a student and when they did not. We converted CPT codes to RVU data. We compared differences in productivity for each individual preceptor, and we used a paired t test to examine collective data with and without a student. Results: Ten preceptors at six FM clerkship sites provided reliable data. The average RVU per half-day without a student was 10.84, and it was slightly higher at 11.25 when a student was present (P=.74). The average number of patients seen per half-day without a student was 8.32 and it was slightly lower at 7.87 when a student was present (P=.58). Conclusion: This study shows promising data that teaching students in the outpatient setting does not decrease preceptor productivity. This pilot study can lead to a larger-scale exploration of family medicine preceptor productivity in different settings and institutions.

OBJECTIVES Physician compensation for procedures is typically rooted in the work relative value unit (wRVU) system. Operative time is one of the factors that goes into the determination of wRVU assignment. There should be consistency between the wRVU/hr rate, irrespective of average operative time required to perform certain procedures. We investigate if wRVU assignment for otolaryngology procedures adequately accounts for increased operative time. STUDY DESIGN Retrospective analysis of a surgical database. METHODS NSQIP was queried from 2015-2018 for the top 50 most frequently performed otolaryngology Current Procedural Terminology (CPT) codes completed as standalone procedures. Median operative time was determined for each CPT code, and wRVU/hr was calculated. Correlations between operative time, wRVU, and wRVU/hr were investigated using linear regression analysis. A secondary analysis using complication rate as an indicator for procedure complexity was performed to examine the relation between wRVUs and complication rates. RESULTS Fifty CPT codes containing 64,084 patients where only one code was reported were included in this analysis. The median operative time was 84 minutes, median wRVU was 11.23, and median wRVU/hour was 7.96. Linear regression analysis demonstrated a strong positive correlation between operative time and wRVU assignment (R2 = 0.805, P

The objective of this study was to evaluate a new academic relative-value unit (aRVU) scoring system linked to faculty compensation and analyze its association with overall departmental academic productivity.Faculty are often not incentivized or financially compensated for educational and research activities crucial to the academic mission.We launched an online, self-reporting aRVU system in 2015 to document and incentivize the academic productivity of our faculty. The system captured 65 specific weighted scores in 5 major categories of research, education, innovation, academic service, and peer review activities. The aRVU scores were rank-aggregated annually, and bonuses were distributed to faculty members in 3 tiers: top 10%, top third, and top half. We compared pre-aRVU (academic year 2015) to post-aRVU (academic year 2017) departmental achievement metrics.Since 2015, annual aRVU bonuses totaling $493,900 were awarded to 59 faculty members (58% of eligible department faculty). Implementing aRVUs was associated with significant increases in several key departmental academic achievement metrics: presentations (579 to 862; P = 0.02; 49% increase), publications (390 to 446; P = 0.02; 14%), total research funding ($4.6 M to $8.4 M; P0.001; 83%), NIH funding ($0.6 M to $3.4 M; P0.001; 467%), industry-sponsored clinical trials (8 to 23; P = 0.002; 188%), academic society committee positions (226 to 298; P0.001; 32%), and editorial leadership positions (50 to 74; P = 0.01; 48%).Implementing an aRVU system was associated with increases in departmental academic productivity. Although other factors undoubtedly contributed to these increases, an aRVU program may represent an important mechanism for tracking and rewarding academic productivity in surgery departments.

To compare the occurrence of short-term postoperative complications between inpatient and outpatient anterior cruciate ligament reconstruction. The ACS National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) from 2007 to 2017. A total of 18,052 patients were available for analysis following application of exclusion criteria. Patients were categorized based on location of surgery. Inpatients and outpatient ACLR groups were matched by demographics and preoperative laboratory values and differences in 30-day complication rates following surgery were assessed. Significance was set with alpha

Purpose Medicare payments to individual physicians are released annually by the CMS. The purpose of this study is to analyze trends in Medicare reimbursement and work relative value unit (wRVU) production to radiation oncologists. Materials and Methods The Medicare Physician Supplier and Other Provider Public Use File and the CMS Physician Fee Schedule Relative Value Files (to calculate wRVUs) for the calendar years 2012 to 2015 were used in this analysis. Medicare reimbursement was aggregated for each calendar year. Using the CMS Physician Fee Schedule Relative Value Files, the number of Medicare wRVUs was calculated for each radiation oncologist. Results In 2015, 4,323 radiation oncologists produced 12,895,298 wRVUs compared with 11,352,286 wRVUs produced in 2012. These datasets include only Medicare reimbursements and do not include wRVUs from private insurance or other payers. In 2015, radiation oncologists produced a median of 2,486 wRVUs from Medicare (range 3 to 24,349). Billing to Healthcare Common Procedure Coding System Code 77427 (radiation treatment management, five treatments), a proxy for total radiation treatments, fell from 1,111,670 in 2012 to 1,039,403 in 2015, a decline of 7%. Conclusion The total number of wRVUs produced by radiation oncologists has risen by 14% from 2012 to 2015. However, the number of external beam radiation fractions has declined by approximately 7% over this same period, likely due to a trend toward hypofractionated courses of treatment and use of special treatment modalities such as proton beam therapy or stereotactic body radiation therapy.

Pediatric optic pathway gliomas are typically indolent but have a variable clinical course. Treatment is dictated by symptoms and changes on contrast-enhanced MRI examinations. Gadolinium retention in children has motivated parsimonious use of gadolinium-based contrast agents. To determine surveillance MR factors that motivate changes in tumor-directed therapies and extrapolate cost-efficacy of a non-contrast follow-up protocol. Using an imaging database search we identified children with isolated optic pathway gliomas and ≥3 follow-up contrast-enhanced MRIs. We reviewed medical records and imaging for: (1) coincident changes on contrast-enhanced MRI and tumor-directed therapy, (2) demographics and duration of follow-up, (3) motivations for intervention, (4) assessment of gadolinium-based contrast agents’ utility and (5) health care utilization data. We assessed cost impact in terms of relative value unit (RVU) burden. We included 17 neurofibromatosis type 1 (NF1) and 21 non-NF1 patients who underwent a median 16.9 and 24.3 cumulative contrast-enhanced MR exams over 7.7 years and 8.1 years of follow-up, respectively. Eight children (one with NF1) had intervention based on contrast-enhanced MR findings alone. For these eight, increased tumor size was the only common feature, and it was apparent on non-contrast T2 sequences. For the median patient, a non-contrast follow-up protocol could result in 15.9 (NF1) and 23.3 (non-NF1) fewer gadolinium-based contrast agent administrations, and a 39% lower yearly RVU burden. Pediatric patients with isolated optic pathway gliomas undergo a large number of routine contrast-enhanced MR follow-up exams. Gadolinium might not be needed for these exams to inform management decisions. Secondary benefits of a non-contrast follow-up protocol include decreased cost and risk to the patient.

To compare effect of free-text versus structured reporting of IR procedures on report quality and report coding and value.In this retrospective study, 432 common consecutive free-text IR reports created during 4 months (from September 2013 to December 2013) before implementation of structured reporting (February 2014) and 415 structured IR reports created after implementation (from September 2014 to December 2014) were reviewed to assess ease of use and compliance with reporting requirements for regulatory requirements and coding. IR staff and trainees and referring physicians to IR were surveyed on procedure report attributes, such as detail, quality, and clarity.Structured reporting increased compliance with reporting fluoroscopy time, radiation dose, and contrast administration compared with free-text reports (402/432 [93.1%] vs 251/415 [60.5%], P.001; 402/432 [93.1%] vs 242/415 [58.3%], P.001; and 395/432 [91.4%] vs 257/415 [61.9%], P.001). Structured reporting decreased addendum requests for insufficient documentation from 43% (121/435 [28%] to 50/415 [12%], P = .01). Most IR physicians found structured reports to require less time to complete (21/26 [81%]), to be easier to complete (23/26 [89%]), and to have a similar or higher level of detail (19/26 [73%]) compared with free-text reports. Referring physicians were more satisfied with structured reports compared with free-text reports (6.9/10 vs 5.6/10, P = .03).Structured IR reporting compared with free-text reporting improves compliance with radiation dose and contrast reporting, reporting and coding efficiency, and satisfaction among IR and referring physicians.

Background Multiple institutions have developed international electives and sustainable global surgery initiatives to facilitate clinical, research, and outreach opportunities with hospitals in resource-poor areas. Despite increasing interest among programs, many institutions have not successfully reached potential involvement. Objective This study evaluates the experiences of Yale residents and faculty, measures interest in the development of an international surgical elective, and enumerates barriers to developing or participating in these opportunities. This was performed to develop a formalized elective and assess interest and capacity for surgical global health initiatives, as a seemingly increasing number of trainee applicants and residents were expressing interest in working in resource-poor settings. Methods Electronic survey of Yale Surgery residents and faculty analyzed using SPSS and Graphpad Prism. Results Among residents, previous global experience correlates with current interest in international opportunities, with 100% remaining interested, and 78% of those without prior experience also expressing interest (p = 0.018). Barriers to pursuing these activities included the use of vacation time, funding, scheduling, family obligations, and concern for personal safety. Among faculty, 28% of respondents have been involved internationally, and most (86%) expressed interest in additional opportunities and all were willing to take residents. Barriers to faculty participation included funding, relative value unit target reduction, protected time, and the desire for institutional support for such activities. Conclusions A substantial proportion of residents and faculty have experience in global health and motivation to pursue additional opportunities. The main barriers to participation are not a lack of interest, but rather needs for funding support, protected time, and institutional recognition of academic contributions. These findings are being used to develop a global surgery elective and establish long-term partnerships with international colleagues.

The purpose of this study was to assess the importance of relative value unit (RVU) flow and other factors in report turnaround time (TAT) in emergency radiologic operations.RVU flow was defined as the normalized (to 60 minutes) total work RVUs for studies performed in a given time interval of 30 minutes (RVU flow 30) or 60 minutes (RVU flow 60). Twenty-five weekday emergency radiology shifts each for four radiologists were randomly selected. The institutional radiology search engine was queried to obtain the following data for each study: study completion time, work RVU, attending radiologist, and report TAT. RVU flow 30, RVU flow 60, presence of resident, and number of hours since start of shift were computed. Two separate multiple linear regression analyses were performed with RVU flow 30 or RVU flow 60 and other factors as independent variables and TAT as the dependent variable.The study included 7378 radiology studies from 100 weekday shifts, from which 1537 RVU flow 30 and 792 RVU flow 60 data points were generated. RVU flow 60 (p = 0.0026) and RVU flow 30 (0.0001) were significantly associated with radiology report TAT. One attending radiologist had statistically significant lower TAT 30 and TAT 60, whereas another had a lower TAT 30 but not TAT 60. The presence of a resident was significantly associated with reduced TAT 30 (p = 0.0005) and TAT 60 (p = 0.0028).RVU flow 60, RVU flow 30, specific attending radiologist, and presence of a resident are significantly correlated with radiology report TAT. RVU flow should be considered when evaluating radiologist and overall system performance with respect to report TAT.

Background The Huntsman Cancer Institute Multiple Myeloma (MM) Program is the primary referral center for the Intermountain West. Over the past 5 years, our Program has experienced a 40% increase in patient volumes, an increase to 4 MM physician providers, and significant expansion of the clinical trial portfolio and clinical/trial support staff. Our previous care model was inefficient and did not optimize the independence of our advanced practice clinicians (APC). Previously, we relied on a traditional “resident model” in which APCs staffed every patient with the attending physician. Our provider group hypothesized that utilizing a more contemporary clinical model would improve clinical efficiency and Relative Value Unit (RVU) generation and enhance job satisfaction for all members of our clinical team while maintaining high patient satisfaction scores. This model, called Project to Improve Volume of Treatment and Satisfaction or PIVOTS, is focused on 4 fundamental pillars including: 1) Modifying physician and APC clinic templates to optimize daily clinic volumes; 2) Establish specific “divisions of labor” for patient follow-up; 3) Standardization of post-autologous transplantation follow-up and disease reassessment; and 4) Standardization of new and return patient clinic notes. The main objective of this project is to fundamentally change our care model to better support our patients and optimize the productivity and moral of our team. Design and implementation Physician templates includes seeing all new patients, follow-up visits with disease reassessments and treatment modification, and per patient request. APC templates shifted to the RCO Model (Revlimid maintenance, Cruising patient, and Outpatient transplant) and acute issue and day 1 treatment visits. Clinic note templates for new, return, and acute patient visits were constructed as a team over the 6 months prior to starting the project Metrics A 12-month period from May 2021 – April 2022 has been specified and the following metrics have been defined pre- and post-PIVOTS implementation. RVU generation will be collected for all providers over this 12-month timeframe and descriptively compared to per provider metrics from the prior 2 years. University Qualtrics and Patient Experience has developed and implemented all job satisfaction surveys that will be completed by all staff (MA, RN, APC, physician) at 3, 6, 9, and 12 months. Patient satisfaction scores and comments are collected per institutional standards. Research productivity for all members of the MM Program will be collected pre- and post-PIVOTS implementation and will include abstract submissions, grant funding, and manuscript production. Results The PIVOTS project will be instrumental in defining a new standard for structuring a dedicated myeloma clinic to improve clinical and academic productivity and job satisfaction without compromising a high-quality patient experience.

Study Design: Retrospective cohort study. Objectives: Adult spinal deformity (ASD) surgery encompasses a wide variety of spinal disorders and is associated with a morbidity rate between 20% and 80%. The utilization of spinal surgery has increased and this trend is expected to continue. To effectively deal with an increasing patient volume, identifying variables associated with patient discharge destination can expedite placement and reduce length of stay. Methods: The 2013-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Classification of Diseases, Ninth Revision diagnosis codes relevant to ASD. Patients were divided based on discharge destination. Bivariate and multivariate logistic regression analyses were employed to identify predictors for patient discharge destination and hospital length of stay. Results: A total of 4552 patients met inclusion criteria, of which 1102 (24.2%) had non-home discharge. Multivariate regression revealed total relative value unit (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 1.00-1.01); female sex (OR = 1.54, 95% CI = 1.32-1.81); American Indian, Alaska Native, Asian, Native Hawaiian, or Pacific Islander versus black race (OR = 0.52, 95% CI = 0.35-0.78, P = .002); age ≥65 years (OR = 3.72, 95% CI = 3.19-4.35); obesity (OR = 1.18, 95% CI = 1.01-1.38, P = .034); partially/totally functionally dependent (OR = 2.11, 95% CI = 1.49-2.99); osteotomy (OR = 1.42, 95% CI = 1.12-1.80, P = .004) pelvis fixation (OR = 2.38, 95% CI = 1.82-3.11); operation time ≥4 hours (OR = 1.74, 95% CI = 1.47-2.05); recent weight loss (OR = 7.66, 95% CI = 1.52-38.65; P = .014); and American Society of Anesthesiologists class ≥3 (OR = 1.80, 95% CI = 1.53-2.11) as predictors of non-home discharge. P values were Conclusions: The authors suggest these results can be used to inform patients preoperatively of expected discharge destination, anticipate patient discharge needs postoperatively, and reduce health care costs and morbidity associated with prolonged LOS.

Introduction On January 1, 2014, the financing and delivery of healthcare in the state of Maryland (MD) profoundly changed. The insurance provisions of the Patient Protection and Affordable Care Act (ACA) began implementation and a major revision of MD’s Medicare Waiver ushered in global budget revenue (GBR) structure for hospital reimbursement. Our objective is to analyze the impact of these policy changes on Emergency Department (ED) utilization, admission practices, insurance profiles, and professional revenue. We stratified our analysis by the socioeconomic status (SES) of the ED patient population. Methods Monthly mean data including patient volume, admission and observation percentages, payer mix, and professional revenue were collected from January 2013 through December 2015 from a convenience sample of 11 EDs in Maryland. Using regression models, we compared each of the variables 18 months after the policy changes and a six-month washout period to the year prior to ACA/GBR implementation. We included the median income of each ED’s patient population as an explanatory variable and stratified our results by SES. Results Our 11 EDs saw an annualized volume of 399,310 patient visits during the study period. This ranged from a mean of 41 daily visits in the lowest volume rural ED to 171 in the highest volume suburban ED. After ACA/GBR, ED volumes were unchanged (95% Confidence Interval (CI): (-1.58, 1.24), p=.817). Admission plus observation percentages decreased significantly by 1.9% from 17.2% to 15.3% (95% CI: (-2.47%, - 1.38%), p

OBJECTIVE Existing studies have shown a high overall rate of adverse events (AEs) following pediatric neurosurgical procedures. However, little is known regarding the morbidity of specific procedures or the association with risk factors to help guide quality improvement (QI) initiatives. The goal of this study was to describe the 30-day mortality and AE rates for pediatric neurosurgical procedures by using the American College of Surgeons (ACS) National Surgical Quality Improvement Program–Pediatrics (NSQIP-Peds) database platform. METHODS Data on 9996 pediatric neurosurgical patients were acquired from the 2012–2014 NSQIP-Peds participant user file. Neurosurgical cases were analyzed by the NSQIP-Peds targeted procedure categories, including craniotomy/craniectomy, defect repair, laminectomy, shunts, and implants. The primary outcome measure was 30-day mortality, with secondary outcomes including individual AEs, composite morbidity (all AEs excluding mortality and unplanned reoperation), surgical-site infection, and unplanned reoperation. Univariate analysis was performed between individual AEs and patient characteristics using Fischer's exact test. Associations between individual AEs and continuous variables (duration from admission to operation, work relative value unit, and operation time) were examined using the Student t-test. Patient characteristics and continuous variables associated with any AE by univariate analysis were used to develop category-specific multivariable models through backward stepwise logistic regression. RESULTS The authors analyzed 3383 craniotomy/craniectomy, 242 defect repair, 1811 laminectomy, and 4560 shunt and implant cases and found a composite overall morbidity of 30.2%, 38.8%, 10.2%, and 10.7%, respectively. Unplanned reoperation rates were highest for defect repair (29.8%). The mortality rate ranged from 0.1% to 1.2%. Preoperative ventilator dependence was a significant predictor of any AE for all procedure groups, whereas admission from outside hospital transfer was a significant predictor of any AE for all procedure groups except craniotomy/craniectomy. CONCLUSIONS This analysis of NSQIP-Peds, a large risk-adjusted national data set, confirms low perioperative mortality but high morbidity for pediatric neurosurgical procedures. These data provide a baseline understanding of current expected clinical outcomes for pediatric neurosurgical procedures, identify the need for collecting neurosurgery-specific risk factors and complications, and should support targeted QI programs and clinical management interventions to improve care of children.

Background In 1992, Congress implemented a relative value unit (RVU) payment system to set reimbursement for all procedures covered by Medicare. In 1997, data supported that a significant gender bias existed in reimbursement for gynecologic compared to urologic procedures. The present study was performed to compare work and total RVU's for gender specific procedures effective January 2015 and to evaluate if time has healed the gender-based RVU worth. Methods Using the 2015 CPT codes, we compared work and total RVU's for 50 pairs of gender specific procedures. We also evaluated 2015 procedure related provider compensation. The groups were matched so that the procedures were anatomically similar. We also compared 2015 to 1997 RVU and fee schedules. Results Evaluation of work RVU's for the paired procedures revealed that in 36 cases (72%), male vs female procedures had a higher wRVU and tRVU. For total fee/reimbursement, 42 (84%) male based procedures were compensated at a higher rate than the paired female procedures. On average, male specific surgeries were reimbursed at an amount that was 27.67% higher for male procedures than for female-specific surgeries. Female procedure based work RVU's have increased minimally from 1997 to 2015. Conclusion Time and effort have trended towards resolution of some gender-related procedure worth discrepancies but there are still significant RVU and compensation differences that should be further reviewed and modified as surgical time and effort highly correlate.

Background The American Society of Hematology and researchers at the Fitzhugh Mullan Institute for Health Workforce Equity at the George Washington University are conducting a 3-year study of the hematology workforce to understand factors that influence the supply of hematology services in the U.S. The Survey of Practicing Hematologists and Oncologists focuses on practicing hematology/oncology physicians' practice activities and experiences, compensation, job satisfaction and burnout. While the prevalence and predictors of burnout in the oncology workforce have been studied in detail previously, less is known about factors associated with burnout in the hematology or combined hematology/oncology workforce--or whether these differ across academic and community practice settings. This study seeks to examine factors associated with severe burnout for hematology/oncology physicians in academic and community practice settings using data from a large-scale, comprehensive survey of hematology/oncology physicians. Methods We collected survey data via mail and online survey (using Qualtrics, an online survey tool) in April through June 2019. The survey included questions about hematology/oncology physicians' work hours, practice activities, compensation, job satisfaction and burnout. This analysis uses data from a single validated question examining respondents' level of burnout: "Overall, based on your definition of burnout, how would you rate your level of burnout?" The question asks respondents to rank their burnout on a 5-point Likert scale. We collapsed responses into a dichotomous variable indicating severe burnout (=4 or 5 on the Likert scale). We used two weighted multiple logistic regression models to examine associations between severe burnout and work hours, practice characteristics and activities, and type of compensation for respondents in academic and community practice in Stata 15, controlling for demographics and type of practice (p Results A total of 675 hematologists/oncologists completed the survey (27% response rate). Of these, 427 respondents reported working in academic or community practice and had complete data to be included in the analysis: 162 (38%) in academic practice settings and 265 (62%) in community practice settings. Respondents in academic practice settings were slightly less likely to report experiencing severe burnout than those in community practice settings (9% [15/162] vs. 12% [34/265], p=0.26). In the logistic regression models, we found statistically significant and positive association between severe burnout and Relative Value Unit or RVU-based compensation (vs. salaried or other compensation models) for both academic (OR=18.42, p Conclusions Study findings suggest that severe burnout rates are similar for hematology/oncology physicians in academic and community practice settings. Severe burnout appears to be related to use of RVU-based compensation systems in both academic and community practices, suggesting that these models may require major revision to reduce burnout and support the health and longevity in practice of hematology/oncology physicians. Improving access to advanced practice providers may mitigate severe burnout, especially in community practice settings. Higher levels of burnout among women in academic hematology/oncology practices suggest an area for further research into possible explanations and solutions. These findings merit further exploration, particularly given the increased pressures on physicians in the era of COVID-19. Disclosures No relevant conflicts of interest to declare.

Objective To assess whether gender inequities exist for pediatric physiatrists and, if affirmative, what factors account for this difference. Design Cohort study. Setting Online REDCap survey administered via e-mail. Participants Pediatric physiatrists practicing in the United States in 2017. Interventions Not applicable. Main Outcome Measures Respondents reported on their gender, training, practice type and location, leadership positions, years in practice and years at their current location, salary, research, and clinical productivity. Results Of the 307 surveys sent, 235 individuals responded, yielding a response rate of 76.5%. Pediatric physiatrists who identified as women were more likely to work part-time but were demographically similar to their colleagues who identified as men. The odds of having no leadership role were higher for women (odds ratio=2.17; P=.02) than men. Pediatric physiatrists who identified as men made on average (in US dollars ± SD) 244,798±52,906 annually compared with those who identified as women 224,497±60,756. The average annual difference in full-time salary was $20,311 in favor of those who identified as men (95% confidence interval, $3135-$37,486). The set of predictors in the multivariable model explained about 40% of the total variability in annual full-time salary (R2=0.389; adjusted R2=0.339; F15,197=7.734; P Conclusions Despite representing a majority of the field, pediatric physiatrists who identified as women were paid less than their counterparts who identified as men. The traditional predictors associated with the salaries of men were not enough to explain salary variation among those who identified as women, thereby providing evidence of the importance of intangible and unmeasured aspects of a women’s career, such as bias and institutional culture.

Academic radiologists spend considerable amounts of time and effort providing nonclinical value-added services in the realms of teaching, research, and administration that are not reimbursable through traditional relative value units (RVUs) under the resource-based relative value scale. Numerous systems of academic RVUs have been proposed by medicine, surgery, and radiology programs to measure and reward these nonclinical contributions. In this article the authors (1) describe the traditional clinical RVU model of reimbursement; (2) review attempts to develop academic compensation models targeted toward research, teaching, and administration; and (3) describe possible models for academic productivity compensation.

Objective To develop a relative value unit (RVU)-based tool for the measurement and reimbursement of pharmacy services for clinical trials. Methods A portfolio of activities was agreed by consensus in four tertiary hospitals. Related activities were pooled into several categories or intermediate products. We recorded the duration of each activity by multiple determinations. We then calculated the average time of all determinations. The reference activity was assigned a value of 1. All other activities were compared to the reference activity to obtain the RVU. To establish which items should be invoiced to third parties for the activities performed, we defined the final products (different types of clinical trials according to their complexity). Results Ten intermediate products and five final products were differentiated. Six intermediate products could be repeated over the course of a clinical trial and seven were performed whether or not the clinical trial had included patients. Each final product consisted of different categories. The total number of RVUs produced for a clinical trial was the sum of each constant category value plus the repetitive category values multiplied by the number of repetitions. Conclusion The application of RVU methodology in investigational drug services allows a more precise quantification of services performed. After a prospective validation to confirm the applicability of this tool, it may contribute to more appropriate invoicing to third parties for these services.

Background/aims It is difficult to reach a social agreement on the appropriate level of compensation for professionals. This study was performed to examine the physician fee embedded in the relative value unit (RVU) system in comparison with the Korean hourly minimum wage. Methods The Health Insurance Service Price and the Korean Classification of Procedural Terminology were used to obtain the hourly wages of physicians for designated health care services. In addition, the physician fee schedule at the United States Centers for Medicare and Medicaid Services and the Organisation for Economic Co-operation and Development (OECD) report on minimal wage were used. Health care service fees were selected based on laboratory, pathology, imaging, and procedure codes as well as examination fees. For calculation of physician labor costs per hour, physician workload × conversion factor was divided by the time involved. To calculate the proportion of physician labor fee in the total fee, the physician workload RVU for each service fee was divided by the total RVU. Results A total of 27 physician fee codes were selected. Compared to the Korean hourly minimum wage in 2015, the average physician wages were greater by 2.80- fold for primary care and by 3.05-fold for tertiary care. The mean proportion of physician labor cost in the total cost was 0.19, which was significantly lower than that of corresponding procedures in the United States RVU (mean, 0.48). Conclusion The average Korean physician wages compared to the hourly minimum wage were disproportionately low compared to the USA and other reference OECD countries.

On-call services provided by physicians are critical to the function of a robust healthcare delivery system, but such services are not generally accounted for by standard physician productivity metrics, such as the work relative value unit (wRVU). There is significant diversity on how physicians are compensated, if at all, for these on-call services. Simultaneously, there exists a considerable shortage, particularly in the surgical subspecialties, for on-call coverage - most commonly in rural and underserved communities. While we agree that "call" services should undergo standardized valuation, we suggest that the wRVU is an ill-posed metric for this purpose as its primary role is to value discrete physician services provided to patients. In contradistinction, "call" is a physician service to a hospital - the disproportionate beneficiary of the service. We maintain that systemic and regulatory factors undervalue physician on-call compensation relative to the hospital's value chain and lead to call shortages that impact patient care and foster inequity. Finally, we urge subspecialty professional organizations to develop guidelines for call valuation.

The Child Neurology Society relative value unit (RVU) Task Force's article1 shines a much-needed light on the work relative value unit model's inadequacy in capturing the scope and value of the work of child neurologists, including our hospital-based work. At the 2019 AAN meeting, the Pediatric Neurohospitalist Work Group formed to foster a sustainable workforce for hospital-based care. To do so, we must ensure that the way our inpatient work is supported matches the actual jobs we do. We provide complex, high stakes care not only at our own institutions but to referring hospitals requesting urgent phone advice, extending the reach of our care, and developing key strategic referral pathways. With the requirement of 24/7 immediate availability and the need to spend time teaching and coordinating complex care—all without a way to predict volume, timing, or urgency—the on-call child neurologist functions similar to a hospitalist. Exploration of novel models of support for our mission-critical inpatient work such as a hospitalist model is urgently needed. We have a great opportunity to partner with hospital leadership and national organizations to establish a standard of support of inpatient child neurology in a way that prevents burnout and facilitates optimal care for our patients.

Surgeon compensation models could potentially influence the utilization of elective procedures. We assessed whether transitioning from salaried to a relative value unit (RVU) productivity-based physician compensation model changed the surgical rate and patient selection in elective total hip and knee arthroplasty (THA and TKA) procedures.Our institution transitioned from salaried to RVU productivity-based reimbursement in July 2016. We performed a retrospective analysis on patients undergoing primary THA and TKA from July 2014 to July 2018 before and after the transition (salary period n = 820; RVU period n = 1188). Beta regression was used to determine the reimbursement structure as a predictor of surgery. The surgical rate was defined as the number of primary THA and TKA procedures per reimbursement period divided by all arthroplasty and osteoarthritis outpatient clinic encounters.There was a surgical rate of 15.8% (95% confidence interval [CI] 13.8%-17.8%) THA and 16.7% (95% CI 15.1%-18.1%) TKA procedures during RVU reimbursement compared to 11.1% (95% CI 9.8%-12.8%) THA and 11.7% (95% CI 10.5%-12.8%) TKA procedures during the salaried period (P.001). The adjusted odds of undergoing a THA or TKA procedure increased in the RVU compared to the salaried model (THA odds ratio 1.48, 95% CI 1.43-1.53; TKA odds ratio 1.50, 95% CI 1.46-1.55; P.001). There were no significant differences in patient age, gender, race, body mass index, or Charlson Comorbidity Index in salaried vs RVU productivity periods (P.05 for all covariates).Productivity-based physician compensation may encourage higher rates of elective arthroplasty procedures without broadening patient selection.

Background: Orthopaedic clinics have acquired a multitude of health professionals to improve clinic efficiency. More recently, athletic trainers (ATs) have been utilized to improve clinical efficiency and patient care because of their extensive background in musculoskeletal injuries and anatomy. Improved clinical efficiency allows for increased patient visits, potentially enhancing patient access and downstream revenue via relative value units (RVUs). Hypothesis: The addition of an AT into a sports medicine physician’s clinic will increase total patient throughput and overall RVU production. Study Design: Retrospective analysis. Level of Evidence: Level 4. Methods: Patients seen by each of the 2 primary care sports medicine physicians at St Luke’s Sports Medicine for a 2-year period were retrospectively evaluated. The initial clinic model included the physician and a medical assistant; during the second year of analysis an AT was added to the clinic staffing model. Two-tailed t tests were used to determine significant differences in patient volume between the 2 periods of data collection. Results: Through the implementation of an AT, patient throughput increased by 0.7 patients per hour over 2 half-day clinics, a 25% increase (P < 0.01). Physician B patient visits increased by 21%, or 3.8 patients per 6.5-hour clinic day (P < 0.01). Additionally, RVU production increased by 3.23 per half-day and 4.3 per full day for physicians A and B, respectively. Conclusion: Clinical efficiency was improved with the addition of an AT. Total physician RVUs improved, thereby raising the potential revenue of both the physician and health care institution. Employing ATs in a sports medicine clinic may improve clinical productivity and financial stability, thereby validating the incorporation of ATs into the established clinical model. Clinical Relevance: Limited research exists measuring patient throughput with an AT in a sports medicine clinic. This study investigates patient throughput and the subsequent increase in work-based RVUs.

Background: Orthopaedic clinics have acquired a multitude of health professionals to improve clinic efficiency. More recently, athletic trainers (ATs) have been utilized to improve clinical efficiency and patient care because of their extensive background in musculoskeletal injuries and anatomy. Improved clinical efficiency allows for increased patient visits, potentially enhancing patient access and downstream revenue via relative value units (RVUs). Hypothesis: The addition of an AT into a sports medicine physician’s clinic will increase total patient throughput and overall RVU production. Study Design: Retrospective analysis. Level of Evidence: Level 4. Methods: Patients seen by each of the 2 primary care sports medicine physicians at St Luke’s Sports Medicine for a 2-year period were retrospectively evaluated. The initial clinic model included the physician and a medical assistant; during the second year of analysis an AT was added to the clinic staffing model. Two-tailed t tests were used to determine significant differences in patient volume between the 2 periods of data collection. Results: Through the implementation of an AT, patient throughput increased by 0.7 patients per hour over 2 half-day clinics, a 25% increase ( P < 0.01). Physician B patient visits increased by 21%, or 3.8 patients per 6.5-hour clinic day ( P < 0.01). Additionally, RVU production increased by 3.23 per half-day and 4.3 per full day for physicians A and B, respectively. Conclusion: Clinical efficiency was improved with the addition of an AT. Total physician RVUs improved, thereby raising the potential revenue of both the physician and health care institution. Employing ATs in a sports medicine clinic may improve clinical productivity and financial stability, thereby validating the incorporation of ATs into the established clinical model. Clinical Relevance: Limited research exists measuring patient throughput with an AT in a sports medicine clinic. This study investigates patient throughput and the subsequent increase in work-based RVUs.

Present resource-based relative value unit (RVU) assignment for echocardiography is based on Current Procedural Terminology (CPT) codes, which do not incorporate complexity of diagnosis, time spent for image acquisition, or interpretation of echocardiograms. The objective of this study was to determine whether CPT-based RVU assignment accurately reflects physician effort in performing and interpreting pediatric echocardiographic examinations.Cardiac complexity category (CCC) and physician time for study interpretation of 123 echocardiograms (June to September 2013) were prospectively assigned. Categories included (1) focused effusion/function evaluation, (2) normal anatomy/focused preterm infant studies, (3) acquired heart disease, (4) congenital heart disease excluding single ventricles, (5) single ventricles including heterotaxy syndrome, and (6) hearts on mechanical support. Subsequently, a random sample of echocardiograms (March to August 2013) were retrospectively analyzed, and each study was assigned a CCC and an extrapolated median interpretation time (MIT) on the basis of prospective data collection. Assigned work RVUs based on CPT codes were recorded. Comparisons were made between CCC and time for study interpretation, work RVUs, number of images acquired, and total scan time.A total of 933 echocardiograms were analyzed: 198 (21%), 174 (19%), 98 (11%), 359 (35%), 84 (9%), and 20 (2%) studies in CCCs 1 to 6, respectively. Total scan time, MIT, number of images, and work RVUs were different among CCCs (P .0001). However, among the more complex studies (CCCs 2-5), work RVUs were similar, while number of images obtained and MIT were different (P .001). Correlation analysis showed no association between work RVUs and CCC, total scan, or number of images per study. Compared with older patients, work RVUs of studies in children2 years of age were lower, while all other markers of study complexity were higher (P .05).Current CPT-based assignment of work RVUs does not discriminate study complexity and physician effort. The results of this study highlight the need for a refined system that accurately assesses physician effort in pediatric echocardiography.

Background Vascular surgery procedural reimbursement depends on accurate procedural coding and documentation. Despite the critical importance of correct coding, there has been a paucity of research focused on the effect of direct physician involvement. We hypothesize that direct physician involvement in procedural coding will lead to improved coding accuracy, increased work relative value unit (wRVU) assignment, and increased physician reimbursement. Methods This prospective observational cohort study evaluated procedural coding accuracy of fistulograms at an academic medical institution (January-June 2014). All fistulograms were coded by institutional coders (traditional coding) and by a single vascular surgeon whose codes were verified by two institution coders (multidisciplinary coding). The coding methods were compared, and differences were translated into revenue and wRVUs using the Medicare Physician Fee Schedule. Comparison between traditional and multidisciplinary coding was performed for three discrete study periods: baseline (period 1), after a coding education session for physicians and coders (period 2), and after a coding education session with implementation of an operative dictation template (period 3). The accuracy of surgeon operative dictations during each study period was also assessed. An external validation at a second academic institution was performed during period 1 to assess and compare coding accuracy. Results During period 1, traditional coding resulted in a 4.4% ( P = .004) loss in reimbursement and a 5.4% ( P = .01) loss in wRVUs compared with multidisciplinary coding. During period 2, no significant difference was found between traditional and multidisciplinary coding in reimbursement (1.3% loss; P = .24) or wRVUs (1.8% loss; P = .20). During period 3, traditional coding yielded a higher overall reimbursement (1.3% gain; P = .26) than multidisciplinary coding. This increase, however, was due to errors by institution coders, with six inappropriately used codes resulting in a higher overall reimbursement that was subsequently corrected. Assessment of physician documentation showed improvement, with decreased documentation errors at each period (11% vs 3.1% vs 0.6%; P = .02). Overall, between period 1 and period 3, multidisciplinary coding resulted in a significant increase in additional reimbursement ($17.63 per procedure; P = .004) and wRVUs (0.50 per procedure; P = .01). External validation at a second academic institution was performed to assess coding accuracy during period 1. Similar to institution 1, traditional coding revealed an 11% loss in reimbursement ($13,178 vs $14,630; P = .007) and a 12% loss in wRVU (293 vs 329; P = .01) compared with multidisciplinary coding. Conclusions Physician involvement in the coding of endovascular procedures leads to improved procedural coding accuracy, increased wRVU assignments, and increased physician reimbursement.

Background As ≥30% of displaced pediatric forearm fractures demonstrate loss of reduction (LOR) following closed reduction (CR); radiographic follow-up is advocated at 1, 2, 4, and 6 weeks for detection of redisplacement. We hypothesized that there is minimal change in fracture alignment 2 weeks after CR, and consequently, that radiographs at 4 weeks add cost but little value to clinical care. Methods A total of 184 patients enrolled in a prospective study of pediatric forearm fractures including both distal and diaphyseal injuries were evaluated. All were treated with CR, casting, and radiographic evaluation at 1, 2, 4, and 6 weeks postinjury. Primary endpoint was radiographic LOR. Secondary endpoint was need for any intervention. A modified number-needed to treat analysis estimated the utility of the week 4 x-ray in predicting intervention. Relative value unit (RVU) costing, time-derived activity-based costing (TDABC), and billing totals were used for cost analysis. Results Seventy patients (38%) demonstrated radiographic LOR. Independent predictors of LOR were initial radius displacement >75% (OR=5.40; CI, 2.23-12.60), concomitant ulna fracture (OR=1.71; CI, 1.15-2.54), and dominant arm involvement (OR=2.87; CI, 1.40-5.87). Eighty percent of all LORs occurred within the first 2 weeks. There was no statistically significant change in radiographic alignment after week 2. Of 40 total interventions, all were performed within the first 2 weeks of follow-up. The 4-week x-ray did not influence decision to intervene, and at most, 1 in every 40 patients would require an intervention after week 2. Elimination of the 4-week x-ray would result in a savings of 4.8% (RVU method) to 11.9% (TDABC method) in the overall cost of nonoperative fracture care. Conclusions There is minimal change in fracture alignment 2 weeks following CR of pediatric forearm fractures, and all interventions are based on early radiographic follow-up. The week 4 x-ray adds little value to clinical decision making, and its elimination would result in savings up to 11.9% of the overall cost of nonoperative fracture care. Level of evidence Level II-prognostic.

Purpose: Use of hypofractionation is increasing in radiation oncology because of several factors. The effects of increasing hypofractionation use on departments and staff currently based on fee-for-service models are not well studied. Methods: We modeled the effects of moving to hypofractionation for prostate, breast, and lung cancer and palliative treatments in a typical-sized hospital-based radiation oncology department. Year 2015 relative value unit (RVU) data were used to determine changes in reimbursement. The change in number of fractions was used to model the effects on machine volume, staff time, and workforce predictions. Results: The per-case marginal reduction in technical revenue was $1,777, $4,297, $9,041, and $9,498 for palliative and breast, prostate, and lung cancer cases, respectively. The physician reduction per case in RVUs was 5.22, 10.44, 43.02, and 43.02 respectively. A department could anticipate an annual reduction in technical revenue of $540,661 and a reduction in workflow of approximately five patients or 1 to 1.5 hours per day from a hypofractionation rate of 40%. Conclusion: The move to hypofractionation in the United States will lead to increased pressures on departments to address budget shortfalls resulting from the decrease in per-patient revenue. This may be done through a combination of an increase in patient volume, recognition of the increased skill sets required to deliver hypofractionated radiotherapy, delay in capital purchases, and/or reduction in staff. In a value-based environment, these evolutions should improve the value proposition of radiation oncology over a fee-for-service model.

The relative value unit (RVU) is an important measuring tool for the work performed by physicians, and is currently used in the United States to calculate physician reimbursement. An understanding of radiology RVUs and current procedural terminology codes is important for radiologists, trainees, radiology managers, and administrators, as this knowledge would help them to understand better their current productivity and reimbursement, as well as controversies regarding reimbursement, and permit them to adapt to reimbursement changes that may occur in the future. This article reviews the components of the RVU and how radiology payment is calculated, highlights trends in RVUs and resultant payment for diagnostic and therapeutic imaging and examinations, and discusses current issues involving RVU and current procedural terminology codes.

Background Informed consent for operative procedures performed on children relies on the ability of the surgeon to estimate and describe accurately the risks and benefits of the planned operation to the parents. Understanding patient-specific risks is also an important prerequisite for surgeons and hospital administrators who wish to change hospital processes and improve patient safety. This study tests the feasibility of estimating the risk of death within 30 days of surgery using National Surgical Quality Improvement Program (NSQIP)-Pediatric data from a single children's hospital. Study design Patient data submitted to NSQIP-Pediatric from our hospital were analyzed to identify variables predictive of death within 30 days of operation. A multiple logistic regression model was constructed using 3 years of data and validated using data submitted the following year. The model was then tested using the participant use file provided by NSQIP-Pediatric for 2012. Results The model identified 7 variables predictive of death: neonatal status, respiratory support, inotropic support, having a blood disorder, cerebrovascular injury, previous cardiac intervention, and the work relative value unit for the procedure. The resulting final model had a c statistic = 0.97. Conclusion It is possible for a participating children's hospital to use NSQIP-Pediatric data to develop risk models for patient mortality occurring within 30 days of operation at their institution. The model presented may be generalizable to other institutions, but needs further testing and refining.

Importance The work relative value units (wRVUs) for a physician service can be conceptualized as the amount of time spent by the physician multiplied by a compensation rate (wRVUs/min). Disproportionately high compensation rates assigned to procedures have been blamed for pay differences across specialties, but to our knowledge, a comprehensive assessment is lacking. Objective To assess how compensation rates built into work RVUs contribute to differences in physician compensation across specialties. Design, Setting, and Participants This cross-sectional analysis examined 2017 Part B fee-for-service Medicare data. The data were analyzed from May 1 to May 30, 2019. Main Outcomes and Measures A specialty-wide compensation rate (wRVUs/min) was generated for 42 medical and surgical specialties defined as the sum of wRVUs for all billed current procedural terminology codes divided by the presumed time to perform those services. This measure accounted for the volume and diversity of services each specialty provides. Sensitivity analyses were performed to assess the association of errors in wRVU time estimates with average compensation rates. Results The final sample included 42 specialties and 6587 distinctCurrent Procedual Terminology (CPT) codes. The number ofCPTcodes attributed to a specialty ranged from 575 (medical oncology) to 4346 (general surgery). Compensation rates ranged from 0.029 wRVUs/min (pathology) to 0.057 wRVUs/min (emergency medicine). Most specialties (34/42 [81.0%]) had compensation rates between 0.035 and 0.045 wRVUs/min. The mean compensation rate for surgical specialties was 7.2% higher than for medical specialties, a difference that was not statistically significant. This narrow range reflects the fact that most specialties had more than 60% of time allocated to activities outside the intraservice period. Assuming that time values for surgical procedures are significantly overestimated increased the difference in average compensation between surgical and medical specialties to 23.4%. Conclusions and Relevance Compensation rates assumed in wRVU valuations are small contributors to differences in physician compensation. Factors outside of the wRVU system, such as payer mix and work hours, could be targeted if narrowing the difference in compensation across specialties is desired.

Background: Developing countries, such as Iran, have been struggling with high rates of insurance deduction. As part of the Health Transformation Plan (HTP) in Iran, a new reference book was introduced to update the medical tariffs. This study aimed to compare the rates and extent of insurance deductions before and after HTP in Iran’s public hospitals. Methods: This was a quasi-experimental study. Overall, 400 medical bills were selected from Iran’s national Health Information System using multilevel random sampling before and after HTP implementation (2014 and 2017). Insurance deductions were divided into 5 groups: (1) diagnostic procedures, (2) medication and medical appliances, (3) accommodation and human capital provision, (4) surgery, and (5) other services. Using STATA Version 14.0, independent t test and Fisher’s exact test were used for data analysis. Significance level was set at 0.5. Results: There was a significant decrease in insurance deductions among Iran’s Health Insurance (HI) and Social Security Insurance (SSI). Accordingly, before HTP, the average amount of insurance deductions was 58.9% and 71.3% in HI and SSI, respectively. Moreover, there was a significant decline in all 5 groups between the pre- and postimplementation of HTP (p

Background & Aims Although single-operator cholangioscopy is considered to be the most sensitive method for tissue acquisition in patients with indeterminate bile duct strictures (IBDS), methods are needed to optimize the specimen collection and processing techniques. We aimed to determine the optimal method for specimen processing and identify the number of biopsies required to establish a definitive diagnosis. Methods Patients with IBDS were randomly assigned to groups that underwent specimen processing using the onsite (n = 32) or offsite (n = 30) method. The primary outcome was to compare operating characteristics of onsite vs offsite specimen processing techniques. The secondary outcome was number of biopsies needed to establish definitive diagnosis. A final diagnosis was established at surgery or after a minimum clinical follow-up period of 18 months Results The final diagnosis was benign disease in 33 patients and malignancy in 29 patients. There were no significant differences between the offsite and onsite groups in diagnostic accuracy (90% vs 87.5%; P=.99), sensitivity (76.9% vs 75%; P=.99), specificity (100% vs 100%; P=.99), positive predictive value (100% vs 100%; P=.99), or negative predictive value (85% vs 80%; P=.99). Although diagnoses were established by analysis of a median of 1 biopsy in the onsite cohort (interquartile range, 1–1.5), the diagnostic accuracy was identical (90%) in each group, regardless of whether 3 or 4 biopsies were collected from each patient in the offsite cohort. Conclusions In a prospective comparative study, we found that centers without onsite cytopathology support that analyze 3 single-operator cholangioscopy-guided biopsies of a biliary stricture and process the specimens offsite make the correct diagnosis for 90% of cases. ClinicalTrials.gov , Number: NCT01815619 .

This chapter will cover three evolving aspects of autopsy pathology practice. It overviews the history and evolution of regional autopsy centers, discusses the benefits of and challenges arising from their creation, and offers guidance for their establishment. Next, it reviews available methodologies for assigning value to the professional component of autopsy work, and it introduces considerations for implementing such assignments in practice. Finally, this chapter explores the current medical malpractice environment in the United States (USA), discusses the role of autopsy in national and international medical malpractice litigation, and offers guidelines for how autopsy pathologists can be more effective in the medicolegal realm.

Background Flap-based breast reconstruction demands greater operative labor and offers superior patient-reported outcomes compared with implants. However, use of implants continues to outpace flaps, with some suggesting inadequate remuneration as one barrier. This study aims to characterize market variation in the ratio of implants to flaps and assess correlation with physician payments. Methods Using the Blue Health Intelligence database from 2009 to 2013, patients were identified who underwent tissue expander (i.e., implant) or free-flap breast reconstruction. The implant-to-flap ratio and physician payments were assessed using quadratic modeling. Matched bootstrapped samples from the early and late periods generated probability distributions, approximating the odds of surgeons switching reconstructive method. Results A total of 21,259 episodes of breast reconstruction occurred in 122 U.S. markets. The distribution of implant-to-flap ratio varied by market, ranging from the fifth percentile at 1.63 to the ninety-fifth percentile at 43.7 (median, 6.19). Modeling the implant-to-flap ratio versus implant payment showed a more elastic quadratic equation compared with the function for flap-to-implant ratio versus flap payment. Probability modeling demonstrated that switching the reconstructive method from implants to flaps with a 0.75 probability required a $1610 payment increase, whereas switching from flaps to implants at the same certainty occurred at a loss of $960. Conclusions There was a correlation between the ratio of flaps to implants and physician reimbursement by market. Switching from implants to flaps required large surgeon payment increases. Despite a relative value unit schedule over twice as high for flaps, current flap reimbursements do not appear commensurate with physician effort.

Objective Endoscopic/colonoscopic procedures are either done with gastroenterologist-administered conscious sedation or with anesthesia-administered sedation with propofol. There are potential benefits to anesthesia-administered sedation, but the concern has been the associated increased cost. Methods To perform this study, we used the time-derived activity-based costing (TDABC) technique to accurately assess the true cost of gastrointestinal procedures done with gastroenterologist-administered conscious sedation vs anesthesia-administered sedation in 2 areas of our practice that use predominantly conscious sedation or anesthesia-administered sedation. This type of study has never been reported using such an integrated approach. This study was performed on 2 different days in June 2015. Results The true cost associated with anesthesia-administered sedation in our practice was associated with only 9% to 24% greater cost when the TDABC technique was applied. Conclusion Gastrointestinal procedures with anesthesia-administered sedation are not as costly when all factors are considered. Using novel approaches to cost measurement, such as the TDABC, allows a total cost measurement approach across an episode of care that existing cost measurements in health care are incapable of.