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Misvaluation of Hospital-Based Upper Extremity Surgery across Payment, Relative Value Units, and Operative Time
Suresh K Nayar, MD, Johns Hopkins University, Baltimore, MD, Keith T Aziz, MD, Johns Hopkins University School of Medicine, Baltimore, MD, Dawn M. Laporte, MD, Orthopaedics, Johns Hopkins Hospital, Baltimore, MD, Ryan M. Zimmerman, MD, Greater Chesapeake Hand Specialists, Lutherville, MD, Uma Srikumaran, MD, Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD and Aviram M Giladi, MD, MS, The Curtis National Hand Center, Baltimore, MD

Purpose: 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 work relative value unit (wRVU) misvaluation for hospital-based hand and upper extremity procedures.

Methods and Methods: Data on wRVUs, payments, and estimated operative times were collected from CMS for 53 procedures. Using regression analysis, we compared relationships between these variables, in addition to actual median operative times as reported in the NSQIP database, from 2011 to 2016. We then determined which procedures may be over-valued or under-valued based on operative time. Procedures were further analyzed in elective and trauma subsets.

Results: There was a wide discrepancy between CMS and NSQIP operative times (R²=0.49), with 60% of CMS times being longer than NSQIP times. Payments were more strongly correlated with CMS operative times (R²=0.55) than with NSQIP operative times (R²=0.24) (Figure 1). Similarly, wRVUs were more strongly correlated with CMS operative times (R²=0.84) than with NSQIP operative times (R²=0.51). In general, for trauma-related procedures, any distal radius open reduction internal fixation (ORIF) was considered over-valued while any ORIF proximal to the distal radius was considered under-valued in analysis of both databases (Figure 2A). Nearly all elective tendon procedures were considered under-valued (Figure 2B). Thirty-nine percent of trauma procedures were considered under-valued compared to 70% of elective procedures. Notable compensation differences were found between pairs of procedures with similar indications. These included: 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.

Conclusions: CMS may misvalue payment and wRVU rates of hospital-based hand procedures due to inaccurate operative time estimates.  By identifying which hospital-based hand surgeries are misvalued in terms of payment and wRVU per operative time, providers and payers may be able to address these imbalances and reduce inappropriate care delivery incentives.