Dataset Information

An Academic Relative Value Unit System: Do Transparency, Consensus, and Accountability Work?

ABSTRACT:

Introduction

Academic medicine continues to struggle in its efforts to compensate scholarly productivity. Academic achievements receive less recognition compared to clinical work, evidenced by a lack of reduced clinical hours or financial incentive. Core departmental education responsibilities are often distributed inequitably across academic departments. An approach using an incentive program, which emphasizes transparency, equity, and consensus may help academic departments share core education responsibilities and reward scholarly activity.

Methods

We launched a two-stage approach to confront the inequitable distribution of educational responsibilities and to recognize the scholarly work among our faculty. In the first stage, baseline education expectations were implemented for all faculty members, which included accountability procedures tied to a financial incentive. The second stage involved the creation of an aAcademic rRelative vValue uUnit (ARVU) system which contained additional activities that were derived and weighted based on stakeholder consensus. The points earned in the ARVU system were applied towards additional financial incentive at academic year-end. We compared education contributions before and after implementation as well as total points earned in the ARVU system.

Results

In the first year of implementing education expectations, 87% of faculty fulfilled requirements. Those with a heavier clinical load made up the majority of deficient faculty. Those who did not meet education expectations were notified and had their year-end incentive reduced to reflect this. Faculty conference attendance increased by 21% (P<.001) and the number of resident assessments completed increased by 30% (P<.001) compared to the previous year. To date, faculty across the department have logged a total of 1,240 academic activities in the database, which will be converted into financial bonus amounts at year-end.

Conclusion

We have seen significant increases in faculty participation in educational activities and learner assessments as well as documentation of activities in the ARVU system. A similar system using different specialty-specific activities may be generalizable and employed at other institutions.

SUBMITTER: Carmody KA

PROVIDER: S-EPMC6860393 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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An Academic Relative Value Unit System: Do Transparency, Consensus, and Accountability Work?

Carmody Kristin A KA

The western journal of emergency medicine 20191014 6

<h4>Introduction</h4>Academic medicine continues to struggle in its efforts to compensate scholarly productivity. Academic achievements receive less recognition compared to clinical work, evidenced by a lack of reduced clinical hours or financial incentive. Core departmental education responsibilities are often distributed inequitably across academic departments. An approach using an incentive program, which emphasizes transparency, equity, and consensus may help academic departments share core ...[more]

PMID: 31738722

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Project description:ImportanceThe 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.ObjectiveTo assess how compensation rates built into work RVUs contribute to differences in physician compensation across specialties.Design, setting, and participantsThis 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 measuresA 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.ResultsThe final sample included 42 specialties and 6587 distinct Current Procedual Terminology (CPT) codes. The number of CPT codes 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 relevanceCompensation 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.

Project description:ImportanceThe primary data sources used to generate and update work relative value units (RVUs) are surveys of small groups of specialists who are asked to estimate the time and intensity needed to perform surgical procedures. Because these surveys are conducted by specialty societies and rely on subjective data, these sources have been challenged as potentially biased.ObjectiveTo assess whether objective work measures are associated with a surgical procedure's assigned work RVUs and whether differences exist by surgical specialty.Design, setting, and participantsThis cross-sectional study obtained data from the 2016 and 2017 participant use files of the American College of Surgeons National Surgical Quality Improvement Program. The 2017 physician fee schedule of the Centers for Medicare & Medicaid Services was a secondary data source. Procedures were included if they had at least 100 patient-level observations over the 2-year period. Data were analyzed from August 29, 2018, to April 2, 2019.Main outcomes and measuresThe dependent variable was a procedure's assigned work RVU. Independent variables of work RVUs were 4 procedure-level work measures (median operative time, median postoperative length of stay, all-cause 30-day readmission rate, and all-cause 30-day reoperation rate) and surgeon specialty (10-level category using general surgery as the reference).ResultsThe data set included 628 unique Current Procedural Terminology (CPT) codes and 726 CPT-specialty combinations from 1 239 991 patient observations. Statistically significant associations were found between each work measure and assigned work RVU, as follows: median operative time (R2 = 0.74; 95% CI, 0.71-0.78), postoperative length of stay (R2 = 0.42; 95% CI, 0.36-0.48), rate of readmission (R2 = 0.18; 95% CI, 0.13-0.23), and rate of reoperation (R2 = 0.15; 95% CI, 0.10-0.20). Including all 4 measures explained 80.2% (95% CI, 77.3%-83.1%) of the variation. Adding the surgical specialty improved the overall fit of the model (likelihood ratio test χ2 = 231.27; P < .001). Cardiac (7.78; 95% CI, 4.25-11.31; P < .001) and neurosurgery (2.46; 95% CI, 1.08-3.83; P < .001) had higher work RVUs compared with general surgery, whereas orthopedics (-1.53; 95% CI, -2.48 to -0.59; P = .002), urology (-1.58; 95% CI, -2.88 to -0.29; P = .02), plastics (-2.70; 95% CI, -4.39 to -1.01; P = .002), and otolaryngology (-3.05; 95% CI, -4.69 to -1.42; P < .001) had lower work RVUs compared with general surgery.Conclusions and relevanceObjective work measures appeared to be associated with assigned work RVUs, predominantly with operative time; registry data can be used to augment and inform the generation and updating processes of the work RVUs.

Project description:PurposeTo assess whether reimbursement for orthopaedic sports procedures adequately compensates for operative time and surgical complexity.MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried for all orthopedic sports medicine procedures performed greater than 150 times from 2016 to 2018 with regard to operative time, preoperative risk factors, morbidity, and mortality data. Physician work relative value units (wRVU) data were obtained from the 2020 Centers for Medicare & Medicaid Services (CMS) fee schedule. The primary outcome was wRVU per minute operative time (wRVU/min). Linear regressions were used to assess wRVU, operative time, and wRVU/min.ResultsA total of 42 CPT codes, including 84,966 cases, were stratified into the top and bottom 50%, according to mean operative time, complications, mortality, reoperations, and readmissions. Mean wRVU/min was significantly lower for longer procedures (.153 vs .187; P = .02), and comparable with regard to ASA score, complications, mortality, readmissions, and reoperations. Arthroscopy reimbursed more (.187 vs .148 wRVU/min; P = .008), with lower complications (1.5 vs 2.6%; P = .115) and operative time (56.1 vs 82.8 min; P = .001) compared to open. Multivariate linear regression revealed that after adjusting for complication rate, there was a decrease of .054 wRVU/h (P = .026) and $116.90/hour less for every additional hour of operative time.ConclusionThe current 2020 RVU scale does not fairly compensate sports procedures with longer operative times. When examining the hourly reimbursement rates for the most commonly performed sports procedures, there is a significant trend toward lower reimbursement for longer procedures even after accounting for complication rates. Furthermore, procedures of the knee reimbursed at higher rates relative to the general pool of sports procedures and open procedures are compensated at a lower rate compared to arthroscopic procedures.

Project description:BackgroundCommunity-led governance can ensure that leaders are accountable to the populations they serve and strengthen health systems for maternal care. A key aspect of democratic accountability is electing respective governance bodies, in this case community boards, and holding public meetings to inform community members about actions taken on their behalf. After helping build and open 10 maternity waiting homes (MWHs) in rural Zambia as part of a randomized controlled trial, we assisted community governance committees to plan and execute annual meetings to present performance results and, where needed, to elect new board members.MethodsWe applied a principally qualitative design using observation and analysis of written documentation of public meetings to answer our research question: how do governance committees enact inward transparency and demonstrate accountability to their communities. The analysis measured participation and stakeholder representation at public meetings, the types and purposes of accountability sought by community members as evidenced by questions asked of the governance committee, and responsiveness of the governance committee to issues raised at public meetings.ResultsPublic meetings were attended by 6 out of 7 possible stakeholder groups, and reports were generally transparent. Stakeholders asked probing questions focused mainly on financial performance. Governance committee members were responsive to questions raised by participants, with 59% of answers rated as fully or mostly responsive (showing understanding of and answering the question). Six of the 10 sites held elections to re-elect or replace governance committee members. Only 2 sites reached the target set by local stakeholder committees of 50% female membership, down from 3 at formation. To further improve transparency and accountability, community governance committees need to engage in advance preparation of reports, and should consult with stakeholders on broader measures for performance assessment. Despite receiving training, community-level governance committees lacked understanding of the strategic purpose of open public meetings and elections, and how these relate to democratic accountability. They were therefore not motivated to engage in tactics to manage stakeholders effectively.ConclusionWhile open meetings and elections have potential to enhance good governance at the community level, continuous training and mentoring are needed to build capacity and enhance sustainability.

Dataset Information

An Academic Relative Value Unit System: Do Transparency, Consensus, and Accountability Work?

Introduction

Methods

Results

Conclusion

Publications

An Academic Relative Value Unit System: Do Transparency, Consensus, and Accountability Work?

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