Southern Association for Vascular surgery

October 15, 2009

Does the current reimbursement system make sense? A real world analysis of payment per unit time in a Maryland vascular practice

John D Martin, Patricia B Warble, Jerry E Mapes, Linda L Weiss, Toni B Schiller, Kimberly A England, Louise A Hanson, Jon A Altschuler, Jon A Hupp, Stephen F Stanziale
Anne Arundel Medical Center, Annapolis, MD

Background: In 1992, CMS instituted the Resource Based Relative Value Scale (RBRVS) system to determine physician reimbursement, incorporating three components of physician services: physician work, practice expense, and liability insurance. The relative value units (RVU), are assigned to each CPT code and are intended to reflect the time and intensity of work. This RVU is the core value that determines the “fair” reimbursement for physician work. Does this system accurately balance the true time it takes for each procedure? The purpose of this study was to determine how well this system distributes payments for hospital based procedures over a 12 month period.
Methods: From July 1, 2008 to June 30, 2009 procedural times for all vascular interventions (time into room until time out of room) were recorded. Additionally recorded were 15 minutes for administrative time on the day of the procedure, each hospital day and all office visits within the global period ; the total care time (TCT)). The actual physician’s total fee collected (TFC) for each of these procedures was divided by the TCT to determine the payment per unit time. We did not isolate unbundled codes, but rather reported the total reimbursement for the entire procedure to more accurately reflect the typical vascular experience.
Results: Data was collected on all 1103 procedures performed during this period. Thirty-seven patients were excluded from analysis (35 no payments received and 2 incomplete times recorded). Carrier distribution was 75 % Medicare 25% private. Reimbursement per unit time is reflected in the following chart for each of the major procedures:



Procedure	Number	OR Time(hrs)	Post-Op Days	Consult Time(hrs)	Total ($) Reimbursement	Reimbursement/ Hour($/hr)
Aortic Bypass	15	65.9	52	22.75	31,809	359
Aortic Endograft	25	66.9	36	27.25	55,807	593
Abdominal Endovascular	39	62.4	0	9.75	44,200	612
Carotid Endarterectomy	118	242.9	150	116.00	137,.559	383
Carotid Stent	20	27.4	20	13.25	26,419	650
Cerebral Arteriography	7	8.2	0	1.75	4,867	487
Bypass Graft Revision Open	6	14.8	15	7.25	8,439	382
Bypass Graft Revision Endo	5	6.1	0	1.25	4,523	617
L. Extremity Bypass	45	166.5	145	74.00	70,211	292
L. Extremity Endarterectomy	23	54.4	34	23.75	38,452	492
L. Extremity Endovascular	179	270.7	0	44.75	192,139	609
L. Extremity Thrombectomy	13	32.1	57	23.00	20,166	366
Dialysis Graft Revision Open	46	73.5	56	39.75	32,019	283
Dialysis Graft Revision Endo	119	125.5	4	35.00	85,725	534
Dialysis Access	76	127.7	15	56.25	49,328	268
L. Extremity Arteriography	106	117.4	0	26.50	52,310	364
Fistulagram	12	9,7	0	3.00	3,261	245
Caval Filter Insert/Remove	22	17.3	39	15.50	19,891	606
L. Extremity Venous	30	34.8	0	15.25	19,498	389
L. Extremity Amputation	47	65.5	244	90.25	34,686	223
Visceral Endovascular	32	43.3	0	8.00	35,020	682

Conclusions: The RUC committee uses information gathered by subjective surveys, rather than prospectively collecting accurate work load data. This unique study demonstrates a “real world” experience of reimbursement per unit time and raises questions as to the validity of the RBRVS process. The disparity between payments for open and endovascular repair of similar conditions, such as aortic aneurysm and carotid stenosis, are typical of this inequality. These data do not reflect the intangible time of operative planning, administrative matters, or overhead and these are factors that must be considered when interpreting this information. Regardless, this study suggests that capturing detailed financial data is possible and is a more accurate source for future discussions on reimbursement.

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