Vascular Surgeons Are Not Adequately Valued By Traditional Productivity Metrics.

Abstract Objectives Reimbursements for professional services performed by clinicians are under constant scrutiny. The value of a vascular surgeon's services as measured by work relative value units (wRVU) and professional reimbursement has decreased for many of the most common procedures performed. Hospital reimbursements, however, often remain stable or increase. We sought to evaluate fistulagrams as a case study and hypothesized that while wRVU and professional reimbursements decrease, hospital reimbursements increase. Methods Medicare 5% claims data were reviewed to identify all fistulagrams with or without angioplasty or stenting performed between 2015-2018 using current procedural terminology codes. Reimbursements were classified into three categories: Medical Center (reimbursements made to a hospital for a fistulagram performed as an outpatient procedure), Professional (reimbursement for fistulagrams based on compensation for procedures: work RVUs, practice expense RVU, malpractice expense RVU), and office-based lab (OBL, reimbursement for fistulagrams performed in an OBL setting). Medicare’s physician fee schedule was used to calculate wRVU and professional reimbursement. Medicare’s national ambulatory payment classification (APC) was used to calculate hospital outpatient reimbursement. Results From 2015-2018, we identified 1,326,993 fistulagrams. During this study period, vascular surgeons experienced a 25% increase in market share for diagnostic fistulagrams. Compared to 2015, total Professional reimbursements from 2017-2018 for all fistulagram procedures decreased by 41% (-$10.3 million) while OBL reimbursement decreased 29% (-$42.5 million) and wRVU decreased 36%. During the same period, Medical Center reimbursement increased by 6.6% (+$14.1 million). Conclusions Vascular Surgeons’ contribution to a hospital may not be accurately reflected through traditional RVU metrics alone. Vascular surgeons performed an increasing volume of diagnostic fistulagrams while experiencing marked reductions in wRVU and reimbursement. Medical Centers, on the other hand, initially experienced a decline in reimbursement but then benefited from a marked increase in reimbursement; none of this increase was realized in Professional or OBL reimbursements. This study highlights that Professional reimbursements, taken in isolation and without consideration of Medical Center reimbursement, undervalues the service and contribution provided by a vascular surgeon.