Misvaluation of Hospital-based Upper Extremity Surgery Across Payment, Relative Value Units, and Operative Time

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 overvalued or undervalued based on operative time. 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). 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 was considered overvalued, whereas any open reduction internal fixation proximal to the distal radius was considered undervalued in analysis of both databases. Nearly all elective tendon procedures were considered undervalued. Thirty-nine percent of trauma procedures were considered undervalued compared to 70% of elective procedures. Notable compensation differences were found between trapeziectomy versus ligament reconstruction and tendon interposition, epicondyle debridement with tendon repair versus denervation, proximal row carpectomy versus 4 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 revising CMS operative times for certain procedures, associated changes in payment may improve physician compensation models, correct misvaluation-based incentives, and serve as a catalyst to improve the quality and value of elective and trauma-related hand surgery.