A real world analysis of payment per unit time in a Maryland Vascular Practice.

PURPOSE: In 1992, Centers for Medicare and Medicaid Services instituted the Resource Based Relative Value Scale (RBRVS) system to determine physician reimbursement. Relative value units (RVU) were assigned to each Current Procedure Terminology (CPT) code and intended to reflect the time and intensity of work. Little data exist correlating actual procedural and clinical time with respect to reimbursement within the RVU value system. The purpose of this study was to determine how well this system distributes payments per hour for hospital-based procedures in a single vascular practice in the state of Maryland between July 1, 2008 and June 30, 2009. METHODS: As part of an ongoing prospective outcomes program, procedural times for all vascular procedures (time into until time out of room) were recorded. Fifteen minutes were added for administrative functions on procedural day, each hospital day, and office visits during the global period. The combination of all times was reflected in the total care time (TCT) for each procedure. We recorded all physician fees collected for each procedure. This total fee collected for each procedure was then divided by the TCT to determine the procedure-specific payment per unit time. All similar procedures were grouped together and the average reimbursement per procedure was reported. RESULTS: Data was collected on all 1103 procedures performed during this period. Insurance carrier distribution was 75% Medicare and 25% private insurance. The average reimbursement was $316/hour for open procedures and $556/hour for endovascular. Higher reimbursing procedures included visceral endovascular procedures ($701/hour) and caval filters ($751/hour). Lower reimbursing procedures included lower extremity bypass ($292/hour), dialysis access ($268/hour) and lower extremity amputations ($223/hour). Striking was the difference between payment based on approach for similar conditions. Reimbursement for carotid stent vs carotid endarterectomy was $643/hour vs $383/hour, endovascular abdominal aortic aneurysm (AAA) repair vs open $593/hour vs $359/hour. CONCLUSION: 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 are typical of this inequality. These data do not reflect the intangible time of operative planning, administrative matters, or overhead, and these factors must be considered when interpreting this data. Regardless, this study suggests that capturing detailed financial data is possible and is a more accurate source for future discussions on reimbursement.

Remote endarterectomy: lessons learned after more than 100 cases.

BACKGROUND: Bypass procedures have been the mainstay of treatment of extensive external iliac and superficial femoral artery (SFA) occlusive disease, particularly total occlusions. Since the early 1990s, reports from Europe have espoused the virtues of endarterectomy of the superficial femoral and iliac arteries from a small groin incision, but adoption in the United States has been limited. Over the past 4 years, we have explored the technical challenges and durability of this procedure and report our findings. METHODS: Remote endarterectomy from an inguinal incision was the primary treatment option for all patients considered surgical candidates for vascular reconstruction of the external iliac and superficial femoral arteries. All data were entered into an outcomes database prospectively and reviewed retrospectively. After the procedure, duplex ultrasound surveillance was performed quarterly the first year and semi-annually thereafter. RESULTS: Remote endarterectomy was the planned procedure in 133 patients. The mean age was 68 years, 68% were men, and 31% were diabetic. The indications for the procedure were claudication in 57% and limb salvage in 43%. In 16 patients (12%), technical issues precluded the completion of the remote endarterectomy and a bypass was performed. Successful retrograde iliac endarterectomy was performed in 7 patients, SFA endarterectomy in 105 patients, and combined retrograde iliac and antegrade SFA in 5 patients. The average duration of the procedure was 162 minutes +/- 69 minutes (SD). Half of the patients were discharged on the first postoperative day, and the average length of stay was 2.52 days. The mean follow-up was 19 months, with a primary patency of 70% at 30 months by life-table analysis. Limb salvage was 94%. CONCLUSIONS: Remote endarterectomy is a viable and durable alternative to standard bypass procedures. It has equivalent patency to published results of bypass or endovascular procedures of the external iliac and superficial femoral arteries and may soon replace bypass as the preferred procedure for long-segment occlusions of these vessels.