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  • Worth of Neurosurgeons in Academic Departments Must Not Be Measured in
    Relative Value Units

    Authors:
    Kunal Vakharia, MD
    Michael Courynea, MBA
    Elad I. Levy, MD, MBA

    Introduction

    Health care has undergone a drastic transformation over the past decade including economic and regulatory changes that have unduly impacted academic medicine. Influences by the Affordable Care Act, along with more pressures of the ongoing COVID-19 pandemic, have resulted in slow and constant pressure leading to closings of community hospitals.1 As demonstrated by consolidations and acquisitions of rural hospitals unable to sustain financial solvency, the vital role of academic medical centers (AMCs) has become increasingly apparent. The value of academic medicine must not be simply measured utilizing relative value units (RVUs), or a standardized dollar value associated with different procedural codes, as this metric fails to capture the research, training, and regional resources generated from academic neurosurgical centers.


    Background to RVU measurement

    If we analyze the RVUs of all the academic neurosurgeons in the U.S., we would find major variations in productivity based on RVUs from physician to physician. For example, see below the median RVUs benchmarks for an academic neurosurgeon (as published by MGMA) by academic rank.

    RVUs take into consideration physician clinical practice, but fail to account for variations in reimbursement and practice expenses. Additionally, the median work relative value units (wRVUs) for neurosurgeons both in the academic and private practice setting (as published by NERVES by sub-specialty) exemplifies the variation in wRVUs generated by various subspecialties in neurosurgery. The table below assumes that >90% of the physician’s practice is within the specialty listed, except for functional neurosurgery which is assumes that>75% of the practice is specialty specific.

    Assuming only RVUs were used measure worth of academic faculty, then spine and endovascular surgeons would require compensation 2.5-3 times that of their pediatric or functional neurosurgical colleagues. Additionally, time spent researching, writing, or lecturing could be viewed as a financial penalty or an opportunity cost, as any time spent not generating wRVUs would be uncompensated time.

    Academic neurosurgical departments are truly the lifeblood of our profession, for their mission is to train the next generation of neurosurgeons. These departments spend precious resources on research, teaching, publishing, mentorships, weekly conferences, and invited guest lectures to promote and enhance the learning environment for our future colleagues. Is there a metric or tool to universally measure the effectiveness of these faculty contributions? Furthermore, is there a formula that chairs or academic departments can use to compensate faculty devoted to programmatic educational enhancement and content development. Without considering the intimate relationship between clinical productivity with other educational activities required to train neurosurgeons and advance quality neurosurgical care through science and technological developments, the myopic concept of relative value units fails.2 Particularly in surgical subspecialities, how does one measure the expertise and training required for complex myelomeningocele closures for pediatric patients, complex intracranial pressure monitoring management for severe traumatic brain injury, or microdissection for complex skull base tumors? Without these critical experiences condensed into one regional program with sufficient volume to create exceptional care and reproducible training, academic physicians would have failed in both their obligation to properly train the next generation, and would have left a critical void in caring for their community populations. Teaching translates almost directly into long-term service to the community and access to complex neurosurgical care. Perhaps we must begin to consider that academic physicians’ productivity must also be measured in the success of their trainees who continue to advance education or ultimately provide exceptional care for patients in their community.


    Interdisciplinary Care

    In addition to teaching, teaching hospitals continue to hold the ideal of research as one of the pillars of academic medicine. Recent years have seen the growth of some newer neurosurgical residency programs highlighting the persistent effort of the academic community to go beyond reproducing the teachings of old and embracing the ideals of the “third curve” in health care.3 In place of the traditional fee-for-service model (first curve), the era of population-based medicine (second curve), the third curve has been driven by patient-centered care. The push to innovative technologies and personalized medicine with a consumer-driven focus on optimizing years lived means that physicians are not working in isolated silos. Collaboration has become the buzz-word with trends in most large health care systems focusing on preventative care and coordination of care between systems and specialties.3 By breaking down silos, interdisciplinary care has led to advances endovascular techniques, spine biomechanics and technology, as well as novel mechanisms for delivery of neuro-oncological pharmacotherapies.


    Pushing the Envelope

    Along with this, a revitalized focus on research amongst residents, research fellowships, and a growth in competition for research grant funding. Nearly half of all National Institutes of Health extramural funding went to academic medical centers. Although some academic department take into consideration time and funding needed for physicians to pursue true research endeavors, the combination of extramural and institutional funding typically does not match typical Medicare RVU reimbursement.4 This research contributes to training the next generation of physician scientists, who will accurately and appropriately interpret burgeoning data required to manage patients effectively. Compensation remains opaque for pursuing such activities, as there is a feeling that part of their endeavor is simply altruistic. Understanding the true value added of research and innovative clinical trials that offer patients more personalized strategic care enhances the worth of a health care system.


    “Sweat” Equity

    Academic physicians typically work at tertiary care centers that end up treating a large volume of highly complex and sick patients. The value of care provided by academic medical centers is highlighted by the fact that such health centers constitute only 8% of hospitals, yet deliver nearly 40% of inpatient care for Medicaid patients.5 Although RVUs attempt to capture information about the number and complexity of cases performed by a physician, it does not take into account the sweat equity involved in nurturing an academic institution and its goals within a community. Having a free-standing children’s hospital has been shown to improve regional care of pediatric patients through immediate increased access to care, but as previously shown, pediatric neurosurgeons tend to generate the least wRVUs for a department.

    Recipe for Success

    Like chocolate chip cookies, there are many recipes that yield winning results. On a personal note, we have found that worth starts with truly “valuing” all faculty members for their contributions, and convincing health care systems of the importance of each member of the faculty team. That which is not reflected in wRVUs must be compensated in research and community need. It is vital for teaching hospitals to have 24/7 coverage of stroke, trauma, and pediatric neurosurgical call. By educating stakeholders such as the health care system, the university, philanthropic entities, and the community, of the importance of each of the subspecialities in neurosurgery, only then does it become possible to create appropriate compensation models for teaching faculty. It is through insightful appreciation of the research, teaching, and community contributions that departmental funding is generated allowing compensation to reflect the real worth of teaching faculty, independent of the flawed system of RVUs. 

    References

    1. Rau J, Emmariem H. Some Urban Hospitals Face Closure Or Cutbacks As The Pandemic Adds To Fiscal Woes. In: NPR, ed. Online2020.
    2. Grover A, Slavin PL, Willson P. The economics of academic medical centers. N Engl J Med. 2014;370(25):2360-2362.
    3. Paz HL. Academic Medicine's Critical Role in the "Third Curve" of Health Care. Acad Med. 2016;91(5):613-614.
    4. Retchin SM. Responding to the Marketplace: Workforce Balance and Financial Risk at Academic Health Centers. Acad Med. 2016;91(7):908-909.
    5. Retchin SM, Xu WY. Medicaid Innovations and the Role of Academic Health Centers. Acad Med. 2018;93(10):1454-1456.

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