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Researchers compared the total care time and payment per unit of time for nine common inpatient and outpatient procedures using Current Procedural Terminology (CPT) codes for the 2009 fiscal year. The analysis showed incongruities in payment for procedures, ranging from a low of $188 per hour for partial colectomy to a high of $700 per hour for laparoscopic gastric bypass. These figures do not include time spent in operative planning, administrative matters or overhead.

Still, “the discrepancy should be considered a red flag,” said lead author Abhishek Chatterjee, MD, MBA, a senior resident in plastic surgery at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., who presented the study at the 2011 Clinical Congress of the American College of Surgeons.

The wide range in hourly compensation reflects major flaws in the formula used to set compensation rates, Dr. Chatterjee said. The formula is based on subjective assessments of physician work rather than hard data, he said. As a result, some procedures are reimbursed much better than others, regardless of case difficulty.

“I’m not saying the RVU [relative value unit] system should be thrown out the door. It has its strengths, but the physician’s time element needs to be better objectively assessed.”

The relative value scale used for CPT reimbursement is based on a formula composed of 52.5% physician work, 43.6% practice expense and 3.9% professional liability. The physician work aspect covers mental effort, technical skill, judgment and physician’s time. Physician’s time includes operating time, hospital days and follow-up clinic days in 15- or 30-minute segments.

The investigators reviewed physician payments for nine operations at a level 1 tertiary care academic health center. They analyzed five common outpatient procedures: laparoscopic gallbladder surgery with cholangiogram, inguinal hernia repair, umbilical hernia repair, thyroidectomy and partial mastectomy with lymph node dissection, and four inpatient procedures: laparoscopic Nissen fundoplication, laparoscopic gastric bypass, partial colectomy with anastomosis and laparoscopic appendectomy.

For each procedure, the investigators compared incision time, postoperative days per case, follow-up days, additional hours, total care hours and physician payment per case. The investigators then broke down the fee into payment per hour for each procedure.

Gastric laparoscopic bypass topped the reimbursement list at $707 per hour, followed by thyroidectomy at $693 and laparoscopic gallbladder with cholangiogram at $541. Laparoscopic Nissen fundoplication, partial mastectomy with lymph node dissection and laparoscopic appendectomy were reimbursed at similar rates of $481, $453 and $443 per hour, respectively. Near the bottom of the list were umbilical hernia repair at $321 and inguinal hernia repair at $326 per hour. Far below all other operations was partial colectomy with anastomosis at $188 per hour. Additionally, the study showed no noticeable differences in reimbursement between inpatient and outpatient procedures.

Dr. Chatterjee emphasized that the study was not designed to assess whether surgeons make too much money or not enough for each procedure. In fact, the dollar value per hour for each procedure does not accurately reflect what a surgeon earns each hour. It fails to take into account many things such as the time spent with patients doing informed consent or answering phone calls in the middle of the night.

But what the study does clearly demonstrate is a lack of consistency in reimbursements from one procedure to the next, Dr. Chatterjee said.

The study is “important and timely,” said Warren D. Widmann, MD, professor of clinical surgery at the State University of New York Downstate Medical Center, in New York City.