Misaligned Incentives in Benign Prostatic Enlargement Surgery: More Complex and Efficacious Procedures are Earning Fewer Relative Value Units.

Background Relative value units (RVU) are the measure of value used in United States Medicare reimbursement. Medicare determines physician work RVU from the Relative Update Committee (RUC) for a procedure based on operative time, technical skill and effort, mental effort and judgement, and stress. In theory, work RVU (wRVU) should account for the complexity and operative time involved in a procedure. The aim of this study was to assess whether major procedures treating benign prostatic enlargement (BPE) are fairly compensated based on complexity and operative time in the RVU system and compare them to the intended reimbursement. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and the Centers for Medicare and Medicaid Services (CMS) Medicare Physician Fee Schedule was queried from 2015 - 2017. Single current procedural terminology (CPT) codes associated with BPE-treatments were included: Transurethral resection of prostate (TURP), photovaporization of prostate (PVP), holmium laser enucleation (HoLEP), retropubic simple prostatectomy (RSP), suprapubic simple prostatectomy (SSP). The CMS operative times and the NSQIP real data were used in turn to calculate separate values for wRVU per hour of operative time (wRVU/hr). The wRVU/hr derived from CMS operative times represents "RUC-estimated wRVU/hr" and the wRVU/hr derived from NSQIP represents "actual wRVU/hr". Results 27,664 cases were included from the NSQIP dataset. Median wRVU was 15.3 (IQR 12.2-15.3), median operative time was 50 minutes (IQR 33-74), and median wRVU/hr was 17.0 (IQR 11.6-26.2). RUC-estimated wRVU/hr were: TURP 12.2, PVP 12.2, RSP 9, SSP 9.3, HoLEP 7.3. The actual wRVU/hr were: TURP 19.1, PVP 15.5, RSP 10.2, HoLEP 9.4, SSP 7.6. Conclusion Laser enucleation and simple prostatectomy are highly complex and efficacious procedures for treating BPE, yet the current payment schedule assigns these procedures the least amount of wRVU/hr. Financial incentives for performing BPE surgeries are clearly misaligned.