VASCULAR-SURGERY AND THE RESOURCE-BASED RELATIVE VALUE SCALE - 5-YEARREVIEW

Purpose: The first 5-year review of the Medicare Resource-based Relati ve Value Scale (RBRVS) work values (RVUs) began in 1995, and adjustmen ts became effective January 1, 1997. This report summarizes the method s used by The Society for Vascular Surgery (SVS) and the International Society for Cardiovascular Surgery, North American Chapter, (ISCVS-NA ) Joint Council Government Relations Committee (GRC) to evaluate vascu lar surgery work RVUs and the results that were achieved. Methods: The GRC performed a work study to determine accurate skin-to-skin operati ve times for typical vascular and nonvascular operations. These were c ompared with the original Harvard/Hsiao time estimates and intraservic e work per unit time (IWPUT) values that had been used to determine wo rk RVUs. For most vascular procedures the current operative times were longer than the original Harvard estimates, resulting in calculated I WPUTs substantially less than the Harvard values. This lack of corresp ondence was not identified in the nonvascular procedures, where operat ing room times and IWPUT values were more consistent with Harvard data . These study results were then used to support compelling evidence ar guments in a petition to the Health Care Financing Administration (HCF A) that identified vascular surgery as being undervalued in the RBRVS. Nine commonly performed vascular procedures mere cited for review in the 5-year update, and five distinct work analysis methods were used t o justify each recommended RW increase. These techniques included a st andardized survey from the American Medical Association (AMA)/Specialt y Society Relative Value Update Committee (RUG), a work calculation us ing accurate intraservice times and appropriate IWPUT values, and an e valuation and management (E&M) building-block approach. Results: The R UC met throughout 1995 to assess codes submitted for review, and recom mendations were forwarded to HCFA. The Notice of Proposed Rule Making (NPRM), which contained HCFA's preliminary RW determinations, was rele ased in May 1996. RW increases from 11.5% to 44.6% were proposed for t he nine vascular services cited by the SVS/ISCVS-NA. Also included wer e two increases and two reductions in less-common vascular operations. Of far greater overall fiscal import, HCFA proposed substantial incre ases in the work RW for all E&M except that performed within global su rgical packages. The SVS/ISCVS and most other surgical societies appea led HCFA's proposal regarding E&M. The Final Rule for the 1997 Medicar e Fee Schedule was published late in 1996. Conclusions: The Final Rule upheld the 11 vascular work value improvements and the E&M increases that excluded global service packages. Because most surgical E&M is pe rformed within 10- or 90-day global periods, the E&M ruling will produ ce an estimated annual $2.5 billion shift from surgical to nonsurgical specialties. Because the overall fiscal impact of the 5-year review w as mandated to be budget-neutral, HCFA imposed an 8.3% reduction in th e work payment of every service in Part B of the Medicare program, pri marily to compensate for the increased nonsurgical E&M payments. The n et fiscal impact of the 5-year review for vascular surgery has been es timated at +0.5%.