The RVUs were developed to reduce healthcare expenditures and Medicare costs (57). The wRVU, which measures surgeon’s work for a particular service, was gradually considered as an important indicator of productivity, performance, and eventually payment for surgeons. In the last decade, more attention has been paid to wRVU and its metrics due to the importance of equity in payment, the proportion of a surgeon's work to earn, and the desire of surgeons to perform certain surgeries, whatever Hsiao et al. did not expect to be one of the most important challenges to the health system in the coming decades. Proper measurement of the surgeon's work is a prerequisite for a proportionate payment system. After three decades, this study provided a native model for measuring surgeons' work. The findings of our study reveal that measuring surgeons' work solely based on metrics, such as operation duration, risk, physical effort, and mental effort, does not accurately reflect surgeon efforts in the operation room (OR). What happens in the OR is more than that. These results go beyond previous reports, showing that RVUs do not accurately measure the time and effort of procedures across many subspecialties (50, 58).
According to the results, several factors influence surgeon’s effort in OR, such as the patient's age, disease severity at referral, preoperative consultation time, postoperative care time, operation duration, surgical risk and complexity, the stress imposed on the surgeon during the operation, surgeons' willingness to operate, skills, physical effort, and comorbidities.
As commented by the participated surgeons, the severity of disease at the referring time, patient’s conditions for example hypertension or diabetes during the operation, and whether the patient is an elderly man in the last years of his life, a child with a high life expectancy, or a young man in his 25s do not make a difference in the patient treatment by the surgeon in the OR, but the stress transferred to the surgeon in OR is far from the payers' view. Schwartz et al. state that RVU does not distinguish extra work required by an emergent patient (41).
Due to the change in people's lifestyle, comorbidities are more common than 30 years ago (59), which not only make surgery more stressful for both the surgeon and the patient but also can lead to postoperative complications. Therefore, these patients need more attention and effort in the OR. Based on this study, patients' conditions have a 17% effect on the amount of physician's work in the OR. As stated above, the age of the patients should be taken into account in determining the relative value (31–33). The findings are directly in line with previous findings, and similar studies have emphasized paying attention to the patient's characteristics in determining the wRVU, which is neglected in the current RVU system (8, 29, 30).
In order to perform an operation, Hsiao considers time as an important factor in calculating the work of the physician (60). However, calculating the surgeon's work only based on the length of a surgical operation causes bias. It may be necessary for a patient to consult a surgeon before surgery, or to be followed up with a surgeon for a long time after surgery in some cases (9). In contrast to measuring operation times, this study suggests considering pre- and post-operative care times as well. For each surgery, the term time refers to the time required for pre-operative consultation, the length of the operation, and the postoperative care required. This is consistent with that found in previous studies surgeons who spend time on such affairs as consulting, operative planning, and committee work, for which no payment is made (36, 48). A study by Shah et al. showed a poor correlation between RVUs and operative time for a variety of high-volume surgical procedures (8).
From the results, it is clear that besides the time, complexity is another metric to measure a surgeon's work. Complicated surgeries take more time and effort and impose more stress on surgeons, therefore, negatively affecting their willingness to perform such procedures. In this regard, these findings are consistent with research showing that complexity in operation may need more attention, time, and effort, and, therefore, would be considered in calculating the surgeon’s work (19–21, 37).
It is important to highlight the fact that the surgeon’s characteristics as the service provider are effective in their work. The present study confirmed the findings about the amount of stress that a physician experiences during surgery, the surgeon's skill during that operation, and the surgeon's willingness to perform that operation affect wRVU by 32%. Therefore, it seems reasonable to measure a surgeon’s work considering this finding.
An operation performed by a more skilled surgeon often results in fewer complications for the patient and a shorter surgical duration. Consequently, it affects the efficiency and cost of the health system. Previous studies have also noted the weakness of the RVU system in not considering the surgeon's skill (8, 45). Also patients may have difficulty accessing certain specialties if the surgeon is unwilling to perform certain operations (61, 62).
Other studies found that metrics, such as the quality of care, patient satisfaction, and the technology used in the procedure, would be considered to measure the surgeon's work, which was not mentioned in our study. This can be attributed to differences in payment structures, inadequate and unreliable data (physical and electronic) of surgical complications, and medical errors. Because of this potential limitation, it was impossible to measure such metrics (10, 42, 43, 52, 63).
Nonetheless, we believe that determining a certain value for each procedure does not accurately estimate the amount of required work for a procedure because, in addition to the disease specification, it is also affected by many factors such as the patient's condition, the surgeon's skill, and the provider's tendency. Therefore, we suggest that a range of values with a minimum and a maximum should be considered instead of a fixed wRVU in the RVU schedule for a procedure. The surgeon’s skill and willingness, the operation complexity, and the patient’s condition will determine the value of minimum or maximum. As discussed above, applying this model to determine wRVU causes similar RVU of a procedure to vary in different situations. In addition to ensuring fair payment for surgeons, it would also ensure that patients have access to the required procedures.