University pediatric surgery: benchmarking performance

doi:10.1016/j.jpedsurg.2009.10.007

Journal of Pediatric Surgery

Volume 45, Issue 1, January 2010, Pages 28-37

https://doi.org/10.1016/j.jpedsurg.2009.10.007 Get rights and content

Abstract

The many ways monies enter and leave a university pediatric section are as poorly understood as the value and relationship to the parent hospital or university. This blinded confidential financial performance survey of similar university pediatric surgery sections begins to benchmark performance and define those relationships.

Section snippets

Methods

University children's hospital pediatric sections were defined as those robust enough to secure accreditation for residency training in pediatric surgery by the American Council on Graduate Medical Education. All such sections as of January 1, 2005, were potential participants in the study. The original concept proposal was brought to the Association of Pediatric Surgery Training Program Directors for general comment, discussion, and modification in May, 2005. Twenty-eight of 30 training

Section participation

Thirty sections were invited to participate Two sections declined the invitation because (a) their parent hospital would not allow participation because their information was proprietary or (b) the survey was viewed as of limited value and exposed the hospital to legal risk.

Of the 28 sections agreeing to participate, 19 ultimately submitted data. The reasons for nonparticipation by 9 sections were not known because of the confidential nature of the survey.

Of the 19 sections submitting data, 11

Discussion

Annualized 2007 results illustrate that pediatric surgeons' discharges provide hospitals with mean CMI of 1.72 on inpatient discharges and 4.8 on discharges of patients that transited the neonatal intensive care unit (NICU). Case mix index values in this range are an important contribution to a typical hospital's bottom line, as they represent and increase above what may typically be seen for CMIs of hospitals without a pediatric surgical program supporting the activities of NICU. To put this

Challenges

The authors did not have sufficient previously published data to allow for a comparative review of information. In addition, the respondent's information may not contain consistent measurement and cost accounting processes to ensure comparability of data that were submitted. Although the respondent's data can be grouped into broad and widely recognized categories such as compensation, assessment, nonpersonnel expense, and malpractice insurance expense, respondent line item validation was not

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Cited by (8)

Value-based surgery physician compensation model: Review of the literature
2022, Journal of Pediatric Surgery
Citation Excerpt :
Additionally, pediatric surgeons had a mean CMI of 4.8 for NICU discharges, highlighting the complexity of those patients, but also the significant financial contributions to hospitals dependent on these cases. Nonetheless, pediatric surgery departments often operate on narrow financial margins, with an average difference in mean collections and mean compensation of only $36,194 [22]. In addition, children's hospitals depend greatly on the contributions of pediatric surgeons to the overall financial health of the institution [23].
In recent history, healthcare payment reform and legislative initiatives have drastically altered the practice environment for many physicians. Individual providers have migrated from self-managed smaller practices toward employed positions with larger entities, in which provider productivity is tracked. In academic institutions, surgical departments are tasked with meeting clinical productivity metrics while maintaining research and education missions. The objective was to review the current literature regarding the status of physician compensation.
A narrative review of the literature with a defined search strategy using Pubmed and MEDLINE was performed. Using keywords of physician reimbursement, physician compensation, performance-based incentives, relative value unit, RVU, searches were completed and subsequently reviewed by the authors for inclusion. Subsequently, all review articles had their included studies hand searched by the research team and any relevant articles were included in our review.
In total, fifteen papers were deemed to meet inclusion criteria. Articles were then divided into 7 domains (Origins of the Work Relative Value Unit, Adjusting for Clinical Complexity, Alternative Compensation Strategies, Aligning Compensation with Department Goals, Individual versus Group Incentives, Minimizing Complexity, Maximize Efficiency, Minimize Loss).
As external powers continue to apply pressure to surgeon compensation, leaders have had to increasingly focus on clinical productivity, while the missions of research and education become more neglected. One solution could be the development of metrics to best align incentives for clinical, research, and education activities with institutional goals.
Development of an academic RVU (aRVU) system to promote pediatric surgical academic productivity
2022, Journal of Pediatric Surgery
Citation Excerpt :
It was noted that surgeons carried a large share of the clinical activity and revenue generation for the hospital, were principal contributors to the hospital's positive operating margin, and contributed more to the hospital's financial health and clinical activity than non-surgeons. To assess the financial value and revenue stream generated by pediatric surgery to parent hospitals or universities, in 2009 Stolar et al. performed a blinded confidential financial performance survey of university-associated children's hospitals with pediatric surgery training programs [18]. The authors demonstrated that hospitals collect substantial revenues from pediatric surgical clinical activity.
Improvements in patient care are directly affected by scientific discovery, and surgeons have historically played a vital role in this process. However, increasing clinical demands and incentivization for pure clinical productivity present challenges for promoting academic productivity. The objective of this work was to analyze the effects of adding an academic relative value unit (aRVU) scoring system to an existing work RVU (wRVU)-based incentivization plan on academic productivity in a Department of Pediatric Surgery.
Prior to 2012, incentive bonuses in our Department were mainly based on clinical wRVU activities. A weighted scoring system for 30 specific aRVUs was established in 2012. Incentivization for wRVUs vs. aRVUs was based on the clinical full-time equivalent (cFTE) of each faculty member. Academic activities incentivized included grant submissions/funding, peer reviewed publications, national presentations, Study Section participation, education and mentoring activities, receipt of research or teaching awards, initiation of Institutional Review Board (IRB) protocols, new academic society committee memberships/chairpersons, and patents. Academic progress was analyzed from 2012 to 2020.
During the study period, annual external federal funding increased from $750,168 to $5,768,243 (7.7-fold increase); annual peer-reviewed publications increased from 24 to 140 (5.8-fold increase); annual national presentations accepted for oral/poster presentations nearly doubled; and faculty members and their trainees received 41 competitive research awards including 8 American Pediatric Surgical Association Awards, 9 American Academy of Pediatrics Section on Surgery Awards, and 3 American College of Surgeons Awards. During the same study period, wRVUs increased by 8%.
Incentivization based on the addition of an aRVU system to a pre-existing wRVU system was associated with a significant increase in academic productivity, while still maintaining clinical productivity. Implementing an aRVU program is an important means of increasing academic productivity in Pediatric and other Surgery Departments.
The impact of removing global periods on pediatric surgeon reimbursement
2021, Journal of Pediatric Surgery
Citation Excerpt :
There is a paucity of research on this topic in pediatric surgery. The studies that have been published to date focus on reimbursement and value of surgeon time and effort [16–18], rather than implications of policy change on the field. For example, one such study noted that RVU valuations do not correlate well with and tend to undervalue pediatric surgeon's time in the operating room [16].
CMS has proposed removing postoperative care from the global periods for surgical procedures and instead requiring surgeons to bill for postoperative visits using evaluation & management (E&M) codes. This policy may alter reimbursement to pediatric surgeons.
To assess the impact of this policy, NSQIP-pediatric data were used to calculate median LOS for high-volume procedures with 10 or 90 day global periods. We then merged these data with CMS physician work time and RVU files. A CMS LOS variable was created by counting the number of hospital-based E&M codes built into the global period based on the fact that if global periods are removed, surgeons may only bill one E&M code per postoperative day. We then compared the CMS and NSQIP LOS values.
The dataset included 201 CPT codes with NSQIP LOS estimates derived from a median of 137 operations. Twenty-nine procedures (14.4%) had higher, 24 (16.9%) had the same, and 138 (68.7%) had lower NSQIP median LOS than current CMS values. On average, NSQIP values were 40.0% (95% confidence interval [95CI] − 50.0, − 29.9%) lower than CMS values. Based on a daily average work RVU per postoperative E&M code of 1.09 (95% CI 1.05, 1.12), and $35.78 per RVU (2017 rate), surgeons in this sample would experience a cumulative annual reduction in reimbursement of approximately $3.4 M following the policy change.
Most pediatric surgical procedures have RVU valuations that include more hospital-based E&M codes than the current median number of postoperative days. Holding all else equal, the removal of global periods would therefore reduce reimbursement for pediatric surgeons. The downstream effects of this policy change, such as the impact on the quality of clinical care, are uncertain and warrant further investigation.
Clinical research paper.
Level II.
The pediatric surgeon's road to research independence: Utility of mentor-based National Institutes of Health grants
2013, Journal of Surgical Research
Citation Excerpt :
The K-award support has recently increased, to almost $1 million over 5 y, between salary support, supplies, and fringe. The salary contribution of ∼$100,000 constitutes over 50% of an average nonsurgical physician salary (internal medicine, <$200,000) but only ∼30% of the average pediatric surgeon salary (>$350,000) [11,12]. This imbalance highlights why additional internal support is necessary to recruit surgeons to undertake investigative careers.
The current research environment for academic surgeons demands that extramural funding be obtained. Financial support from the National Institutes of Health (NIH) is historically the gold standard for funding in the biomedical research community, with the R01 funding mechanism viewed as indicator of research independence. The NIH also supports a mentor-based career development mechanism (K-series awards) in order to support early-stage investigators. The goal of this study was to investigate the grants successfully awarded to pediatric surgeon-scientists and then determine the success of the K-series award recipients at achieving research independence.
In July 2012, all current members of the American Pediatric Surgery Association (APSA) were queried in the NIH database from 1988–2012 through the NIH Research Portfolio Online Reporting Tools. The following factors were analyzed: type of grant, institution, amount of funding, and funding institute or center.
Among current APSA members, there have been 83 independent investigators receiving grants, representing 13% of the current APSA membership, with 171 independent grants funded through various mechanisms. Six percent currently have active NIH funding, with $7.2 million distributed in 2012. There have been 28 K-series grants awarded. Of the recipients of expired K08 awards, 39% recipients were subsequently awarded an R01 grant. A total of 63% of these K-awarded investigators transitioned to an independent NIH award mechanism.
Pediatric surgeon-scientists successfully compete for NIH funding. Our data suggest that although the K-series funding mechanism is not the only path to research independence, over half of the pediatric surgeons who receive a K-award are successful in the transition to independent investigator.
Formative research experiences in pediatric surgeons: a mixed methods study of Pediatric Trauma Society members
2019, Pediatric Surgery International
Workforce issues in pediatric surgery
2017, American Surgeon

View all citing articles on Scopus

: Presented at the 40th Annual Meeting of the American Pediatric Surgical Association, Fajardo, Puerto Rico, May 28-June 1, 2009.

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APSA papersUniversity pediatric surgery: benchmarking performance