Uncompensated Work in Transplantation
Christine Hwang, MD
Assistant Professor, Surgery
UT Southwestern Medical Center
In most specialties of general surgery, surgeons have a set schedule and patients are seen at regular intervals in clinic and scheduled for elective cases. Relative value units (RVUs) are generated in a predictable fashion, both in clinic and in the operating room.
Transplant surgery is quite the opposite. We see our patients in evaluation, but the procurements and transplants occur at unpredictable times, and transplant activity waxes and wanes. When we do receive organ offers, it is not uncommon for multiple recipients to be evaluated for the same organ offer. This translates into going through several potential recipients’ charts, then admitting potential recipients, with only the possibility of transplantation.
In the ideal situation, one of those potential recipients will receive the organ, which will allow for RVU generation, but there are times where nobody will receive the organ, and the work of evaluating each potential recipient is wasted. This work will not generate any RVUs except for at best reimbursement for seeing a patient to perform a history and physical.
There are models in surgery where one is reimbursed for being on call, and in addition to that, any activity and RVU generation when being on call is compensated. This model extends into the call schedule for ancillary staff, such as OR staff, who are paid to take call and receive additional compensation if called in. Unfortunately, there is no such model in transplant surgery.
In our field, we perform many other activities without any or minimal RVU compensation. Procurement activity is a perfect example of work without RVU compensation. There is no RVU value associated with procurement activity. In general, most procurements take about 3 hours. There is also the travel time to the donor hospital and back to the transplant center, which is usually a couple of hours each way. Delays are not uncommon, where the procurement may be bumped for an undisclosed amount of time for an emergency at the donor hospital or waiting for other teams to arrive. These delays can add several hours to the process. All the time associated with a procurement can easily take 8 hours, or the time one puts in a “regular” working day. Finally, if the organ is procured and ultimately not used, there is no fee paid for the procurement. It is interesting to note that some institutions have assigned an RVU value to procurement activity1.
Likewise, backtable preparation of the organ, despite having a charge, also does not generate any RVU activity, unless a complex vascular reconstruction is involved. Some backtable activity can be simple enough, but the activity takes time and skill to perform and in some instances is critical in performing the transplant. A backtable reconstruction of the arterial system of a liver can be quite complex and can significantly simplify the arterial anastomosis in the recipient; the CPT code for arterial reconstruction, 47147, will generate only 7 RVUs. To put that into perspective, a laparoscopic appendectomy, 44970, will generate 9.45 RVUs.
In an era where RVUs are increasingly viewed and equated to productivity, lack of recognition of work performed by transplant surgeons in the form of RVUs can become troublesome. As noted above, much of our work as transplant surgeons is not accounted for in work RVU activity. Some centers have adopted the strategy to have co-surgeons be involved in a liver transplant, which would allow for 125% of charges to be generated, rather than an assistant fee, which would be 110%. A virtual RVU system has been suggested2 by Abouljoud et al.
It is again reasonable to have such a system account for this discrepancy in work performance; the other option is that transplant surgeons should work toward having their activities and work accounted for properly. This is not to ask for higher pay, but simply to receive credit for the work that we perform.
- https://www.aamc.org/download/105928/data/
- Abouljoud M, Whitehouse S, Langnas A et al. Compensating the transplant professional: time for a model change. Am J Transplant 2015 Mar; 15(3):601-5.