Financial Implications for Physicians Accepting Higher Level of Care Transfers

Mark I. Langdorf, MD, MHPE; Sharon Lee, MD; Michael D. Menchine, MD, MPH

Disclosures

Western J Emerg Med. 2013;14(3):227-232. 

In This Article

Results

We present our reimbursement data comparisons for HLOC patients in 4 ways.

  1. Reimbursement per RVU for each group of HLOC patients by specialty (n=12) ( Table 1 , Figure 2).

  2. Percent RBRVS reimbursement for HLOC patients by specialty (n=12) (Figure 3).

  3. Reimbursement per RVU for HLOC patients compared to all of this tertiary center's patients by specialty (n=8) (Figure 4).

  4. Reimbursement per RVU for HLOC patients by specialty (n=12) compared to national benchmarks and all of each specialty's patients at this study site (Figure 5).

Figure 2.

Reimbursement per relative value unit (RVU) for higher level of care (HLOC) transfer patients for 12 specialties. Average reimbursement per RVU for all specialites = $49.81.

Figure 3.

Percent resource based relative value scale (%RBRVS) by specialty (n=12) for higher level of care (HLOC) transfer patients (N=570).

Figure 4.

Reimbursement per relative value unit (RVU) for higher level of care (HLOC) transfer patients vs. all study site patients by specialty (n=8 specialties). All patient data not available at study site for 4 specialties: obstetrics and gynecology, head and neck surgery, orthopedics and plastic surgery.

Figure 5.

Reimbursement per relative value unit (RVU) for higher level of care (HLOC) transfer patients vs. national benchmarks vs. study site patients.

Finally, to isolate the potential effect of HLOC status alone vs. overall payer mix of our tertiary care center, we present reimbursement per RVU for this study site (not only HLOC patients) vs. national benchmarks (Figure 6).

Figure 6.

Reimbursement per relative value unit (RVU) for all study site patients by specialty, as a percentage of national reimbursement per RVU from Medical Group Management Association (MGMA) data for 8 specialties. All patient data not available at study site for 4 specialties: obstetrics and gynecology, head and neck surgery, orthopedics and plastic surgery.

In this period 576 patients were transferred, or 1.6 per day. The number of patients per specialty ranged from a low of 6 for family medicine to a high of 319 for emergency medicine (EM) (Figure 1). The remaining 251 patients were transferred directly to an inpatient unit, and so did not trigger any ED charges. Total RVUs for all patients at the receiving center were 19,040, or 33.40 RVU per patient. RVU per patient varied from a low of 3.42 for family medicine to a high of 28.23 for obstetrics/gynecology ( Table 1 ) (e.g. normal spontaneous vaginal delivery= 26.80 work RVU). EM had 6.49 RVU per patient (e.g. evaluation and management code level 5= 3.80 RVU).[10]

Figure 1.

Number of higher level of care (HLOC) transfer patients per specialty for 12 specialties at one tertiary care site over 14 months. N=570 total patients billed 1280 times by specialty services.

Total reimbursement from all payers (government, private and self-pay) was $948,450 ( Table 1 ). Reimbursement per RVU varied from a high of $74.93 for neurosurgery to $25.91 for family medicine ( Table 1 , Figure 2). The average reimbursement per RVU for all HLOC transfer patients was $49.81. Five of the 6 specialties shown by hospital surveys to have the most trouble maintaining call panels (neurosurgery, head and neck surgery, orthopedics, ophthalmology, and plastic surgery) had higher-than-average reimbursement per RVU compared to other specialties. The sixth, plastic surgery, had lower-than-average reimbursement per RVU.[1,2]

We also compared specialties using the 2007 RBRVS as determined by Centers for Medicare and Medicaid Services (CMS). The percent RBRVS ranged from a high of 197% for neurosurgery to 68% for family medicine. Percent RBRVS for EM was 132.7% ( Table 1 , Figure 3).

Not all specialties at this tertiary center had billing data available for reimbursements per RVU for all of that specialty's patients during the same time period. Head and neck surgery, obstetrics, orthopedics, and plastic surgery were unavailable from the billing group.

Looking more closely at the individual specialties, EM had $50.54 reimbursement per RVU for their HLOC transfer patients ( Table 1 , Figure 2). Reimbursement to EM for transferred patients was 16% above the average reimbursement per RVU for all ED patients for the period (Figure 4). Compared to national data from the 2006 MGMA survey, reimbursement to EM for transferred patients was 8% below the national EM average (Figure 5).

For the most problematic specialties, neurosurgery transferred-patient reimbursement per RVU was 24 % above the average patient reimbursement per RVU for all neurosurgery patients at this center ($75.93 vs. $61.27 per RVU) for the period ( Table 1 and and Table 2 , Figure 4). However, compared to national data, reimbursement per RVU at this center was 22% lower ($97.66 nationally) (Figure 5).

The remainder of specialties were reimbursed less per RVU for HLOC patients than for all of their patients at this center (Figure 4). The largest loss was seen in family medicine patients. For surgery with trauma (the second highest volume specialty for HLOC transfers after EM), reimbursement per RVU was 8.9% less than for all Level I Trauma Center patients combined ( Table 1 and and Table 2 , Figure 4).

Compared to the national average, this study site had an overall lower reimbursement per RVU for all specialties. This demonstrates that this study site likely has a lower payer mix than national average, leading to lower reimbursements per RVU (Figure 5).

Figure 6 is a graphical representation of this tertiary center's overall reimbursement by specialty (not just HLOC patients) vs. the national benchmark. This illustrates the degree to which average reimbursement at our center lags behind national norms.

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