Are Gender-Affirming Plastic Surgeons Adequately Compensated? An Analysis of Relative Value Units

Abstract

Background:

Gender-affirming surgery (GAS) has a complicated history within US health care. As GAS procedures and reimbursement availability continue to uptrend, the present study aims to investigate whether compensation is equitable between GAS procedures and general plastic surgery procedures.

Methods:

The National Surgical Quality Improvement Program database was queried for all surgeries performed by plastic surgeons from 2016 to 2020. Cases were assigned to the GAS or non-GAS cohort using ICD-10 codes. Duplicate Current Procedural Terminology (CPT) codes were removed for analysis. Operative time, total wRVUs, wRVUs per hour (wRVU/h), reoperation/readmission rate, and number of concurrent procedures were compared between the cohorts.

Results:

A total of 132,319 non-GAS and 3,583 GAS were identified. After duplicate CPT removal, 299 cases (21 unique CPTs) remained in the GAS cohort and 20,022 (37 unique CPTs) in the non-GAS cohort. Operative time was higher in the GAS cohort (262.9 vs 120.7 min, P < 0.001), as were total wRVUs (59.4 vs 21.6, P < 0.001). Reoperation/readmission rate (7.0% vs 6.0%) and wRVU/h (15.8 vs 15.1) were not significantly different (all P > 0.05). There was a positive correlation between total operative time and total wRVUs (P < 0.001) and a negative correlation between total operative time and wRVU/h (P < 0.001).

Conclusions:

Proportional wRVUs are allocated to gender affirming plastic procedures. However, the RVU scale does not allocate proportional wRVUs to longer operative times for both GAS and general plastic surgeries. Compensation for gender affirming plastic surgeries is higher than that of general plastic surgeries; however, there is no difference in wRVUs per hour on comparison.

The World Professional Association for Transgender Health published their Standards of Care in 2012, ascribing medical necessity to gender-affirming surgery (GAS) as part of the psychological and medical treatment for transgender and gender diverse (TGD) patients.¹ In the United States, demand for GAS has increased yearly since 2000, largely due to professional recommendations and insurance nondiscrimination laws.^2,3 Within the field of plastic surgery, gender affirming surgeries are becoming more prominent with more and more plastic surgery programs offering specialization and fellowship,^4,5 although there is increasing need for gender affirming surgical training.⁶

The American Medical Association’s Specialty Relative Value Scale Update Committee (also known as the “RUC”) assigns and revises work relative value units (wRVUs) for all of the commonly performed procedures in the United States.⁷ Work RVUs are meant to encompass value for the physician’s time, skill, and intensity of work, and both commercial and public payers use the wRVU to determine physician reimbursement rates. While the payment per work relative value unit allows for standardization when comparing procedures of differing complexity, the actual work relative value units vary from procedure to procedure. This may open a discussion on the appropriateness of the assigned value units for certain procedures, as compared with others.

As wRVUs are meant to represent physicians’ work and assign fair compensation, study is needed to ensure that surgeons performing GAS are compensated fairly, both to incentivize plastic surgeons to perform these procedures, and to ensure that gender-affirming care is receiving equitable allocation of value. As the volume and scope of GAS expands within the field of plastic and reconstructive surgery, this study aims to investigate whether compensation is equitable for plastic GAS procedures when compared with general plastic surgery procedures.

MATERIALS AND METHODS

Database

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was utilized to identify all cases performed by plastic surgeons between 2016 and 2020. The NSQIP database is nationwide and collects data from more than 700 participating hospitals in the United States. Data is entered by trained surgical reviewers on 135 retrospectively reviewed clinical variables. The dataset contains Health Insurance Portability and Accountability Act (HIPAA) compliant variables which can be accessed at the NSQIP Website (http://www.acsnsqip.org/). Because of the public availability and deidentified nature of this database, this study was deemed exempt by the International Review Board.

The NSQIP database was queried for all cases in which the primary procedure was performed by plastic surgeons. Cases were excluded if they were missing wRVU or operative time data. Procedures that were reimbursed less than 1 wRVU or had operative time of zero were also excluded as these do not represent a typical plastic and/or GAS procedure. Gender-affirming surgery procedures were identified by postoperative diagnosis relating to “gender identity disorders” (International Classification of Disease codes Z87.890, F64, F64.0, F64.1, F64.2, F64.8, F64.9, F66.0), as previously described.⁸ Cases without this designation were placed in the general plastics (non-GAS) cohort if they were performed over 200 times in the 4 year study period, as this is more representative of a typical plastic surgery procedure. The cohorts were then assessed for duplicate Current Procedural Terminology (CPT) cases and these cases were removed.

Statistical Analysis

The primary outcome measure assessed was wRVU/h. This was calculated by summing the total assigned wRVUs for the primary and concurrent procedures and dividing by the operative time in hours. Work RVU data within the NSQIP database is obtained from the 2020 US Centers for Medicare and Medicaid Services (CMS) fee schedule. wRVUs were converted into estimated reimbursement rates using the 2020 CMS RVU dollar conversion factor of $36.09 per RVU. Secondary outcome measures included demographic characteristics, operative time, Common Procedural Terminology codes, data on concurrent procedures, reoperations, and readmissions. These data were compared between cohorts using Welch t-tests and χ² tests. Univariate regression was utilized to compare wRVU and wRVU/h with operative time. Significance was set at α = 0.05 for all tests.

RESULTS

A total of 132,902 cases were identified, 132,319 non-GAS and 3,583 GAS. After removing duplicate CPT codes (Supplemental Table 1, http://links.lww.com/SAP/A926), 299 cases remained in the GAS cohort and 20,022 in the non-GAS cohort. There were 21 unique CPT codes in the GAS cohort and 37 unique CPT codes in the non-GAS cohort (Table 1). Operative time was significantly higher in the GAS cohort (262.9 vs 120.7 minutes, P < 0.001), as were total wRVUs (59.4 vs 21.6, P < 0.001), and number of concurrent procedures (1.5 vs. 1.2, P < 0.001). Reoperation/readmission rate (7.0% vs 6.0%) and wRVU/h (15.8 vs 15.1) were not significantly different when comparing GAS to non-GAS procedures (all P > 0.05). However, the average reimbursement was significantly higher in the GAS cohort ($2,143.56 ± 1,208.70 vs $781.23 ± 763.39, P < 0.001) (Fig. 1).

TABLE 1.

Comparison of GAS and non-GAS procedures

With Duplicate CPT Codes Removed	GAS Procedures	Non-GAS Procedures	P
No. Cases (n)	299	20,022	—
No. CPTs (n)	21	37	—
Operative time (min)	262.9 ± 120.7	120.7 ± 133.3	<0.001
Total wRVUs	59.4 ± 21.6	21.6 ± 21.2	<0.001
Reimbursement	2143.56 ± 1208.70	781.23 ± 763.39	<0.001
wRVU/h	15.8 ± 11.1	15.1 ± 29.5	0.312
No. concurrent procedures	1.5 ± .9	1.2 ± 0.6	<0.001
Reoperation/readmission rate (n, %)	21 (7.0%)	1211 (6.0%)	0.483
Duplicate CPT codes included
No. cases	3583	132,319	—
No. CPTs (n)	66	88	—
Operative time (min)	158.9 ± 93.4	161.3 ± 134.5	0.893
Total wRVUs	31.6 ± 24.5	31.7 ± 23.7	<0.001
Reimbursement	$1140.44 ± 884.21	$1144.05 ± 855.33	<0.001
wRVU/h	13.3 ±9.5	15.7 ± 18.1	0.146
No. concurrent procedures	1.2 ± 0.7	1.4 ± 1.0	<0.001
Reoperation/readmission rate (n, %)	117 (3.3%)	7283 (5.5%)	<0.001

FIGURE 1.

Distribution of Reimbursement for GAS and non-GAS procedures.

There was a positive correlation between total operative time and total wRVUs (P < 0.001) and a negative correlation between total operative time and wRVU/h (P < 0.001) for both GAS and non-GAS procedures (Table 2). Regression analysis found that an additional 0.106 wRVUs were added for each additional minute of operative time for GAS procedures, and an additional 0.107 wRVUs for each additional minute of operative time for non-GAS procedures. For each additional minute of operative time, the wRVU/h decreased by 0.04 for GAS procedures and decreased by 0.03 for non-GAS procedures.

TABLE 2.

Univariate Regression of wRVU and wRVU/h vs. Operative Time

With Duplicate CPT Codes Removed		B	95% Confidence Interval		P
wRVUs	Operative time (non-GAS)	0.107	0.106	0.109	<0.001
	Operative time (GAS)	0.106	0.077	0.135	<0.001
wRVU/h	Operative time (non-GAS)	−0.03	−0.033	−0.026	<0.001
	Operative time (GAS)	−0.04	−0.05	−0.031	<0.001
Duplicate CPT codes included
wRVUs	Operative time (non-GAS)	0.104	0.104	0.105	<0.001
	Operative time (GAS)	0.145	0.137	0.152	<0.001
wRVU/h	Operative time (non-GAS)	−0.035	−0.036	−0.034	<0.001
	Operative time (GAS)	−0.025	−0.028	−0.022	<0.001

DISCUSSION

Designation of wRVUs was established to standardize and fairly compensate physicians based on time and effort for any given procedure.⁷ It follows that changes in wRVU have the greatest potential to affect physician reimbursement.⁹ This is especially true for gender affirming surgeons, as the coverage of these procedures by insurance companies has been historically controversial. Notably, several states added Medicaid coverage for gender affirming care and Medicare lifted its ban on GAS in 2014.¹⁰ Two years later, in 2016, the Department of Health and Human Services ruled that the Affordable Care Act prohibited discrimination based on gender identity in federally funded insurance plans.¹¹ Similar changes were made at the state level in this year and the years that followed.¹² As equity in insurance coverage has been advocated, physicians should be aware of potentially undervalued surgeries in support of a system that is appropriate and fair.

The present study is the first to investigate gender affirming surgeon reimbursement based on work RVUs as compared with those of general plastic surgeons. The data herein demonstrate a positive correlation between operative time and wRVUs generated, although wRVU per unit time decreased for longer and more complex cases (Table 2). This was true for both GAS and non-GAS procedures. Past studies have shown that wRVUs largely correlate with operative time, without necessarily taking complexity into account.^13–15 While there were no differences between the cohorts in this regard, the present findings suggest that the wRVUs require updates to adequately represent surgeon effort and operative complexity, as originally intended.⁷

Transgender and gender diverse patients have a long history of discrimination both within medicine and larger society.^16–18 A recent study uncovered a nationwide shift in the GAS primary payer from self-pay to private or federally funded insurance after favorable policy changes in 2016.¹⁹ However, patients still incur great out-of-pocket costs, as medical practices specializing in comprehensive gender affirming care are often in urban centers, requiring many patients to travel out of state.²⁰ As insurance coverage expands, equitable reimbursement should be offered to surgeons performing GAS procedures to ensure incentivization, and not contribute to barriers in care for TGD patients. The present study does show that overall, GAS procedures generated higher total wRVUs and subsequently higher compensation. However, GAS procedures were found to take longer than general plastic procedures. It should be noted that equitable wRVU per unit time was found for both GAS and non-GAS cases.

The present study is not without limitations. There are many variables that contribute to the allocation of wRVUs to each CPT, other than operative time and complication rates. Many of these factors are subjective and not easily quantified. This analysis was limited by the variables reported in the NSQIP database. Further, data was collected on the database from 2016 to 2020, and the wRVU values were collected from the 2020 CMS fee schedule. The use of different years was done to reflect the most current reimbursement rates reflected in the data. Although updates in surgical procedures may change operative times, it was assumed that operative time for most of these plastic surgery procedures did not significantly change in the four-year study period. In addition, not all private insurers participate in the wRVU system. The present study therefore cannot capture the variability in coverage and compensation for these types of insurers. Gender affirming care is often multidisciplinary and can often take place in private practices with a comprehensive medical care team. Such institutions are not represented in NSQIP and may limit the numbers of cases and CPTs included for analysis.

As GAS is a broad surgical field that quite often involves a multidisciplinary team of medical and surgical physicians, our results should prompt further comparison of reimbursement rates among other surgical specialties such as otolaryngology, urology, gynecology, and general surgery. Further, this study shows that plastic surgeons (both GAS and non-GAS) may not be adequately compensated for time spent in the operating room. Surgeons should be aware of these discrepancies to appropriately advocate for changes in this system.

CONCLUSIONS

The present study is the first to examine reimbursement trends within the subspecialty of gender affirming surgery as compared with general plastic and reconstructive surgery.

The 2020 Physician wRVU scale does allocate proportional wRVUs to gender affirming plastic procedures. The total compensation for gender affirming plastic surgeries is higher than that of general plastic surgeries, however there is no difference in compensation per unit time on comparison. However, the current wRVU scale does not allocate proportional wRVUs to longer operative times for both GAS and general plastic surgeries, and these surgeons may not be adequately compensated for time spent in the operating room.