Outpatient dermatology clinic half days with more women, racial minority, and younger patients generate fewer work relative value units : International Journal of Women's Dermatology

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Outpatient dermatology clinic half days with more women, racial minority, and younger patients generate fewer work relative value units

Supapannachart, Krittin J. MPHa; Wolner, Zachary MDa; Swerlick, Robert A. MDa; Orenstein, Lauren A. V. MD, MSca,*

Author Information
International Journal of Women’s Dermatology: October 2022 - Volume 8 - Issue 3 - p e048
doi: 10.1097/JW9.0000000000000048
  • Open

What is known about this subject in regard to women and their families?

  • Work relative value units (wRVU) are a measure of physician productivity tied to reimbursement, and therefore may influence physician behavior.
  • In outpatient dermatology, encounters with women generate fewer wRVU when compared with encounters with men.
  • wRVU differences may be explained by the fact that women often require fewer procedures.

What is new from this article as messages for women and their families?

  • We evaluated whether encounter length influences wRVU differences by patient sex, race, and age
  • We found that encounter length does not explain wRVU differences by patient sociodemographic characteristics.
  • This study provides further evidence that wRVU differences represent disparities in care that should be addressed through policy change.

Dear Editor,

Fewer work relative value units (wRVU) may be generated from encounters with female, racial minority, and younger patients because these populations require fewer procedures such as biopsies and cryotherapy.1,2 How medical complexity and encounter length influence wRVU differences by patient sex, race, and age is unknown.2 If encounter length accounted for more wRVU differences than discrepancies in procedures, then differences may not reflect disparities. We aimed to evaluate if differences in wRVU by patient sex, race, and age persist after encounters are grouped into 4-hour clinic half days (HD) to control for time.

Billing data for adult outpatient dermatology encounters within an academic center in Atlanta from September 1, 2016, to March 31, 2020, were reviewed. Advanced practice provider visits were included. Pediatric, Mohs surgery, and resident continuity clinics were excluded. Encounters were grouped by HD, and HDs with >50% of encounters missing patient age, race, or sex were excluded (n = 43). Clinic HDs with <6 encounters were excluded (n = 842); manual review of clinic schedules for 60 random HDs with 4–9 encounters revealed those with <6 did not represent full HDs. Associations between demographics and wRVUs per HD were characterized through mixed linear models adjusted for fixed effects of proportion of patients who were male, proportion White, and median age, and random effect of attending dermatologist. Analyses were performed with SAS 9.4 and P < 0.05 was considered significant. Emory University Institutional Review Board approved the study.

In total, 6,758 HDs were included. Patients were predominantly female (n = 36,490, 56.7%) and white (n = 39,839, 61.9%) (Table 1). HDs had a mean of 9.5 (SD, 2.1) encounters and generated a mean of 12.8 (SD, 4.3) wRVUs. In multivariable models, HDs with all male patients were associated with 1.80 (1.23–2.36) more wRVUs than HDs with no male patients. HDs with all white patients were associated with 4.03 (95% CI, 3.52–4.56) more wRVUs than HDs with no white patients. A 10-year increase in HD median age was associated with a 0.84 (0.75–0.94) increase in wRVUs (Table 2).

Table 1 - Encounter-level sociodemographic characteristics of patients seen in an academic dermatology practice from September 1, 2016, to March 31, 2020
Variable N (%)
Sex
 Male 26157 (40.7)
 Female 36490 (56.7)
 Missing 1701 (2.6)
Race
 White 39839 (61.9)
 Black 13298 (20.7)
 Asian 2324 (3.6)
 Other 660 (1.2)
 Missing 8227 (12.8)
Median (interquartile range)
Age (years) a , b 57.0 (49.0–63.0)
aMedian patient age at encounter for all encounters; individual patients with multiple encounters have multiple datapoints
bThere were no missing data for patient age

Table 2 - Crude and adjusted associations between work relative value units generated during dermatology clinic half-day sessions and demographic mix of patients
Unstandardized beta coefficients (95% confidence interval)
Variable Crude a Adjusted a , b
Proportion of male patients 4.17 (3.60–4.73) 1.80 (1.23–2.36) c
Proportion of white patients 5.97 (5.48–6.46) 4.03 (4.02–5.11) d
Median age (per 10-year increase) 1.17 (1.07–1.26) 0.84 (0.75–0.94) e
aAll p < .05.
bAdjusted for fixed effects of median age, proportion of whites, and proportion of males, and random effect of provider.
cThe proportion of male patients is a continuous variable. When a clinic half day has no male patients, the proportion of male patients is 0. If a half day has all male patients, the proportion of male patients is 1. Therefore, if the proportion of male patients increases by 1 unit (from 0 to 1) we expect a corresponding 1.80 increase in work relative value units generated per half day. The estimated increase in work Relative Value Units accounts for potential confounding by age, race, and provider.
dThe proportion of white patients is a continuous variable. When a clinic half day has no white patients, the proportion is 0. If a half day has all white patients, the proportion of white patients is 1. Therefore, if the proportion of white patients increases by 1 unit (from 0 to 1) we expect a corresponding 4.03 increase in work relative value units generated per half day. The estimated increase in work relative value units also accounts for potential confounding by age, sex, and provider.
eMedian age is a continuous variable that was divided by 10 to increase ease of interpretation. If the median age increases by 10 years (from 40 to 50 years), we expect a corresponding 0.84 increase in work relative value units generated per half day. The estimate increase in work relative value units also accounts for potential confounding by race, sex, and provider.

Clinic HDs with more male, white, and older patients generated more wRVUs. If encounter length explained wRVU differences, then time equivalent HDs should generate similar total wRVUs regardless of patient demographics.1 Our findings support the hypothesis that procedures generate more wRVU per unit time than cognitive services, which may disincentivize physicians from caring for conditions more prevalent in female, racial minority, and younger patients.1 Increasing wRVUs generated for cognitive services may mitigate disparities in care.3,4 Study limitations included lack of encounter length data, preventing time-motion analyses to characterize associations between wRVU and encounter length.5 Despite manual review of random HD, encounters could have been miscategorized into wrong HDs. Missed clinic appointments were not accounted for.

Clinic HDs with higher proportions of male, white, and older patients were associated with increased wRVUs. Assuming equal length HDs, encounter length likely does not explain wRVU differences by patient sex, race, and age. Future studies should evaluate how 2021 changes to the Center for Medicare & Medicaid Services billing guidelines have impacted wRVU differences by patient sociodemographic characteristics in outpatient dermatology.

Conflicts of interest

The authors made the following disclosures: L.A.V.O.: advisory boards—ChemoCentryx and Novartis; grant funding—Pfizer; paid investigator—ChemoCentryx. There are no other conflicts of interest to disclose.

Funding

None.

Study Approval

The study was approved by the Emory Institutional Review Board (Protocol no. 00114867).

References

1. Orenstein LA, Nelson MM, Wolner Z, et al. Differences in outpatient dermatology encounter work relative value units and net payments by patient race, sex, and age. JAMA Dermatology 2021;157:406–412.
2. DeMeester RH, Xu LJ, Nocon RS, et al. Solving disparities through payment and delivery system reform: a program to achieve health equity. Health Affairs 2017;36:1133–1139.
3. Lê Cook B. Effect of Medicaid Managed Care on racial disparities in health care access. Health Services Res 2007;42:124–145.
4. Wang L, Adelekun A, Taylor S, et al. Fee-for-service and structural forces may drive racial disparities in US dermatology. Br J Dermatol 2020;183:750–751.
5. Penneys NS, Glaser DA. The incidence of cancellation and nonattendance at a dermatology clinic. J Am Acad Dermatol 1999;40:714–718.
Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Women’s Dermatologic Society.