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The price of acute care surgery

Sweeting, Raeshell S. MD; Carter, Jeffrey E. MD; Meyer, Anthony A. MD, PhD; Rich, Preston B. MD, MBA

Journal of Trauma and Acute Care Surgery: May 2013 - Volume 74 - Issue 5 - p 1239–1245
AAST 2012 Plenary Papers

BACKGROUND: Numerous organizations have identified access to emergency surgical care as a crisis. One barrier is the financial disincentive associated with caring for this patient population. We sought to identify contributing factors by analyzing endemic data during the development of an acute care surgery (ACS) service at an academic health care system.

METHODS: Financial data (receipts, payer mix, and dollar/relative value unit [RVU]) and productivity measures (OR procedures and RVUs) were obtained for a surgical division for 6-month periods before and after transition to an ACS model. Using national data, a sensitivity analysis was performed to identify salary targets required for an ACS surgeon to have equitable career reimbursement using standard financial modeling (net present value) with comparable surgical specialists.

RESULTS: Post-ACS, operative volume increased 25%, work RVUs increased 21%, but net receipts increased only 11%. Dollar/RVU decreased primarily due to a higher proportion of uncompensated care. As a result, the dollar/RVU for ACS patients was 28% lower in comparison to non-ACS specialties. Increasing ACS salaries proportionate to the observed dollar/RVU discount realigned ACS economic value with other specialties in aggregate.

CONCLUSION: A national shortage of ACS surgeons exists due to in part financial misalignment. We demonstrated that despite an increase in clinical activity, transition to an ACS model resulted in a relative reduction in payment. A rational systems-based approach to ACS development that objectively targets the RVU reimbursement disparity would reduce economic disincentives related to careers in ACS and potentially address the emergency surgical care crisis.

From the University of North Carolina at Chapel Hill.

Submitted: October 27, 2012, Revised: January 22, 2013, Accepted: January 22, 2013.

This study was presented at the American Association for the Surgery of Trauma Annual Meeting, September 12–15, 2012, in Kauai, Hawaii.

Address for reprints: Preston B. Rich, MD, Division of Trauma and Critical Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7228; email:

© 2013 Lippincott Williams & Wilkins, Inc.