Relative value units and payer mix analysis of facial trauma coverage at a level 1 trauma center: Is the current model sustainable?

Relative value units and payer mix analysis of facial trauma coverage at a level 1 trauma center: Is the current model sustainable? Mohamed F. Osman, MD,a,b Reginald F. Baugh, MD,b Aaron D. Baugh, MD,b Marlene C. Welch, MD, PhD,b Joseph J. Sferra, MD, FACS,c and Mallory Williams, MD, MPH,b Boston, MA, and Toledo, OH Purpose. We aimed to approximate the annual clinical work that is performed during facial trauma coverage and analyze the economic incentives for subspecialty surgeons providing the coverage. Methods. A retrospective, clinical productivity data analysis of 6 consecutive years of facial trauma coverage at an American College of Surgeons–verified Level I trauma center was performed by the use of a trauma database and relative value unit (RVU) data. A payer mix analysis also was completed. SPSS V19 was used for analysis. Results. Between 2006 and 2011, 526 patients were treated for facial injuries. The annual nonoperative RVUs ranged from 371 to 539, whereas the annual operative RVUs range was 235–426. Trend analysis displayed that most of the annual RVUs were nonoperative until the year 2011, when the operative RVUs surpassed the nonoperative. Payer mix analysis revealed that commercial insurance coverage was the most common (range 21–54%, median 41%) followed by self-pay coverage (18–32%, median 29%). This finding was a consistent phenomenon except in the year 2009, when self-pay covered the majority of the RVUs (32%). Nasal bone fractures (24%) and mandibular fractures (16%) were the two most common diagnoses. Open reduction and internal fixation of mandibular fractures (17%), open reduction and internal fixation orbital bone fractures (15%), and complex facial repair (12%) constituted the most common operative procedures. Facial trauma consultations were obtained 22% (16–24%) of covered days. The percent of days requiring emergency procedures was (0.5–1%). Conclusion. The infrequency of subspecialty consultations and operative interventions, and significant payer mix differences between facial trauma patients relative to the current ambulatory surgery population of the covering subspecialties poses economical challenges for both the hospitals and providers that use the traditional coverage models. (Surgery 2014;j:j-j.) From the Brigham and Women’s Hospital, Harvard Medical School,a Boston, MA; University of Toledo College of Medicine,b and ProMedica Health System/The ProMedica Toledo Hospital,c Toledo, OH AMERICAN COLLEGE OF SURGEONS (ACS)-verified trauma centers improved clinical outcomes in injured patients.1-3 At least one in each five patients cared for in ACS-verified trauma centers will have facial trauma. An essential component of trauma The study was supported by the Department of Surgery at the University of Toledo College of Medicine. Presented at the Central Surgical Association 2014 Annual Meeting in Indianapolis, IN, March 8, 2014. Accepted for publication June 23, 2014. Reprint requests: Mohamed F. Osman, MD, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail: Mohamed.Osman@UToledo.edu. 0039-6060/$ - see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.06.046 care at Level I centers is subspecialty operative coverage for facial trauma.4 Call coverage for facial trauma usually is shared by several subspecialties, including oral and maxillofacial surgeons, otolaryngologists, and plastic surgeons. In the United States, recent observed trends have identified a decrease in emergency department (ED) coverage for facial trauma.5,6 The demanding and irregular hours, poor compensation/reimbursement by third-party payers, competing clinical activities, and the lack of insurance coverage by a large percentage of the trauma population are major deterrents for many subspecialty surgeons to dedicate their time toward this discipline.5,6 As physician reimbursement models continue to change and payment for subspecialty call coverage remains highly variable,7 a thorough analysis of both the work performed by SURGERY 1 2 Osman et al these subspecialty surgeons and the economics of the call coverage (both for the hospital and the surgeon) is required to determine the long-term feasibility of providing this call coverage using the traditional subspecialty models. Furthermore, a weak economic incentive model for maxillofacial subspecialty coverage threatens both trauma center viability and expansion. Specifically within the current ACS Committee on Trauma definition of Level I trauma care, trauma center structure, operations, and capability are threatened. Therefore, in this study, we performed a relative value unit (RVU) analysis of facial trauma coverage at an ACSverified Level I trauma center. Our goals were to evaluate the annual in-hospital clinical work that is performed during facial trauma coverage and quantify the economic incentives for subspecialty surgeons providing the coverage. METHODS A retrospective RVU analysis of 6 consecutive years of maxillofacial trauma coverage at the University of Toledo Medical Center (UTMC), an ACS-verified, Level I trauma center, was performed by the use of a trauma database and calculated RVUs. The trauma database includes all trauma patients admitted to UTMC and is quality assured for accuracy with daily admission logs from the hospital ED and all inpatient services. All maxillofacial trauma subspecialty coverage services’ patients are admitted to the trauma service, and admissions for outpatient surgery are listed on daily inpatient admission logs that are screened by the trauma program manager. During the period of January 1, 2006, to December 31, 2011, a total of 526 patients with facial injuries were entered into the UTMC trauma database. The following patient data were collected: mechanism of injury, type of injury (location and concomitant injuries), length of stay, International Classification of Diseases, Tenth Revision, codes, operative procedure and their Current Procedural Terminology codes, and payer source. Trauma care process data also were extracted, including subspecialty coverage of specific injuries, number of consultation days, type of consultation (routine vs emergent), time of consultation performance, and days with operative procedure. Using the January 2013 Revision file, we used the resource-based relative value scale (RBRVS) to translate each scheduled Current Procedural Terminology code into RVUs.8 A descriptive analysis of the data was performed. SPSS V19 (SPSS Institute, Chicago, IL) was used for analysis. Because of the lack of recent published data on the Surgery j 2014 Fig 1. Operative versus nonoperative relative value units (RVUs). numbers and incidences of facial trauma cases among ACS-verified trauma centers, these values were extracted from the National Trauma Data Bank for the years 2008–2013. RESULTS The total number of facial trauma patients was 526, with a hospital-based incidence rate of 7%. The maxillofacial trauma coverage in our institution was provided by maxillofacial surgeons 50%, plastic surgeons 25%, and otolaryngologists 25%. From 2006 to 2011, the total RVUs were 4564, ranging annually between 579 and 874 with an average of 760 RVUs per year (2 RVUs/day). The annual operative RVUs range was 235–426 with an average of 309. The annual nonoperative RVUs ranged from 371 to 539 with an average of 452 (Fig 1). Trend analysis displayed that most of the annual RVUs were nonoperative until the year 2011, when the operative RVUs (426) surpassed the nonoperative counterpart (370), Table I. Payers’ data analysis revealed that the commercial insurance coverage (range 21–54%, median 41%) was the most common, followed by self-pay coverage (18–32%, median 29%; Fig 2). This finding was a consistent phenomenon except in the year 2009 when self-pay covered the majority of the RVUs. Medicare coverage was (7–27%, median 17%), whereas Medicaid coverage was (8– 19%, median 17%), Table I and Table II. Open reduction and internal fixation of mandibular fractures (17%), open reduction and internal fixation orbital bone fractures (15%), and complex facial repair (12%) constituted the most common operative procedures for maxillofacial trauma patients. Nasal bone fractures (24%), mandibular fractures (16%), and facial lacerations (14%) represented the most common diagnoses in our patient population (Table III). Osman et al 3 Surgery Volume j, Number j Table I. RVUs and payer mix Insurance status of patients, % Year Total RVUs Nonoperative RVUs Operative RVUs Commercial Medicare Medicaid Self-pay 2006 2007 2008 2009 2010 2011 874.03 817.59 731.04 765.42 579.11 796.69 539.20 512.24 431.36 512.24 343.74 370.70 334.83 305.35 299.68 253.18 235.37 425.99 54 51.42 40.45 21.87 38.71 41.66 7 8.57 13.48 27.08 27.42 21.43 8 8.57 19.10 18.75 16.13 17.86 31 31.44 26.97 32.29 17.74 19.05 RVU, relative value unit. Fig 2. Payers’ trend analysis. Subspecialty coverage for facial trauma was available 24 hours a day, 7 days a week. Consultations were needed on an average of 22% (16–24%) of covered days. The number of days with emergency procedures was 2–4 days/year (0.5–1%), Table IV. DISCUSSION The creation of trauma centers and trauma programs has been shown to have positive impact on outcomes in the management of severely injured patients.1-3 The clinical capability of managing complex facial injuries is essential for Level 1 trauma verification by the ACS4; however, maintaining a Level I trauma center is a resource-intense institutional effort that requires the commitment of subspecialty surgeons. Trauma care is associated with low reimbursement by federal agencies, placing an economic burden on major trauma centers in the United States.9-13 So far in the medical literature, analyses of financial data have been limited to studies that compared economic outcomes of different treatment strategies for mandible and isolated midface fractures14-19; however, there is no systematic economic analysis that describes the underlying economic incentives for specific subspecialties to invest the needed commitment. Current subspecialty coverage models provide a stipend or mandate call coverage as a part of staff privileges. This call coverage mandate may informally expire with seniority in larger trauma centers and is assumed by younger subspecialty surgeons. There are no published data that analyze the cost of providing subspecialty call coverage to the hospital or to the surgeon. Both changes to physician reimbursement and lean management policies have made these types of data essential. Assuming that subspecialty coverage will continue under the current models may understate the challenges facing trauma centers in the future. Our institution has been an ACS-verified, Level 1 trauma center all through the 6 years of study time and facial trauma is covered by maxillofacial surgeons, plastic surgeons, and otolaryngologists. At UTMC, most of the coverage was provided by maxillofacial surgeons (50%), and the rest was equally shared by otolaryngologists and plastic surgeons. Recent national survey of 57 Level I trauma centers indicates that plastic surgeons are responsible for 40% of the subspecialty call coverage for facial trauma followed by maxillofacial surgeons (36%), and otolaryngologists (23%).20 Each of these specialties’ participation in trauma care is usually secondary to robust consultative and outpatient practices. Hence, the management of trauma patients usually is not the primary focus or motivation of these subspecialties, particularly the call coverage, which can interfere with both elective surgery and clinic schedules. Recent survey data of 1,300 otolaryngologists, 85% of respondents participated in trauma call coverage revealed that only 36% of those surveyed would increase their volume of maxillofacial trauma if reimbursement improved.21 A sense of duty was the number one reason for respondents participating in trauma call coverage.21 Although admirable, this is certainly not an economic strategy or incentive model. The incidence of facial injuries occurring in conjunction with major trauma was shown in 4 Osman et al Surgery j 2014 Table II. Payer mix analysis Nonoperative RVUs, N, % Year Commercial 2006 2007 2008 2009 2010 2011 283 270 196 182 162 148 (53%) (53%) (45%) (36%) (47%) (40%) Medicare 34 74 54 101 74 94 (6%) (14%) (13%) (20%) (22%) (25%) Operative RVUs, N, % Medicaid 34 47 81 94 47 61 (6%) (9%) (18%) (18%) (14%) (16%) Self-Pay 189 121 101 135 61 67 (35%) (24%) (23%) (26%) (18%) (18%) Commercial 205 140 133 156 94 217 (61%) (46%) (45%) (62%) (40%) (51%) Medicare 47 12 44 38 15 95 Medicaid (14%) (4%) (15%) (15%) (6%) (22%) 44 17 40 26 33 88 Self-Pay (13%) (5%) (13%) (10%) (14%) (21%) 39 137 83 34 95 26 (12%) (45%) (28%) (13%) (40%) (6%) RVU, Relative value unit. Table III. Frequent diagnosis and procedures Year 2006 2007 2008 2009 2010 2011 Three most frequent ICD codes Nasal bone Frx Facial Lac Mandibular Frx Nasal bone Frx Facial Lac Mandibular Frx Nasal bone Frx Orbital bone Frx Mandibular Frx Orbital bone Frx Facial Lac Mandibular Frx Nasal bone Frx Zygomatic bone Frx Mandibular Frx Nasal bone Frx Orbital bone Frx Mandibular Frx Table IV. Work intensity Three most frequent CPT codes ORIF mandible ORIF orbital bone Complex repair facial ORIF mandible ORIF orbital bone Complex repair facial ORIF mandible ORIF orbital bone Complex repair facial ORIF mandible ORIF orbital bone Complex repair facial ORIF mandible ORIF orbital bone Complex repair facial ORIF mandible ORIF orbital bone Complex repair facial Year Lac Lac Lac Lac Lac Lac CPT, Current Procedural Terminology; Frx, fracture; ICD, International Classification of Diseases; Lac, laceration; ORIF, open reduction and internal fixation. several surveys that ranged from 34% of 87,174 trauma patients in a North American Database on Trauma to 15% of 1,088 trauma patients in Liverpool, and 25% of 802 trauma patients in London.22-24 Extracted from the National Trauma Data Bank from 2008 to 2013, the incidence of facial trauma has ranged between 14 and 25%, with an average of 22.6% (Table V). The rate of facial injury within our trauma population was 7%, which is substantially less than the rates previously reported in the literature. This finding should not impact the overall annual RVU data presented here because the actual facial trauma volume presented is comparable to similar ACS-verified centers reported in National Trauma Data Bank. Moreover, the numbers presented here are absolute RVUs and no denominator effect included. It would be an oversimplification to suggest the 2006 2007 2008 2009 2010 2011 Consultations/day Days with no Days with emergent of coverage consultations operation 84 87 82 85 58 78 (23%) (24%) (22%) (23%) (16%) (21%) 281 278 284 280 305 288 (77%) (76%) (78%) (77%) (84%) (79%) 2 4 2 2 4 4 (0.5%) (1.1%) (0.5%) (0.5%) (1.1%) (1.1%) Table V. Incidence of facial trauma from NTDB annual reports Year No. facial trauma cases Percent 2008 2009 2010 2011 2012 2013 127,751 155,848 178,352 170,821 182,671 201,013 25.22 24.82 14.06 23.63 23.62 24.12 NTDB, National Trauma Data Bank. RVU data presented in this study are attributable to the fact that there are 3 ACS-verified, Level I trauma centers in Toledo. In fact, an informal review of operative volume in facial trauma at the two other centers revealed similar numbers. Most previous epidemiologic studies have found that the most common site of facial injury to be the mandible.25-27 A 5-year review of facial fractures from Canada by Hogg et al28 noted an excess of mandibular fractures over zygomatic and maxillary fractures with a ratio of 6:2:1; however, a nationwide administrative data based study by Allareddy et al29 have shown that 50% of visits to the ED with facial fractures were associated with fractures of the nasal bone. The facial injuries pattern in our trauma population was consistent over the 6 years, with nasal bone fractures (24%) and mandibular fractures (16%) the two most common diagnoses. The cause of this contrast in Surgery Volume j, Number j Fig 3. Payers trends for nonoperative relative value units (RVUs). Fig 4. Payers trends for operative relative value units (RVUs). incidence is unclear, but one explanation could be related to the inclusion criteria. Although previous studies have included facial fracture patients after admission to a hospital, our study and ED population-based studies included all patients who presented to EDs with facial trauma. Moreover, nasal fractures only need to be corrected when there is a functional or esthetic defect, and it may be that many of the nasal fractures presenting to an ED may not require inpatient hospitalization. Since the Health Care Financing Administration introduced the RBRVS in 1992, it has become the prevailing model to describe, quantify, and reimburse physician services. Medicare, Medicaid, and many private insurance companies use the RBRVS to determine payment for physician services, and many practices and institutions use RVUs to track physician productivity and evaluate job performance.8 Our facial trauma RVU data analysis revealed that the majority of the RVUs were from nonoperative clinical work, a finding that reflects on the relatively lower rate of procedures needed in caring for this subset of trauma victims (Figs 3 and 4). Over the study 6 years period the total RVUs were 4,564, ranging annually between 579 and 874 with an average of 760 RVUs per year. This equals to 2 RVUs/day, an absolute Osman et al 5 number that highlights the lesser financial yield and hence economic drive. Our analysis shows that facial trauma subspecialty consultations were obtained in only 22% (16–24%) of covered days. Moreover the emergency procedures needed only in 0.5–1% of the time. These findings materialize significant challenges to both the hospitals ability to justify providing financial support for subspecialty call coverage and the surgeons’ ability to both remain highly skilled at providing operative trauma services and rationalize the allocation of their time. A concern with maintenance of skill levels is revealed in a survey of ear-nose-throat surgeons who specifically stated ongoing clinical education in trauma as heavily needed.21 A recent analysis based on the Nationwide Emergency Department Sample of the Healthcare Cost showed that 26.4% of those who presented to an ED with facial fracture were uninsured and only 37.5% of those who presented with facial fractures had private health insurance.29 Our payers mix analysis revealed that commercial insurance coverage was the most common (range 21–54%, median 41%), followed by self-pay coverage. This is not typical of most ACS-verified trauma centers, which consistently had average of 21% commercial coverage over the last 6 years. However, even with a facial fracture population with a superior payer mix to most other trauma centers, the payer mix is substantially inferior to the ambulatory practices of the covering subspecialists. A close look at the trend analysis reveals that there is more year-to-year variability in the contribution of the commercial and self-pay groups compared with the relatively stable contribution in the Medicare and Medicaid groups. Comparing these data with the outpatient private practices of the subspecialty surgeons makes the relatively high commercial insurance coverage in this cohort of trauma patients still appear less desirable from the perspective of the subspecialty surgeon. Our subspecialty surgeons’ private practice payer sources are 82% commercial and 15% Medicare. Therefore, operative or nonoperative time spent in trauma coverage is inefficient for these surgeons. This study is a retrospective descriptive analysis from a single Level 1 trauma center. To our knowledge, this is the first report on RVU and payer mix analysis of subspecialty facial trauma coverage. The observations in this study challenge the sustainability of the current coverage models and could potentially undermine the quality of facial trauma care in trauma centers unless a more comprehensive and effective solutions to on-call 6 Osman et al coverage are entertained. This study highlights the critical situation of the economic incentives and sustainability of subspecialty trauma coverage. The infrequency of subspecialty consultations and operative interventions needed in the coverage of facial trauma challenges the longterm feasibility of providing this coverage using the traditional subspecialty models. Further studies are needed to assess the reproducibility of this data and to further characterize the facial trauma work load in different regions of the country. This research is essential to understanding the sustainability of current level I trauma care in the context of health care reform and payment innovation. REFERENCES 1. Sampalis JS, Lavoie A, Bookas S, et al. 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Henry MC, Thode HC Jr, Shrestha C, Noack P. Inadequate hospital reimbursement for victims of motor vehicle crashes due to health reform legislation. Ann Emerg Med 2000;35:277-82. 13. Lanzarotti S, Cook CS, Porter JM, et al. The cost of trauma. Am Surg 2003;69:766-70. Surgery j 2014 14. Abubaker AO, Lynam GT. Changes in charges and costs associated with hospitalization of patients with mandibular fractures between 1991 and 1993. J Oral Maxillofac Surg 1998;56:161-7; discussion 167-8. 15. Azevedo AB, Trent RB, Ellis A. Population-based analysis of 10,766 hospitalizations for mandibular fractures in California, 1991 to 1993. J Trauma 1998;45:1084-7. 16. Dodson TB, Pfeffle RC. Cost-effectiveness analysis of open reduction/nonrigid fixation and open reduction/rigid fixation to treat mandibular fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:5-11. 17. David LR, Bisseck M, Defranzo A, et al. 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Maxillofacial injuries in the multiply injured. Eur J Emerg Med 1996;3:43-7. 24. Down KE, Boot DA, Gorman DF. Maxillofacial and associated injuries in severely traumatized patients: implications of a regional survey. Int J Oral Maxillofac Surg 1995;24: 409-12. 25. Imahara SD, Hooper RA, Wang J, et al. Patterns and outcomes of pediatric facial fractures in the United States: A survey of the national Trauma DataBank. J Am Coll Surg 2008;207:710-6. 26. Al-Khateeb T, Abdullah FM. Craniomaxillofacial injuries in the United Arab Emirates: A retrospective study. J Oral Maxillofac Surg 2007;65:1094-101. 27. Bakardjiev A, Pechalova P. Maxillofacial fractures in Southern Bulgaria---A retrospective study of 1706 cases. J Craniomaxillofac Surg 2007;35:147-50. 28. Hogg NJ, Stewart TC, Armstrong JE, Girotti MJ. Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada between 1992 and 1997. J Trauma 2000;49: 425-32. 29. Allareddy V, Allareddy V, Nalliah RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg 2011;69:2613-8. DISCUSSION Dr Steven Steinberg (Columbus, OH): Dr Osman and his team have performed a retrospective study looking at facial trauma care and, in particular, the ability to support a facial trauma team, at their Level 1 trauma center. They found that the clinical volume was low, about one consult every 5 days. Well less than one half of the consults resulted in an operation. RVU productivity per year was low, about 800 total RVUs per year, which is far too little to support even one physician full-time equivalent. Surgery Volume j, Number j Payer mix was not terribly abysmal for a trauma center, with 20–25% of patients being self-pay. Their implied conclusion is that the ACS should back off on their requirement that Level I trauma centers need to be able to provide facial trauma care, as that has the possibility to drive some trauma centers out of the business of trauma care. But, as Lee Corso says during his football broadcasts, ‘‘Not so fast, my friend!’’ First, the authors have given an incomplete picture of what their earnose-throat, oral and maxillofacial surgery, and plastic surgery colleagues do in their spare time when they are not operating on trauma patients. Does the rest of their practice allow them to make ends meet? We all have ‘‘loss leaders’’ in our practice, but we make up for it in other ways. Second, is this an indictment of the finances of facial trauma and ACS standards for trauma centers, or is this an indictment of the Toledo community and how it chooses to spend its resources? I have some knowledge of the trauma system in Toledo, as I live in Ohio, and have some knowledge of the status of the trauma system on the state level. Also, I will admit that I am from Toledo. As of the 2010 census, the city of Toledo had a population of 287,000, and the metropolitan area contained 651,000 people. It is the fourth most populous city in Ohio, but it has three Level 1 trauma centers, more than Cleveland, Columbus, or Cincinnati. In addition, there is another Level 1 trauma center 50 miles away in Ann Arbor, Michigan, two other Level 2 centers in northwestern Ohio, and five Level 3 trauma centers in northwestern Ohio, one of which is within the city of Toledo. I don’t know the volume of each of Toledo’s Level 1 trauma centers, but my experience tells me that Toledo does not need three Level 1 trauma centers, especially if they don’t work well with each other. Are there opportunities to share some resources, such as those surgeons who manage facial trauma, between the trauma centers in Toledo, or combine three trauma centers into two? Dr Mohamed Osman: Thank you Dr Steinberg for the comments and valuable insight. Answering the second question, in Toledo, yes, we have three Level 1 trauma centers, and we might have overcapacity in Level 1 trauma centers for the city. Toledo might have the highest Level 1 trauma per population in the world after Boston, but we believe that this observation does not explain the phenomenon that we are highlighting here, because with two RVUs per day, even if we quadruple this clinical work, it doesn’t seem to be feasible or sustainable for the coverage of Level 1 trauma centers under the current model. Osman et al 7 The other point is, with combining the trauma centers, we might have a greater number of patients but the ratio will be the same, around 7%. If we share the resources that will be hospital-centric, it may well help the hospitals, but I don’t believe it’s going to help the coverage providers, because the trauma population and practice will continue to be the same with greater risk, greater liability, and irregular compensation. That will not be an attractive solution from the provider standpoint; it might be from the hospital administrations standpoint. The first question, about the providers and what they do, we performed informal discussion, and we talked to the providers about the incentives and their opinion in different populations. We think that, with the impending payment innovation which is going to put strains on their ambulatory practices, it’s very hard to convince them to continue to be the loss leaders and to continue to take the risk and offer Level 1 traumas. Recent national review showed that sense of responsibility is the main driver for those providers to cover trauma. It’s indeed admirable, but it’s definitely not an economically viable model to sustain the coverage of trauma. Dr Charles Scoggins (Louisville, KY): I have two quick questions. First, can you tell us what percentage of your RVU data are procedure-based and what percent are Evaluation and management based? Because, as you know, a lot of trauma care involves the nonoperative management of patients, and that generates evaluation and management charges. I wonder if you’ve captured those. Second, I think the point was raised, and is very valid, that you might be, on average, getting two RVUs a day for taking care of facial trauma patients, but I suspect that folks are doing other stuff when they are not rounding on trauma patients who have a facial injury. Dr Mohamed Osman: Around two thirds of the RVUs were from nonoperative clinical work, and one third from operative clinical work. The ratio has been consistent. The two RVUs per year is a reflection of the total RVUs. Regarding the subspecialty coverage, as you know nontrauma activities for plastics and ENT surgeons is definitely more lucrative and more efficient and lower risk. Dr Timothy Pritts (Cincinnati, OH): A couple of questions. First, what is the real opportunity cost to your providers? That is, how often are they coming in at night? How often does this actually disrupt their practices? If you are looking at one consult every few days, it doesn’t seem like there’s a lot of disruption to their normal income stream and 8 Osman et al that taking trauma call really isn’t even a nuisance but a rare opportunity to do something different. Second, we’ve learned it at a trauma center far to your south. The key to all of this is really efficiency in billing and not leaving money on the table. Along those lines, how often are folks coming in at night, and how often are they billing for the lacerations that are being repaired, or the lacerations being repaired by the emergency medicine team, the trauma team, or residents that are covering the services and therefore going unbilled and you’re potentially losing those RVUs to attending-level attribution? Dr Mohamed Osman: Regarding the billing of the procedures being performed by the residents and by the ED, we don’t have specific data on that. All of our data are extracted from the trauma database which did not include such details. I agree, it would be interesting to know those numbers though. The second question about the frequency of these consultations and the procedures, approximately 24% of the time, there was consultation for facial trauma. In only half to 1% of the time, those consultations resulted in procedures. Our informal discussions with the providers, revealed a general consensus and feeling that is phenomenon was Surgery j 2014 very disruptive because of the irregularity factor. It’s hard for them to schedule a procedure at 7:00 in the morning if there is a risk of staying up all night dealing with a facial trauma patient in the operating room. So, it is more disruptive to their schedule and to their lifestyle, again with greater risk and lesser profit and lesser yield. Dr Mallory Williams (Toledo, OH): Mallory Williams, senior author on the paper. One quick comment: at the end of the day, as the trauma director there, the models and how we compensate these people don’t work. And it doesn’t matter whether you look into their lucrative practices for offsetting costs or any other models. They could spend and allocate their time concentrated in their subspecialty practices and make significantly more money. What we are raising in this article---we are not challenging, Steve, the criteria of the College that this coverage be provided. What we are simply saying is that it has to be put into an economic model that everybody can understand, and that is both workable for the hospital and for the providers, because the providers will walk when the economic downward pressures are put on their revenue cycles from their subspecialty practice.