- Email: [email protected]
Acute care surgery practice model: Targeted growth for fiscal success
Acute care surgery practice model: Targeted growth for fiscal success Matthew S. Alexander, MHA,a Chris Nelson, MD,a Jeff Coughenour, MD,a Matthew A. Levsen, CPA, MBA, FHFMA,b Carol L. Toliver, BS,b and Stephen L. Barnes, MD, FACS,a Columbia, MO
Purpose. Acute care surgery (ACS) remains in its infancy as a defined surgical specialty within hospital systems. Little has been published regarding the financial impact of this method of care delivery to hospital systems and departments when combining trauma, surgical critical care, emergent, and elective general surgery into a single practice model. We sought to compare hospital net income and divisional clinical productivity measures of a newly formed, university division of ACS based on patient type--trauma, emergency general surgery, and elective surgery---to determine the best avenues by which to focus on programmatic growth. Methods. Single calendar year, retrospective review of hospital system income and divisional fiscal productivity of specific patient visits by patient type (trauma, emergent, or elective) admitted to or discharged by the acute care surgeons. Demographic data, payor mix, patient volumes, and operative rates were determined for each patient type. Fiscal contribution by patient type to both hospital and clinical productivity were measured by hospital net income and divisional work relative value units (wRVU) production respectively. The Chi-square test for independence compared payor mix and analysis of variance was used for comparison of fiscal performance between patient types. Results. We included 1,492 patients in the analysis of calendar year 2010; 1,056 trauma (67% male; mean age, 41.9; range, 0–102), 346 emergent (53% male; mean age, 44.6; range, 15–91), and 90 elective (51% male; mean age, 46; range, 16–87) patient encounters met criteria for analysis. There were no differences in payor mix between patient types. Significant differences were seen in average per patient encounter hospital net income, divisional wRVU production and duration of stay. The ACS team (n = 3) operated on 12% of trauma patients compared with 52% of emergent and 100% of elective surgery encounters. Hospital net income per patient was greatest for trauma encounters, whereas divisional clinical productivity per patient encounter was greatest for emergent patients. Elective encounters contributed negatively to hospital margins. Conclusion. Per-patient hospital system income and a majority of clinical wRVU productivity remains greatest for the care of injured patients in our ACS practice model; emergent general surgical encounters demonstrate the greatest per-patient rates of divisional clinical productivity. (Surgery 2013;154:867-74.) From the Division of Acute Care Surgery,a Department of Surgery, University of Missouri School of Medicine, and University of Missouri Healthcare,b Columbia, MO
THE TRAUMA/CRITICAL CARE surgical subspecialty is in the midst of a professional evolution toward a more diverse model of acute care surgery (ACS) that combines traumatic, emergent, and elective surgical management.1,2 One driver of this advancement is the need to raise human resource Accepted for publication July 15, 2013. Reprint requests: Stephen L. Barnes, MD, FACS, Associate Professor of Surgery & Anesthesia, Chief, Division of Acute Care Surgery, Department of Surgery, University of Missouri, One Hospital Drive, Columbia, MO 65212. E-mail: barnesste@ health.missouri.edu. 0039-6060/$ - see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2013.07.012
interest in the field of trauma surgery, which is facing a surgeon shortage.2-4 Compared with the traditional trauma service model, ACS offers a wider range of skill sets, a preset schedule, expertise in technically challenging procedures, decreased cost of care, and increased exposure to medical students and residents for recruitment.2 Renewed interest in the field has been appreciated by recent data from resident survey suggesting ACS is gaining appeal.5 ACS increases the operative volume for the trauma surgeon with the addition of nontrauma cases, leading to improved surgeon satisfaction rates and offering a more appealing alternative to the traditional trauma framework without compromising the care of patients.6-8 Additional benefits of the ACS model are seen in SURGERY 867
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improved timeliness of care and improved patient outcomes, including duration of stay.9,10 The financial struggles of trauma centers have been well-represented in the literature. The change to a structure of fixed fee reimbursement and low-volume, high-variation disease-related groups have stunted the economic performance of the high-cost trauma field in many academic medical centers owing to shifted financial risk toward hospital systems.11 The high rate of uninsured patients in the patient population treated by an ACS model negatively affects work relative value unit (wRVU) production and enhances the challenge to correct the shortage of ACS surgeons.12 As a result, many trauma programs rely on financial support from the hospital system or Disproportionate Share Hospital governmental funds and/or tax dollars to maintain the service.4,13 Consequently, many organizations see the trauma service as a financial burden,14 whereas others find trauma care to be expensive, although fiscally rewarding.15,16 On the level of the individual provider, trauma surgeons tend to bill much less than their subspecialty colleagues considering the relative time invested in care,17 often leading to a lack of financial reward many surgeons find unappealing.3 Disunion, however, remains as the number of trauma centers continues to rise as interest in the traditional model of trauma surgery as a subspecialty declines.18,19 Despite the financial turmoil facing trauma centers nationwide, evidence has begun to accumulate suggesting that ACS programs have both financial and recruiting potential. Greater injury severity scores, emergency department admissions, and controlled durations of stay all improve organizational financial reward.16,20,21 ACS performs among the top 3 surgical subspecialties in operating room contribution margin per relative value unit,22 and offers substantial operative training for residents.23 Additionally, the ACS practice model has been found to generate a positive contribution margin despite hospital subsidies to ACS divisions to support physician salaries necessary to maintain the service,24 and has been shown to simultaneously improve productivity and job satisfaction without detriment to the elective general surgeon’s practice.8 In light of this emerging evidence, the ACS practice model makes a compelling argument for implementation. The acute care surgeon possesses broad training in elective and emergency general surgery, trauma surgery, and surgical critical care. By expanding the trauma surgeon’s range of expertise to emergent and elective surgery, acute care surgeons
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maintain their skills by operating more frequently than the traditional trauma surgeon in an age of growing, nonoperative management.25 Moreover, a widened expertise and skill base makes an acute care surgeon a very attractive asset to hospital systems. Financial data on the relatively young and more complex ACS model are scarce. Patient service revenues have shown to be insufficient at some institutions to support a division of ACS and rely on other sources of income for financial stability.26 In fact, many programs require institutional support owing to insufficient clinical revenue to cover the costs of practice and, thus, must partner with their hospital in a collaborative fashion to grow ACS programs in a fiscally responsible manner.4,12,26 The purpose of this study was to compare hospital income and measures of clinical productivity of a newly formed, university division of ACS based on patient type: Trauma, emergent, and elective surgical care. The intent is to inform decision makers and facilitate optimal strategies to focus growth and achieve departmental and institutional financial stability. METHODS The Frank L. Mitchell, Jr, MD, Trauma Center of the University of Missouri Health Care Center is an ACS-verified level I trauma center serving Central Missouri with a patient population of approximately 1.5 million. It is the only ACS-verified level I trauma center in mid-Missouri and 1 of just 3 in the state serving a diverse population of both urban and rural patients. In 2009, faculty turnover, recruitment, and departmental reorganization led to the development of the Division of Acute Care Surgery. Fellowship-trained trauma surgeons now care for all acutely injured and emergency general surgery patients on a 24/7 basis while providing simultaneously a practice of elective surgical management. The medical records of all patients managed by the ACS division physicians in calendar 2010 were reviewed. Patients included in this analysis were those admitted to or discharged by the ACS service. Patients receiving care through routine consultation, nonemergent procedures, such as tracheostomy and feeding tube access, and those intensive care patients admitted by other services but in consultation with ACS were excluded from this analysis. These excluded patients did in fact contribute to the divisional clinical productivity; however, they likely did not uniquely affect the hospital net income and were, therefore, not unique to the ACS practice model under study. Patient encounters meeting criteria were categorized into 1 of 3 components of the ACS model: Trauma,
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emergency general surgery, and elective surgical care. Additionally, age, duration of stay, and operative intervention were gathered for comparison among categorized patients. Hospital net income per patient encounter was generated from individualized patient expense and reimbursement data to contrast hospital productivity. Expenses formulated in this evaluation reflect both direct and indirect costs. The ACS division at the University of Missouri receives substantial financial support from the hospital system to remain fiscally solvent, because practice costs exceed generation of clinical revenue. This hospital support is reflected as a direct cost and is accounted for in the hospital net income metric. ACS divisional clinical productivity was measured through the production of total wRVU. Evaluation and management (E&M) wRVU and procedural (operative and bedside) wRVU generated per patient encounter were compiled to drive the clinical productivity dimension of the analysis. As with the hospital analysis, wRVU analysis was limited to the defined patient encounter group and did not include downstream revenue or ongoing evaluation. The analysis was limited to individual episodes of care as determined by numbers of hospital visits in the defined categories of trauma, emergent, and elective general surgery in an effort to determine most fiscally rewarding types of patient characteristic. Average net hospital income and divisional wRVU calculations were generated for each of the identified unique components of the ACS service and statistically compared with single-factor analysis of variance using a commercially available spreadsheet computer application (Microsoft Office Excel; Microsoft Corp., Redmond, WA). Chi-squared tests for independence were used to compare the ratios of E&M and procedural wRVU production among ACS patient types and to compare payor mix of ACS patient types. RESULTS In calendar 2010, 1,492 patients met criteria for analysis; 1,056 were classified as trauma patients, 67% were male, and 125 patients (12%) received operative intervention from the acute care surgeon. Overall, 346 patients were classified as emergent general surgery; 53% were male, and 181 (52%) received operative intervention from the acute care surgeon. Ninety patients were classified as elective, 51% were male, and all 90 underwent operative intervention (100%). Patient payer mix was found to be similar between patient types (P = .20; Table I). Financial and statistical analysis of care provided by the ACS division at our institution revealed a
Table I. Payor mix Chi-square test for independence: Trauma, emergent, elective cases, 2010 Payor type
Trauma, n (%)
Emergent, n (%)
Elective, n (%)
Commercial Government Self-pay
375 (35.5) 488 (46.2) 193 (18.3)
140 (40.5) 160 (46.2) 46 (13.3)
30 (33.3) 44 (48.9) 16 (17.8)
Chi-square = 5.96; P = .20.
substantial overall contribution to hospital net income. Total hospital net income generated by the division of ACS specifically identified patient encounters in 2010 was $8,488,329. Total hospital net income from the care of trauma patients was $8,087,196. The contribution to total hospital net income was $413,358 from emergency general surgery and a $12,227 hospital net loss was realized from elective encounters with patients requiring surgical care. There was a difference between average hospital net income per patient encounter associated with the trauma, emergent, and elective surgery components of the ACS care model (P < .001). Trauma surgery yielded the greatest hospital net income per patient encounter at $7,658 (n = 1,056), whereas emergency general surgery contributed $1,194 per encounter (n = 346). Elective surgery was found to contribute negatively to hospital margins with a $136 per-patient encounter loss (n = 90). Total ACS Divisional wRVU productivity for CY10 was 38,494 (Full time equivalent [FTE] = 3, average of 12,831 per FTE, Fig 1). The wRVU data were then linked to the specific patient encounters identified for both hospital and divisional fiscal analysis. We included 26,089 wRVU (Fig 2) in the analysis of the specifically identified patient encounters by patient type: Trauma, emergency general surgery, and elective general surgery. An additional 12,405 wRVU were excluded because these were a result of care outside of the identified patients for analysis and not attributable directly to the ACS practice model. Clinical measures of productivity revealed a substantial contribution to the analyzed total divisional clinical productivity through the care of trauma patients, namely 17,852 total wRVU (Fig 3). There was a difference in the average wRVU production between trauma, emergency general surgery, and elective surgery components of the ACS model (P < .001). Although trauma patients generated the greatest average net income per patient for the hospital, divisional clinical productivity per patient encounter was greatest among the emergency
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Fig 1. Overall divisional productivity, 2010. E&M, Evaluation and management; wRVU, work relative value units.
Fig 2. Analyzed divisional productivity, 2010. E&M, Evaluation and management; wRVU, work relative value units.
general surgery patients at 22.5 wRVU per patient encounter (n = 346). Trauma patients encounters contributed the second highest average, 16.9 wRVU (n = 1,056) per patient encounter, and elective patients added an average of 5.1 wRVU per patient encounter (n = 90). Total wRVU stratified into E&M and procedural components proved to be different among ACS patient types. Trauma patients generated the least percentage of total wRVU productivity through procedures (operative and bedside) at 29%, whereas emergency general surgery patients produced 58% procedural productivity and elective patients generated 76%. Average duration of stay was different between patient groups (Table II). Trauma patients on average had the greatest duration of stay at 5.6 days. Emergency general surgery patient average duration of stay was 4.2 days, and the elective patient cohort duration of stay was 0.3 days. DISCUSSION The ACS model has begun to take shape in recent years as a multifaceted approach to delivery of care focusing on trauma, emergency general
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surgery, surgical critical care, and elective surgical practice.1,2 This growing subspecialty is a promising alternative to the traditional trauma surgeon through greater appeal generated by improved lifestyle and better career satisfaction through increased opportunities for operative management.5,7,22,24 Additionally, hospitals view the acute care surgeon as a valuable asset, acting as a single physician capable of managing a wide range of complex, acutely ill and injured patients. Given the broad range of clinical services provided by the acute care surgeon, it is important to better understand the financial complexion of this new practice model in terms of hospital income and clinical productivity to guide strategic utilization of this limited asset. As ACS has grown, both a clinical and economic picture has begun to emerge. The acute care surgeon is more satisfied with the new practice structure,8 delivers quality and timely patient care,9,10 and improves resident education and interest in an ACS career.5,22 Financial data, however, on the ACS model suggest a high cost of care in this practice model,27 often in excess of clinical revenue generation, and thus may require outside support for financial stability, as is done at our institution.12 The acute care surgeon must, therefore, be cognizant of delivery of both timely and quality care as well as the fiscal impact this new practice model has on their individual institution’s bottom line. Our analysis demonstrates that for our patient base and payor mix, the trauma patient remains the driving economic force for both the hospital and the divisional bottom line (Table II). The care of acutely injured patients, although timeconsuming, complex, and nonoperative in its scope, remains at the core of the practice of the acute care surgeon. Trauma patients occupied 71% of our ACS division’s patient encounter volume and contributed greater total hospital net income, average per-patient net income, and total divisional wRVU production despite a 12% rate of operative management. The total net revenue produced through management of the acutely injured by ACS was substantial and represented 95% of the total hospital net income generated by the division for 2010. The total wRVU produced through ACS management of trauma patients represented 68% of the total wRVU produced by the division (Fig 3). Trauma patients are vital to the financial success of the practice of ACS for both hospitals and divisions. Emergency general surgery shows similar promise with positive net income and substantial operative
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Fig 3. Work relative value units (wRVU) evaluation and management (E&M) and procedural ratios by patient type. Chi-square = 2,190; P < .001.
Table II. Acute care surgery: Hospital and clinical performance, 2010 Type of operation
Patients (n)
Patients operated, n (%)
Average net increase per patient ($)*
Average wRVU per patient*
Average duration of stay per patient*
Trauma Emergent Elective
1,056 346 90
125 (12) 181 (52) 90 (100)
7,658.33 1,194.68 135.86
16.9 22.5 5.1
5.6 4.2 0.3
*P < .001. wRVU, Work relative value units.
experience in our analysis contributing positively to both hospital net income and divisional clinical productivity. Emergent patients made up 23% of the ACS division patient encounter volume and contributed the greatest average wRVU per patient. Our definition of an emergency general surgery patient encounter also included almost 48% that did not undergo traditional operative intervention (Fig 1). Many of these patients represent outside transfers with acute postoperative and/or newonset problems managed nonoperatively or percutaneously in conjunction with our interventional teams. With a broad-based, ACS practice, management of these acute problems are common and much like we have seen with the practice of trauma care, many of these patients fall into a nonoperative plan of care through advances in technology, and thus were most appropriately included in the emergency surgery group for this analysis. Elective general surgery in our practice, although minimal with only 90 patients early in our ACS program experience, demonstrated negative hospital net income for 2010. Elective surgical management comprised just 6% of the ACS division patient encounter volume. This component of the ACS delivery model underperformed consistently trauma and emergent care fiscally at our facility. In our analysis, management of an elective general surgical patient came at a cost to the institution with minimal contribution to divisional wRVU productivity. One appealing aspect of the
elective surgical patient is the high rate of operative management as demonstrated by the high percentage of procedural wRVU production (76%) and 100% operative rate that the acute care surgeon may find beneficial to maintaining operative skill and job satisfaction. Although payor mix was not different from the other groups, both the smaller volume and case type may have contributed to these finding. With an average duration of stay of 0.3 days, this outpatient elective surgical practice with presumed high use of laparoscopy, mesh implantation, and disposables, likely contributed to our fiscal finding for individual patient encounters. Further analysis of these findings continues to improve our fiscal picture in the elective component of the ACS practice model. Our analysis has in its structure a number of limitations. This single institutional analysis of a 3 FTE ACS practice early in its evolution is limited in its scope and universal application. Our definition of unique encounters could be questioned, because it excludes the surgical critical care component of the ACS model as a unique entity as well as routine, non-emergent general surgical consultation and does not take into account the halo effect or additional upstream or downstream revenues as a result of patient encounters. We felt this to be appropriate, because the surgical critical care management was captured in each of the individual patient groups of the analysis and the routine, nonemergent, and non-ACS specific
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patient evaluation, both inside and outside of the intensive care unit, would have likely been accomplished without a division of ACS. How effectively the elective general surgeon addresses emergency general surgical problems is beyond the scope of this analysis. Additionally, our goal was to broadly categorize hospital net income and divisional productivity based on our institutional cost and fiscal decision support systems. An in-depth analysis of our institutional costs was not undertaken; rather, a standardized fiscal and productivity analysis by patient type to provide a financial snapshot of the injured, emergent, and elective patient groups from the standpoint of both hospital net income and divisional wRVU trends to guide a fiscally responsible approach to growth of our program. Although actual costs and net income differ between institutions, we believe this trend seen between the injured, emergent, and elective patient types in hospital net income and divisional wRVU productivity will hold true. In depth analysis of institutional cost is beyond the scope of this analysis. Based on these data, the University of Missouri Healthcare Division of Acute Care Surgery pursued the emergency general surgery population within the Central Missouri Region and at present has increased the annual emergency general surgery volume 3-fold with a positive impact to both divisional and hospital fiscal operations. REFERENCES 1. Moore EE, Maier RV, Hoyt DB, et al. Acute care surgery: eraritjaritjaka. J Am Coll Surg 2006;202:698-701. 2. The Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma 2005;58:614-6. 3. Esposito TJ, Totondo M, Barie PS, et al. Making the case for a paradigm shift in trauma surgery. J Am Coll Surg 2006; 202:655-67. 4. Cohn SM, Price MA, Virrarreal CL. Trauma and surgical critical care workforce in the United States: a severe surgeon shortage appears imminent. J Am Coll Surg 2009; 209:446-52. 5. Coleman J, Esposito TJ, Feliciano DV. Acute Care Surgery: Will They Come? Session IX: Acute Care Surgery; Paper 31. Presented at: 71st Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery. 2012 Sep 12-15; Kauai, HI. 6. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma 2004;57:467-73. 7. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg 2004; 199:96-101.
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8. Barnes SL, Cooper CJ, Coughenour JP, et al. Impact of Acute Care Surgery to Departmental Productivity. J Trauma 2011;71:1027-32. 9. Britt RC, Weireter LJ, Britt LD. Initial Implementation of an Acute Care Surgery Model: Implications for Timeliness of Care. J Am Coll Surg 2009;209:421-4. 10. Cubas RF, Gomez NR, Garberoglio CA, et al. Outcomes in the Management of Appendicitis and Cholecystitis in the Setting of a New Acute Care Surgery Service Model: Impact on Timing and Cost. J Am Coll Surg 2012;215:715-21. 11. Taheri PA, Butz DA, Dechert R, et al. How DRGs hurt academic health systems. J Am Coll Surg 2001;193:1-11. 12. Sweeting R, Carter J, Rich PB, et al. The Price of Acute Care Surgery. Session IX: Acute Care Surgery; Paper 30. Presented at: 71st Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery. 2012 Sep 12-15; Kauai, HI. 13. Selzer D, Gomez G, Jacobsen L, et al. Public hospital-based level I trauma centers: financial survival in the new millennium. J Trauma 2001;51:301-7. 14. Lanzarotti S, Cook CS, Porter JM, et al. The cost of trauma. AmSurg 2003;69:766-70. 15. Fortune JB, Sutyak J, Wohltmann C, Margold B, Callahan C. Maximizing Reimbursement From Trauma Activation Fees (Ub-92:68X) - Lessons learned from a hospital comparison. J Trauma 2005;58:482-6. 16. Taheri PA, Butz DA, Watts CM, et al. Trauma services: a profit center? J Am Coll Surg 1999;188:349-54. 17. Rogers FB, Osler R, Shackford SR, et al. Charges and Reimbursement at a rural level I trauma center: a disparity between effort and reward among professionals. J Trauma 2003;54:9-15. 18. MacKenzie EF, Hoyt DB, Sacra JC, et al. National inventory of hospital trauma centers. JAMA 2003;289:1515-22. 19. Rodriguez JL, Christmas AB, Franklin GA, et al. Trauma/ critical care surgeon: a specialist gasping for air. J Trauma 2005;59:1-7. 20. Henneman PL, Lemanski M, Smithline HA, et al. Emergency department admissions are more profitable than non-emergency department admissions. Ann Emerg Med 2008;52:249-55. 21. Fakhry SM, Couillard D, Liddy CT, et al. Trauma center finances and length of stay: identifying a profitability inflection point. J Am Coll Surg 2010;210:817-23. 22. Resnick AS, Corrigan D, Mullen JL, et al. Surgeon contribution to the hospital bottom line not all are created equal. Annals Surgery 2005;242:530-9. 23. Stanley MD, Davenport DL, Procter LD, et al. An acute care surgery rotation contributes significant general surgical operative volume to residency training compared with other rotations. J Trauma 2011;70:590-4. 24. Procter L, Bernard AC, Zwischenberger JB, et al. An acute care surgery service generates a positive contribution margin in an appropriately staffed hospital. J Am Coll Surg 2013;216:298-301. 25. Spain DA, Richardson DJ, Carrillo EH, et al. Should trauma surgeons to do general surgery? J Trauma 2000;48:433-8. 26. Ciesla DJ, Cha JY, Smith DJ, et al. Implementation of an acute care surgery service at an academic trauma center. Am J Surg 2011;202:779-86. 27. Fakhry SM, Martin B, Harakeh AH, Norcross ED, Ferguson PL. Proportional costs in trauma and acute care surgery patients: dominant role of intensive care unit costs. J Am Coll Surg 2013;216:607-14.
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DISCUSSION Dr Michael S. Nussbaum (Jacksonville, FL): We have had some outstanding presentations this week from medical students and residents. I congratulate you on the excellent work that you have done. Again, this study sought to compare hospital net income and divisional clinical productivity measures of a newly formed university division of acute care surgery based on patient type, trauma, emergency general surgery, and elective surgery. In this particular setting, with <20% self-pay uninsured patients, which many of us would love to have that few numbers, you were able to show that trauma patients drove hospital and clinical productivity through high hospital net income potential and total clinical relative value unit (RVU) production. Emergent patients offered modest profit potential for the hospital, yet produced the greatest RVU efficiency. And elective surgical patient encounters were neither cost effective for the hospital nor contribute significant clinical productivity for a division with low volume based on RVUs. And you concluded that targeted growth of your acute care surgery practice model should focus on the acutely injured and acutely ill, with less focus on elective surgical practice. I have several questions. First, does the acute care surgery division receive a subsidy from the hospital to cover your costs? And how does that compare with the greater $8 million contribution to the hospital’s bottom line? Second, why does elective surgery lose money when performed by ACS surgeons at your institution? Do you have details regarding the types of elective operations performed? Do you have comparative data from any other surgical divisions that rely primarily on elective surgery for the majority of their volume? If so, how do they compare related to productivity? Is elective surgery too expensive at the University of Missouri? Based on these findings, have you changed the practice paradigm for your division to trauma and emergency surgery, or do you continue to perform elective surgery? Dr Stephen L. Barnes (Columbia, MO): We do receive, as the division chief of acute care surgery, significant subsidy from the hospital. It is built into the decision support tool, so that net profitability of $8.1 million includes almost $1 million in support from the hospital system. Your second question, about why do our elective cases lose money? I was surprised at those findings. Most of them are outpatient. Most of them involve significant disposables. And most of them are now done because we are physically linked with the trauma center in an inpatient operating room. So we have not compared with our partners in the department who do much of their work at the outpatient center, which has a little bit lower cost. But I believe a lot of the contribution to that essentially neutral fiscal picture for elective surgery at our hospital has to do with the patient types that we are doing electively, and the fact that we are doing them in an inpatient operating room with a large use of disposables.
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We had originally included all the patient types. And it muddied the water and really, I thought, clouded the picture of what we were trying to show here. We do continue to do elective surgery. It is fascinating, as you do more and more emergency general surgery, you establish those relationships with families, and they come back to you for their elective procedures. What we have done is moved a faculty member 3 days a week to the outpatient surgical center and are doing most of that now there. Dr Carol Scott-Connor (Iowa City, IA): This is a fascinating analysis. And it sort of confirms some of my gut feelings as I’ve watched this evolve. In our area, trauma surgery is extremely well reimbursed, because of the combination of automobile insurance, workers compensation, and various other mechanisms that reimburse very well. And also, because, as you demonstrated, there’s a high percentage of E&M coding for nonoperative work, and those codes have retained their value better than many of the operative procedures. What I think is new and striking about your work is that you demonstrated this also for the emergency cases. I think that as we move toward using this model more and more to improve, if nothing else, the quality of life for our trauma surgeons who like to operate, after all, they are surgeons, and recognizing practice patterns in the community, where these cases are being referred in, it’s something we’re all going to work with. I think that my question for you would be, how will you continue to grow in such a way that you can satisfy the needs of the faculty that you recruit? When you bring in faculty on the trauma ACS service, do you find that being able to develop an elective practice is important to them? And how are you going to do that, if so? The second question would be, the finding that you uncovered with the general surgery cases, is that a phenomenon with other general surgeons in your department as well? Is it just simply the nature of the beast that laparoscopic cholecystectomies are not reimbursed very well, and if you use a lot of disposables, you’re going to be kind of revenue neutral at best? Dr Stephen L. Barnes: I’ll be honest, we grew from 3 to 5. And let me tell you, the difference between 3 and 5, from a lifestyle standpoint, is outstanding. Most of what I have focused on recruiting was people with interest in emergency trauma critical care education and research. So although they do establish relationships and do have patients referred directly to them, right now, other than myself, who was trained by Nussbaum, none of them have a real big interest in doing elective surgery, although they do perform it, and are very happy with the practice of trauma and emergency care. But the other way, I believe, to look at these data is that surgical critical care is a key component of any acute care surgery program. And it drives a lot of the fiscal performance. A lot of the emergency general surgery patients have high case mix index, high risk of mortality, and high severity of illness. Therefore, their reimbursement to the
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hospital is higher. And we spend more time with them in the intensive care unit, which benefits our bottom line as well. I do believe that general surgery has been reduced to a point that it is almost cost neutral, with the number of cases being done laparoscopically and you are linked to the cost of your disposables. If we had used the upstream and downstream revenue in this analysis for the elective general surgery patients, I think you would have seen it swing a little bit further to the positive side. But with the cost of mesh, the cost of disposables, the margins on outpatient and elective general surgery are such that it becomes a very difficult process to make elective general surgery profitable at the rates that you see for the injured or acutely ill patient because it’s elective surgery. It’s outpatient, and they are not sick. Therefore, those risks of mortality, severity of illness, and case mix index are significantly lower with the ASA1 and ASA2 cases. Dr Frederick Luchette (Maywood, IL): Stephen, I rise to congratulate you on your continued explorations of the financial benefits of acute care surgery. And, Matthew, I want to congratulate you, too, on an excellent presentation. You sort of answered my first question, Stephen, when you said you’ve now expanded to 5, because asking 3 faculty to cover all of those services, with 12,000 work RVUs, is not sustainable. They’ll burn out on you. So what has been the financial impact to your 5 faculty now with the expansion? Has the hospital increased the stipends to you in the supplemental income? Second, you talked on the dollar side, but what’s the real impact on efficiencies with the acute care surgery and getting the patients out of the hospital quicker, having the referring doctors more satisfied with a prompt consultation? Dr Stephen L. Barnes: When I was recruited to go to the University of Missouri, I negotiated that I had would need $1.2 million to start an acute care surgery program. That support has now been decreased to $860,000 a year, with 5 faculty. The growth of the emergency general surgery, which we targeted and went to all these smaller
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rural hospitals in our area and said, ‘‘If they’re sick, if they’re aged, if they have significant comorbidities, if it’s the middle of the night, or if you’re just uncomfortable, send it to us,’’ has grown so significantly that we’ve been able to keep up fiscally with the pace of adding new faculty and plan to. I believe we are starting to level out and not seeing the rate of growth that we’ve seen in the first four years. And we will land at about 6 faculty, with 1 moving into more of a part-time position. So we have decreased but continue to receive support. The efficiency, we didn’t look at in this. It needs to be looked at. It’s been looked at before. It is clearly easier. We do not disrupt our elective surgical partners’ clinics and practices because we are immediately available to go to the operating room. My division has block OR time that is protected until 6:00 in the morning, from 7:00 to noon, 6 days a week. And we fill that block every day, which allows us to very timely take people to the operating room as they come into the institution. As we all know, many of these things brew at an outside hospital in the daylight hours and don’t get shipped to us until the wee hours of the morning. The other piece that I think is important is, as far as incentivizing performance, I was very firm in the fact that we would have a group incentive for performance. Most of our departments at our institution are in an individualized performance model for incentive. And by group incentivizing and not providing competition between my faculty members, the goal, as things get busier, and what you’re talking about, efficiency of delivery of care, allows if we have one room going and someone else needs an operation, and Dr Coughenour is on call today, Dr Barnes comes in and does the next one, and Dr Ahmad comes in and does the next one, Dr Nelson comes in. We, at times, will have 4 rooms running. All in an effort to, in a very timely fashion, deliver quality care in a very efficient manner. And I believe that’s linked to the way we incentivize as a group, as opposed to individual performance.
Purpose. Acute care surgery (ACS) remains in its infancy as a defined surgical specialty within hospital systems. Little has been published regarding the financial impact of this method of care delivery to hospital systems and departments when combining trauma, surgical critical care, emergent, and elective general surgery into a single practice model. We sought to compare hospital net income and divisional clinical productivity measures of a newly formed, university division of ACS based on patient type--trauma, emergency general surgery, and elective surgery---to determine the best avenues by which to focus on programmatic growth. Methods. Single calendar year, retrospective review of hospital system income and divisional fiscal productivity of specific patient visits by patient type (trauma, emergent, or elective) admitted to or discharged by the acute care surgeons. Demographic data, payor mix, patient volumes, and operative rates were determined for each patient type. Fiscal contribution by patient type to both hospital and clinical productivity were measured by hospital net income and divisional work relative value units (wRVU) production respectively. The Chi-square test for independence compared payor mix and analysis of variance was used for comparison of fiscal performance between patient types. Results. We included 1,492 patients in the analysis of calendar year 2010; 1,056 trauma (67% male; mean age, 41.9; range, 0–102), 346 emergent (53% male; mean age, 44.6; range, 15–91), and 90 elective (51% male; mean age, 46; range, 16–87) patient encounters met criteria for analysis. There were no differences in payor mix between patient types. Significant differences were seen in average per patient encounter hospital net income, divisional wRVU production and duration of stay. The ACS team (n = 3) operated on 12% of trauma patients compared with 52% of emergent and 100% of elective surgery encounters. Hospital net income per patient was greatest for trauma encounters, whereas divisional clinical productivity per patient encounter was greatest for emergent patients. Elective encounters contributed negatively to hospital margins. Conclusion. Per-patient hospital system income and a majority of clinical wRVU productivity remains greatest for the care of injured patients in our ACS practice model; emergent general surgical encounters demonstrate the greatest per-patient rates of divisional clinical productivity. (Surgery 2013;154:867-74.) From the Division of Acute Care Surgery,a Department of Surgery, University of Missouri School of Medicine, and University of Missouri Healthcare,b Columbia, MO
THE TRAUMA/CRITICAL CARE surgical subspecialty is in the midst of a professional evolution toward a more diverse model of acute care surgery (ACS) that combines traumatic, emergent, and elective surgical management.1,2 One driver of this advancement is the need to raise human resource Accepted for publication July 15, 2013. Reprint requests: Stephen L. Barnes, MD, FACS, Associate Professor of Surgery & Anesthesia, Chief, Division of Acute Care Surgery, Department of Surgery, University of Missouri, One Hospital Drive, Columbia, MO 65212. E-mail: barnesste@ health.missouri.edu. 0039-6060/$ - see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2013.07.012
interest in the field of trauma surgery, which is facing a surgeon shortage.2-4 Compared with the traditional trauma service model, ACS offers a wider range of skill sets, a preset schedule, expertise in technically challenging procedures, decreased cost of care, and increased exposure to medical students and residents for recruitment.2 Renewed interest in the field has been appreciated by recent data from resident survey suggesting ACS is gaining appeal.5 ACS increases the operative volume for the trauma surgeon with the addition of nontrauma cases, leading to improved surgeon satisfaction rates and offering a more appealing alternative to the traditional trauma framework without compromising the care of patients.6-8 Additional benefits of the ACS model are seen in SURGERY 867
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improved timeliness of care and improved patient outcomes, including duration of stay.9,10 The financial struggles of trauma centers have been well-represented in the literature. The change to a structure of fixed fee reimbursement and low-volume, high-variation disease-related groups have stunted the economic performance of the high-cost trauma field in many academic medical centers owing to shifted financial risk toward hospital systems.11 The high rate of uninsured patients in the patient population treated by an ACS model negatively affects work relative value unit (wRVU) production and enhances the challenge to correct the shortage of ACS surgeons.12 As a result, many trauma programs rely on financial support from the hospital system or Disproportionate Share Hospital governmental funds and/or tax dollars to maintain the service.4,13 Consequently, many organizations see the trauma service as a financial burden,14 whereas others find trauma care to be expensive, although fiscally rewarding.15,16 On the level of the individual provider, trauma surgeons tend to bill much less than their subspecialty colleagues considering the relative time invested in care,17 often leading to a lack of financial reward many surgeons find unappealing.3 Disunion, however, remains as the number of trauma centers continues to rise as interest in the traditional model of trauma surgery as a subspecialty declines.18,19 Despite the financial turmoil facing trauma centers nationwide, evidence has begun to accumulate suggesting that ACS programs have both financial and recruiting potential. Greater injury severity scores, emergency department admissions, and controlled durations of stay all improve organizational financial reward.16,20,21 ACS performs among the top 3 surgical subspecialties in operating room contribution margin per relative value unit,22 and offers substantial operative training for residents.23 Additionally, the ACS practice model has been found to generate a positive contribution margin despite hospital subsidies to ACS divisions to support physician salaries necessary to maintain the service,24 and has been shown to simultaneously improve productivity and job satisfaction without detriment to the elective general surgeon’s practice.8 In light of this emerging evidence, the ACS practice model makes a compelling argument for implementation. The acute care surgeon possesses broad training in elective and emergency general surgery, trauma surgery, and surgical critical care. By expanding the trauma surgeon’s range of expertise to emergent and elective surgery, acute care surgeons
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maintain their skills by operating more frequently than the traditional trauma surgeon in an age of growing, nonoperative management.25 Moreover, a widened expertise and skill base makes an acute care surgeon a very attractive asset to hospital systems. Financial data on the relatively young and more complex ACS model are scarce. Patient service revenues have shown to be insufficient at some institutions to support a division of ACS and rely on other sources of income for financial stability.26 In fact, many programs require institutional support owing to insufficient clinical revenue to cover the costs of practice and, thus, must partner with their hospital in a collaborative fashion to grow ACS programs in a fiscally responsible manner.4,12,26 The purpose of this study was to compare hospital income and measures of clinical productivity of a newly formed, university division of ACS based on patient type: Trauma, emergent, and elective surgical care. The intent is to inform decision makers and facilitate optimal strategies to focus growth and achieve departmental and institutional financial stability. METHODS The Frank L. Mitchell, Jr, MD, Trauma Center of the University of Missouri Health Care Center is an ACS-verified level I trauma center serving Central Missouri with a patient population of approximately 1.5 million. It is the only ACS-verified level I trauma center in mid-Missouri and 1 of just 3 in the state serving a diverse population of both urban and rural patients. In 2009, faculty turnover, recruitment, and departmental reorganization led to the development of the Division of Acute Care Surgery. Fellowship-trained trauma surgeons now care for all acutely injured and emergency general surgery patients on a 24/7 basis while providing simultaneously a practice of elective surgical management. The medical records of all patients managed by the ACS division physicians in calendar 2010 were reviewed. Patients included in this analysis were those admitted to or discharged by the ACS service. Patients receiving care through routine consultation, nonemergent procedures, such as tracheostomy and feeding tube access, and those intensive care patients admitted by other services but in consultation with ACS were excluded from this analysis. These excluded patients did in fact contribute to the divisional clinical productivity; however, they likely did not uniquely affect the hospital net income and were, therefore, not unique to the ACS practice model under study. Patient encounters meeting criteria were categorized into 1 of 3 components of the ACS model: Trauma,
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emergency general surgery, and elective surgical care. Additionally, age, duration of stay, and operative intervention were gathered for comparison among categorized patients. Hospital net income per patient encounter was generated from individualized patient expense and reimbursement data to contrast hospital productivity. Expenses formulated in this evaluation reflect both direct and indirect costs. The ACS division at the University of Missouri receives substantial financial support from the hospital system to remain fiscally solvent, because practice costs exceed generation of clinical revenue. This hospital support is reflected as a direct cost and is accounted for in the hospital net income metric. ACS divisional clinical productivity was measured through the production of total wRVU. Evaluation and management (E&M) wRVU and procedural (operative and bedside) wRVU generated per patient encounter were compiled to drive the clinical productivity dimension of the analysis. As with the hospital analysis, wRVU analysis was limited to the defined patient encounter group and did not include downstream revenue or ongoing evaluation. The analysis was limited to individual episodes of care as determined by numbers of hospital visits in the defined categories of trauma, emergent, and elective general surgery in an effort to determine most fiscally rewarding types of patient characteristic. Average net hospital income and divisional wRVU calculations were generated for each of the identified unique components of the ACS service and statistically compared with single-factor analysis of variance using a commercially available spreadsheet computer application (Microsoft Office Excel; Microsoft Corp., Redmond, WA). Chi-squared tests for independence were used to compare the ratios of E&M and procedural wRVU production among ACS patient types and to compare payor mix of ACS patient types. RESULTS In calendar 2010, 1,492 patients met criteria for analysis; 1,056 were classified as trauma patients, 67% were male, and 125 patients (12%) received operative intervention from the acute care surgeon. Overall, 346 patients were classified as emergent general surgery; 53% were male, and 181 (52%) received operative intervention from the acute care surgeon. Ninety patients were classified as elective, 51% were male, and all 90 underwent operative intervention (100%). Patient payer mix was found to be similar between patient types (P = .20; Table I). Financial and statistical analysis of care provided by the ACS division at our institution revealed a
Table I. Payor mix Chi-square test for independence: Trauma, emergent, elective cases, 2010 Payor type
Trauma, n (%)
Emergent, n (%)
Elective, n (%)
Commercial Government Self-pay
375 (35.5) 488 (46.2) 193 (18.3)
140 (40.5) 160 (46.2) 46 (13.3)
30 (33.3) 44 (48.9) 16 (17.8)
Chi-square = 5.96; P = .20.
substantial overall contribution to hospital net income. Total hospital net income generated by the division of ACS specifically identified patient encounters in 2010 was $8,488,329. Total hospital net income from the care of trauma patients was $8,087,196. The contribution to total hospital net income was $413,358 from emergency general surgery and a $12,227 hospital net loss was realized from elective encounters with patients requiring surgical care. There was a difference between average hospital net income per patient encounter associated with the trauma, emergent, and elective surgery components of the ACS care model (P < .001). Trauma surgery yielded the greatest hospital net income per patient encounter at $7,658 (n = 1,056), whereas emergency general surgery contributed $1,194 per encounter (n = 346). Elective surgery was found to contribute negatively to hospital margins with a $136 per-patient encounter loss (n = 90). Total ACS Divisional wRVU productivity for CY10 was 38,494 (Full time equivalent [FTE] = 3, average of 12,831 per FTE, Fig 1). The wRVU data were then linked to the specific patient encounters identified for both hospital and divisional fiscal analysis. We included 26,089 wRVU (Fig 2) in the analysis of the specifically identified patient encounters by patient type: Trauma, emergency general surgery, and elective general surgery. An additional 12,405 wRVU were excluded because these were a result of care outside of the identified patients for analysis and not attributable directly to the ACS practice model. Clinical measures of productivity revealed a substantial contribution to the analyzed total divisional clinical productivity through the care of trauma patients, namely 17,852 total wRVU (Fig 3). There was a difference in the average wRVU production between trauma, emergency general surgery, and elective surgery components of the ACS model (P < .001). Although trauma patients generated the greatest average net income per patient for the hospital, divisional clinical productivity per patient encounter was greatest among the emergency
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Fig 1. Overall divisional productivity, 2010. E&M, Evaluation and management; wRVU, work relative value units.
Fig 2. Analyzed divisional productivity, 2010. E&M, Evaluation and management; wRVU, work relative value units.
general surgery patients at 22.5 wRVU per patient encounter (n = 346). Trauma patients encounters contributed the second highest average, 16.9 wRVU (n = 1,056) per patient encounter, and elective patients added an average of 5.1 wRVU per patient encounter (n = 90). Total wRVU stratified into E&M and procedural components proved to be different among ACS patient types. Trauma patients generated the least percentage of total wRVU productivity through procedures (operative and bedside) at 29%, whereas emergency general surgery patients produced 58% procedural productivity and elective patients generated 76%. Average duration of stay was different between patient groups (Table II). Trauma patients on average had the greatest duration of stay at 5.6 days. Emergency general surgery patient average duration of stay was 4.2 days, and the elective patient cohort duration of stay was 0.3 days. DISCUSSION The ACS model has begun to take shape in recent years as a multifaceted approach to delivery of care focusing on trauma, emergency general
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surgery, surgical critical care, and elective surgical practice.1,2 This growing subspecialty is a promising alternative to the traditional trauma surgeon through greater appeal generated by improved lifestyle and better career satisfaction through increased opportunities for operative management.5,7,22,24 Additionally, hospitals view the acute care surgeon as a valuable asset, acting as a single physician capable of managing a wide range of complex, acutely ill and injured patients. Given the broad range of clinical services provided by the acute care surgeon, it is important to better understand the financial complexion of this new practice model in terms of hospital income and clinical productivity to guide strategic utilization of this limited asset. As ACS has grown, both a clinical and economic picture has begun to emerge. The acute care surgeon is more satisfied with the new practice structure,8 delivers quality and timely patient care,9,10 and improves resident education and interest in an ACS career.5,22 Financial data, however, on the ACS model suggest a high cost of care in this practice model,27 often in excess of clinical revenue generation, and thus may require outside support for financial stability, as is done at our institution.12 The acute care surgeon must, therefore, be cognizant of delivery of both timely and quality care as well as the fiscal impact this new practice model has on their individual institution’s bottom line. Our analysis demonstrates that for our patient base and payor mix, the trauma patient remains the driving economic force for both the hospital and the divisional bottom line (Table II). The care of acutely injured patients, although timeconsuming, complex, and nonoperative in its scope, remains at the core of the practice of the acute care surgeon. Trauma patients occupied 71% of our ACS division’s patient encounter volume and contributed greater total hospital net income, average per-patient net income, and total divisional wRVU production despite a 12% rate of operative management. The total net revenue produced through management of the acutely injured by ACS was substantial and represented 95% of the total hospital net income generated by the division for 2010. The total wRVU produced through ACS management of trauma patients represented 68% of the total wRVU produced by the division (Fig 3). Trauma patients are vital to the financial success of the practice of ACS for both hospitals and divisions. Emergency general surgery shows similar promise with positive net income and substantial operative
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Fig 3. Work relative value units (wRVU) evaluation and management (E&M) and procedural ratios by patient type. Chi-square = 2,190; P < .001.
Table II. Acute care surgery: Hospital and clinical performance, 2010 Type of operation
Patients (n)
Patients operated, n (%)
Average net increase per patient ($)*
Average wRVU per patient*
Average duration of stay per patient*
Trauma Emergent Elective
1,056 346 90
125 (12) 181 (52) 90 (100)
7,658.33 1,194.68 135.86
16.9 22.5 5.1
5.6 4.2 0.3
*P < .001. wRVU, Work relative value units.
experience in our analysis contributing positively to both hospital net income and divisional clinical productivity. Emergent patients made up 23% of the ACS division patient encounter volume and contributed the greatest average wRVU per patient. Our definition of an emergency general surgery patient encounter also included almost 48% that did not undergo traditional operative intervention (Fig 1). Many of these patients represent outside transfers with acute postoperative and/or newonset problems managed nonoperatively or percutaneously in conjunction with our interventional teams. With a broad-based, ACS practice, management of these acute problems are common and much like we have seen with the practice of trauma care, many of these patients fall into a nonoperative plan of care through advances in technology, and thus were most appropriately included in the emergency surgery group for this analysis. Elective general surgery in our practice, although minimal with only 90 patients early in our ACS program experience, demonstrated negative hospital net income for 2010. Elective surgical management comprised just 6% of the ACS division patient encounter volume. This component of the ACS delivery model underperformed consistently trauma and emergent care fiscally at our facility. In our analysis, management of an elective general surgical patient came at a cost to the institution with minimal contribution to divisional wRVU productivity. One appealing aspect of the
elective surgical patient is the high rate of operative management as demonstrated by the high percentage of procedural wRVU production (76%) and 100% operative rate that the acute care surgeon may find beneficial to maintaining operative skill and job satisfaction. Although payor mix was not different from the other groups, both the smaller volume and case type may have contributed to these finding. With an average duration of stay of 0.3 days, this outpatient elective surgical practice with presumed high use of laparoscopy, mesh implantation, and disposables, likely contributed to our fiscal finding for individual patient encounters. Further analysis of these findings continues to improve our fiscal picture in the elective component of the ACS practice model. Our analysis has in its structure a number of limitations. This single institutional analysis of a 3 FTE ACS practice early in its evolution is limited in its scope and universal application. Our definition of unique encounters could be questioned, because it excludes the surgical critical care component of the ACS model as a unique entity as well as routine, non-emergent general surgical consultation and does not take into account the halo effect or additional upstream or downstream revenues as a result of patient encounters. We felt this to be appropriate, because the surgical critical care management was captured in each of the individual patient groups of the analysis and the routine, nonemergent, and non-ACS specific
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patient evaluation, both inside and outside of the intensive care unit, would have likely been accomplished without a division of ACS. How effectively the elective general surgeon addresses emergency general surgical problems is beyond the scope of this analysis. Additionally, our goal was to broadly categorize hospital net income and divisional productivity based on our institutional cost and fiscal decision support systems. An in-depth analysis of our institutional costs was not undertaken; rather, a standardized fiscal and productivity analysis by patient type to provide a financial snapshot of the injured, emergent, and elective patient groups from the standpoint of both hospital net income and divisional wRVU trends to guide a fiscally responsible approach to growth of our program. Although actual costs and net income differ between institutions, we believe this trend seen between the injured, emergent, and elective patient types in hospital net income and divisional wRVU productivity will hold true. In depth analysis of institutional cost is beyond the scope of this analysis. Based on these data, the University of Missouri Healthcare Division of Acute Care Surgery pursued the emergency general surgery population within the Central Missouri Region and at present has increased the annual emergency general surgery volume 3-fold with a positive impact to both divisional and hospital fiscal operations. REFERENCES 1. Moore EE, Maier RV, Hoyt DB, et al. Acute care surgery: eraritjaritjaka. J Am Coll Surg 2006;202:698-701. 2. The Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma 2005;58:614-6. 3. Esposito TJ, Totondo M, Barie PS, et al. Making the case for a paradigm shift in trauma surgery. J Am Coll Surg 2006; 202:655-67. 4. Cohn SM, Price MA, Virrarreal CL. Trauma and surgical critical care workforce in the United States: a severe surgeon shortage appears imminent. J Am Coll Surg 2009; 209:446-52. 5. Coleman J, Esposito TJ, Feliciano DV. Acute Care Surgery: Will They Come? Session IX: Acute Care Surgery; Paper 31. Presented at: 71st Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery. 2012 Sep 12-15; Kauai, HI. 6. Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma 2004;57:467-73. 7. Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg 2004; 199:96-101.
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8. Barnes SL, Cooper CJ, Coughenour JP, et al. Impact of Acute Care Surgery to Departmental Productivity. J Trauma 2011;71:1027-32. 9. Britt RC, Weireter LJ, Britt LD. Initial Implementation of an Acute Care Surgery Model: Implications for Timeliness of Care. J Am Coll Surg 2009;209:421-4. 10. Cubas RF, Gomez NR, Garberoglio CA, et al. Outcomes in the Management of Appendicitis and Cholecystitis in the Setting of a New Acute Care Surgery Service Model: Impact on Timing and Cost. J Am Coll Surg 2012;215:715-21. 11. Taheri PA, Butz DA, Dechert R, et al. How DRGs hurt academic health systems. J Am Coll Surg 2001;193:1-11. 12. Sweeting R, Carter J, Rich PB, et al. The Price of Acute Care Surgery. Session IX: Acute Care Surgery; Paper 30. Presented at: 71st Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery. 2012 Sep 12-15; Kauai, HI. 13. Selzer D, Gomez G, Jacobsen L, et al. Public hospital-based level I trauma centers: financial survival in the new millennium. J Trauma 2001;51:301-7. 14. Lanzarotti S, Cook CS, Porter JM, et al. The cost of trauma. AmSurg 2003;69:766-70. 15. Fortune JB, Sutyak J, Wohltmann C, Margold B, Callahan C. Maximizing Reimbursement From Trauma Activation Fees (Ub-92:68X) - Lessons learned from a hospital comparison. J Trauma 2005;58:482-6. 16. Taheri PA, Butz DA, Watts CM, et al. Trauma services: a profit center? J Am Coll Surg 1999;188:349-54. 17. Rogers FB, Osler R, Shackford SR, et al. Charges and Reimbursement at a rural level I trauma center: a disparity between effort and reward among professionals. J Trauma 2003;54:9-15. 18. MacKenzie EF, Hoyt DB, Sacra JC, et al. National inventory of hospital trauma centers. JAMA 2003;289:1515-22. 19. Rodriguez JL, Christmas AB, Franklin GA, et al. Trauma/ critical care surgeon: a specialist gasping for air. J Trauma 2005;59:1-7. 20. Henneman PL, Lemanski M, Smithline HA, et al. Emergency department admissions are more profitable than non-emergency department admissions. Ann Emerg Med 2008;52:249-55. 21. Fakhry SM, Couillard D, Liddy CT, et al. Trauma center finances and length of stay: identifying a profitability inflection point. J Am Coll Surg 2010;210:817-23. 22. Resnick AS, Corrigan D, Mullen JL, et al. Surgeon contribution to the hospital bottom line not all are created equal. Annals Surgery 2005;242:530-9. 23. Stanley MD, Davenport DL, Procter LD, et al. An acute care surgery rotation contributes significant general surgical operative volume to residency training compared with other rotations. J Trauma 2011;70:590-4. 24. Procter L, Bernard AC, Zwischenberger JB, et al. An acute care surgery service generates a positive contribution margin in an appropriately staffed hospital. J Am Coll Surg 2013;216:298-301. 25. Spain DA, Richardson DJ, Carrillo EH, et al. Should trauma surgeons to do general surgery? J Trauma 2000;48:433-8. 26. Ciesla DJ, Cha JY, Smith DJ, et al. Implementation of an acute care surgery service at an academic trauma center. Am J Surg 2011;202:779-86. 27. Fakhry SM, Martin B, Harakeh AH, Norcross ED, Ferguson PL. Proportional costs in trauma and acute care surgery patients: dominant role of intensive care unit costs. J Am Coll Surg 2013;216:607-14.
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DISCUSSION Dr Michael S. Nussbaum (Jacksonville, FL): We have had some outstanding presentations this week from medical students and residents. I congratulate you on the excellent work that you have done. Again, this study sought to compare hospital net income and divisional clinical productivity measures of a newly formed university division of acute care surgery based on patient type, trauma, emergency general surgery, and elective surgery. In this particular setting, with <20% self-pay uninsured patients, which many of us would love to have that few numbers, you were able to show that trauma patients drove hospital and clinical productivity through high hospital net income potential and total clinical relative value unit (RVU) production. Emergent patients offered modest profit potential for the hospital, yet produced the greatest RVU efficiency. And elective surgical patient encounters were neither cost effective for the hospital nor contribute significant clinical productivity for a division with low volume based on RVUs. And you concluded that targeted growth of your acute care surgery practice model should focus on the acutely injured and acutely ill, with less focus on elective surgical practice. I have several questions. First, does the acute care surgery division receive a subsidy from the hospital to cover your costs? And how does that compare with the greater $8 million contribution to the hospital’s bottom line? Second, why does elective surgery lose money when performed by ACS surgeons at your institution? Do you have details regarding the types of elective operations performed? Do you have comparative data from any other surgical divisions that rely primarily on elective surgery for the majority of their volume? If so, how do they compare related to productivity? Is elective surgery too expensive at the University of Missouri? Based on these findings, have you changed the practice paradigm for your division to trauma and emergency surgery, or do you continue to perform elective surgery? Dr Stephen L. Barnes (Columbia, MO): We do receive, as the division chief of acute care surgery, significant subsidy from the hospital. It is built into the decision support tool, so that net profitability of $8.1 million includes almost $1 million in support from the hospital system. Your second question, about why do our elective cases lose money? I was surprised at those findings. Most of them are outpatient. Most of them involve significant disposables. And most of them are now done because we are physically linked with the trauma center in an inpatient operating room. So we have not compared with our partners in the department who do much of their work at the outpatient center, which has a little bit lower cost. But I believe a lot of the contribution to that essentially neutral fiscal picture for elective surgery at our hospital has to do with the patient types that we are doing electively, and the fact that we are doing them in an inpatient operating room with a large use of disposables.
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We had originally included all the patient types. And it muddied the water and really, I thought, clouded the picture of what we were trying to show here. We do continue to do elective surgery. It is fascinating, as you do more and more emergency general surgery, you establish those relationships with families, and they come back to you for their elective procedures. What we have done is moved a faculty member 3 days a week to the outpatient surgical center and are doing most of that now there. Dr Carol Scott-Connor (Iowa City, IA): This is a fascinating analysis. And it sort of confirms some of my gut feelings as I’ve watched this evolve. In our area, trauma surgery is extremely well reimbursed, because of the combination of automobile insurance, workers compensation, and various other mechanisms that reimburse very well. And also, because, as you demonstrated, there’s a high percentage of E&M coding for nonoperative work, and those codes have retained their value better than many of the operative procedures. What I think is new and striking about your work is that you demonstrated this also for the emergency cases. I think that as we move toward using this model more and more to improve, if nothing else, the quality of life for our trauma surgeons who like to operate, after all, they are surgeons, and recognizing practice patterns in the community, where these cases are being referred in, it’s something we’re all going to work with. I think that my question for you would be, how will you continue to grow in such a way that you can satisfy the needs of the faculty that you recruit? When you bring in faculty on the trauma ACS service, do you find that being able to develop an elective practice is important to them? And how are you going to do that, if so? The second question would be, the finding that you uncovered with the general surgery cases, is that a phenomenon with other general surgeons in your department as well? Is it just simply the nature of the beast that laparoscopic cholecystectomies are not reimbursed very well, and if you use a lot of disposables, you’re going to be kind of revenue neutral at best? Dr Stephen L. Barnes: I’ll be honest, we grew from 3 to 5. And let me tell you, the difference between 3 and 5, from a lifestyle standpoint, is outstanding. Most of what I have focused on recruiting was people with interest in emergency trauma critical care education and research. So although they do establish relationships and do have patients referred directly to them, right now, other than myself, who was trained by Nussbaum, none of them have a real big interest in doing elective surgery, although they do perform it, and are very happy with the practice of trauma and emergency care. But the other way, I believe, to look at these data is that surgical critical care is a key component of any acute care surgery program. And it drives a lot of the fiscal performance. A lot of the emergency general surgery patients have high case mix index, high risk of mortality, and high severity of illness. Therefore, their reimbursement to the
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hospital is higher. And we spend more time with them in the intensive care unit, which benefits our bottom line as well. I do believe that general surgery has been reduced to a point that it is almost cost neutral, with the number of cases being done laparoscopically and you are linked to the cost of your disposables. If we had used the upstream and downstream revenue in this analysis for the elective general surgery patients, I think you would have seen it swing a little bit further to the positive side. But with the cost of mesh, the cost of disposables, the margins on outpatient and elective general surgery are such that it becomes a very difficult process to make elective general surgery profitable at the rates that you see for the injured or acutely ill patient because it’s elective surgery. It’s outpatient, and they are not sick. Therefore, those risks of mortality, severity of illness, and case mix index are significantly lower with the ASA1 and ASA2 cases. Dr Frederick Luchette (Maywood, IL): Stephen, I rise to congratulate you on your continued explorations of the financial benefits of acute care surgery. And, Matthew, I want to congratulate you, too, on an excellent presentation. You sort of answered my first question, Stephen, when you said you’ve now expanded to 5, because asking 3 faculty to cover all of those services, with 12,000 work RVUs, is not sustainable. They’ll burn out on you. So what has been the financial impact to your 5 faculty now with the expansion? Has the hospital increased the stipends to you in the supplemental income? Second, you talked on the dollar side, but what’s the real impact on efficiencies with the acute care surgery and getting the patients out of the hospital quicker, having the referring doctors more satisfied with a prompt consultation? Dr Stephen L. Barnes: When I was recruited to go to the University of Missouri, I negotiated that I had would need $1.2 million to start an acute care surgery program. That support has now been decreased to $860,000 a year, with 5 faculty. The growth of the emergency general surgery, which we targeted and went to all these smaller
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rural hospitals in our area and said, ‘‘If they’re sick, if they’re aged, if they have significant comorbidities, if it’s the middle of the night, or if you’re just uncomfortable, send it to us,’’ has grown so significantly that we’ve been able to keep up fiscally with the pace of adding new faculty and plan to. I believe we are starting to level out and not seeing the rate of growth that we’ve seen in the first four years. And we will land at about 6 faculty, with 1 moving into more of a part-time position. So we have decreased but continue to receive support. The efficiency, we didn’t look at in this. It needs to be looked at. It’s been looked at before. It is clearly easier. We do not disrupt our elective surgical partners’ clinics and practices because we are immediately available to go to the operating room. My division has block OR time that is protected until 6:00 in the morning, from 7:00 to noon, 6 days a week. And we fill that block every day, which allows us to very timely take people to the operating room as they come into the institution. As we all know, many of these things brew at an outside hospital in the daylight hours and don’t get shipped to us until the wee hours of the morning. The other piece that I think is important is, as far as incentivizing performance, I was very firm in the fact that we would have a group incentive for performance. Most of our departments at our institution are in an individualized performance model for incentive. And by group incentivizing and not providing competition between my faculty members, the goal, as things get busier, and what you’re talking about, efficiency of delivery of care, allows if we have one room going and someone else needs an operation, and Dr Coughenour is on call today, Dr Barnes comes in and does the next one, and Dr Ahmad comes in and does the next one, Dr Nelson comes in. We, at times, will have 4 rooms running. All in an effort to, in a very timely fashion, deliver quality care in a very efficient manner. And I believe that’s linked to the way we incentivize as a group, as opposed to individual performance.