Laparoscopic Inguinal Hernia Repair: Undervalued by the Relative Value Unit System

Abstract

Work relative value units (wRVUs) serve as a proxy of surgeon’s effort, technical skill, and time to determine reimbursement. The aim of this study is to determine how accurately wRVUs reflect the work effort of surgeons performing laparoscopic inguinal hernia repair (LIHR) as compared to open repair (OIHR). Within the National Surgical Quality Improvement Program database, 40 099 patients who underwent LIHR and 99 176 patients who underwent OIHR between 2012 and 2017 were identified. Mean wRVUs, wRVUs per minute, and operative times were compared between 8 groups based on clinical factors (unilateral vs. bilateral; obstructed vs. non-obstructed; primary vs. recurrent; 2 × 2 × 2 = 8). In both aggregate and matched cohorts, wRVUs for LIHR were significantly lower than OIHR in all 8 categories (P < .001). On regression analysis, the mean difference in assigned vs. calculated relative value units (RVUs) was most divergent among unilateral, recurrent, obstructed IHR (3.12 mean RVUs, P < .001). Despite the rising utilization of LIHR, current wRVUs significantly undervalue this technique across all categories and consequently the work of surgeons who perform laparoscopic procedures. This RVU discrepancy in an increasing minimally invasive, value-driven surgical environment calls for more objective criteria to assign RVUs, whereby the value is measured by operative complexity—patient clinical factors and severity of the hernia itself—not solely operative technique.