Dr. Metz explains that differences in surgical time among individuals and institutions can be very large, markedly affecting anesthesia group revenue per operating room (OR). This point is so much not under debate that anesthesiologists are paid based on anesthetic time, unlike surgeons and other physicians. German hospitals are describing encouraging success with using transfer pricing so that reimbursement is based just on the surgical time.1,2 

Depending on the vagaries of reimbursement, sometimes payment based on anesthesia time is insufficient to compensate an anesthesia group fully for slower surgeons (e.g. , revenue per hour is less than costs per hour).3This is precisely why Amr Abouleish et al.  3developed the methodology that affected anesthesia groups can apply or have applied for quantification of these differences (e.g. , to explain to stakeholders why group profits are less than expected). For many anesthesia groups, though, the larger financial problem in having variability in OR times among surgeons is the resulting empty but staffed OR time. Statistically developed staffing plans perform well at reducing such variation, thereby increasing anesthesia group productivity and profits. The methods can also be used to calculate an appropriate stipend for the anesthesia group based on the empty but staffed OR time.4 

Dr. Metz suggests that “Hospitals might consider rewarding surgeons who can, for example, perform a routine laparoscopic cholecystectomy in 45 min and retraining surgeons taking 3 h for the same procedure.” Dr. Metz addresses a concept that I too5thought was logical. However, scientific research found this argument to be economically irrational.

First, rewards of additional resources cannot and should not relate to individual patients, but rather a surgeon's overall impact on a hospital.6The majority of hospital costs are fixed.7Therefore, contribution margin (i.e. , revenue minus variable costs) invariably6–8averages at least $1,600 per OR hour for a cholecystectomy. Regardless of whether the general surgeon works fast or slowly, on average the hospital increases profit by doing his or her cases. This is important, because hospitals need excess of revenue to costs (i.e. , profit) to buy information systems (e.g. , anesthesia information management systems), to buy equipment (e.g. , anesthesia machines), and to provide financial support to physicians (e.g. , anesthesiologists available in-house for obstetrics and trauma).

Second, if facilities were to select surgeons to be rewarded with more resources based on production, speed in performing cases would likely have little influence. Because of differences in fixed costs (e.g. , perfusion), reimbursement (e.g. , many patients without insurance), and/or implant costs (e.g. , cochlear implant), contribution margins per OR hour consistently vary among subspecialties by more than 1,500%. The surgeon's subspecialty is the key issue. This is like a comparison of stocks for rebalancing one's portfolio9—economic return often depends more on a company's industry and market than on how well the company executes. The decision of whether to provide more resources to one general surgeon performing cholecystectomies versus  another is of small financial importance as compared with the comparison of a general surgeon to a cardiac surgeon. The financial argument is even stronger when considered for facilities without incremental reimbursement for each patient (e.g. , Canada).10Regardless of whether a breast surgeon is fast or slow, the money spent in a day of OR time is insignificant relative to a spinal surgeon. If preferred, these tactical analyses can also be considered in terms of value to society by using cost utility (e.g. , cataract replacement vs.  bariatric surgery).

The University of Iowa, Iowa City, Iowa. franklin-dexter@uiowa.edu

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