Outpatient Dermatology Productivity Measures by Patient Race, Sex, and Age

Abstract

Importance: Clinical productivity measures may incentivize clinical care to specific patient populations and thus perpetuate inequitable care. Before the 2021 Medicare physician fee schedule changes, outpatient dermatology encounters for patients who were younger, female, and races other than White systematically generated fewer work relative value units (wRVUs). Objective: To examine the association of patient race, age, and sex with wRVUs generated by outpatient dermatology encounters after 2021. Design, setting, and participants: This multi-institutional cross-sectional study evaluated demographic and billing data for outpatient dermatology encounters across 3 academic dermatology practices. The study compared wRVUs generated by outpatient general dermatology encounters in 6-month periods before and after the 2021 fee schedule updates (March 1 to August 31, 2019, and March 1 to August 31, 2021). Eligibility required an age of 18 years or older and available age, race, and sex data. Data analysis was performed from September 2022 to March 2024. Main outcomes and measures: The primary outcome was wRVUs generated per encounter. Results: This study included 89 656 encounters (47 607 before the 2021 Medicare physician fee schedule update and 42 049 after the update). Across all encounters, the mean (SD) patient age was 56.3 (17.8) years; 55 460 encounters (61.9%) were with female patients and 34 196 (38.1%) were with male patients; and 3457 encounters (3.9%) were with Asian patients, 10 478 (11.7%) with Black patients, 72 894 (81.3%) with White patients, and 2287 (3.2%) with patients of other race or ethnicity (Latino and multiracial). The mean (SD) wRVUs per outpatient dermatology encounter was 1.44 (0.88) before the update and 1.80 (0.99) after (P < .001). After 2021, adjusted analyses demonstrated significantly fewer wRVUs per encounter for female (β, -0.11; 95% CI, -0.13 to -0.10) compared with male patients, and for younger (β, 0.04 [95% CI, 0.04 to 0.05] per 10-year increase in age) compared with older patients. After the update, compared with White patients, visits with Asian patients generated fewer wRVUs (β, -0.12; 95% CI, -0.17 to -0.08) as did visits with Black patients (β, -0.14; 95% CI, -0.17 to -0.11), both statistically significant reductions compared with prior comparisons (P < .001 for both). After 2021, mediation analysis identified that premalignant destructions and biopsies mediated many of the remaining differences in wRVU generation by patient age, race, and sex. Conclusions and relevance: This study found that after the 2021 Medicare fee schedule updates, there was a persistent, albeit reduced, gap between wRVU productivity in outpatient dermatology visits for Asian and Black compared with White patients. These persisting differences were attributable to skin biopsies and cryotherapy of premalignant lesions.