Since it’s introduction in 1977, the national health insurance program in Korea has paid health care providers on a fee-for-service basis, and the reimbursement for health care providers has been regulated by the government. Regulated fee-for-service payment has resulted in an increased volume and intensity of medical care5). This led to the creation of the Korean Resource Based Relative Value Scale (K-RBRVS), which remains in force, with continual evolution, to the current day. K-RBRVS was developed in 1997 based on the RBRVS of the United States of America (USA), which was established in 1992, and was introduced in 2001 as an alternative of the previous Korean medical fee schedule.

Not unexpectedly, most neurosurgeons are unfamiliar with the details of the K-RBRVS and how changes in the K-RBRVS affects the reimbursement rates for the surgical procedures we perform. Unfortunately, most physicians might also be unaware of the update process and of the trend of change in relative values (RVs). Physicians in a wide variety of settings may benefit from understanding the K-RBRVS, and from precisely knowing the trend of change in RVs in our surgical specialty. However, to our knowledge no article about this issue in our field has been published yet.

In this article, we summarize the K-RBRVS in brief, and discuss on how the relative value (RV) of the spinal neurosurgical procedures have changed since the introduction of this system in 2001. We also compare these changes with the brain neurosurgical practices, and finally discuss on the fairness regarding whether if we are properly paid or not, for the practices we do in the spinal neurosurgical field.

In this study, in order to estimate whether we are reimbursed for surgical practices properly or not by the K-RBRVS, we have analyzed the RV of spinal neurosurgical practices under K-RBRVS. And also compared the results with that of brain neurosurgical practices. Reimbursement to neurosurgeons, is categorized into three broad areas by the Korean Health Insurance Review & Assessment Service (K-HIAS) which is not different from that of the United States’ RBRVS7). First, like all clinical specialties, diagnostic imaging studies as well as laboratory examinations provide revenue for neurosurgeons based on specific codes given by the K-HIAS. Second, some minor outpatient department based simple procedures and some functional test or physical examinations have codes for reimbursement. Third, as we are surgeons, we earn revenue by performing operations performed in hospital based operating rooms.

While medical practices such as imaging studies or functional studies are the majority of practices in many non-surgical based specialties, the majority of reimbursement for neurosurgeons come from surgical procedures. 143 out of 159 (89.9%) coded practices in the neurosurgical field are surgical procedures, and the total amount of money reimbursed for these surgical procedures were 112 billion Korean Won, 76.8% of the total amount of reimbursement in 20132). As surgeons, reimbursement for surgical procedures are surely of most interest.

In our study, we have found that the reimbursement for surgical procedures has been advantageous to brain surgeries than spinal surgeries. The gap of increase rates of RVs between two neurosurgical fields has been quite significant, as previously described (Table 1). The Korean neurosurgeons have a single large society, the Korean Neurosurgical Society (KNS) and both brain surgeons and spinal neurosurgeons are participating in this community. Although majority of the members are actually engaged in the spinal neurosurgical field, many policy decisions have been made mainly by brain neurosurgeons for a long period of time. The Chairman and President of this community has also been usually consisted of brain neurosurgeons much more often than spinal neurosurgeons. As brain neurosurgeons have played an active role in the society, policies related to the reimbursement for neurosurgical procedures might have also been mainly focused on brain surgeries, and spinal surgical procedures might have been relatively estranged from the main stream of policy interests. When comparing the actual increase of RVs in both neurosurgical fields between Korea and USA, we could recognize how much the RVs of spinal procedures were estranged from proper increase. RVs of several frequently performed surgical procedures of both field in both nations are presented on Table 2. While the RV increase for such particular procedures were not so different between both fields in the USA, the increase rate was significantly higher for the brain procedures in Korea.

Another reason could be because of the unique circumstances of spinal surgical fields in Korea. Both neurosurgeons and orthopedic surgeons have their own society of spinal surgeons, and actually do not have an active academic exchange between societies. Nonetheless, the K-RBRVS have a single system of RVs for spinal surgical procedures, regardless of the spinal surgeon’s specialty. Therefore, both societies should have closely collaborated and should have made united efforts in order to achieve adequate increase of RVs in the spinal surgical field, however they didn’t for more than a decade. These complex circumstances probably resulted in a relatively low increase rate of RVs for spinal surgeries during the past 15 years.

As mentioned previously, RVs for the procedures we perform are determined on the basis of resource costs required to produce services: total work (time and intensity) of the physician, practice (overhead) costs and the opportunity costs regarding possible risks of professional negligence during procedures4,5). Currently, the average proportion of physician’s labor in total surgical practice RVs is 16%3). After the second major revision in K-RBRVS, the overall average for percentage of physician’s labor in RVs are supposed to be 26% for surgical procedures2), which is much larger than before. But unfortunately, this trend of increase in the physician’s labor doesn’t seem that it will be reflected in the neurosurgical field. The percentage of each costs planned for the second revision of K-RBRVS in representative neurosurgical procedural categories of both brain and spinal surgeries are shown on Table 3. The average percentage of physicians’ labor in RV will be 22.8% in brain surgeries while it will be only 18.0% in spinal surgeries2). The opportunity cost representing possible risks of medical negligence is also lower in spinal surgical procedures than brain surgeries2) (10.5% vs. 6.3%). This result suggests that the K-HIAS estimates the spinal surgeons’ labor much lower than that of brain surgeons, and also estimates that opportunity costs for risk of spinal procedure related issues are also much smaller than brain surgeries. The physicians’ labor in brain neurosurgical procedures are lower than the average, and that of spinal neurosurgeries are even much more below the average. In the United States, the physician’s labor takes 55% of the total RV1,6) which is much higher than that of K-RBRVS which is 18% currently3) (Fig. 4). The physician’s work is defined as the physician time and intensity involved in providing a surgical procedure, and it includes mental effort, physical effort, technical skills and psychologic stress involved in providing this surgical service6). Although we do not have objective measures for this currently, however there surely is doubt in whether we are adequately reimbursed for these efforts or not. Especially more when we compare the proportion of physician’s work with brain surgeons or that in the United States’ RBRVS.

Finally, our study has found that the reimbursement for spinal surgical procedures have been relatively underestimated for more than a decade under the K-RBRVS. When we analyzed the RVs of spinal surgeries, they were significantly smaller than that of brain surgeries and the increase rate for 15 years was smaller as well. Another important point was that it was not only the overall RV of spinal surgeries that was underestimated, but also the proportion of surgeons’ labor. Compared with that of United States’ RBRVS, the underestimation of a spinal physician’s labor was even more significant. Concerns that the RVs under RBRVS may not accurately reflect a surgeon’s work, productivity or value is not surprising, and has already been an issue also in other surgical specialty societies8). The problem is, that not much attention has been paid for this problem for a long period of time in our surgical society and maybe this lack of interest for proper reimbursement might have led to this discrimination of RVs. As the second major revision for K-RBRVS has already been done and is about to be under force within this year, it might be quite late to start any effort in order to fix this problem, and gain impartial reimbursement within a short period of time. However, it is surely better late than never, and effort trying to reduce the gap of increase in RVs between spinal surgeries and brain surgeries should be done as soon as possible. Having regular policy meetings with the K-HIAS and effort to let them understand the current discrimination, and let them know our demands for proper reimbursement should be done. We should also show our effort in developing more objective measures of surgeon work to make the proportion of physician’s work more adequate. And additionally, effort to collaborate closely with the orthopedic spinal surgeons to achieve this matters of mutual concern will be necessary as well.

During the past 15 years, RVs for spinal neurosurgical procedures have increased in a rate of 62.8%, however this is hardly an actual increase when compared to the cumulative increase of consumer prices during this time period or the increase rate of 92.3% for brain surgeries. More effort of the society of spinal surgeons seems to be needed to get adequate reimbursement, as there have been some discrimination compared to brain surgeons in the increase of RVs. And considering the relative underestimation of spinal neurosurgeons’ labor, more objective measures of neurospinal surgeons’ work and productivity should be developed for impartial reimbursement.