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Original Investigation
February 17, 2021

Differences in Outpatient Dermatology Encounter Work Relative Value Units and Net Payments by Patient Race, Sex, and Age

Author Affiliations
  • 1Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
  • 2Emory University School of Medicine, Atlanta, Georgia
  • 3Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York
  • 4Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
JAMA Dermatol. Published online February 17, 2021. doi:10.1001/jamadermatol.2020.5823
Key Points

Question  Are patient race, sex, and age associated with the work relative value units (wRVUs) generated per outpatient dermatology encounter?

Findings  In this cross-sectional study of 66 463 outpatient dermatology encounters among 30 036 patients, visits with patients who were White, older, and male generated more wRVUs than visits with other demographic groups. Destruction of premalignant lesions and biopsies accounted for the preponderance of the observed differences by race, sex, and age.

Meaning  Results of this study suggest that race, sex, and age differences in wRVUs for outpatient dermatology encounters may incentivize dermatologists to care for patients who are most likely to develop skin cancers and thereby perpetuate disparities in access to dermatologic care.


Importance  Clinical productivity measures may be factors in financial incentives for providing care to specific patient populations and thus may perpetuate inequitable health care.

Objective  To identify the association of patient race, age, and sex with work relative value units (wRVUs) generated by outpatient dermatology encounters.

Design, Setting, and Participants  This cross-sectional study obtained demographic and billing data for outpatient dermatology encounters (ie, an encounter performed within a department of dermatology) from September 1, 2016, to March 31, 2020, at the Emory Clinic, an academic dermatologic practice in Atlanta, Georgia. Participants included adults aged 18 years or older with available age, race, and sex data in the electronic health record system.

Main Outcomes and Measures  The primary outcome was wRVUs generated per encounter.

Results  A total of 66 463 encounters among 30 036 unique patients were included. Patients had a mean (SD) age of 55.9 (18.5) years and were predominantly White (46 575 [70.1%]) and female (39 598 [59.6%]) individuals. In the general dermatologic practice, the mean (SD) wRVUs per encounter was 1.40 (0.71). In adjusted analysis, Black, Asian, and other races (eg, American Indian or Native American, Native Hawaiian or Other Pacific Islander, and multiple races); female sex; and younger age were associated with fewer wRVUs per outpatient dermatology encounter. Compared with general dermatologic visits with White patients, visits with Black patients generated 0.27 (95% CI, 0.25-0.28) fewer wRVUs per encounter, visits with Asian patients generated 0.22 (95% CI, 0.20-0.25) fewer wRVUs per encounter, and visits with patients of other race generated 0.19 (95% CI, 0.14-0.24) fewer wRVUs per encounter. Female sex was also associated with 0.11 (95% CI, 0.10-0.12) fewer wRVUs per encounter, and wRVUs per encounter increased by 0.006 (95% CI, 0.006-0.006) with each 1-year increase in age. In the general dermatologic practice excluding Mohs surgeons, destruction of premalignant lesions and biopsies were mediators for the observed differences in race (56.2% [95% CI, 53.1%-59.3%] for Black race, 53.2% [95% CI, 45.6%-63.8%] for Asian race, and 53.6% [95% CI, 40.4%-77.4%] for other races), age (65.6%; 95% CI, 60.5%-71.4%), and sex (82.3%; 95% CI, 72.7%-93.1%). In a data set including encounters with Mohs surgeons, the race, age, and sex differences in wRVUs per encounter were greater than in the general dermatologic data set. Mohs surgery for basal cell and squamous cell carcinomas was a mediator for the observed differences in race (46.0% [95% CI, 42.6%-49.4%] for Black race, 41.9% [95% CI, 35.5%-49.2%] for Asian race, and 34.6% [95% CI, 13.8%-51.5%] for other races), age (49.2%; 95% CI, 44.9%-53.7%), and sex (47.9%; 95% CI, 42.0%-54.6%).

Conclusions and Relevance  This cross-sectional study found that dermatology encounters with racial minority groups, women, and younger patients generated fewer wRVUs than encounters with older White male patients. This finding suggests that physician compensation based on wRVUs may encourage the provision of services that exacerbate disparities in access to dermatologic care.

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