Is there a financial disincentive to perform partial nephrectomy?

Purpose: Despite the explicit endorsement of the American Urological Association guidelines of partial nephrectomy as the treatment of choice for T1a renal cell carcinoma, a considerable underuse of nephron sparing surgery characterizes general practice patterns in the United States. We explored possible financial disincentives associated with partial nephrectomy that may contribute to this important quality of care deficit. Materials and Methods: A PubMed® query on perioperative outcomes identified 10 series on open or laparoscopic radical nephrectomy and 16 on open, laparoscopic or robot-assisted partial nephrectomy. Mean operative time and hospital length of stay were calculated for each group. Using these data in conjunction with Health Care Financing Administration data on physician work time, which guides the current Resource-Based Relative Value Scale Medicare fee schedule, we calculated global physician time expenditure and hourly Medicare reimbursement rates for each of these 5 surgical services. Results: Mean ± SD operative time for open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy was 180.7 ± 24.7 minutes (95% CI 119.3-242.0) in 3 studies, 178.8 ± 16.5 (95% CI 163.5-194.1) in 7, 226.0 ± 36.9 (95% CI 187.2-264.8) in 6, 227.9 ± 40.2 (95% CI 185.8-270.1) in 6 and 227.9 ± 37.8 (95% CI 167.7-288.1) in 4, respectively (p = 0.028). Mean length of stay (days) after open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy was 5.8 ± 0.7 days (95% CI 4.0-7.7) in 3 studies, 2.5 ± 1.1 (95% CI 1.4-3.6) in 6, 5.8 ± 0.4 (95% CI 5.3-6.2) in 5, 2.9 ± 0.3 (95% CI 2.6-3.3) in 6 and 2.8 ± 1.0 (95% CI 1.2-4.4) in 4, respectively (p <0.001). The hourly reimbursement rate was calculated at $200.61, $242.03, $185.66, $231.27 and $231.97 for open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy, respectively. Hence, open partial nephrectomy emerged as the lowest paying of these procedures. Conclusions: Inferior compensation for open partial nephrectomy relative to that of laparoscopic or open radical nephrectomy may impede the dissemination of nephron sparing surgery for small renal masses. This may occur particularly in a general practice setting, where the expertise required for laparoscopic or robot-assisted partial nephrectomy may be lacking. We propose rectifying this inequity to facilitate wider use of nephron sparing surgery in the clinically appropriate setting.