Surgeon compensation models in the US remain heterogeneous, including salary, work relative value unit–based, hybrid, fee-for-service, and value-based structures, according to a systematic review of 39 studies across 13 surgical specialties.
In the review, researchers identified five primary compensation models—salary (n = 8 studies), work relative value unit (wRVU)-based (n = 8), hybrid (n = 7), fee-for-service (n = 5), and value-based (n = 3)—with reported differences in productivity, quality, and nonclinical contributions.
The researchers conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, querying PubMed and Embase for studies published between January 1, 2014, and August 20, 2024. Two reviewers independently screened 3,268 records, with 39 studies meeting inclusion criteria. Risk of bias was assessed using the Newcastle-Ottawa Scale and Appraisal tool for Cross-Sectional Studies, with most studies rated as low to moderate risk of bias.
Productivity-based models were consistently associated with increased surgical volume. For example, transitioning to wRVU-based compensation was linked to a 45% increase in elective hip and knee arthroplasty volume in one institution, while another reported increases of 6% in surgical volume and 5% in wRVU generation.
However, these models often did not account for case complexity, outcomes, or nonclinical contributions such as teaching and research. Across studies, wRVU and fee-for-service models were associated with reduced support for teamwork and nonclinical activities and an increased risk of overutilization.
Salary-based models provided financial stability and promoted team-based care but were associated with lower clinical productivity compared with fee-for-service models. In one comparison of spine surgeons, salaried physicians demonstrated lower procedural volume, while qualitative data suggested clinical decisions were less influenced by revenue considerations.
Hybrid compensation models, which combine base salary with incentives tied to productivity, quality, or academic contributions, were described as offering flexibility. These models included incentives for clinical productivity as well as research and education. However, they were administratively complex and often remained weighted toward procedural volume unless explicitly designed otherwise.
Value-based compensation models were infrequently reported and showed limited adoption. Among breast surgeons, 18% reported receiving bonuses tied to non–revenue-generating activities. In a national cohort of more than 9,800 general surgeons, those caring for higher proportions of dual-eligible patients were more likely to receive negative payment adjustments under the Merit-based Incentive Payment System, despite similar interoperability metrics.
Across models, variation was reported in how nonclinical activities such as teaching, research, and administrative work were recognized, and wRVUs were noted to account for approximately 80% of surgeon effort in some analyses.
The researchers noted that heterogeneity in study design and outcomes limited quantitative synthesis and causal inference. Most included studies were observational, and compensation data may not fully reflect institutional nuances or market influences.
Understanding the trade-offs of each compensation model may help inform the development of payment structures that better align the interests of surgeons and institutions, the researchers noted.
J. Walker Rosenthal, BS, of the Department of Surgery in the Perelman School of Medicine at the University of Pennsylvania, and colleagues conducted the study.
Disclosures: Elliott R. Haut, MD, PhD, reported receiving grant funding from the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality, serving in unpaid board roles, and as paid editor in chief of Trauma Surgery & Acute Care Open; Justin B. Dimick, MD, reported equity ownership in ArborMetrix; and Rachel R. Kelz, MD, MSCE, MBA, reported National Institutes of Health funding and serves as Deputy Editor of JACS. No other disclosures were reported.
Source: JAMA Surgery
