In previous SpineLine editorials1,2, I have repeatedly criticized the relative value unit (RVU) as an inaccurate reflection of clinical activity, a deeply flawed and outmoded metric, and destructive to cost containment, as it rewards the volume—as opposed to the quality—of clinical activity. Unfortunately, this persists, despite rep­eated suggestions for an in-depth reevaluation of this widely used tool.3 Regrettably, as the system stands now, the RVU remains Really Very Useless. It is useless on a very large scale. The RVU is the central determinant of the Physician Fee Schedule (PFS) which is expected to have a cost of more than $1 trillion per year by 2031.4 Even as early as 1988, the economist, William Hsiao, who was instrumental in the development of the Resource Based Relative Value System (RBRVS) noted that the influence of the RVU driving economic incentives and care delivery "remains largely unknown", presumably due to a lack of adequate empirical evidence.5 There were considerable methodological issues with the initial development, which have persisted to this day. The American Medical Association's Relative Value Scale Update Committee (RUC), relies on the same methods used in the 1980s, surveys of physicians to quantify their work.6 Initially, this was based on valuing various vignettes. Despite the current absence of vignettes, there is little, if any, meaningful methodological difference in the way RVUs are determined, and have been "updated" in the last 40 years. Despite this, Medicare adopted the RBRVS system across specialties in 1992.

Methods of care delivery have changed dramatically over the years. A significant proportion of care occurs at times not directly linked to patient visits, including precharting, telemedicine, billable telephone calls, and administrative issues related to insurance and preapproval. McMahon et al, recently reported that roughly 33% of physician work is no longer determined by visits.7 Additionally, in primary care, a significant amount of physician work outside of the clinic physician work involves managing the health of a given population. I would submit that as spine practitioners, we face many of the same challenges, as a great deal of our care is delivered outside of the visit; this not only entails the mundane administrative tasks which have become ever more daunting, but patient education, and in response to direct patient questions via the electronic medical record. Clearly very few physicians, regardless of their specialty, are truly getting credit for all the care being provided. Clearly, the system is neither balanced nor equitable. Is there any hope that it can be reformed? McMahon and Song3 suggest that the Medicare Payment Advisory Commission should consider gathering newer data, recalibrating RVU equivalency guided by these data, and set the RVU dollar amount on volume and site of care. Presumably the latter would take into account the increasing volume of care that is delivered outside of the clinic. Needless to say, this is a very daunting task and I am not overly optimistic that can be accomplished in either a rational manner, or in a reasonable timeframe. In the meantime, we will all face the challenges that this suboptimal system presents. Arguably, the most glaring challenge is the fee-for-service mentality which rewards volume but not necessarily appropriateness or efficacy of care. The cautionary tale for spine practitioners could not resonate more clearly, given the ongoing clinical, financial, and emotional burden associated with the postoperative Persistent Spinal Pain Syndrome.9 Would there be a lower incidence of chronic postoperative spinal pain with a better compensation structure? Obviously, this is a delicate subject and would be very difficult to determine. However, with a more contemporary and balanced system, we would certainly be increasing our chances of optimal care delivery. In this issue, as we prepare for a superb annual meeting, our outgoing president, Zo Ghogawala provides a very clear and precise vision for the future of a leaner, forward thinking, and more efficient NASS. Malithuruthel et al, in the Invited Review address a critically important issue. Minimally invasive surgery continues to grow in popularity. In this paper, the authors look at the cost deficiency of MIS, obviously a crucial issue. The Literature Review, penned by Ajjawi and Grauer, addresses a topic in which there is considerable variation of protocol and opinion, namely activity increase after cervical spine surgery. There is summary is perceptive; their conclusions may surprise you. In the NASS News section are the profiles of our excellent 20 Under 40, as well as highlights of the impending meeting. I am looking forward to seeing the entire membership in Chicago. Finally, I would very much like to thank Donna Ohnmeiss, PhD, for her contributions and insight during her time on the editorial board. Donna is a nationally recognized thought leader and has been a valuable contributor to SpineLine. Her input, enthusiasm, and expertise will be greatly missed. Thank you again, Donna.