Background: There is a high demand for shoulder/elbow experience among hand-fellowship trainees due to the
perception that this exposure will improve their professional “marketability” in a subspecialty they perceive as having
Methods: Using Medicare data, we investigated the most common surgeries from these fields and determined
which have the highest compensation [work relative value unit (wRVU), payment, charge, and reimbursement
(payment-to-charge percentage] rates per operative time. We then determined whether the overall non-weighted
and weighted (by surgical frequency/volume) compensation rates of shoulder/elbow surgery are greater than that
of hand surgery.
Results: Among 30 shoulder/elbow procedures, arthroplasty and arthroscopic rotator cuff repair had the highest payment
and wRVU assignments. Among 83 hand procedures, upper-extremity flaps, carpal stabilization, distal radius open
reduction internal fixation (ORIF), both-bone ORIF, and interposition arthroplasty had the greatest wRVU assignments
with correspondingly high payments. A non-weighted comparison of the two subspecialties showed that hand surgery
has a higher mean payment/min ($10.46±3.22 vs. $7.52±2.89), charge/min ($51.02±17.11 vs. $41.96±11.32), and
reimbursement (21±4.7% vs. 18±5.1%) compared with shoulder/elbow surgery (all, P<0.01). Non-weighted mean
wRVUs/min were similar (0.12±0.03 vs. 0.13±0.03, P = 0.12). When weighted by procedure frequency, hand surgery
had greater wRVUs/min (0.15±0.036 vs. 0.13±0.032), payments/min ($14.17±4.50 vs. $6.97±2.26), charges/min
($75.68±30.47 vs. $42.61±7.83), and reimbursement (20±5.0% vs. 17±6.0%) (all, P<0.01).
Conclusion: According to Medicare compensation, and when weighted by procedure frequency, hand procedures
are associated with greater overall mean wRVUs/min, payments/min, charges/min, and reimbursement compared with
shoulder and elbow procedures. Hand-surgery fellowship applicants should be aware that subspecialty compensation
is complex in nature but should seek shoulder/elbow elective experience to acquire an additional surgical skill-set as
opposed to primarily monetary reason.
Level of evidence: III