Visibility Is Not Control: Construct Separation and Variable Attribution in Surgical Reimbursement Policy

Surgical reimbursement policy frequently treats dollar-denominated figures as interchangeable even when they measure different economic constructs. Physician professional fees, facility revenue, Medicare Physician Fee Schedule rates, qualifying payment amounts, contracted rates, billed charges, adjudicated payments, and total episode costs differ in provenance, construction method, purpose, and interpretive boundary. A related attribution error occurs when accountability is assigned to the actor most visible to the patient rather than to the actor that controlled the operative variable. This technical report proposes a construct-separation and variable-attribution framework for distinguishing what reimbursement figures measure from who controlled the variables that produced disputed payment, access, or cost-containment outcomes. The report presents two operational checks: a five-filter construct-separation test and a six-question variable-attribution test. These checks apply symmetrically to physician charges, payer benchmarks, adjudicated outcomes, directory-based network claims, and savings assertions. Functional specialist availability is identified as an access-relevant construct distinct from directory enrollment. A network listing may establish contractual presence but does not establish emergency coverage, complex case acceptance, transfer acceptance, after-hours availability, or post-operative continuity. The framework does not set prices, validate billed charges, invalidate statutory benchmarks, or prove access harm. It establishes a measurement discipline that should precede policy judgment: identify the construct, define its boundary, state what it omits, and map operative control before assigning accountability. The intended audience includes clinicians, health-policy researchers, payers, regulators, hospitals, independent dispute-resolution entities, and legislators seeking a structured method for interpreting reimbursement figures, evaluating network adequacy, and assigning accountability according to operative control rather than patient-facing visibility.