Relative value units, and how the RVU payment system doesn’t allow doctors to practice good medicine

For those who don’t know, every piece of work that a doctor performs is quantified and measured.

The base unit of physician work is known as the relative value unit (RVU). Most physician salaries are determined by the amount of RVUs a doctor produces in a given year, and in most cases, can range between$35 and $45 per RVU in primary care, depending on geographic location and specialty.

For instance, in an RVU-based salary structure, if a 15-minute office visit is assigned an RVU value of 0.7, and a doctor is paid $35 per RVU, that visit will add $24 to a physician’s yearly salary.

Just for comparison’s sake, a colonoscopy, which may take twice the time, is valued at close to 6 RVUs, which is 8-times the value given to a 15-minute primary care office visit.

But I digress.

The reason I bring this up is that Boston Globe columnist Sam Allis talks about the issue, and interviews a few select Harvard physicians about its flaws. Physician-author Jerome Groopman, of How Doctors Think fame, rightly notes that the system does not value some of the truly important things that doctors do: “There are no RVUs for spending an hour with a grieving family, or a colleague who wants you to lend him your brain on a case. There are no RVUs for sitting with a confused third-year medical student. There are no RVUs for the humanistic core of medicine that drew me into this profession in the first place.”

I would also add that although there are RVUs for talking over the phone with a patient, or communicating via e-mail, they are rarely paid for by Medicare or insurers, and hence, worthless.

Perhaps instead of searching for ways to re-invent systems to pay doctors, modifying the RVU system to value, and having the insurers to recognize, this type of work will go a long way to incentivize doctors to provide the type of care that’s truly important to patients.

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  • Chuck Brooks

    It’s unlikely that customers/patients are aware of this bureaucratic arcana, much less company HR departments that subsidize employee’s health costs. Doctors are not going to get a better deal on their own; making customers/patients aware of things like this, and how it impacts them directly, could only help as these battles continue. A simple printed handout citing these bizarre dealings would be a good start.
    Chuck Brooks
    FutureWare SCG

  • Bad Medicine, Good Solutions

    A better solution would be to just say no in primary care and opt out of the system. Cash for primary care. No cash? Go see the government Nurse Practitioner and hope for the best.

  • Anonymous

    When these agencies look at reimbursement for primary care, they see how many more people use primary care than sick care; the most efficient way to cut costs is to pay as little as possible for the services used most, and so primary care ends up undervalued. People also put less priority on primary care because they don’t have the same urgency for it as they do for emergent care, so they want to shop around for a better deal. When people don’t have they urgency, it amplifies the core problem with our healthcare system: people want great healthcare, they just don’t want to pay for it.

  • Anonymous

    Does the RUV for a colonoscopy just count for the Physician, or does the cost of the helpers involved have to come out of that also?

    An office visit might include a receptionist and someone to show you to the exam room, take your weight/height. Both are pretty low-level skill sets.

    A colonoscopy involves someone to administer anesthesia, someone to supervise the after-room, most likely also a receptionist.

    If the RUV value has to cover those folks also then maybe it is worth 6 8ore than an office visit.

  • Anonymous

    The disparity in procedure based RVUs makes sense based on the added skill needed and the complexity. The gastroenterologist spents an additional three years in fellowship training to perform colonooscopy, during which time they made less than minimum wage. The RVU assigned to a given task is higher for those aspects of care which involve greater training, complexity and risk. You certainly are not going to perforate a patient’s intestine during a routine office visit, but I have seen a gastroenterologist do it during colonoscopy..

  • Anonymous

    Consider this scenario in a patient withOUT insurance…

    You were injured playing soccer, you had a misstep thus twisting your ankle, you proceed to the doctor and s/he then performs an examination ($100), takes an xray ($150), does some therapy ($50), does some other therapy ($50) and says “I’ll see you next week.” You have a bill of $350.

    Not having any insurance the patient inquires prior to service and would perhaps be inclined to shop elsewhere. $350 is rather steep. Well here’s the thing, a doctor knows s/he would never charge a patient that amount of money on a simple ankle twist, the doctor instead rolls it all into the examination fee and calls it a day. Yes, you get $350 worth of services for $100. The patient is happy for the discount and the doctor is happy for the monetary value received on the spot.

    Now, in an insurance model where a population puts money toward a pot every month and this pot now has billions, yes billions of dollars at it’s disposal and a patient comes in with the same problem, the doctor will be more inclined to bill individually for every item. Yes the doctor will now charge the full $350. The doctor is now taking from the system (pot) and let’s face it, the everyday person doesn’t have their mind on the system as they do on their own wallet. And thus you have a doctors who perform as much as possible for as much as possible because no one is looking. Plus the doctor now has the possibility of a lawsuit on his hands should something not have been performed in the best interest of the patient. Plus the doctor has medical school to pay for and well patients aren’t as common as one would think…they have to compete with the other thousands of grads that just entered the workforce.

    Also, it would be rather eye opening if a common patient understood the amount of radiation they were getting from a single CT scan which is perhaps the most common test in the ER now a days

    This is a mess.

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