Physicians are increasingly choosing employed positions, and 80% of these employment contracts pay based, at least partly, on productivity. Though originally intended as a measure of resource utilization, the RVU (Relative Value Unit) has become synonymous with productivity. Employment contracts often utilize the “work RVU” (wRVU) as an adjusted measure of productivity and pay a salary with a bonus based on wRVUs.
Google these terms and you can spend countless hours reading statistics about how many wRVUs doctors produce and how much they get paid for them. You’ll also find lots of articles from practice managers and administrators telling you why RVU-based incentives are good and fair and how they’ll help you recruit young and ambitious physicians. What you won’t find is any discussion of how these things are calculated; and as is usually the case with complex formulas, the devil is in the details.
There are all kinds of ways in which wRVU-based incentives are skewed to favor some practice types, specialties, and even clinically insignificant details of procedures. But for those in the know, these biases can be manipulated for immense gain.
The most obvious example is the undervaluation of the cognitive clinical visit (the office visit) (1). This implies a relative overvaluation of procedures. Remember that wRVUs are based on resource utilization, not efficacy or value to the patient. So many procedures with minimal or questionable clinical value may yield big wRVUs. Cardiac catheterizations clearly can have life-saving benefits in the right clinical context. But as they have paid big bucks (and high wRVUs), their use has expanded well beyond those clinical contexts into areas of unclear clinical benefit. Yet even as the clinical benefit may decrease, the resources required, the payments reimbursed and the wRVUs accrued, remain high. Cardiac caths have become the quintessential example of a high-cost procedure of questionable clinical utility (in specific clinical circumstances). The media has latched onto these stories as potential explanations for the high and rising cost of medicine.
But wherever there’s a game, there will be a gamer. And the gaming can be had at even finer levels of minutiae. A screening colonoscopy yields a few wRVUs, but if a polyp is found and removed, the wRVUs for the procedure is slightly higher, and rightly so. But what if there are two polyps, or even eight? More work should mean more wRVUs, right? That’s where the details matter. Colonoscopy codes yield wRVUs for the method you use to remove the polyp, but not for the number of polyps removed. If that seems counterintuitive to you, good, you are paying attention. So removing one or eight polyps using the same method for all polyps yields the same wRVUs despite obviously involving a lot more work to remove eight. If instead, you remove one polyp with one method (a snare, for example) and another polyp with another method (a forceps, for example), you accrue wRVUs for both methods. This may effectively “double” your productivity. It’s fee for service, but not the amount of service. It’s the diversity of service that counts.
The obvious product of this is the gastroenterologist who always finds three polyps and uses three different methods to remove each one. This gastroenterologist maximizes their wRVUs, reimbursement, and so-called “productivity” to the tune of 2–3 times their unwitting colleague who might remove many more polyps (having a greater clinical value) but uses only one instrument and is therefore less “productive.”
Nobody seems to mind, or discuss, these glaring inconsistencies. But why should they? No one wants to kill the goose that lays the golden egg.
Dr. Budhraja is a Gastroenterologist in Springfield, Massachusetts.
- http://www.gastroenterologyandhepatology.net/index.php/archives/april-2016/how-relative- value-units- undervalue-the- cognitive-physician- visit-a- focus-on-inflammatory- bowel-disease/