This morning, I was contacted by the emergency department. We had a patient who came in with severe agitated delirium to the point that no combination of sedative and anti-psychotic medications could...
To some physicians, the words “relative value unit” or RVU were created by Satan to inflict pain and torment on physicians. But the reality is that an RVU is just another medium of exchange. A few years ago, we had a fellow in our department who was from Peru. He said that if a family did not have the money to pay their medical bills, they would give their doctor a chicken or do some yard work at the doctor’s home. Compared to bartering a chicken or a couple of hours of yard work, using money allows us to have put a relative value on individual services. The RVU is simply the way that physicians and Medicare agree on the price of the different services that physicians provide. RVUs are not inherently evil, they are just another way of stating what the fee is for any given service.
But no pricing system is perfect and some physicians will always be performing services that are over-valued or under-valued using the RVU system. If a doctor is getting a lot of RVUs for an hour of work doing a particular service or procedure, then that doctor tends to be quiet about it and not draw attention to him/herself so as to avoid someone from revaluing that service with a lower RVU. On the other hand, if a doctor is getting paid relatively few RVUs for an hour of work, that doctor is going to be very vocal about how their services are undervalued. The reality is that it is human nature for us to think that whatever service we are providing should be valued more and that we should get paid more for doing it.
Most physician practices will use the RVU as a measure of physician work effort as opposed to using the amount of cash collected. This has the advantage of overcoming the disparities between reimbursement by different insurance companies and eliminating the disincentive for individual physicians within a practice to care for uninsured patients and Medicaid patients. Therefore, physician practices will often set an annual RVU target for individual physicians to achieve in order to get paid a base salary and then provide a bonus to the physicians based on the number of RVUs they produce over that annual target.
In theory, the RVU system will generally reflect the amount of time a physician has to spend to do a given service plus the training and subspecialty expertise that goes into that particular service or procedure. However, the reality is that some procedures and services generate a lot more RVUs per hour than other procedures and services. Physicians tend to be pretty smart and they will quickly figure out which services they perform generate the most RVUs.
In my own world of pulmonary and critical care medicine, I know that the fastest way to generate a lot of RVUs is by interpreting pulmonary function tests. If I sat in front of a computer for an hour reading PFTs, I’d generate nearly 6-times more RVUs that I would by seeing patients in the office for an hour. I did an analysis of how much money I can generate per hour doing the various things I do as a pulmonary critical care physician, including my outpatient practice, working purely in the ICU, doing a combination of ICU and inpatient pulmonary consult work, seeing patients in an LTACH (long-term acute care hospital), and reading PFTs. I used the 2018 Ohio Medicare physician fee schedule and just used the work RVUs (wRVUs). I timed myself reading PFTs one day to determine how many PFTs I can read in a typical hour. I determined that I spend about 2 hours doing charting, making patient phone calls, managing test results, etc. for every 4 hours I see patients in the outpatient clinic. I timed myself doing LTACH rounds and doing a typical day of regular inpatient pulmonary/critical care practice. Overall, I can generate $614/hour reading PFTs but only $107/hour doing outpatient pulmonary practice.
For cardiologists, it is reading cardiac echos and stress tests. For neurologists, it is reading EEGs and EMGs. For sleep specialists, it is reading sleep studies. For each specialty, there are certain things the doctor does that can bring in a lot of RVUs for rather little time and effort.
But if all I did every day was read PFTs, I think my brain would melt. I might more easily hit my annual RVU targets and I might get a bigger bonus at the end of the year, but I wouldn’t necessarily be happy. The enjoyment I get from being a doctor is in the human connections made from doctor-patient relationships. The satisfaction I get is from knowing that at the end of the day, I made patients’ health a little better. I never go home at the end of the day telling my wife that I generated a record number of RVUs that day, instead, we talk about the patient whose cancer got cured or the patient who survived after getting an emergent coronary stent after an out-of-hospital cardiac arrest from an acute MI.
It is often said that money can’t buy you happiness. But money can buy you the time to do the things that can bring you happiness. Similarly, the RVU won’t buy you happiness but it does buy you the extra time to do the undercompensated things that doctors do that can bring happiness and professional satisfaction.
So, yes, every year I do spend hours in a room by myself in front of a computer reading pulmonary function tests. And I do it so that I can also have the luxury of the time to talk to my patients about their last vacation and the luxury of spending a little more time with a patient explaining the implications of a newly diagnosed disease. More than anything else, those PFT RVUs buy me the time to listen to my patients.
October 8, 2018