We cringe when we hear about how many relative value units (RVUs) we have produced. There is no doubt that being a clinician is defined by much more than our RVUs. Nephrologists care for the most complex patients, and many elements of this care are not easily captured by the RVU system (1, 2). It is no wonder that RVUs have become a “four-letter word” for clinicians.
Relative value scales date back to the 1950s and were designed to establish prices that state and federal governments would pay for physician services on the basis of relative value of time and intensity of physician work and resource costs. The Centers for Medicare & Medicaid Services (CMS) is responsible for updating RVUs, and CMS relies on advice and recommendations from the American Medical Association/Specialty Society Relative Value Scale Update Committee (2). RVUs are broken down into three components as shown in Figure 1.
Despite the system being designed to determine reimbursement and compensation, RVUs are the de facto national standard for measuring productivity. A work RVU approximates the amount of work required to perform a service, thus providing a quantitative measure for tracking productivity beyond counting numbers of patients seen and procedures performed. There are clear flaws in the RVU system, most notably its failure to capture the effort outside of patient encounters required to provide high-quality care, as well as issues in stifling the growth of value-based care models. One of the greatest problems with this system is its use in benchmarking productivity. The RVU system itself has value that is well validated (3).
There are three commonly used benchmarking services: Clinical Practice Solutions Center (CPSC; Vizient), SullivanCotter, and Medical Group Management Association (MGMA). All attempt to describe the distribution of RVU productivity levels (given as percentiles). There are variations among these services that include nuances for regional variations, academic versus private practice, as well as subspecialty care. It is commonplace for a clinician to be told, for example, that his or her productivity target is the 55th percentile or 6500 RVUs.
CPSC benchmarks are derived using the CMS payment rule directly from encounter-specific billing data, and the MGMA and SullivanCotter benchmarks are derived using self-reported data. All benchmarks emanate from small samples ranging from approximately 180 to 300 physicians. These are woefully small surveys and subject to reporting bias. Factors that are not clearly accounted for in these benchmarking data include: 1) normalization to amount of clinical activity; 2) use of fellows or residents to enhance productivity in academic settings (some benchmarks have an academic subcategory); 3) use of physician extenders; 4) normalization to the amount of dialysis care provided, which is valued at a higher level than clinic work (some benchmarking groups include a dialysis component, and some do not); and 5) actual mix of clinical activity. For example, subspecialties within nephrology participate in extensive work that has no RVU value and is not captured in current benchmarking. This might include traveling to a remote dialysis center, care coordination meetings for patients with end-stage kidney disease (ESKD), or transplant-related meetings such as donor and recipient selection meetings. In addition, many benchmarking services do not include specific percentiles of productivity for transplant physicians or interventional nephrologists.
The end result of over-reliance on flawed benchmarking data is that clinicians are not appropriately evaluated for their efforts, feel disrespected, suffer burnout, and ultimately feel like they are chasing numbers rather than focused on high-value, cost-conscious care. The issue is not the RVU system but how RVU benchmarking has been translated into inflexible productivity targets.
A potential solution to the issue of inadequate benchmarking is for organizations such as the American Society of Nephrology (ASN) to contribute to producing granular, accurate, and actionable data to measure our work and ensure we are appropriately compensated for our efforts.
Tonelli M, et al. Comparison of the complexity of patients seen by different medical subspecialists in a universal health care system. JAMA Netw Open 2018; 1:e184852. doi: 10.1001/jamanetworkopen.2018.4852
Katz S, Melmed G. How relative value units undervalue the cognitive physician visit: A focus on inflamma-tory bowel disease. Gastroenterol Hepatol (NY) 2016; 12:240–244. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872854/
Wynn BO, et al. Development of a model for the validation of work relative value units for the Medicare physician fee schedule. RAND Health Quarterly 2015; 5:5. Accessed May 5, 2021. https://www.rand.org/pubs/periodicals/health-quarterly/issues/v5/n1/05.html