In their article “The RVU Does Have Value but Also a Cost,” authors Rosner and Manley note that the relative value unit (RVU) system for determining physician work and reimbursement has merit, but it does not fully account for non-encounter-based work that supports patient care.
The Renal Physicians Association (RPA) concurs with this assessment. Furthermore, although this shortfall admittedly affects all physicians, specialties, and practice settings, nephrology is uniquely poised to be adversely affected by virtue of the patient population for which it provides care. Activities that support high-quality patient care but are not reflected in Current Procedural Terminology (CPT) code-specific RVUs include but are not limited to the following: 1) team leadership and running team-based care models; 2) travel to remote locations required for dialysis-dependent patients; 3) membership and participation in committees (such as for quality improvement); and 4) administrative time spent in private or academic practice management. Moreover, nephrologists serve as key liaisons among patients, dialysis organizations, hospitals, and academic institutions.
Certain activities should not be included, such as time spent on dialysis, facility medical director responsibilities (separately reimbursed), and those activities not part of the face-to-face patient encounter but for which Medicare is now assigning work value (e.g., care management), a move that reflects recognition of the concept that comprehensive patient care may require work not captured by the RVU as currently defined. In fact, effective use of the care management code families (chronic care management, transitional care management, or principal care management), in addition to participation in value-based payment models in the kidney arena, may provide a pathway to accounting and receiving compensation for activities that historically have fallen outside of a specific reimbursable physician service.
Given these advancements, the time seems ripe for a reexamination of how the RVU methodology is utilized. In both private practice and academia, there is great variability with regard to how this work is valued and credited, and as noted by Rosner and Manley, the RVU has become a measure of productivity used by many institutions to determine compensation. We agree that commonly used benchmarking surveys do not capture the essence of the work done by a nephrologist and join the call for the national specialty societies for nephrology (RPA and the American Society of Nephrology) to lead efforts to clarify the scope of the problem and identify the non-patient encounter activities where value has not been recognized. Understanding the degree of value associated with these activities and the volume or frequency at which those activities occur would enhance applicability across geographies and practice settings.
Existing structures could inform the data-gathering process, notably the RPA Nephrology Practice Business Benchmarking Survey, which has been conducted biannually by RPA for over 20 years. This initiative compiles data from nephrology practices nationwide on diverse data points, such as physician compensation, use of advanced practitioners, total income per full-time employee in nephrology practices, and integration of clinical research, among many others. A survey of patient care activities occurring outside of patient encounters, based on the RPA Benchmarking data, would be of tremendous benefit to the nephrology community and provide a more realistic basis upon which to apply productivity targets. This would provide nephrology practices, regardless of setting, with benchmarks and points of comparison through which value for currently uncompensated work could be ascertained. RPA welcomes the opportunity to participate in such an endeavor.