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August 5, 2019

Relative Value Units and the Measurement of Physician Performance

Author Affiliations
  • 1Cardiac Surgery Intensive Care Unit, Division of Cardiothoracic Surgery, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
  • 2Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
JAMA. 2019;322(12):1139-1140. doi:10.1001/jama.2019.11163

In response to a need for a standardized language to describe medical services, the Current Procedural Terminology (CPT) coding system was created in 1966. This system persists today and is used by most payers to communicate standardized information about medical services.1 In 1991, the Relative Value Scale Update Committee (RUC) was created by the American Medical Association to make recommendations about the relative value of physician work for Medicare and Medicaid beneficiaries based on CPT codes.1 In 1992, Medicare began reimbursing hospitals and physicians based on the values established for services by the RUC, which are now used by both commercial and government payers.

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    5 Comments for this article
    RVU Pitfalls
    Jeffrey Brown, MD | New York Medical College
    The most obvious pitfall to using a Relative Value Unit system is that the complexity of the patient's problem has an inverse correlation with the clinician's experience and skill. An experienced physician who makes a spot diagnosis of a patient's problem will bill that visit as routine. An inexperienced or poorly skilled physician may require multiple visits and numerous tests before coming to the same diagnosis. That "complex" visit is then billed at a higher RVU rate. In other words, everything is complex to poorly skilled physicians who are then rewarded for lack of acumen.
    RVUs: An Imprecise But Potentially Useful Metric
    Donald DeNucci, DDS, MS | Research Consultant
    Relative Value Units (RVUs) provided one of the primary metrics employed by the military and the VA dental services to assess the productivity of clinic personnel for many decades. Having spent the majority of my clinical career in the federal services (35 years) as a chairside clinician and a supervisor, I was able to observe the strengths and weakness of this metric first hand:

    • The system could be manipulated by more experienced clinicians to provide a desired outcome
    • Conversely, junior clinicians were penalized because of their inexperience
    • Management tended to bundle procedures, clinicians strove to unbundle
    • Clinicians often
    complained that they were not provided adequate credit for managing difficult patients, particularly those with complex medical histories.
    • Because dentistry is primarily a procedure-driven surgical specialty, clinicians were not adequately credited for treatment planning, patient education, and so forth.

    Bottom line: RVUs, in the context of a federal dental service with salaried personnel, provided supervisors and management with an imprecise but nonetheless useful measure of one aspect of clinician productivity and performance.
    Centralized Bureaucratic Units (CBUs)
    Thomas Morgan, MD | University
    Relative Value Units (RVUs) should be called Centralized Bureaucratic Units (CBUs) to highlight the disconnect between this crude metric and the actual value being provided by doctors to particular patients. What single “metric” do parents use to guide children? Grades? Cleanliness of rooms? Sharing of toys per child-hour of play? Number of doors politely held open for others to pass? No, that’s ludicrous. We take a holistic view of children. We know and care about them. Centralized health system bureaucrats are too far removed to really know and care about physicians or patients. However we measure physician performance, such measurement should be holistic and performed in a knowing, caring way at the most local level possible. It’s time for devolution!
    RVUs Erodes Doctors' Professionalism
    Edward Volpintesta, MD | 155 Greenwood Avenue Bethel CT
    Even if the RVU system is intended ideally to improve physicians’ performance in areas that are not procedural like patient satisfaction, the idea that physicians need to be incentivized to do what they were trained to do runs against the grain of professionalism.

    Incentivizing workers on assembly lines to make more radios and toasters in the same time period may increase productivity but they are working with inanimate materials that don’t have a human personality, that are basically similar in all respects, and do not ask questions.

    Incentivization erodes the soul of medicine; it began with managed care
    and the rise of the insurance industry as a sovereign force in health care. It adds another layer of concern and distraction to physicians’ busy days.

    If physicians were free of insurers’ restrictions and RVU's, they would be less distracted and more effective, and they would be more inclined to work on their personal relationships with patients.
    Definition of Value
    Edoardo Cervoni, M.D. | LD4U
    The Authors are making very valid points, and the same can be said about the comments that followed this publication. That is to say, there is no easy solution in sight.

    It may also be worthwhile considering that monetary value should, perhaps, be the result of functional + social + psychological value.

    The complexity of the equation is such that it would be very difficult to define an arbitrary monetary value, and that this value should and could be variable as suggested by Alfred Marshall under the assumption of perfect competition.