A Corrosive Force in Medical Care

It comes in a large white envelope each month. It’s marked confidential.

When I hold it up to the light, I can see through the envelope. I can’t see the details, but the colored graphs give it away.

It’s my monthly productivity report. Most employed doctors get these graphs.

These “dashboards” of value include your own productivity as well as many graphs on how you stack up with other doctors across the country. It shows your employer if you are a hard worker.

The measure of productivity we use is called the relative value unit or RVU.

Doing an ablation, cath, stent or valve replacement earns a bunch of RVUs.

Listening to patients, examining patients, counseling patients, hugging patients earns very few RVUs.

Doing important research, teaching colleagues, and reading the medical evidence earns zero RVUs.

Too often, in too many medical systems, RVUs have become the primary unit of success.

No, you can’t be a mean and nasty doctor. And no, you can’t be a totally unskilled doctor who has too many complications.

But short of those extremes, if you make few waves, have good templates on your electronic health record so documentation is complete, and do tons of procedures, you are valuable.

If, on the other hand, you like slow conservative medicine, or narrative notes rather than templates, or worse, if you are thoughtful and frank about silly policies, you become an outlier. If you do these things, your RVU tally usually does not reach the 75% of standard. Then trouble can come to you.

These trends are not so problematic for people close to the end of their career.

What’s really scary, though, is that this is the milieu in which a younger generation is learning the craft. I was shocked to learn that a major teaching center (will remain nameless) has its teaching faculty on 100% productivity compensation. Imagine that. Teachers of young people whose paychecks are determined by how many RVUs they generate.

This, my friends, is happening in many of the places you go to get health care.

It’s why I tweeted this yesterday.

Productivity and the RVU has no place in medical care. There needs to be a different system of valuing the care of people with disease.

JMM

9 comments

  1. 100% agree with you. This is the corporate practice of medicine. It’s all about the $$$.

  2. As usual — you are RIGHT ON the mark with this post! It is sad that much of the “care” ( = caring) in medicine has evolved to being “all about the money” — and even sadder (as you write) that the younger generation of clinicians is learning that the “reward” comes from getting more RVUs, rather than from efforts at providing comprehensive caring with an emphasis on prevention and minimizing income-generating tests and procedures that are not necessarily needed …

    1. I think your “Corrosive force in Medical Care” post is all too true. The establishment with their “one shoe fits all” approach fails in their productivity measurement by over-valuing a variety of procedures which are largely ineffective. For one thing the health care consumer has been left out of their productivity measure. What is needed is a turn toward Functional Medicine where doctors try to understand the causes of their patients chronic illnesses and then prescribe treatments to deal with the causes, not the symptoms, of their illnesses.

      1. Even many functional medicine doctors are paid by RVUs. And those of us who practice primary care ARE wholistic – we care for the whole person and look for root causes. This payment model drives us to burnout and to quit medicine.

        1. Natalie, thanks for your comments. If you get paid by insurance the issue of RVUs inevitably will impinge on a doctor’s practice of medicine. RVUs seem to force doctors into a corner. The fact that it drives doctors to burnout and then quitting medicine it so sad! Hopefully, in the future the stranglehold that government, insurance companies, and pharmaceutical companies have on medicine will be abated.
          I’m afraid that the current discussions in Congress about improving healthcare fall short of the mark.

  3. The same thing is happening in the legal field, which caused me to get out of the fast lane, and onto a more palatable side road.

    But doctors should pay attention to some objective measure–like how many Rxs for pain meds you are writing verse your peers, or how many procedures you do, verse your peers. Don’t make the comparison for compensation, but for introspection on whether you are providing appropriate care.

  4. This does NOT seem right – especially for Patients. May be good for Corporate Profits, if I understand it correctly; i.e.; Good for Business but NOT for Patients!

  5. It’s the neoliberal model. As a humanities prof at a university in Canada, I see creeping bureaucratization and bottom-line based policy formulation every day of my working life. It’s dehumanizing in my field with unfortunate consequences. It’s dehumanizing in your field with catastrophic consequences.

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