Viewpoint: Academic missions, physicians suffer in RVU system

The relative value unit (RVU)-based compensation model in U.S. academic medical centers can twist incentives and prioritize clinical productivity over research and teaching, three researchers argued in a viewpoint published Oct. 20 in the European Heart Journal.

“The downside of the ‘RVU culture’ is that it threatens the very mission of academic medicine—patient care, education and research,” wrote Ankur Kalra, MD, and colleagues. “Patient care is affected when there is incentive to supplant value with volume. This fosters the annihilation of a deliberate, stepwise approach to medical practice.”

The authors acknowledged that a work RVU (wRVU) system has some benefits and may have been well-intentioned when it was first developed.

“In theory, compensation based on clinical productivity seems to be fair, a ‘reap what you sow’ system. It rewards providers for their efforts, which appears more just than systems based entirely on salary or equal shares,” the researchers wrote.

However, Kalra et al. pointed to evidence indicating non-clinical activities suffer when wRVUs are the primary means of compensation. In addition to time spent teaching and researching, activities that contribute to quality care—such as meetings with families, pre-procedure planning and preauthorization responsibilities—aren’t compensated in a wRVU system.

Robert Hromas, MD, MS, a professor and chair for University of Florida’s Department of Medicine, spoke to Cardiovascular Business last year about a model his department developed to translate educational and research activities into RVU values. He believes this approach better balanced the sometimes-competing missions of clinical productivity and academic work, including research and teaching students. After year three of the new program, 61 percent of surveyed faculty said they preferred the new compensation arrangement, which was also linked to increased clinical RVUs (7 percent) and an increase in publications per faculty member (15 percent).

Time value units (TVUs) are used in some practices to inform cash distribution to employees, although RVUs remain the predominant payment mechanism from payers to healthcare systems. In a TVU system, every activity commonly performed in the delivery of healthcare is assigned a value based on the expected time it would take an average clinician to complete. Some argue this is a fairer way to gauge clinicians’ workloads, as RVUs aren’t always an accurate reflection of how much time or effort it takes to deliver a service.

But the fact remains that many physicians at academic medical centers are judged solely on RVUs, which Kalra et al. contend can increase burnout, lower physician satisfaction and lead to “young providers becoming expeditiously disillusioned with academia.”

“While money isn’t the main driver why providers work in academics, having non-clinical work be recognized and valued can tangibly increase the inclination to take part in it,” they wrote. “The prevailing compensation system needs to be re-evaluated to create a model that is more sustainable for the mission of academic medicine.”