Your Relative’s Value Unit
Existing metrics don't measure what people value in the patient experience
Designed over two decades ago as a reproducible resource-based metric for standardizing Medicare payments to physicians, the relative value unit (RVU) has since morphed in many ways beyond its designers' intent. At the payment policy level, its current methodology is criticized by many as a terrible byproduct of closed-door sausage-making. At the individual practice and health system level, the RVU is vilified by many physicians for very different reasons, frequently fueling emotionally charged debates with administrators. For right or for wrong, though, the RVU is the most widely used metric for evaluating and tracking physician performance across the United States.
On the surface, the RVU is conceptually brilliant. As the Medicare program evolved, it needed a rigorous and reproducible mechanism for valuing physician services for its physician fee schedule. And, so the Resource Based Relative Value Scale (RBRVS) was born. Work RVUs are assigned to physician services based on encounter time and intensity, taking into consideration such factors as technical skill and physical and mental effort. What began as a transparently elegant cost-accounting exercise, however, devolved in two ways. First, human nature being what it is, and knowing that a bigger slice of the pie for you means a smaller slice for me, the RVU assignment process has been criticized as a highly politicized specialist-driven money grab. And second, while RBRVS was created for a very specific policy goal — standardization of the Medicare physician fee schedule — physician practice and health systems now use it for a variety of benchmarking and differential compensation purposes for which it was never designed.
Today, most administrators RVU-score their physicians based on how much they do — rather than how well they do it. Value is thus commonly measured though the eyes of bean counters, rather than our patients and other clinical stakeholders. Under RBRVS, for example, radiologists rarely get credit for talking with patients or treating physicians. That creates some rather perverse incentives. In most practices, it's both easier and more lucrative for radiologists to simply follow the Nike® imperative — just do it — and not engage in time-consuming but important conversations about unnecessary duplicative, low-yield, or otherwise injudicious imaging.
But, what if we could start over? What if we had the opportunity to create a whole new RVU system where value was determined not by health economists, but instead by patients and their families and their doctors, emphasizing the totality of each individual's experience with regard to not only outcomes, but also shared decision making and ongoing engagement? That new system would value those things we all seek as patients, such as compassion, good clinical decision judgement, and meaningful communication. As physicians, we are all acutely aware of which colleagues in our community we want treating our family members — and which ones we don't. And, we know the reasons why. What if we started measuring those things instead?
If I could turn back the clock, the RVU I would design would be my Relative's Value Unit. Sure, it would acknowledge traditional services — we all have to get the work done. But, it would also provide very real ways of recognizing the amazingly compassionate hematologist who spent so much time with our family making some really hard decisions when Dad's leukemia went into blast crisis. It would recognize as well the callous judgmental emergency physician who many years ago treated our then-toddler daughter after she overdosed on Tylenol while visiting someone else's house (clearly, he wouldn't score so well).
As physicians, we all know good care when our family members receive it. Why not redesign our metrics with that in mind? Quantifying what really matters to patients, of course, is much easier said than done. But, if we are going to really transform our health care delivery system in a substantive way — and in the process make our professional lives more meaningful and rewarding — then we need to start thinking outside the box. If we don't collectively challenge existing metrics — and innovate within our own organizations to promote the kind of care we'd want our relatives to receive — then we will have no one to blame for the status quo but ourselves.
The next time an administrator starts focusing on pennies, please bring the focus back on the patient: "Are you saying that's what you'd want me to do if I were taking care of your mom?" Good health care is very personal. And so should the conversations about how it is best delivered and measured.