RVUs Simplified
Probability would indicate that this article will the most boring in the history of The Pager. The Relative Value Unit (RVU) is a mundane topic; but one about which are most often asked and a topic physicians cannot ignore. More residency programs are integrating the teaching of productivity and billing, however “multiple studies have shown that trainees are un-satisfied with the quantity and quality of education they are receiving in these areas” (Baadh A, 2015). RVUs are in widespread use to measure physician productivity and, therefore, compensation. Here we provide a quick primer on the RVU.
The Resource Based Relative Value Scale (RBRVS) was developed at Harvard in 1985 and published in JAMA later that year. The idea was to crate a measure of the: time; mental and technical effort; complexity and other factors that are required by the physician (and her or his practice) to care for the patient. There are, in essence, three types of RVUs: the Work RVU (wRVU); the Practice Expense RVU (peRVU); and Malpractice Expense (mpRVU). The measurement for physician productivity relates only to the wRVU; or the time, mental and technical effort and complexity of the physicians effort to perform the office visit or procedure. For example for a level one primary care visit, the wRVU is 0.45, while a colonoscopy’s RVU is 6.04. Many have debated the reliability of the wRVUs and the sometimes inherent unfairness of more cognitive versus technical activities. We won’t address this debate here. The wRVU often sets payment for physicians by multiplying the wRVU by a conversion factor. For example, an Orthopedic surgeon in Chicago is paid $70 per wRVU and produces 7,000 wRVUs for the year. She would make make $490,000 per year based on her group’s plan. Based on national datasets, standards are set for percentile productivity expectations and the correlated payment per RVU; which vary by specialty. At AlfredMD, we use datasets in attempt to bring symmetry to the recruitment process so that physicians are paid fairly based on objective data.
The total RVU is expressed as:
Total RVU = (wRVU x GPCI) + (peRVU x GPCI) + (mpRVU x GPCI)
The Medicare Geographic Practice Cost Index (GPCI) is an adjustment factor that allows an adjustment to help physicians in higher cost areas. Let’s use a hypothetical primary care physician’s office visit for a 99214 base visit in Los Angeles. The physican’s total is expressed as: (0.45 x 1.06) + (0.25 x 1.06) + (0.2 x 1.06) = 0.96 total RVUs. The peRVU helps cover supplies and staffing for the clinic while the mpRVU helps to cover a portion of the malpractice expense incurred by the physician. The GPCI in Los Angeles is higher than Kansas City, for example, to account for variation in practice cost. Medicare’s base conversion rate in 2020 is $36.09, so our primary care physician in the example above would receive $34.64 for a 99214 visit.
We understand that the physician compensation process can be a complex piece to understand. We’ll be hosting a webinar in the near future on the Future of Physician Payments and Contracts. Check out the link here to sign up.
In Health,
Ryan
Physician Mental Health Journey
By AlfredMD
Physicians and medical professionals report some of the highest statistics when it comes to having symptoms for mental illnesses, we are taking a look at some of the factors during each stage of a physician's journey.
Medical Students
A study conducted by the University of Michigan medical school found that 57% of medical students had moderate to serve symptoms of anxiety and 27% displayed moderate to severe symptoms of depression. Sources of this elevated stress include pressure for a competitive MCAT score, rigorous coursework, and the grueling medical school application process.
Resident Physicians
The extremely demanding schedule that resident physicians are required to follow takes a severe toll on their ability to live a healthy lifestyle. Working up to 80 hours a week on a $60,000-65,000 salary makes it difficult for resident physicians to get enough sleep, eat healthy, and exercise. Student loans pose an additional stress as most accumulate interest just six months after students graduate from medical school.
Attendings
Increased patient caseloads, time spent doing administrative work, and quicker appointment times can place additional stress on attendings and fellows as they gain increased clinical responsibility. Additionally, as attendings, the transition to making a higher salary and lack of experience when managing and allocating their new income can lead to financial stress and headache.
Words From The Frontline
By Dr. Satish Subramanian, MD
Last week my car was broken into in front of my house. I woke up in the morning and found glass covering a portion of my front yard and front passenger seat. My passenger side window was smashed and my work bag was stolen from my car. The stolen bag carried sentimental value as it was a gift from my father-in-law.
Along with many fellow physicians, I have made many changes to my day to routines to reduce risk of exposing my family to COVID-19. So I buried this bag at the foot of the passenger seat, hiding it under a dingy grocery bag. Now it’s gone.
In response to discovering my bag had been stolen, my six year old daughter asked “Why would somebody do this? Don’t they have good manners? They should have knocked on the door and asked if they could have your bag.” I simply responded, “hopefully there is somebody who needed the bag more than we did.”
In the hospital and in life, we physicians feel the negative downstream effects of COVID-19 on our mental health. COVID-19 has already ravaged our emotions, causing large amounts of stress on our departments and our hospitals. Many physicians throughout the world have had to play the part of disaster triage doctor, attempting to choose who medical resources should be directed towards. After these difficult situations, we are expected to move on with our lives and be okay to help the next patient. There may be counselors, debriefs and wellness committees. But these are really small bandaids for gaping wounds.
Physicians will also have to deal with the toll the virus will play on our personal lives. Not only are we separated from our family and friends, many of us have to figure out how our children are properly cared for while they are not in school. Homeschooling is something I never imagined doing between shifts in the ED.
During this time, it is imperative that we physicians take time to care for ourselves. Meditate. Journal. Exercise. Reflect. Vent to your friends and family. Vent to other physicians. Vent to your dog. Do not keep your feelings bottled up. Do not just move on after you suffer a devastating patient loss. Do everything you can to be aware of your mental health and when you do not feel right, please seek help!
It is also time that hospital rivalries and grudges between specialties are put aside. In my department, the pediatricians, neurologists, gynecologists and orthopedists, to name a few, have all leaned in to see patients during any potential surge. More importantly, we as physicians must unite not only to fight COVID but to fight the effects it will have on our emotions. When you see a colleague, ask them how they are doing and what they are doing to deal with the stress of the situation. Reach out to the most vulnerable physicians and keep them in close touch. If you see that a fellow physician is struggling it is not only your responsibility but your duty to get them the proper help and support. A large part of our army of physicians is going to struggle to recover psychologically from this terrible pandemic. As physicians, a “suck it up” attitude has prevailed in our thinking and mentality. But this is not the time and place for machismo and toughness. We are in the 2nd inning of an extra inning game (sorry to all of you baseball fans for the analogy) and we need a healthy staff of healthcare workers to fight this virus.
Despite being so early in this fight, I still see a light at the end of the tunnel. The community here in Los Angeles has really stepped up to take care of our hospital staff. Families in our neighborhood and our school community have created wellness bags to make sure our staff has snacks for work and products for home to care for themselves. I feel a lot of hope as I see that our doctors, nurses, EMTs, unit secretaries and janitors all smile at one another through our masks, using our eyes to make sure we’re all right. We as humans are resilient and when times are tough, we work hard for one another. I am optimistic for what our futures hold.
This issue is dedicated to Dr. Lorna Breen, M.D. a true hero of the frontlines in the battle against COVID-19.