Monday, August 14, 2000

The Why’s and How’s of Relative Value Units (RVUs)

I’m necessarily digressing below from the theme begun in last month’s column on using “relative value units (RVUs)” in measuring physician work and productivity. What follows briefly describes what RVUs are and from whence they come. For more information on how the RBRVS and RVUs work read the two-part article on the ACEP web site: “Basics of Reimbursement” (ACEP membership is not required).
On January 1, 1992, federal regulations that implemented federal resource-based relative value scales (RBRVS) for the payment of physicians under Medicare went into effect. Since that time all federally sponsored physician payment programs and many others have adopted the RBRVS method of payment. ACEP estimates that over 70% of all payments for physician services are based on the RBRVS data, so that even if Medicare patients are not a large part of your practice, RBRVS will impact what you are paid for a given service (see web page citations above).

The RBRVS method uses RVUs to measure the work involved in performing a clinical service, the expense involved in delivering the service and the malpractice risk associated costs of performing the service. The “work RVUs” incorporated in the method explicitly include the physician work expended on a patient service before, during and after the service itself. Thus work RVUs provide an explicit tool to measure and compare physician work and productivity across a varied mix of services, including the services delivered by emergency physicians.

Each clinical service an emergency physician provides to a patient is billed through the use of a “CPT Code”. The book, Current Procedural Terminology (CPT), is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties.

Each CPT code is associated with an RVU value that is segmented into work, practice expense and malpractice costs as noted above. The association of RVUs with the CPT codes that most apply to your practice can probably be best obtained from your billing service. The entire list of CPT codes and associated RVUs including the segmentation can be downloaded at the Centers for Medicare & Medicaid Services site.

Once we understand that every physician delivered clinical service has a CPT code with an associated RVU, this allows us to use the measurement of RVUs to begin the process of comparing our physician group members. Measurement of RVUs billed, adjusted for clinical hours worked, or “RVUs per hour” provides a far more reliable tool—better able to compare productivity among physicians—than does the traditional emergency medicine measure of patient’s per hour. Why? Because over equal intervals physicians can no longer assert that their productivity is unrecognized because their patients are sicker: The very measure, relative value unit, adjusts for that phenomenon. Only in the event that one or another group member is routinely assigned to a distinct clinical population (e.g., “minor-care,” “fast-track” or pediatrics) or to a distinct schedule (e.g., all nights) should that individual’s productivity be excluded from direct comparison with colleagues.

Let me once again emphasize that not everything about a doctor can be told from measurements of clinical productivity as measured by RVUs per hour. In fact, this one measure will give a hugely distorted evaluation if not coupled with at least measures of patient waiting times or throughput intervals and measures of medical staff, ED nursing and support staff and patient satisfaction. Other subjective evaluations such as “group citizenship” also matter. Some current approaches to economic benchmarking also seek to evaluate emergency physicians’ comparative utilization of laboratory tests, imaging studies and consultations.

Someday perhaps we’ll have other quantitative measures of physician quality, but in the meantime RVUs are one useful guide. Nonetheless, RVU measurements should not be used to bludgeon physicians, but rather used as a measure for comparison to articulated expectations as I explained last month in describing the pyramid for medical staff development. Measurement and comparison of RVUs with adoption of the pyramid by your medical director or ED chief speaks to enlightened leadership; bullying by your group’s leader over productivity and RVU comparisons suggests it may be time to move on.

The group should measure monthly for one year before identifying baseline performance expectations. Monthly measurement with reporting of the group’s overall performance at the 20th, 50th, 80th and 99th percentiles should complement monthly reporting to each group member of individual performance. Provision of individual performance data in this fashion, supported with explicit feedback will over time tend to reduce the variability of performance among the group on this one measure. Remember, not to lose sight of other important subjective and objective measures as mentioned above.

Reporting productivity in this fashion will quickly unmask differences in quality of documentation among members of your group. Exhortation to improve documentation is not the answer and neither is a new system for documentation whether dictation, templates or electronic. Rather, investing energy in identifying the best documentation captured by members of your own group and using these “best documentation practices” when teaching the rest of the group will improve documentation overall while simultaneously optimizing revenue capture which is based upon documentation. In those groups in which physician earnings are based upon the individual emergency physician’s own documentation, the incentive is obvious. But rare is the group that does not depend at least in part on direct clinical revenues and reminders of the importance of clinical revenues to the group’s well-being associated with other feedback as part of the implementation of the pyramid for medical staff development may help.

If physician productivity measurement is used as a threat, it is probably time to look for another job, if possible. Yet, when used as one measurement in implementing the pyramid for medical staff development it can be an invaluable tool for both assisting in the maturation of the group practice as a whole and in retaining excellent emergency physicians.

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