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[drags chair across the floor]

Hi, US friends. Have you heard of the “RVU system” in medicine? If not, stay a minute for story time. It’s a major reason US healthcare sucks so badly.

Once upon a time there were some “researchers” at Vanderbilt University who wanted to test a new model of paying physicians using performance metrics based on the RVU system in Medicare, which had been around for a while but never used in this way. The new scheme assigned units to the duties a physician does as part of their job, and gave more weight to a duty that collected more money for the hospital or clinic.

So, for example, a return visit for an established patient doesn’t generate much money so they gave it a lower number like 0.2. But a procedure, like a colonoscopy, is billed much higher so that might get a 2.0.

Each physician is assigned a quota of RVUs. If they don’t meet their quota, they get a warning first and then their pay will be docked. Yes, this is true. So low RVU tasks become psychologically negative. They get labeled as “low performers” even if they’re excellent doctors.

The researchers found using an RVU system motivated physicians to work harder. They published their study and then a few of them went out into the country and got jobs that allowed them to implement this system. One of them came to the academic hospital where I worked in the mid 00s. Over a decade or so, I watched the entire system transform into a corporate grind focused on metrics and electronic medical record documentation. Also with shorter visit times, long waits for follow up appointments, and increasing physician burnout. Then COVID hit.

Not all clinics use the RVU system but if you’re at a place affiliated with a university I can almost guarantee they do. I always ask when I see a new doctor and their reaction is usually telling.

RVUs + private equity led us here.

[drags chair back across the floor]

Study on RVUs: https://journals.lww.com/academicmedicine/abstract/2003/07000/effects_of_performance_based_compensation_and.8.aspx