Relative value unseen
Healthcare units don't always measure the real benefits
Barack Obama read the riot act last Tuesday evening to members of Congress and American people on healthcare reform. He added new urgency to the obvious reality that our healthcare system is a wreck. The reform effort, he added, can only succeed by making the system more efficient.
"Efficient," for the seven individuals in the world who are unaware of its significance in this context, means cutting costs. Big time. How we cut those costs has, like the Civil War, divided families, shattered friendships, and ruined dinner parties.
The timing of Obama's words about healthcare efficiencies came two days after I had a great conversation on the subject with the noted oncologist Dr. Jerome Groopman. It was he who first introduced me to the acronym RVU, which sounded like a new all-terrain vehicle or perhaps a new metric to gauge heat.
What it really stands for is Relative Value Unit, a bloodless term to measure the productivity of a physician every hour of his or her day. The more RVUs you accumulate, the more money you make.
RVUs have been around for years since a reform bill years ago embedded them into the Medicare structure in hopes of reigning in the spectacular rise in costs. They have since spread beyond Medicare to hospital management and even doctors' group practices.
"RVU is the default position among hospitals now," says Dr. Thomas Lee, Network President of Partners Healthcare System. Doctors at Brigham and Women's Hospital, where he practices, Massachusetts General Hospital, and Beth Israel Deaconess Medical Center, among many, are all compensated by the RVU system.
"It's like a runaway train," says Groopman, who compares RVUs to the odious billable hours in law firms. The analogy isn't perfect, because one is strictly about time, but the larger truth is they're both about money.
Groopman has been on the warpath against RVUs for ages. "There are no RVUs for spending an hour with a grieving family, or a colleague who wants you to lend him your brain on a case," he says. "There are no RVUs for sitting with a confused third-year medical student. There are no RVUs for the humanistic core of medicine that drew me into this profession in the first place."
The more doctors engage in this side of medicine, the less money they make. RVUs reward doctors who perform high-risk procedures that require great skill and produce large money at the expense of primary care physicians. This imbalance has existed for ages; the RVU system formalizes it. The number of RVUs awarded a primary care doctor who finds a bump on a patient's neck and refers said patient to a specialist, for example, is dwarfed by the RVUs earned by the dermatologist who removes it.
"I agree with Jerry on this," says David Blumenthal, a primary care doctor at MGH who also heads its Institute for Health Policy. "I don't want to diminish the importance of a good surgeon operating on a patient with pancreatic cancer, but the value of interpersonal relationships is underappreciated."
Some consider Groopman an awfully smart stegosaurus who is out of touch with the current economic challenges facing healthcare.
All agree something has to be done to reduce healthcare costs. If RVUs didn't exist, another metric with an equally horrid name would materialize. RVUs are the symptom, not the cause, of the problem.
Lee, like Groopman and Blumenthal, believe the pendulum has swung too far from the expensive fee-for-service system of the past to the brutal RVU-based model today and agree that the bias toward specialists needs to be moderated.
"RVUs began with noble, good intentions," says Lee. "My problem is not what's paid for, but what's not paid for. I certainly think there are there are better ways to do this. We're fumbling our own way looking for new payment models."
The humanistic side of medicine that Groopman extols is now essentially charity work. On a recent Saturday morning, for example, Lee drove to the house in Cambridge of a 96-year-old cancer patient who was about to die. He wanted to make sure her family was all right. This was on his own time. No RVUs apply. Kudos to Lee, but how often can we expect a doctor to sacrifice a Saturday morning gratis? "If she were in Salem instead of Cambridge, I wonder if I'd have gone," he muses.
Groopman and his wife, Pamela Hartzband, an endocrinologist at Beth Israel, presented a paper that was recently published in The New England Journal of Medicine addressing the unintended consequences of the RVU system. They construct an imaginary dialogue between two doctors and wonder how that exchange would change if the two had just come from a meeting where individual RVU goals were presented.
Groopman and Hartzband think the change would be much for the worse, citing a study showing that the mere suggestion of money promotes "behavior marked by selfishness and lack of collegiality." Throw money into the equation and a doctor's inherent generosity of spirit diminishes.
The future of the RVU-based reward system is anyone's guess. Blumenthal notes there is $1 billion in Obama's stimulus package for research in comparative efficiencies in healthcare. "What is the effect of different kinds of care?" he asks.
Meanwhile, the bean counters and the humanists remain the Hatfields and McCoys of healthcare. The truth is, we need them both.
Sam Allis is a Globe columnist. He can be reached at firstname.lastname@example.org.