RVU’S ‐ Successes, Perils and Pitfalls

RVU Components

The RVU (Relative Value Unit) is becoming an important consideration for ED physicians. Its original intent was to become a standard measuring tool for incentivizing clinicians toward increased productivity.

CMS assigns an RVU value to every CPT code, using 3 components:

1. Work –55% ‐ with five sub‐components:
• Time
• Mental effort and judgement
• Technical skill
• Physical effort
• Stress
2. Practice expense ‐ 42% ‐to account for overhead to run the practice / manage the entity to which the CPT code refers (does not include the EMTALA effect)
3. Professional liability‐ 3% ‐ allotted to “address” the cost of malpractice insurance.  Applied at 3%, even if actual PL costs are 1%, 10%, or 50%.

Rationale for RVU Incentivized Programs

 

The rationale for an RVU incentivized program is to increase the overall efficiency of the provider staff by rewarding efficiency. In theory this tool will stimulate clinicians who are marginally efficient, or less than optimally efficient, to improve by linking rewards to performance.

Again in theory, CMS hopes to decrease its (endangered) costs for services by stimulating efficiency. Physician groups would correspondingly hope to gain profitably by improving patient flow.

In an ideal world, this would be a win‐win situation for both CMS and clinicians.

RVU Implementation Systems

There are essentially two ways to implement an RVU system.

The first uses 100% RVU reimbursement, also known as “eat what you kill.”

The second guarantees a base salary; to that base is added a “piece” of the group’s overall RVU pie; the size of each piece is determined by the individual’s percentage contribution to the total RVU pie. Other factors may be given value in either methodology, so that RVU credits can additionally be offered for positive patient satisfaction scores, meeting attendance, night shift differentials, absence of complaints, participation on committees, etc. RVU credits may be subtracted for such things as above average number of complaints, failure to complete charts in a timely fashion, lateness, or other negatives that impact the group’s image or performance.

RVU Program Pitfalls

The unintended (and therefore problematic) consequences of an RVU program are especially evident in three areas:   

1. Competition between physicians
2. Potential for some to game the system
3. Invisible impact on departmental workflow

Competition occurs when clinicians attempt to sequester certain types of (higher RVU) chief complaints, and maintain control of their progress principally for the benefit of their own bottom line. Such activities may become evident as general attitude changes, cherry‐picking of chief complaints, evading of opportunities to pitch‐in and help when these do not directly impact one’s RVU tally, chart hoarding, and others.

Gaming the system has various forms, including uneven use of practice assets (PAs, NPs, scribes), requisition of choice shifts, buffing critical of care charges, working unpaid hours, and others.

Impact on ED Workflow may be unapparent but significant. When the analytic focus is on just RVUs, they become a somewhat distorted numerical representation of efficiency. Other major factors may be hidden by the dominance of the RVU process. Such hiddenness may be of greater consequence in a big department, where some physicians may perform non‐RVU activities that facilitate and support essential ED functionality.

For example a “fast” ED physician who can clear out the waiting room and the incoming queue by seeing a load of “lower value” RVU patients, opens up the department in key ways that enable the influx of higher RVU value patients. In the final calculation, in this case, the clearing physician is of inestimable value, while it is the other physician who gets the RVU credit, creating an imbalance that does not represent true value.

The Solution

Ultimately, it takes sophisticated analysis and constant adjustment to make such a system work. It will not be a walk in the park. Attention should be paid to the cumulative acquisition of know‐how about RVUs and applying them most appropriately for your particular ED and its physician staff.

The best solution might be a combination of equal shares of:

1.  Base Salary
2. "Eat what you kill" - minus practice expense of PA's,NP's, and scribes
3. Rewards for intangibles
• performance metrics (door-to doctor/door to balloon/LOS etc
• patient satisfaction scores
• complaints and compliments
• meeting attendance/committee participation
• risk management CME's
• quality measures (how to measure?)
• resource utilization and consumption

• 
  

What to Do About PAIN in the ED?

The treatment of chronic pain has become a very complex and hot topic for providers. Little or no controversy exists about the treatment of acute pain; one just treats as necessary.  Acute exacerbation of chronic pain is also less clear.   

The goal is to treat patients humanely and appropriately without facilitating drug dependence and drug trafficking.

The pressures are complex and complicated. On the one hand, are those forces that make a physician more reluctant to prescribe pain medication, including:

1. States have created databases that keep, and make available online, records of all controlled medications prescribed, including the DEA number of the prescribing provider

2. Certain states, such as Florida, now require special licensure to treat non-cancer pain chronic pain.

3.Peer pressure from colleagues and support teams who feel everybody is a potential abuser. This puts certain patients with severe, painful conditions in the assumed category of “potential drug abuser”.

On the other hand, the real-time daily forces of clinical practice lead one to be less restrictive in administering pain medication. These include:

1.     CMS has made pain a de facto “vital sign” that must be addressed and documented.

2.     Patients request pain relief for a variety of complaints that are often very reasonable.

3.     Patient satisfaction scores like PRC and Press-Gainey emphasize pain relief. These scores affect contracts, RVU’s and levels of complaint to administrators. The #1 complaint in our ED is that the doctor was insensitive to pain relief and refused treatment.

What should one do? It is indeed a challenge to find a balanced, thoughtful approach trying to blend the various demands into a reasonable outcome. Our ED actually considered hiring its own pain specialist to deal with these endless problems.