What Lies Beneath

Relative value units are an intrinsic part of tracking physician payment and productivity but do they show the whole picture?what lies beneath

Take a moment and think back to when you were in middle school. You took a whole spectrum of subjuects, from English to gym. When you received your report card, your grades were predictably based on criteria individualized for each subject — in English, it was the papers you wrote or the vocabulary tests you took. In gym, it may have been how fast you could run a mile.

 But what if instead of each grade being calculated on individual specifications, you were graded for one thing across the board? What if your grade in English or algebra depended on how fast you could run or how many pull-ups you did?

Although this is an extreme example, some physicians feel that as health care shifts to a value-based payment model, tracking radiologist productivity and payment by relative value units (RVUs) may have some of the same problems. Recording productivity by how many images radiologists read may work well with fee-for-service, but because value includes a variety of other activities, CMS or practice leaders may not be getting a clear picture of just how much work radiologists are doing.

A Look Inside

Let’s back up a moment. It’s important to understand how RVUs work before you can examine how well they are functioning. The current system for payment for physician services within the Medicare physician fee schedule is predicated on the resource-based relative value scale (RBRVS), which was designed to serve as a foundation for reimbursement. RVUs are part of that scale and are maintained by the RVS Update Committee of the AMA, known as the RUC, which evaluates medical services and makes recommendations for RVU values, which are eventually approved by CMS.1

An RVU value is assigned to nearly every service described by current procedural technology (CPT) codes. The more intense and time-consuming a procedure, the more RVUs it is assigned. RVUs are comprised of three elements: 1) a work RVU, which accounts for the total amount of physician work done for the procedure, 2) a practice expense RVU, which involves costs for items such as staff paychecks or equipment fees, and 3) a malpractice expense RVU, which is related to the malpractice risk for the procedure.

Medicare payment is then calculated by adding these RVU values up and multiplying the total by a conversion factor. The conversion factor is decided upon and calculated by CMS using the formula known as the sustainable growth rate. To learn more about the sustainable growth rate and how RVUs are calculated, visit the JACR® article “An Introduction to Business Essentials,” at http://bit.ly/RadBus101.

Many practices use the work RVU to also monitor productivity among specialists because this figure specifically accounts for both the time and the difficulty of an individual service. This means that the more RVUs a radiologist generates, the more money he or she will likely get paid.

Stumbling Blocks

While RVUs are generally agreed upon as the best way to measure physician work in our current system, there are some problems with them. One issue with the RVU system is that there is no way to reliably measure services that aren’t clinically based, says Richard Duszak Jr., MD, FACR, chief medical officer of the Harvey L. Neiman Health Policy Institute and vice chair of the department of radiology and imaging services at Emory University. While this system may have worked while fee-for-service was the general mode of payment, a transition to pay-forperformance means that there are a lot of services that RVUs do not account for.

Ezequiel Silva III, MD, vice chair of the Commission on Economics, explains, “Because non-clinical activities are not determined under existing RVUs, we face two challenges as we move forward: What value do we assign to non-clinical activities? And how does that value compare to other services? For example, if you spend an hour in a multi-disciplinary conference, is that the same as 15 chest x-rays? It’s a very subjective evaluation.”

The fact that these non-clinical activities do not have a set payment leads to another issue: “If your productivity is strictly defined by interpreting examinations, there is really no incentive other than your own altruism and your willingness to contribute to the larger system,” says Silva, by participating in non-work RVU activities. This means that some radiologists may focus purely on reading high-RVU studies, while activities that are critical to value-based care, or those images that have smaller RVUs attached to them, are left to flounder by the wayside.

Neglecting these tasks can have a negative impact on your practice. “When I was consulting, I received a panicked call from a leader in a large group,” recalls Duszak. “The group had pursued a purely RVU-based form of compensation, and their radiologists would come in, grab the highest-paying readings, and leave the others behind. They would not speak to referring physicians. Their hospital had just given them notice that they would be terminated in 90 days, and they wanted me to come in and redo their model. But by then, it was too late. That’s an extreme, but real, example of what can wind up happening as the health care environment shifts.”

Even if payment plans change, RVUs will likely play a large role in future reimbursement.

Laying a Foundation

While the RVU system is imperfect, this is not to say that it is going away, or even that it should. RVUs are the existing metric and a good indicator of the amount of work that goes into image interpretation. Because of this, even if payment plans change, RVUs will likely play a large role in future reimbursement.

“It’s hard to imagine a scenario where the existing RVUs for reading a pelvic x-ray or an MRI of the hip aren’t part of the future payment model. They’re an objective, existing criteria. They are what physicians are currently being paid, so they’re going to have to factor in,” notes Silva. Even if there is a move to bundled payments for most conditions, he says, there is no way that the government and CMS can account for every condition. There will still be a need to determine payments for conditions that do not fall under a payment plan or additional care that was not covered in the original payment plan. Silva believes that the system for determining those will be based on RVUs.

Adds Duszak, “There will always be a role for RVUs. While the system may be imperfect, they are still a measure of how many patients we’re interacting with as imagers. And that’s an important piece of the scorecard.”

Looking Ahead

While radiologists may not be able to change how RVUs affect their reimbursement, they can consider changing how productivity is tracked. Duszak cautions that there is no quick or easy metric for every practice to measure productivity, nor is there one that will work for every radiologist. Some radiologists, for example, may be more suited to spending most of the workday reading images, while others may want to divide their time among patients. Still others might have leadership or administrative roles to play. The amount that all participate in these activities varies.

In the JACR article “Measuring and Managing Radiologist Productivity, Part 2: Beyond the Clinical Numbers,” Duszak and Lawrence R. Muroff, MD, FACR, suggest a framework for a system that tracks nonclinical RVUs. The system is similar to the existing academic RVUs, which are often used by academic institutions to track productivity in physicians who are involved in teaching or research rather than more clinical duties. Duszak and Muroff’s formula includes RVUs for administration and leadership; practice, hospital, and community service; professionalism; and quality and safety. The authors suggest that other criteria could be added, and these benchmarks could then be weighted depending on the practice’s priorities.2

While this system is only a framework and will need to be individualized for each practice’s needs, Duszak and Muroff note that it can be effectively used as a scorecard during annual physician review and that its implementation alone suggests a group’s commitment to performance assessment and improvement, an effort practices could convey to referring physicians or hospitals.

Silva also recommends paying attention to the current shift in payment and making small adjustments while you can. “If we acknowledge that health care is transitioning from a volume- to a value-based system, at some point you have to make that leap. Hopefully, you make a gradual transition,” he says. To do that, Silva recommends checking out the Imaging 3.0™ movement, which has steps your practice can take to begin the transition. To learn more about Imaging 3.0, visit www.acr.org/imaging3.

By Meghan Edwards

1. Duszak R, Muroff L. “Measuring and Managing Radiologist Productivity, Part One: Clinical Metrics and Benchmarks.” JACR 2010;7(6):452–58.
2. Duszak R, Muroff L. “Measuring and Managing Radiologist Productivity, Part Two: Beyond the Clinical Numbers.” JACR 2010;7(7):482–89.

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