American Journal of Transplantation 2015; 15: 579–580 Wiley Periodicals Inc.
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Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.13112
Editorial
Fee-for-Value and wRVU-Based Physician Productivity—An Emerging Paradox M. Abecassis1,* and T. Pearson2 1
Northwestern University, Division of Transplantation, Chicago, IL 2 Emory University, Transplant Center, Atlanta, GA Corresponding author: Michael Abecassis, [email protected]
Received 23 October 2014, accepted for publication 11 November 2014 In this edition of AJT, Abouljoud et al present a timely and important perspective on transplant physician compensation (1). The authors draw parallels between the tenets and principles behind the role of primary care in the Medical Home, and the care of transplant recipients as provided by transplant physicians and surgeons. These include functions typically attributed to primary care, such as development of a care model with coordination of care between various specialties to improve the quality of healthcare while decreasing costs. The authors propose that ‘‘virtual’’ or ‘‘supplemental’’ relative value unit (vRVU) should be used as a currency to compensate physicians for these services that do not qualify as work RVU (w-RVU) as recognized by the current system. The authors further point to the need for RVU ‘‘equivalents’’ in constructs such as models for bundled services and payment. This manuscript unmasks a paradox that has been developing of late, particularly in academic centers. While the Affordable Care Act (ACA) of 2010 clearly emphasizes payment for quality, vilifying payment for quantity, leaders of academic institutions are turning to w-RVU as the most important measure of productivity for physicians involved in delivering clinical care. Increasingly, national benchmarks relating physician productivity to compensation use w-RVU as the metric for physician productivity that defines how physicians should be compensated. Healthcare consultants specializing in physician compensation have, it seems without exception, recommended this methodology to calibrate physician salaries (2). While some adjustments are made for research and teaching efforts, no adjustments are made for efficiency of care, or for a number of functions, such as those outlined by the authors for both the Medical Home model and for transplant care. While modifications, such as recognition of quality and ‘‘good citizenship,’’ can
be made to adjust for these, these are not typically included in calculations of physician compensation, making current practice largely inconsistent with the ACA. Thus, the paper by Aboulijoud et al underscores a general and pervasive inconsistency between RVU-based compensation and the intent of the ACA to reward providers for cost-efficiencies in the delivery of quality care consistent with the Triple Aim (3). This contradiction in terms is most apparent in the case of primary care where despite the clear objective of providing the least number of care units while maintaining outcomes through preventative measures, the productivity of the provider is measured by the number of care units, or w-RVU. The fundamental concept behind Accountable Care Organizations (ACOs), one of the most important provisions of the ACA, is that capitated budgets for specific populations, managed by primary care physicians can lead to shared savings, resulting in financial incentives for providers. While ACO models are reminiscent of the health maintenance organizations (HMOs) and capitated care models of yesteryear, the main difference is that participating ACO physicians do not play the role of a ‘‘gatekeeper,’’ denying referrals to other providers. The ACO provision has been touted as the most promising strategy within the ACA to align physicians, patients and payers as we all attempt to bend the cost curve. The major principle underpinning ACOs is the ability of primary care physicians to predict unnecessary utilization of care resources and to pre-empt them. These types of clinical activities, described by Abouljoud et al, for transplant patients cannot be easily captured through the w-RVU mechanism. Therein lies the paradox: While this type of care requires significant effort by providers, it is not counted as work as defined by w-RVU because of the lack of appropriate billing codes, and therefore this effort is not captured by w-RVU calculations. Transplantation, which exists almost exclusively in academic institutions, has led the way in executing on the concept of accountable, team-based, coordinated care now codified by the ACO provision. As a result of being considered a carve-out in most provider contracts, transplantation is viewed as the model for bundled services and capitated payment models. In addition, transparency of outcomes has been in place since 1987, and a high level of regulation and public scrutiny has been in effect since 2007 (4). Thus, transplant programs have been delivering ‘‘value-based care’’ for at least two decades. The business 579
Abecassis and Pearson
school definition of value is the simple equation: ‘‘quality divided by cost’’. Given that quality, as measured by transplant outcomes is publically reported twice a year, and that costs have been contained through reimbursement set by capitated ‘‘case rates’’, transplant providers have been delivering care according to this value equation for years. In addition, as stipulated in the federal regulations that govern transplantation, ownership of transplant programs rests with hospitals, as opposed to most clinical practices that ‘‘belong’’ to physicians. As a result, the ‘‘provider’’ of transplant services is not simply a physician, but a team that includes physicians, nurses, and in some cases, hospital and practice administrators from a number of disciplines. While most transplant physicians continue to be compensated on a w-RVU-based model, these facts place transplantation in a position to lead the current transition in healthcare reform, from a fee-for-service to a fee-for-value model (5,6). This unique set of circumstances highlights the irony implicit in the fact that Abouljoud et al feel the need to defend against the w-RVU model.
compensation models that are in synchrony with the tenets of delivering value-based care, defined by the lowest overall cost that allows us to achieve a desired clinical outcome for each patient and each condition. At the very least, the v-RVU solution proposed by the authors may provide a useful model for creating w-RVU equivalents and may aid in the quantification of an individual’s effort aligned with the team’s goals. To quote the physicist Neils Bohr: ‘‘how wonderful that we have met with a paradox – now we have some hope of making progress’’.
The sentiments expressed by Abouljoud et al should apply to any and every physician involved in the care of patients in the current environment. While w-RVU represent an important measure of ‘‘work,’’ they certainly do not tell the entire story. This may be further complicated by the recent decision by CMS to uncouple intraoperative RVUs from postoperative care RVUs ‘‘by transitioning all 10- and 90-day global surgical codes to 0-day global surgical codes’’ (7). Moreover, using the w-RVU as the sole metric of work contradicts the entire concept of value-based care and can only result in increasing units of care delivered and consequently cost of care delivered. Therefore, we should take the message of this manuscript seriously, and use it as clear evidence that we are all shamefully not on the same page. Any compensation system should reward individual providers based on a true measure of successfully delivering value-based care. We submit that using w-RVU as the sole metric of provider productivity is akin to trying to put square pegs into round holes, creates conflict and may result in unintended consequences. Instead, our profession and our leaders should seek alignment, and actively participate in the design of care and physician
1. Abouljoud M, Whitehouse S, Langnas A, Brown K. Compensating the transplant professional: Time for a model change. Am J Transplant 2015; 15: 601–605. 2. AMGA 2012 Medical Group Compensation and Financial Survey Highlights. Available at: https://www.uthsc.edu/finaid/flight/ documents/Physician_Compensation_Where_the_Market_is_Going. pdf. 3. Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. 4. Medicare program; hospital conditions of participation: Requirements for approval and re-approval of transplant centers toperform organ transplantation. Final Rule (42 CFR 405, 482, 488,and 498). Fed Regist. 2007; 72: 15198–15280. 5. Axelrod DA, Millman D, Abecassis MM. US health care reform and transplantation. Part I: Overview and impact on access and reimbursement in the private sector. Am J Transplant. 2010; 10: 2197–2202. 6. Axelrod DA, Millman D, Abecassis MM. US health care reform and transplantation, Part II: Impact on the public sector and novel health care delivery systems. Am J Transplant. 2010; 10: 2203–2207. 7. https://www.federalregister.gov/public-inspection. Accessed January 27, 2015.
580
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
References
American Journal of Transplantation 2015; 15: 579–580
Copyright of American Journal of Transplantation is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
C
Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.13112
Editorial
Fee-for-Value and wRVU-Based Physician Productivity—An Emerging Paradox M. Abecassis1,* and T. Pearson2 1
Northwestern University, Division of Transplantation, Chicago, IL 2 Emory University, Transplant Center, Atlanta, GA Corresponding author: Michael Abecassis, [email protected]
Received 23 October 2014, accepted for publication 11 November 2014 In this edition of AJT, Abouljoud et al present a timely and important perspective on transplant physician compensation (1). The authors draw parallels between the tenets and principles behind the role of primary care in the Medical Home, and the care of transplant recipients as provided by transplant physicians and surgeons. These include functions typically attributed to primary care, such as development of a care model with coordination of care between various specialties to improve the quality of healthcare while decreasing costs. The authors propose that ‘‘virtual’’ or ‘‘supplemental’’ relative value unit (vRVU) should be used as a currency to compensate physicians for these services that do not qualify as work RVU (w-RVU) as recognized by the current system. The authors further point to the need for RVU ‘‘equivalents’’ in constructs such as models for bundled services and payment. This manuscript unmasks a paradox that has been developing of late, particularly in academic centers. While the Affordable Care Act (ACA) of 2010 clearly emphasizes payment for quality, vilifying payment for quantity, leaders of academic institutions are turning to w-RVU as the most important measure of productivity for physicians involved in delivering clinical care. Increasingly, national benchmarks relating physician productivity to compensation use w-RVU as the metric for physician productivity that defines how physicians should be compensated. Healthcare consultants specializing in physician compensation have, it seems without exception, recommended this methodology to calibrate physician salaries (2). While some adjustments are made for research and teaching efforts, no adjustments are made for efficiency of care, or for a number of functions, such as those outlined by the authors for both the Medical Home model and for transplant care. While modifications, such as recognition of quality and ‘‘good citizenship,’’ can
be made to adjust for these, these are not typically included in calculations of physician compensation, making current practice largely inconsistent with the ACA. Thus, the paper by Aboulijoud et al underscores a general and pervasive inconsistency between RVU-based compensation and the intent of the ACA to reward providers for cost-efficiencies in the delivery of quality care consistent with the Triple Aim (3). This contradiction in terms is most apparent in the case of primary care where despite the clear objective of providing the least number of care units while maintaining outcomes through preventative measures, the productivity of the provider is measured by the number of care units, or w-RVU. The fundamental concept behind Accountable Care Organizations (ACOs), one of the most important provisions of the ACA, is that capitated budgets for specific populations, managed by primary care physicians can lead to shared savings, resulting in financial incentives for providers. While ACO models are reminiscent of the health maintenance organizations (HMOs) and capitated care models of yesteryear, the main difference is that participating ACO physicians do not play the role of a ‘‘gatekeeper,’’ denying referrals to other providers. The ACO provision has been touted as the most promising strategy within the ACA to align physicians, patients and payers as we all attempt to bend the cost curve. The major principle underpinning ACOs is the ability of primary care physicians to predict unnecessary utilization of care resources and to pre-empt them. These types of clinical activities, described by Abouljoud et al, for transplant patients cannot be easily captured through the w-RVU mechanism. Therein lies the paradox: While this type of care requires significant effort by providers, it is not counted as work as defined by w-RVU because of the lack of appropriate billing codes, and therefore this effort is not captured by w-RVU calculations. Transplantation, which exists almost exclusively in academic institutions, has led the way in executing on the concept of accountable, team-based, coordinated care now codified by the ACO provision. As a result of being considered a carve-out in most provider contracts, transplantation is viewed as the model for bundled services and capitated payment models. In addition, transparency of outcomes has been in place since 1987, and a high level of regulation and public scrutiny has been in effect since 2007 (4). Thus, transplant programs have been delivering ‘‘value-based care’’ for at least two decades. The business 579
Abecassis and Pearson
school definition of value is the simple equation: ‘‘quality divided by cost’’. Given that quality, as measured by transplant outcomes is publically reported twice a year, and that costs have been contained through reimbursement set by capitated ‘‘case rates’’, transplant providers have been delivering care according to this value equation for years. In addition, as stipulated in the federal regulations that govern transplantation, ownership of transplant programs rests with hospitals, as opposed to most clinical practices that ‘‘belong’’ to physicians. As a result, the ‘‘provider’’ of transplant services is not simply a physician, but a team that includes physicians, nurses, and in some cases, hospital and practice administrators from a number of disciplines. While most transplant physicians continue to be compensated on a w-RVU-based model, these facts place transplantation in a position to lead the current transition in healthcare reform, from a fee-for-service to a fee-for-value model (5,6). This unique set of circumstances highlights the irony implicit in the fact that Abouljoud et al feel the need to defend against the w-RVU model.
compensation models that are in synchrony with the tenets of delivering value-based care, defined by the lowest overall cost that allows us to achieve a desired clinical outcome for each patient and each condition. At the very least, the v-RVU solution proposed by the authors may provide a useful model for creating w-RVU equivalents and may aid in the quantification of an individual’s effort aligned with the team’s goals. To quote the physicist Neils Bohr: ‘‘how wonderful that we have met with a paradox – now we have some hope of making progress’’.
The sentiments expressed by Abouljoud et al should apply to any and every physician involved in the care of patients in the current environment. While w-RVU represent an important measure of ‘‘work,’’ they certainly do not tell the entire story. This may be further complicated by the recent decision by CMS to uncouple intraoperative RVUs from postoperative care RVUs ‘‘by transitioning all 10- and 90-day global surgical codes to 0-day global surgical codes’’ (7). Moreover, using the w-RVU as the sole metric of work contradicts the entire concept of value-based care and can only result in increasing units of care delivered and consequently cost of care delivered. Therefore, we should take the message of this manuscript seriously, and use it as clear evidence that we are all shamefully not on the same page. Any compensation system should reward individual providers based on a true measure of successfully delivering value-based care. We submit that using w-RVU as the sole metric of provider productivity is akin to trying to put square pegs into round holes, creates conflict and may result in unintended consequences. Instead, our profession and our leaders should seek alignment, and actively participate in the design of care and physician
1. Abouljoud M, Whitehouse S, Langnas A, Brown K. Compensating the transplant professional: Time for a model change. Am J Transplant 2015; 15: 601–605. 2. AMGA 2012 Medical Group Compensation and Financial Survey Highlights. Available at: https://www.uthsc.edu/finaid/flight/ documents/Physician_Compensation_Where_the_Market_is_Going. pdf. 3. Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. 4. Medicare program; hospital conditions of participation: Requirements for approval and re-approval of transplant centers toperform organ transplantation. Final Rule (42 CFR 405, 482, 488,and 498). Fed Regist. 2007; 72: 15198–15280. 5. Axelrod DA, Millman D, Abecassis MM. US health care reform and transplantation. Part I: Overview and impact on access and reimbursement in the private sector. Am J Transplant. 2010; 10: 2197–2202. 6. Axelrod DA, Millman D, Abecassis MM. US health care reform and transplantation, Part II: Impact on the public sector and novel health care delivery systems. Am J Transplant. 2010; 10: 2203–2207. 7. https://www.federalregister.gov/public-inspection. Accessed January 27, 2015.
580
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
References
American Journal of Transplantation 2015; 15: 579–580
Copyright of American Journal of Transplantation is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
