The Relationship Between Work Relative Value Unit Awareness and Work Relative Value Unit Accumulation Among Physicians

The fee-for-service payment methodology remains the dominant form of reimbursement for physician services despite ongoing efforts to shift payment toward quality and value.(1) At the core of fee-for-service reimbursement is the resource-based relative value scale (RBRVS), which determines payment based on the relative value of three factors: physician work, practice expense, and practice liability insurance. Physician work relative value units (wRVUs) represent approximately 50% of the weight used to determine total payment for a given service, which makes them a key predictor of financial performance for healthcare organizations.(2) wRVUs are also a valuable metric of productivity(3) and present an opportunity to make comparisons on volume and efficiency.(4) Strategies for improving wRVU generation have become increasingly important, due to the obstacles that healthcare organizations face today.(3) Reimbursement levels have been in steady decline, which has come in conjunction with an increased pressure to provide cost-effective care. These conflicting pressures are forcing healthcare organizations to do more with less, and any method that is shown to improve wRVU generation can put healthcare organizations in a position to overcome these challenges.

It is difficult to optimize any metric when there is ambiguity regarding its calculation and measurement.

Research on the drivers of wRVU generation has shown that many factors have an impact, among them gender,(5-8) age and experience,(7,8) compensation format,(7-12) practice patterns,(13) accessibility,(10) and performance transparency.(14,15) It has been theorized that resident supervision and other academic duties hinder wRVU accumulation; however, the evidence shows resident supervision does not negatively impact wRVU generation, and that part-time clinical physicians are at least as productive as full-time clinical physicians per clinical hour.(16,17) What remains unclear is the impact that physician awareness of wRVUs can have on wRVU generation. We defined awareness to include the following factors: an understanding of the system, an ability to control output, belief in the system’s effectiveness, education and provided resources, performance communication, and knowledge on documentation best practices.

It is difficult to optimize any metric when there is ambiguity regarding its calculation and measurement, and physicians typically receive little or no education on the RBRVS, they receive limited training on documentation, and the communication of wRVU metrics can be inconsistent or even nonexistent.(18) These inconsistencies led us to question whether variances in wRVU awareness are associated with variances in wRVU output. We hypothesized that there is a positive association between awareness and accumulation, and that physicians with above-average awareness would be more likely to surpass their wRVU benchmark. The conceptual model we used to answer our research question is located in Appendix A. The independent variable was physician awareness of wRVUs, and the dependent variable was physician wRVU accumulation. We also tested both variables against physician characteristics to control for gender, age, race, tenure, and moonlighting activity.

Method

This was a retrospective, cross-sectional study of the faculty physicians at a large, Midwestern academic medical center. Physician productivity data were obtained for fiscal years 2014 and 2015. Physicians who were contracted at below a 0.50 clinical full-time equivalent (cFTE) during the study period were excluded from the sample, because only physicians above this threshold were eligible for wRVU-based incentives. Additionally, physicians were excluded if they did not practice within the organization during the study period, or if they were no longer with the organization at the time of survey distribution.

An electronic survey designed to assess individual awareness of wRVUs was distributed to qualifying physicians during the winter and spring of 2016. Participation was voluntary. Physician name/employee ID was an optional field, although it was required to map survey respondents to provider-specific wRVU accumulation. Each question was a Likert scale item with four anchors, scored from 0 to 3 (0 = strongly disagree, 1 = somewhat disagree, 2 = somewhat agree, 3 = strongly agree).

A total awareness score was calculated for each respondent by summing across all items, and a categorical variable was created to classify each respondent as having either above-average awareness or below-average awareness based on the overall mean of the summary score. (Table 1 provides a list of survey questions and a summary of responses.) The survey also provided an opportunity for respondents to leave open-ended comments. Content validity was ensured by working with wRVU and physician productivity experts to create the survey, and the organization’s physician leadership was leveraged to ensure the wording and phrasing used would elicit reliable responses. Two hundred fifty-one physicians were eligible for our study, and a total of 91 (36%) responses that could be mapped to wRVU output were received. The survey displayed high internal consistency (9 items, Cronbach’s a =.79).

wRVU accumulation data were obtained from the Faculty Practice Solutions Center (FPSC) for each qualifying respondent. The FPSC collects wRVU productivity data by pulling directly from each member’s billing system, and uses data from its 99 members (all academic medical centers) to create specialty-specific benchmarks. These nationally derived benchmarks were essential in allowing an analysis that included multiple specialties. Due to extensive faculty and leadership responsibilities that are typical in an academic setting, the cFTE of faculty physicians varies between 0.00 and 1.00. For this reason, each respondent’s actual wRVU generation was extrapolated to the 1.00 cFTE level, which allowed for a meaningful comparison of wRVU data.

The extrapolated FY14 and FY15 wRVU outputs for each respondent were summed to provide total wRVU accumulation; the specialty-specific FPSC benchmarks from FY14 and FY15 were summed to provide each respondent’s total benchmark; and then total wRVU accumulation was subtracted by the total benchmark to determine each respondent’s output relative to the benchmark. Finally, this number was converted to the percentage above or below the benchmark, and a categorical variable was created to identify those providers who were above or below their benchmark.

The analysis included descriptive tests to understand the characteristics of the sample, as well as one-way analysis of variance and independent t-tests to test the association among physician characteristics, wRVU awareness, and wRVU accumulation. A binary logistic regression model was used to predict wRVU benchmark status (above/below) by awareness level (above average/below average), and a linear regression model was used to determine whether a relationship exists between percent wRVU accumulation relative to the benchmark and awareness score. All statistical analysis was performed using SPSS Statistical Package Software, Version 22 (IBM, USA), and Institutional Review Board approval was obtained from Rush University prior to survey distribution and collection of wRVU data.

Results

Description of Sample

The mean awareness score among respondents was 13.5, and the mean wRVU accumulation relative to the benchmark was +12%. The average age among respondents was 48, and the average tenure among respondents was 9 years. Fifty-five (60%) of the respondents were male, and 36 (40%) of the respondents were female. Respondents represented 15 different departments. A full description of the sample, including analyses of wRVU awareness and wRVU accumulation by physician characteristic, can be found in Tables 2 and 3. There was a statistically significant bivariate relationship between awareness score and specialty (F (14, 76) = 1.82, p = .05), but no corresponding association between practice and wRVU accumulation. There were no other statistically significant bivariate relationships between physician characteristics and wRVU awareness or wRVU accumulation.

The Relationship Between wRVU Awareness and wRVU Accumulation

Physicians with above-average awareness produced 25% more wRVUs than their specialty-specific benchmark, on average, and physicians with below-average awareness produced 3% less wRVUs than their specialty-specific benchmark, on average. This difference proved to be statistically significant (t(89) = –3.3, p <.01). All bivariate results can be seen in Table 2. The results also indicated that physicians with above-average awareness were 4.1 times more likely to outperform their wRVU benchmark. This result proved to be statistically significant (OR = 4.1; 95% CI =1.7-10, p <.01). Lastly, there was a statistically significant positive linear relationship between wRVU awareness and wRVU accumulation. Awareness score accounted for 11% of the variance in output, and a single unit increase in awareness increased wRVU accumulation relative to the benchmark by three percentage points (95% CI [.01, .05]) (b1 = 0.03; p <.01).

Open-Ended Comments

Of the 91 subjects who responded to the survey, 40 (44%) left an open-ended comment. Sixteen (40%) of the comments suggested a need for more training on documentation and wRVUs. For example, one respondent noted “I was lucky enough to get some intense training on this topic when I became an employee, and it has made all the difference in my RVU accumulation.” Other comments on this subject included, “I feel like there are likely easy ways to increase my RVUs through documentation that are not communicated to me,” “I have not received any help in understanding how to improve RVUs in our office or appropriate billing,” and “Education would be tremendously helpful, right now there is no transparency.”

Eight (20%) of the comments suggested a need for more consistent communication and feedback. For example, comments included, “I have yet to have a meeting with any administrator to explain wRVUs for my practice,” and “I haven’t been given any input on what my RVUs have been for the last year.” The remainder of the comments suggested a lack of control over wRVU generation for various reasons, as well as an inability of the wRVU system to accurately capture physician work.

Discussion

We found a significant relationship between physician wRVU awareness and wRVU accumulation. Our models predict that wRVU accumulation will increase as awareness increases and demonstrate that physicians with an above-average awareness level are significantly more likely to surpass their wRVU benchmark, when compared with physicians with a below-average awareness level.

Implications

wRVUs are a key determinant of financial performance for healthcare organizations, which makes it necessary for both practice administrators and physicians to understand the drivers of wRVU generation. While physicians need to learn proactively about the RBRVS and wRVUs, it is ultimately up to practice administrators and other organizational leaders to put physicians in the best possible position to succeed. The statistically significant difference in awareness by specialty, the wide range of awareness among all respondents, and our review of open-ended survey responses indicate inconsistency in the awareness-building methods being deployed across departments. Areas of focus for administrators should include physician education on the wRVU system, training on documentation, consistent and actionable communication of wRVU-based productivity metrics, and ensuring that physicians understand the broader financial implications of their productivity.

There was a significant relationship between physician wRVU awareness and wRVU accumulation.

Physicians typically receive little formal education on reimbursement methodologies, and it is often their responsibility to learn this information on the job.(18) There is a need to provide physicians with a focused education on the intricacies of the RBRVS, including offering effective tools and resources to assist in understanding how activity translates to wRVUs. With increased information on the RBRVS and wRVU-based productivity, physicians will be more likely to feel in control of their output and will be in a better position to hit their productivity targets.

Documentation and coding is at the core of billing for patient encounters, yet the level of training provided to physicians does not appropriately reflect its importance. The nuances between CPT codes and the complexity of the billing process often present ambiguity in terms of the specificity that is required for proper documentation. This ambiguity can lead to frequent underbilling of physician services, which leaves revenue on the table and results in actual wRVU output being understated. Frequently used CPT codes should be analyzed, and coding experts should be leveraged to work with physicians on identifying improvement opportunities. Monitoring of coding practices and other documentation-related trends needs to occur regularly as well.

Providing physicians with consistent feedback on productivity metrics also is necessary to improve awareness. It is difficult to make improvements without information on current performance, so feedback should be communicated so it is clear and appropriate action can be taken in response. Frequent and consistent feedback can lead to a better understanding of how work translates to wRVUs by allowing physicians to associate trends in the data with their activity. The use of outside benchmarks should be included, and physicians should be educated on any benchmark they are being compared against. Healthcare leaders need to determine the most appropriate timing and the most effective methods for providing feedback on productivity. Best practices should be investigated, and effective and consistent approaches should be implemented.

Finally, it is critical for practice administrators to effectively link wRVU output with the broader financial implications for the practice and the organization. Declining reimbursement levels and increasing cost pressures have made it more difficult for healthcare organizations to be financially successful. In many cases, achieving the same number of billable patient encounters as in previous years will result in a decrease in revenue, and this decrease limits an organization’s ability to add resources in order to grow individual practices. Improving wRVU-based productivity can boost revenues, which can put the organization in a better position to grow. If physicians are able to link their wRVU output to the financial success of the organization and to the potential growth or decline of their practice, there may be an increased likelihood of success. Healthcare administrators should help physicians understand the financial challenges that the organization is facing, involve them more in the budget process, and find a way to link wRVU output to real dollars.

Future Research

The findings of our study indicate a wide range of wRVU awareness among physicians, and this range explains a significant portion of the observed variance in wRVU accumulation. However, there is a need for additional research on which awareness components best predict wRVU accumulation and which strategies are the most effective for improving awareness (e.g., education and training, one-on-one meetings with supervisors, performance feedback). Additionally, this study was correlational in nature, and we were unable to demonstrate causation. An interventional study could help shed more light on a causal relationship between awareness and output.

Regardless of which form of payment becomes dominant in the future, the association between awareness and performance should continue to be investigated. There is also an opportunity to research the association between awareness and other physician performance metrics, such as patient satisfaction and quality measures. For example, studies could be done on the relationship between patient satisfaction survey awareness and patient satisfaction scores, or awareness of readmission policies and readmission rates. Expanding research beyond productivity could improve our knowledge on the impact that awareness has on performance.

Limitations

This study does have limitations that must be acknowledged. First, this study used only the faculty practices of a single academic medical center. It is important to note that the results are isolated to this specific physician sample, and generalization of the results to other medical centers and care settings should be applied thoughtfully.

Second, the basis of comparison for wRVU generation was the national FPSC benchmark, which is based on data from 99 faculty group practices. Although the data used to create the benchmark provided us with the ability to make wRVU productivity comparisons with other academic practices, the broad range of size, cultures, competitive environments, and other unique challenges found in these organizations may be a limitation of the benchmark itself.

Conclusion

This study was the first to investigate the relationship between wRVU awareness and wRVU generation and presented new evidence demonstrating the existence of a statistically significant association. Considering the financial importance of wRVU generation for healthcare organizations and the wide range of awareness regarding wRVUs our study found, there is a need to devote more time and resources to developing best practices for building physician awareness of wRVUs. Future studies should determine which components of awareness are the most predictive of wRVU accumulation, and which strategies are the most effective in optimizing productivity. Improving wRVU education, training on coding and documentation, and providing consistent and actionable feedback are potential strategies to consider. As payment methodologies evolve, and financial pressures increase for healthcare organizations, it will be important to continue studying physician awareness as a potential driver of wRVU optimization.

References

1. Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Affairs. 2016;35:411-414.

2. Centers for Medicare and Medicaid Services. Medicare Physician Fee Schedule. Medicare Learning Network. 2014; www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedcrephysFeeSchedfctsht.pdf . Accessed August 10, 2016.

3. Satiani B, Matthews MA, Gable D. Work effort, productivity, and compensation trends in members of the Society For Vascular Surgery. Vasc Endovasc Surg. 2012;46:509-514.

4. Bergman M. Resource-based relative value scale (RBRVS): a useful tool for practice analysis. JCR J Clin Rheumatol. 2003;9:325-327.

5. Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: a meta-analytic review. JAMA. 2002;288:765-664.

6. Bloor K, Freemantle N, Maynard A. Gender and variation in activity rates of hospital consultants.J Royal Soc Med. 2008;101:27-33.

7. Gaynor M, Pauly MW. Compensation and productive efficiency in partnerships: evidence from medical group partnerships. Journal of Political Economy. 1990;98:544-573.

8. Conrad DA, Sales A, Liang SY, et al. The impact of financial incentives on physician productivity in medical groups. Health Services Research. 2002;37:885-906.

9. Andreae MC, Freed GL. Using a productivity-based physician compensation program at an academic health center: a case study. Acad Med. 2002;77894-899.

10. Lewandowski S, O’Connor PJ, Solberg LI, Lais T, Hroscikoski M, Sperl-Hillen JM. Increasing primary care physician productivity: a case study. Am J Manag Care. 2006;12:573-576.

11. Gaynor M, Gertler P. Moral hazard and risk spreading in partnerships. RAND Journal of Economics. 1995;26:591-613.

12. Conrad D, Fishman P, Grembowski D, et al. Access intervention in an integrated, prepaid group practice: effects on primary care physician productivity. Health Serv Res. 2008;43:1888-1905.

13. Smith DM, Martin DK, Langefeld CD, Miller ME, Feedman JA. Primary care physician productivity: the physician factor. J Gen Intern Med. 1995;10:495-503.

14. Scoggins CR, Crockett T, Wafford L, Cannon RM, McMasters KM. Improving clinical productivity in an academic surgical practice through transparency. J Am Coll Surg. 2013;217:46-51.

15. Robinson RL, Burk MS. Influencing hospitalist clinical productivity with feedback. J Med Pract Manage. 2012;27:301-304.

16. Albritton AT, Miller MD, Johnson, MH, Rahn DW. Using relative value units to measure faculty clinical productivity. J Gen Intern Med. 1997;12:715-717.

17. Fairchild DG, McLoughlin KS, Gharib S, et al. Productivity, quality, and patient satisfaction: comparison of part-time and full time primary care physicians. J Gen Intern Med. 2001;16:663-667.

18. Avitzur O. In practice: how do you get paid? As RVU methodologies gain favor, what you should know. Neurology Today. 2013;13(8):10-11.

Appendix