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RVUs—Whose Value Is It, Anyway?

RVUs—Whose Value Is It, Anyway?

As I discuss career options with a group of third-year
medical students, I imagine a marketing brochure
for psychiatry residencies in a world of mental health
parity:

The brain is undeniably the most
complex organ of the human body.
Beyond controlling virtually all body
functions, the brain is the source of the
mind, which is but an ethereal concept,
so hard to grasp that even the language
of mental theory requires methodical
parsing. Treatments for diseases of the
mind and brain require the intricate
understanding of chemistry, physiology,
and anatomy that is common to all
branches of medicine and also the ability
to step outside of oneself and objectively
observe personality and emotion.
The psychiatrist must tolerate the unsettling
awareness of the mysterious relationship
between mind and matter and
must help others find their own answers
to the mysteries of the human condition.
The shortage of physicians willing
to engage in this area of study
reflects the enormity of the challenges.
Some medical students become cardiovascular
surgeons, the plumbers of
medicine, while others choose to nail
bones together, taking pleasure in the
simplicity of hand tools. Still others find
a good living looking at see-through
images of body parts—often a day or
2 after the images have been used and
care has been provided. These tasks
pale in comparison to the labors of
understanding and treating diseases
based in the final frontiers of medical
knowledge. No wonder that the masters
of medicine—those who work in the vast
field of interventional psychiatry—are
so valued by society.

The time has come for my transition
from psychiatric residency to psychiatric
practice. Not surprisingly, we graduates
have encountered great demand
for our services; the posting of resumes
on Internet boards results in a slew of
telephone calls from eager recruiters.
For my younger colleagues, the prospect
of 6-figure incomes suggests reward, at
last, for years of work and debt. Most
job offers come from health care systems
looking for someone to prescribe
medication to complement their bevy
of lower-paid psychotherapists.

Under the guarantee of income and
benefits lies the expectation of productivity.
This productivity is not measured
by patient satisfaction, symptom improvement,
or reduced morbidity. Rather, the name of the game is the relative value
unit, or RVU. The way to get more RVUs
is to see more patients in whatever time
is available. While many residents long
for the independence to practice as they
see fit, their debt loads require more practical
approaches. Concerns over production
and practice limitations pale in
comparison to long-delayed plans to start
families and buy houses.

For my part, I am grateful for the
opportunity to earn good money in the
service of a challenging and rewarding
career, but I am also aware of the striking difference between the salaries of
psychiatrists and the salaries of many
other physicians. As a former practitioner
in one of medicine's more lucrative
specialties, I find myself comparing
my apparent value now with my value
then. Why is my work now worth less
than half as much as my work as an
anesthesiologist?

At the end of a night in the crisis
service last week, I walked past a group
of patients huddled in the cold, waiting
for the doors of the walk-in clinic
to open. As I looked at their tired faces,
I realized the desperation they must feel
that compels them to leave their homes
or homeless shelters at such a cold and
early hour and make the trek to the clinic
by foot or by bus. Their pains were certainly
as great as the pains of any of
my patients presenting for surgery. But
for some reason, there is less outrage
over their lack of care than there would
be for a group of patients with untreated
diabetes, appendicitis, or heart disease
standing outside a hospital. I realized
that like many in society, I had unwittingly
accepted the scene before me as
representing adequate care for the mentally
ill.

The RBRVS, or resource-based relative
value scale, was instituted by Medicare in 1992 in an attempt to standardize
payments for physician services.
RVUs are assigned to physician
services based on 3 main factors: physician
work, practice expenses, and the
cost of liability insurance. Physician
work is determined by several factors,
including time required for the service,
technical skill and physical effort, mental
effort and judgment, and amount of
stress experienced by the physician
from the risk to the patient. To arrive
at the fair value of services, the number
of RVUs is multiplied by a universal
dollar value and adjusted slightly for
practice location, according to regional
cost of living indices.

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