Bonus Round
The patient’s value is not relative
The New Physician December 2009
by Nancy Merrick, M.D. Volume 58, Number 9
“I could skip checking her medication bottles. That’ll help. And if I have to, I’ll just focus on the dizziness. The diabetes and arthritis will have to wait ’til next time. Maybe even the breast cancer. Surely the oncologist is on top of that.”
Mrs. Gutierrez, age 88, had just passed by my office door, headed toward the exam room. She walked with a limp and used a quad cane. She had diabetes with nephropathy, hypertension, dyslipidemia, degenerative arthritis, osteoporosis and breast cancer—and today, she needed evaluation for dizziness too. I felt depressed. How in the world was I supposed to handle this complicated, elderly woman in a 15-minute slot?
“So what’s an RVU again?” my 21-year-old medical assistant (MA) asked me for what seemed like the 20th time.
“How about we talk about it later? Can you make sure Mrs. Gutierrez gets into the exam room all right? I think she’s here for dizziness.”
My MA had just named my least favorite subject: the RVU, or relative value unit, a numerical system for describing a doctor’s productivity and, sometimes, for assigning payment. I had little recovered from my em-ployer introducing an RVU-based financial bonus into my contract three years ago, reducing my base pay but offering the “opportunity” to augment it according to the RVUs I could rack up. The more treatments I packed into a day, the more I would be paid. By sticking to the 15-minute slots, he assured me, I would do well.
I found this new productivity incentive insulting and unfair, particularly for a county-employed physician already working for less pay and with less support. I had a practice laden with geriatric and chronically ill pa-tients, the help of a single MA, and now a new personal financial inducement.
I started to feel angry at Mrs. G. As things were going, it looked as though the 15 minutes were probably going to be mostly consumed by her slow plodding to the room. Finally hearing her sink into the exam room chair, I walked toward the room, trying to imagine what she would say were I to tell her the truth of RVU bo-nuses. No doubt, I would be dead of quad cane to the occiput.
It was then that I caught sight of Mrs. G. through the slightly open door. She was fumbling with her purse, trying to find all her medicines. Perhaps she had finally remembered to bring them today, sensing my frustra-tion at her last visit. She looked nervous and a little shaky. As I walked in, she started but then smiled, honoring me as she always did with words of appreciation. She started to get up, but quickly reversed, her dizziness speaking.
Now it was finally starting to register just how distorted my thinking had become. Here was this lovely, vul-nerable lady, entirely in my hands. Clearly, I could neither ignore nor delay any of the elements of her evalua-tion. If Mrs. G’s dizziness went undiagnosed, she could end up with a fractured hip within the week. And what if it was dehydration or bleeding or a stroke?
Thankfully, at that moment, my RVU puppet string broke irreparably, snapping me back to self-respect. Disgusted, I decided that this was the final indignity that RVUs would inflict upon me. I would no longer endure them as part of my day or my practice of medicine. They would no longer jeopardize the well-being of my el-derly and chronically ill patients. All thoughts of RVU bonuses were vanquished.
My mother, like Mrs. G., is 88 years old, struggling to remain living independently in her own home. One of our weekly activities is a trip to the grocery store, where she reigns over the aisles as she steers the store’s motorized cart. She’s a bit hard of hearing and doesn’t always see so well. Last week, she drifted to the right while studying cheese prices across the aisle and nearly pinned my neighbor against the frozen-foods case. Visions of having to rescind her market-scooter driving privileges flashed through my mind. It’s hard being a daughter of an elderly mother, and I’m convinced it’s far harder still to be the slowly failing yet gracious mother.
My mother is blessed with doctors who kindly give her the extra time that she needs to understand what they are telling her. But I wonder, when I take her to her appointments, what happens to most elderly people in these days in which the country doctor has been replaced by RVUs and HMOs and DRGs and—well, you know the acronyms. All of them provide financial disincentives to caring for the elderly and increase the risk of fragmented or even risky care.
I am able to live unfettered by worries of how big my RVU bonus, if any, will be because I am not the sole breadwinner for my family, and because I do not have tremendous school loans or a hefty mortgage to pay off. For me, the RVUs serve as a true bonus, not as a minimum required in order to keep my job. I am lucky to have this little bit of freedom. But I know that there are others not so lucky.
Ultimately, there is no perfect solution. Although the push to create a “medical home” may help, we, as physicians, will need to join together to maintain our voices as employers and systems push us to cut corners, or offer deleterious incentives. But in the end, it comes down to each of us choosing to do what’s right.
In this, my post-RVU era, I still grapple each workday with developing the perfect scheduling routine, trying to roll masterfully with the unpredictable, and staying as on time as I can be. Not caring about my bonus has not solved these problems. But, now, as a free woman, I can tell you that I am a better doctor and that my patients notice the difference. I am more focused on my patients and less on how to game the system.
And one more thing—I’m sleeping better. I can look Mrs. G. in the eye again, feeling like a true advocate and friend, rather than a “health care machine with client” Picasso painting. I have looked high and low for pol-icy solutions to this RVU dilemma but, ultimately, my best idea comes down to this: It is time to ask health executives to join physicians in taking that all-important Hippocratic oath of “first do no harm.”
Dr. Nancy Merrick is an internist in Ventura, California. A pseudonym was used for her patient.