Our healthcare system continues to shift toward value-based care but can relative value units handle the transition? Read on to learn more.
Our healthcare system has seen a growing shift toward value-based care, which focuses on rewarding quality and positive health outcomes over volume. One of the questions surrounding this transition is how to align the incentives driving provider behavior with the goals of value-based healthcare. There have been plenty of discussions about whether relative value units (RVUs), the current model for determining reimbursements for services under Medicare, can evolve to handle this shift or if more changes to the RVU system are needed.
Accurately assessing clinical productivity has always posed challenges. Historical metrics ranging from the number of procedures performed to accumulated charges have all been used in the past, but while useful, inconsistencies can occur. Providers may also define terms differently, further complicating matters. This spurred the 1989 introduction of Relative Value Units (RVUs).
RVUs deliver standardized productivity scoring for providers by connecting units to existing billing codes. The methodology considers the relative value of services including time, skill, and intensity required. This grants unprecedented fairness for monitoring clinical workload across specialties. Today, the relationship between RVUs and coding remains important for reviewing procedural intensity and enabling reliable revenue projections.
However, Medicare directly bases payments on RVUs, leading to criticisms of fee-for-service's focus on volume over care quality. As landscape changes drive value-based care growth, the question stands of whether and how RVUs can effectively adapt.
Understanding Relative Value Units
Relative value units reflect the total resources required to perform a medical service. Each service has three corresponding RVUs that represent:
- Physician work effort
- Practice costs
- Malpractice expenses
These RVUs serve some key purposes:
- Standardizing comparisons across services
- Calculating Medicare reimbursement conversions
Up until 1992, Medicare payments were based on historical reimbursement charges. However, it became clear Medicare needed a consistent and unbiased system across specialties. This led to the introduction of the Resource-Based Relative Value Scale (RBRVS) and RVUs as the foundation. The RBRVS mapped out the total RVUs for each CPT code, and this allowed direct conversion into a Medicare payment amount.
Since its implementation, the RVU scale has become deeply embedded within Medicare's administration and fee-for-service physician reimbursement model.
Limitations of Fee-for-Service Models
The RVU system functions within a fee-for-service payer model for determining provider reimbursement. However, fee-for-service arrangements have received criticism for promoting volume over value. As our healthcare system moves toward value-based care, exploring whether relative value units will remain relevant requires examining common fee-for-service weaknesses.
Under fee-for-service, provider payments are directly tied to the number of services provided, regardless of whether quality or outcomes improve. As a result, some argue the model incentivizes overutilization and fragmentation. Also, fee-for-service reimbursement does not properly support care coordination efforts.
In addition, fee-for-service creates obstacles to focusing on preventative, evidence-based care shown to deliver better patient outcomes. There is little incentive to invest time in disease management programs or comprehensive health assessments unpaid by Medicare. This misalignment leads to substandard quality performance under current metrics.
Reimbursement arrangements should reward healthcare providers for efficiency and positive impacts on a patient's health status. However, under fee-for-service, financial incentives are separated from performance benchmarks around outcomes, quality metrics, cost savings, or population health management.
Since payment is connected to volume, reducing inappropriate or nonessential complex services counters a provider's financial interests. These disincentives toward cost containment and measuring outcomes have driven the push for Medicare payment reforms.
The Emergence of Value-Based Care
Recognizing Medicare's fee-for-service model often causes poor coordination and waste, governmental and private insurers have shifted toward value-based payment. If relative value units were designed for fee-for-service contracts, would they have a place in the future? When we take the time to analyze new value-focused models, it sheds some light on where relative value units currently fit – and where changes may be needed.
Value-based care aims to shift the focus of healthcare from volume to value. After all, one of the most effective ways to provide efficient care is by providing “the right care for the right patient at the right time.” A few key principles of value-based systems include:
- Coordinating care across settings
- Investing in preventative services
- Utilizing evidence-based medicine
- Leveraging health IT
- Managing population health
More payers are exploring value-based reimbursement models as alternatives to fee-for-service. These new payment models tie financial rewards to achieving specific quality benchmarks, outcome metrics, and cost targets—not just service quantity. Examples include bundled payment programs for procedures and chronic disease management, shared savings arrangements with ACOs, and population health-based capitation models.
Value-based care directly aims to address flaws in the traditional fee-for-service model. By connecting revenue to positive health outcomes and efficient resource use, value-based models prevent overutilization while promoting investments in high-impact preventative and coordinated services lacking under fee-for-service.
Can Relative Value Units Adapt to Value-Based Care?
Medicare's physician reimbursement methodology should directly promote high-value, coordinated care. As payment models move further away from fee-for-service, RVUs' future position comes into question. Their purpose within volume-based systems does have legitimate challenges. The current RVU model does not seem to be compatible with key value-based principles around coordinated care, health equity, and prevention. However, given how rooted relative value units remain, they may still play a role in certain value-based arrangements—if purposefully adapted to align with quality and efficiency.
To integrate relative value units effectively, there will need to be changes to the RVU formula so it can capture wider care investments. For example, malpractice relative value units could expand to account for liability risk reduction through preventative disease management programs. While making specific changes will be beneficial, there will certainly be challenges during this process.
Some challenges in adjusting RVUs include the following:
- Extensive new analysis
- Needing engagement from medical societies on methodology shifts
- Getting provider buy-in
- Properly implementing the changes through technology and policy adjustments
Benefits and Challenges of an RVU-Based Value Model
Relative value units attempt to measure the resources involved in providing care, and this can indirectly incentivize efficiency and quality in service delivery. By placing more attention on the value of services and not just the quantity, RVUs have the potential to encourage healthcare providers to invest more in preventive measures and comprehensive care strategies that support patient wellness over time.
Increasing relative value units for preventative counseling, screenings, and education programs based on proven health benefits would offset current disincentives and lack of compensation. Higher potential reimbursement may lead to expanded access and utilization among vulnerable communities. However, even if adapted to a value-based environment, RVUs have limitations. As individually assigned unit values, RVUs are not able to account for the various services, from nutrition to transportation, that contribute to health beyond direct medical care.
Making the shift to value-based RVUs would require bringing in new risk adjustment calculation methods while giving healthcare providers time to invest in care coordination resources to seize incentives. Grants could serve as a funding source for coordination training and health equity interventions to speed up adoption.
Gaining support from medical societies on valuing currently unpaid components like preventative counseling will be essential to successful integration. Policymakers must also slowly adjust relative value units and bundled pricing to emphasize outcomes over volume. With any potential for change, there is going to be some resistance. If there is any skepticism that RVUs can enable value-based care, the skepticism can be overcome through the use of bundled pricing models that limit financial risks during initial transitions.
Relative value units will likely stick around in some form as we focus more on quality. We could first see hybrid systems mixing RVUs with bonus payments for efficient, careful treatment. As devices get smarter at analyzing care, providers may gain more trust in tracking their work.
Over time, primary family healthcare providers may shift completely from relative value units to being paid per patient instead. However, specialists could keep using adjusted RVUs. That said, paying to keep patients healthy matters most. So, rules must stress that, not just visit numbers.
While relative value units help administer fee-for-service reimbursement, their role allows for a development aligned with value-based care. Your practice can achieve this through a redesign that considers aspects like care coordination and prevention. However, larger delivery and policy reforms are necessary to fully realize the potential of value-based care. It's not just about changing the current system but implementing reforms that promote high-quality and cost-effective care.
BillFlash can help practices transition smoothly towards value-based care by streamlining the billing process. As our healthcare system continues to progress towards value, the right solutions will be instrumental in supporting change. While the journey toward value-based care is challenging, it is full of potential. With the right tools and reforms, we can transform our healthcare system into one that rewards value and improves patient outcomes.