From independent interventional radiologist Dr. Kavi Devulapalli’s recent article, “Coming to Terms With Reality“:
I can build a program that did not exist before I got there, develop the referral relationships, create the clinic, generate the patients, perform the procedures and produce millions of dollars of new facility economics. The hospital can measure that value, present it to a board, use it to justify investment and congratulate itself on the growth of the service line. When it comes time to figure out what I should be paid, however, we are suddenly talking about how many wRVUs I produced, what fair market value is for call coverage, how many hours I spent doing administrative work, what other employed IRs make and what percentile my compensation falls into.
This is why I increasingly describe the game as rigged. I don’t mean there is some guy at CMS sitting around trying to figure out how to personally ruin my life. What I mean is that once you understand how the pieces fit together, the result becomes pretty obvious. CMS separates the physician economics from the facility economics. The hospital owns the facility and employs the physician. The physician can then create tremendous additional enterprise value for the hospital, while Stark and AKS make it difficult to simply reconnect physician compensation to the downstream economics that physician helped create. Compensation gets pushed back toward the defensible value of physician labor, which is then informed in part by surveys of what other physicians operating inside the same system are being paid. If that doesn’t strike you as at least somewhat circular, I don’t know what to tell you.
Value has always been hard to define, but even if RVUs were a perfect measure of physician work in direct patient care, they would never, ever tell the complete story. The hospitals know this, even if they pretend not to during negotiations or their usual budgetary gerrymandering.