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The RVU Rundown: Interview with Kashyap Patel, MD
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Released: May 29, 2024

John Marshall
John Marshall, MD
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The RVU Rundown: Interview with Kashyap Patel, MD
[00:08:48] Now, as our final section, I really wanted to talk about something that is near and dear to my world as an administrator. So, I'm director of a division, and I work in a big healthcare system, and the metric that we use nowadays to incentivize, credit physicians, and other providers, is the RVU, relative value unit. I sort of think of it as our cryptocurrency. And how do we really understand how that came about, and how we're going to use it? Should we be using it? Should we be tailoring it in some way? And I don't know enough about this. So what I have done is invite somebody who does.

[00:09:34] I promised you all a world expert in the world of RVUs and there is no one smarter or more experienced about it than Dr. Kashyap Patel. He is the CEO of the Carolina Blood and Cancer Care Associates. He's the chair elect for clinical affairs and the trustee of the Association of Community Cancer Centers, ACCC. Huge organization is the immediate past president of COA. And, more important to me as a coauthor, he has written a brilliant book that I think everybody out there should get called between life and death. It's a beautiful set of stories about his relationship with patients, and all oncology teams should, should read this. Great book club book for that. But that's not why we're here today. We're here for a much more important topic than patient doctor interaction. We're here to talk about money and in specific, the RVU. He and I are both giving up maybe one or two RVUs right now to be here with you guys.

https://betweenlifeanddeath.org/

[00:10:31] Dr. Patel, let me first welcome you, but jump right in. You know, what is an RVU? Why was it created? Let's get into the weeds of this a bit.

[00:10:43] Kashyap Patel, MD: First of all, it's my honor to be Speaking with you, John, I think you're a big personality.

[00:10:48] You have name all over the world. And my first memory goes back to when we meet at the Ballantyne Hotel back in 2002, when you came and spoke on colorectal cancer as an expert. I remember that. So, I'm so honored to be here with you.

[00:11:01] And coming back to our core point here, the RVU, Relative Value Unit, It's actually one of the methods that CMS has organized to identify a way to compensate physicians, and it looks into the training time. For example, if you're oncologist in primary care, it also looks into something called GPCI, which is geographical practice cost index. It has a lot of inbuilt adjustments within that. And so, it's a way to define the time that a doctor spends, the overhead cost for the practice, and other logistical expenses. And then what would be that cost plus physician time be combined together, and how does the American Medical Association CPT Committee and CMS decide together. And it also applies to not just the patient, it also applies to procedure as well.

[00:11:58] John Marshall, MD: So, would you and I actually get different RVUs? I'm in Washington, you’re in the Carolinas. Would you, would we have differences or we're the same?

[00:12:07] Kashyap Patel, MD: No, we are different. So, so they, they adjusted with something called GIPC, which is Geographical Practice Costing Index. And they make adjustments based on the cost of living, based on the cost of hiring employees, and the cost of the rent . So, it's adjusted based on where you practice. You may be having highest RVU when you're in New York, and the lowest when you're in Alabama, like South Carolina, because CMS perceives that the cost of running business is low there.

[00:12:33] John Marshall, MD: And so, but then we've got the differences between like, orthopedic surgeons who are making 10,000 RVUs a year, and we oncologists who average somewhere around, you know, 4,000, 5,000, depending on what kind of practice you have, some more, some less. Is that because we're different busyness or we get different credit for what we do?

[00:12:55] Kashyap Patel, MD: So, it's very interesting. The RVUs forcing patients is one thing, but if an orthopedic surgeon does a procedure where they do surgical procedure, there's an RVU tied to that as well. Now the big limitation is that going back to like 20 years back, when technology was not so much evolved, we didn't have robotic surgery.

[00:13:15] If you had a procedure that, you know, somebody did surgery and spent four hours, technology evolved, time become very efficient. The same thing could be done in one hour, but RVUs still four times. So that's a discrepancy there itself, that with the evolution of the time and technology, the RVUs lag behind adjustment. That's why you're somebody said this may be getting paid 10,000 hours for the RVU versus us probably 4,000.

[00:13:43] John Marshall, MD: So, you think that it's a good system? Do you think in general, it's a fair way of giving credit where credit is due? Because I remember the good old days when you got a salary. Right. You just got this much money. You might get bonused if you were really busy or there was some sort of extra way to make money here or there, but this really does credit you for the individual part of your role in the health care system, you know, one patient, one doctor encounter versus your role as a sort of leader and organizer of a practice. Do you think it's a pretty fair way to do things?

[00:14:22] Kashyap Patel, MD: I think at the beginning of the career, it may be pretty fair way to do that, but then people like me and you, we spend a lot of time outside seeing patients. For example, you teach so many students, you do so much research, you publish so many papers, and it doesn't come free.

[00:14:38] I mean, you give up something. time that you can never reproduce. Unfortunately, the CMS as well as AMA committee that looks at RVU has not factored in the length of experience, the type of experience, and the administrative time. So to a certain extent, people who go beyond their call of duty of seeing patients, doing research, bring new technology in particularly into the medicines, elective specialties.

[00:15:08] We may be treated unfairly because the time spent in teaching research or experience is not factored in into the compensation. So it's almost like if you started your career with a fresh MD from the same school at the same hospital, John Marshall will still be within the same money that he started making, but your MBA colleague becomes CEO and he probably will get 50 times more than what you get.

[00:15:32] John Marshall, MD: Well, we went through this, right? So, we went from this salaried, you know, differed by rank here at the medical center, you know, different rank, you made different money, um, to where everybody essentially got the same pay, whether you were right out of residency, or if you were a 30-year senior physician, and so it normalized that. And there was a lot of initial pushback on that, of course, is that you don't get any credit for your seniority, as you mentioned, your experience. But also, as you get older, you have more duties, and, so, our docs are now pushing back and saying, well, if this is how you're going to pay me, then that committee I'm on or whatever else I need to be doing to keep a practice and a hospital going, you need to credit me for that. And I think that part of our compensation hasn't caught up. Do you think that's right?

[00:16:24] Kashyap Patel, MD: That's absolutely right. I think they need to factor in the extra clinical duties that you do other being a part of the committee or part of the NCCN coming to write guidelines for part of the ASCO committees. All of this should be factored in within the legitimate kind of time frame to ensure that people who want to give back in a different way are not disincentivized.

[00:16:46] And let me tell you one more thing here, John, that, for example, seeing a patient after 20 years’ experience and make a clinical decision is a lot different than seeing a patient right out of college. So, there's definitely a wisdom to aging and maybe, you know, people like us with gray hair and wrinkles. But I do feel that RVUs should factor in that element, even in the clinical side as well, in addition to the extra clinical duties.

[00:17:12] John Marshall, MD: Yeah, I think there are a lot of places around the world that do acknowledge that expertise. And, you know, there might be a base healthcare system for everybody and then kind of a premium healthcare system for those with more experience out there.

[00:17:27] And so, again, we don't, right now, we don't, everybody's treated the same, uh, in most of our healthcare systems. And I do think RVUs seem to be the dominant way it is done, although there are still Those that have kind of a more traditional thing, let's look at it from the health care system because I know you're big into that too on that side.

[00:17:48] You understand that part of it. Is it fair from the health care system? There's some people come to me and say they're making money on us. Because what they're paying us, they're making more money in revenue than what we're doing. So in fact, we're not being credited for that back in the day when people owned their practices, they could pay themselves what their practice could make.

[00:18:11] And so do you think that's fair under an RVU model?

[00:18:16] Kashyap Patel, MD: No, I think you're right. Because once again, I think, you know, the RVU probably ends up in people work hard to earn some bonuses based on RVU, but then RVU produces more and more revenue for the health systems, which unfortunately ends up going into the administrative costs without having a lot of other kind of rewards to the person who does it. So, I feel that it's important to have a base as an RVU, but then they should, they should evolve. From my perspective, RVU space has failed to evolve to keep up with the changes of the time. And if you don't change with time, you may become like a dinosaur.

[00:18:57] John Marshall, MD: Last sort of point about this that I want to bring out and then whatever you want to share is that, you know, when you're driven by these RVUs, you don't take a Friday afternoon off anymore to go to a meeting or to go to a CME event or, um, or frankly go play nine holes of golf and clear your head because you're driven to see more patients.

[00:19:20] And so I worry a lot about our sort of mental health, both emotional, social health, but also our education and keeping up because we're so driven by these RVUs. Are you feeling that happening?

[00:19:35] Kashyap Patel, MD: I do feel because, you know, we experience compassion fatigue when you deal with the patient over and over again. And if you don't have time to take a break, to attend a meeting, shake hands with people who know something may be better than what I know, or maybe, you know, take some time off to unwind. It's only going to make mental health crisis worse. I think we are in the perfect storm between the post COVID recovery phase, between the RVU world, and between the push to do more and more and more without getting time. I think we are entering into a whole different era of healthcare delivery systems.

[00:20:10] John Marshall, MD: I can't thank you enough for joining me today. I hope everybody listening appreciates it. I think it's you and me and people like us that need to keep this conversation going so that we allow this system to evolve to take care of some of the issues that you and I brought together. So, thanks very much for joining.

[00:20:29] Kashyap Patel, MD: Thank you very much, my friend. I look forward to learning more from you, my brother.

[00:20:33] John Marshall, MD: And both of us back to clinic so we can stay down for the long haul.

[00:20:36] Kashyap Patel, MD: Get some RVUs.

[00:20:38] John Marshall, MD: So that's a wrap. Oncology update, John Marshall, May 22, 2024, a week ahead of ASCO. I hope this has been useful and I hope these insights and our world of oncology will make us all better so one day we indeed will find the cure for all cancers.