A patient with newly diagnosed stomach cancer understandably had immediate questions about his health and future. He was concerned that he may never be able to eat food again due to the cancer, which was now so large it obstructed the entrance to his stomach.
He was trying to appear strong, but I could tell he was scared as he understood he was nearing the end of his life.
As the palliative care physician caring for him, I discussed with him his options for medical care such as considering a feeding tube and transferring to a rehabilitation facility versus going home with hospice care and significant family support.
“What does a feeding tube look like?” he asked. “Will my insurance cover it? Will my family be able to afford time off work to care for me if I choose to go home?”
He had many questions; I knew he would benefit from discussing them further with me. I also knew he was concerned about hospital costs and my visits with him may increase those costs.
Of course I wanted to help, but I also knew that seeing this patient again could financially benefit me depending on where I work. I wondered if personal physician financial incentives could unconsciously influence my decision to see patients like him again.
I am not alone in this concern.
It is an ages-old quantity vs. quality debate, but with lives in the balance.
To be sure, RVUs are an important measure of physician work and expertise. However, these units alone do not account for the true quality and value of care physicians provide to patients.
For measurement of RVUs to be the most frequent financial incentives method for physicians is wrong. Incentives based on these units can and will increase patient costs, as physicians will be incentivized to see more patients, potentially even those without true medical indications for their physician care, instead of focusing solely on improving patient health and outcomes. This structure leads some physicians to intentionally see patients who medically do not need to be seen.
Incentivizing RVUs also may lead to abuse of medical trainees, who may be instructed to see more patients than is beneficial for learning, which financially benefits their attending physicians.
What’s more, this incentive system negatively impacts the value of care physicians can provide. For example, as palliative medicine physicians, we often must spend significant time with each patient to build trust that allows patients and families to discuss life and death decisions with us.
Incentivizing palliative medicine specialists to spend less time with each individual patient so they can see more patients negatively affects the relationships and the care we can provide these patients.
For the patient with stomach cancer, I know I made the right decision by seeing him again, but I continue to feel guilt that, depending on where I work, I may financially profit from visits like these which increase patient hospital costs. My goal was to improve his quality of care, not to increase the number of patients I saw that day.
But as long as RVUs remain a predominant structure of financial incentives for physicians in the United States, physicians will experience this same conflict between wanting to provide high quality patient care and being financially incentivized to see more patients.
It is immoral to allow this conflict to occur. If physician financial incentives are to exist, they should promote quality and value in patient care. Individual hospitals and medical groups should be prohibited from choosing physician incentive measures which prioritize volume of patients seen over quality of care.
Quality over quantity must be the driving force in medical care.