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Abstract and Introduction
Abstract
Compensation models for physicians are currently based primarily on the work relative value unit (wRVU) that rewards productivity by work volume. The value-based payment structure soon to be ushered in by the Centers for Medicare and Medicaid Services rewards clinical quality and outcomes. This has prompted changes in wRVU value for certain services that will result in reduced payment for specialty procedures such as transplantation. To maintain a stable and competent workforce and achieve alignment between clinical activity, growth imperatives, and cost effectiveness, compensation of transplant physicians must evolve toward a matrix of measures beyond the procedure-based activity. This personal viewpoint proposes a redesign of transplant physician compensation plans to include the "virtual RVU" to recognize and reward meaningful clinical integration defined as hospital–physician commitment to specified and measurable metrics for current non-RVU-producing activities. Transplantation has been a leader in public outcomes reporting and is well suited to meet the challenges ahead that can only be overcome with a tight collaboration and alignment between surgeons, other physicians, support staff, and their respective institution and leadership.
Introduction
The healthcare landscape has been undergoing seismic shifts over the past decade and none more powerful than the passage of the Affordable Care Act (ACA). The events have resulted in dramatic changes in the relationship between physicians and payers and subsequently the manner in which physicians are compensated. The idea of a single or even a group of transplant physicians in independent practice appears soon to be a way of the past. Integration of the various components of the academic healthcare world now faces new challenges in creating compensations plans for physicians. An advantage of creating a single academic business that incorporates the medical school, hospital, and practice plan is that it can provide greater opportunity in determining fair and reliable compensation models for the transplant physician. The movement away from volume to quality as a major metric for compensation requires new alignments. Thus as the Centers for Medicare and Medicaid Services (CMS) transitions to a value-based payment structure that rewards clinical quality and outcomes, the question becomes when and how new compensation models for physicians will arise and become better aligned with value-oriented goals and systems. In the Midwest, two health systems have changed primary care compensation plans linking as much as 40% of physician payment to quality measures. Kaplan et al recommend that any new model move beyond "soft measures" to quantitative measures for quality as well as be budget neutral to the organization. Others have proposed an overhaul to the relative value unit (RVU) scale of which the work component (wRVU) is used to measure physician productivity.
In de-emphasizing volume-based productivity in favor of value-based performance, CMS must meet a budget-neutral imperative from Congress. This has prompted changes in wRVU value for certain services that will primarily reduce payment for specialty procedures to offset increased payment for cognitive clinical work in primary care. The American Society of Transplant Surgeons (ASTS) reported that more than 50% of 464 transplant surgeons responding to the 2013 compensation survey have RVU-based compensation and incentive plans and only 8% have compensation based on surgical outcomes. Transplant physicians and centers thus face decreased revenues and physician compensation under current plans even though the specialty is already highly regulated by CMS. Transplantation follows the quality assessment and performance improvement regulations for pre- and post-transplant care and reimbursement is now more commonly tied to bundled payments. Payers have often limited access to their transplant networks based on quality outcomes that have long been reported publicly, among other characteristics and agreements. However, there is no linkage between such quality outcomes or performance measures and payment models from providers.
To address the changes ahead, in this personal perspective editorial we propose that organ transplantation may be ideally suited to serve as a national model for redesign of specialty physician compensation plans.
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