Read the Full Video Transcript

Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and today I'm really excited to be joined by Dr. Logan Briggs from the Mayo Clinic in Arizona. He'll be chatting with us about some work that he recently published in Urology Practice on urologic practice work RVU-related productivity. Thanks, Dr. Briggs.
Logan Briggs: Thanks again, Dr. Talwar, for having me. It's an honor to be here today with UroToday. I'm a PGY2 at Mayo Clinic, and today I'll be talking about this project that we did on productivity in urologic practice. It's about to be published in the Gold Journal of Urology, and we're excited to talk about it a little bit today.

We decided to look at this topic because everyone is interested in how to increase productivity in urologic practice, how to be more efficient, but there are limited data on which physician and practice factors are associated with increased productivity.

So, work-relative value units, or RVUs, they account for relative skill, complexity, and time required to complete a service. And they're the most commonly used metric to estimate physician productivity. So this study aims to evaluate what factors are associated with urologic RVU productivity. To do this, we performed a retrospective review of the CMS database from 2017 to 2018. We chose those years because they were the two years right before COVID and we didn't want COVID to impact the results. But we extracted provider and patient demographics as well as procedural and service details, and then performed adjusted and unadjusted linear mixed models to predict RVU production.

Our analysis included just over 6,700 urologists, 91% of whom were male, though there were higher percentages of females in the younger generations, kind of reflecting increased interest in the female gender going into urology, which is great.

And then here is the breakdown by specialty. We found overall that Baby Boomers generated the most Medicare RVUs, with 4,200 over the study period, followed by Gen X with about 4,000, then Post-War urologists with 2,600, and then last but not least, Millennials with 2,230. And these differences were statistically significant.

We found, as one would probably predict, that years in practice was the most powerful predictor of productivity, following a bell-shaped curve over time. Starting from graduation from medical school, peaking at about 34 years in practice, and then downtrending towards retirement. Other interesting predictors of productivity on adjusted analysis included subspecialization in FPMRS, men's health, and oncology, male gender, and practicing in zip codes where patients are less educated and less impoverished.

In conclusion, practice experience is the strongest predictor of urologist productivity, peaking 20 to 35 years after graduation from med school. And we feel that further work is needed to incorporate quality metrics into RVUs and ensure that patient demographics do not affect or predict reimbursement.

Ruchika Talwar: Thank you, Dr. Briggs. Really interesting work. There's been a lot of focus on how RVUs actually do play into how urologists get paid. Oftentimes in the majority of fee-for-service type contracts, they are the biggest factor in salary negotiations, et cetera. So I think this work is important just to understand what RVU productivity targets potentially could be, although obviously we're looking just at Medicare here.

But tell me a little bit about your thoughts. Were there any findings that surprised you? Anything that perhaps you predicted?

Logan Briggs: Yeah, I think that doing this project kind of gave me a lot of... I hadn't done a real deep analysis of RVU productivity or much in the Medicare space, but I thought it was interesting how... I kind of started looking at the flaws of the RVU system and how it's a great system, it's the best system we have so far, but whether it means to or not, it kind of incentivizes the quantity of services.

For the most part, the RVU system I think is pretty fair, giving higher RVUs to longer cases, like radical cystectomy with ileal conduit I think has 46 RVUs. That's the most RVUs you can get, compared to a bladder biopsy which is two. And as urologists, that kind of intuitively makes sense. There are certain things like ESWL that generate probably more RVUs than you would expect compared to a ureteroscopy.

And then I think some of that stuff, those issues will go away as we transition to more value-based care, bundled care payments, et cetera. So I think that'll be interesting to see how practice patterns change.

Ruchika Talwar: Absolutely. I think the biggest flaw with the RVU system is that it really is a zero-sum game. Specifically in urology, as new technologies emerge and we seek reimbursement for them, those RVUs have to be coming from somewhere. And so that's when we see... When ESWL was a new technology and people advocated for its inclusion, perhaps maybe that's why we saw a lot of RVUs associated with that. And they had to come from somewhere, so you can imagine that things like bladder biopsy and other really common procedures would be decreased.

And I totally agree with you. I think as Medicare specifically pushes towards value-based care payment programs, it'll be really interesting to see how the RVU system adapts to that. You still need some way of measuring care complexity, case complexity, and volume, but I think that we're really going to see a shift here. That's why I think these analyses are really helpful to try to figure out based on 2017, 2018 data where we were and where we have to be.

Just tell me a little bit about your thoughts on the fact that male gender was associated with higher productivity. I think you touched on this in that there is some sampling bias there in that there just weren't as many females available in your data, but I'm curious to hear potentially how you think that'll shift over time.

Logan Briggs: Yeah. Yeah, absolutely. That's a great question. Definitely sample size I think has something to do with it. When we saw this result, we actually brought in Sima Porten from UCSF to collaborate with us, because she had published a paper previously on work hours in urology and found initially that females worked fewer hours, but after accounting for specialization, where they practice, and whether they perform inpatient procedures, those differences went away.

And so, in our adjusted analysis, we actually incorporated this. We went back and incorporated the same things that she did, and most of the difference went away. There was still some residual effect there, and we kind of ascribed that to a few things that we kind of searched the literature for, and found that one, males have been shown to actually upcode more often than females. So they may be kind of upcoding or billing more RVUs than females, even if they're doing the same amount.

And then this kind of goes back to the value-based care. There has been some data to show that female providers have better outcomes, improved survival for... This is the inpatient stays, is where a lot of this data came from. And they spend more time with the patient. So as we transition, which might... So that's kind of higher value care. Spending more time with the patient, getting better outcomes in the long run, as opposed to just kind of churning through patients and getting them through. So I think some of those differences could go away with value-based care too.

Ruchika Talwar: Yeah, yeah. Absolutely. Well, thank you Dr. Briggs for joining us. Really interesting study. We appreciate you sharing your findings with the UroToday community.

Logan Briggs: Thank you for having me. Again, it was an honor to be here. And congrats again on your new position at Vanderbilt.

Ruchika Talwar: Thank you. Thank you so much. And to our audience, thanks for joining. We'll see you next time.