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  • Writer's picturePaul DeChant MD, MBA

The Quadruple Threat: RVUs, administrivia, employment agreements, and burnout

Updated: May 29

We hear a lot about the Quadruple Aim – improving quality, patient experience, financial performance, and clinician wellbeing. Achieving all four simultaneously seems elusive at best.


I often talk of “flipping the ratio”. Studies have shown that PCPs spend about 1/3 of their time doing the meaningful work of direct patient care that we all trained for, and 2/3 of our time is wasted on meaningless administrivia.


With changes in technology, we are now at a point where can flip the ratio to 2/3 time on meaningful work and 1/3 on administrivia. We can do this by combining tech advances such as ambient listening and other AI approaches to reducing administrative tasks in the EHR with advanced process redesign to ensure teams are maximizing the benefits.


My question is, why aren’t more organizations investing in these approaches to counter the Quadruple Threat?

When I poll audiences during my keynote speeches, about 1/3 of physicians are still typing passwords, and less than five percent are using ambient technology.


Implementing these tech advances would be a win/win for physicians and senior leaders in healthcare provider organizations. Not only would it improve productivity, and therefore much-needed revenue, without overburdening physicians, this represents an opportunity for senior leaders and front-line physicians to align around mutual interests.


In most organizations, there is a significant disconnect and deep distrust between these key stakeholders. Physicians feel that administration does not respect them and is only interested in having them work harder to produce more revenue.


Administrators are frustrated by the financial impact of supporting employed physicians. Depending on the formula uses to assess financial impact, it may “cost” the health system up to $500,000 per physician to provide support, or may result in a net positive impact of $1,000,000 or more per physician.


One key factor in all this is the way health systems are paid by insurers and the government for employed physician work, and in turn, the way physicians are paid by the health system. Both depend on the number of Relative Value Units (RVUs) that are billed. Health systems are paid based on “total RVUs, while physicians are usually paid based on “work RVUs”, which are a component of the total RVUs.


The amount of physician compensation per wRVU is determined by a compensation formula. For most physicians, they find they need to work 60 – 80 hours per week in order to generate a high enough salary to support their families, pay off their med school debt, and save for the future.

All in all, this amounts to The Quadruple Threat - the combined impact of RVUs, administrivia, employment agreements, and burnout.


Senior leaders calculate the amount of RVU productivity needed from each physician in order to keep the hospital and clinic going financially (to keep the doors open and the lights on). These models indicate this need for high levels of physician productivity which drives burnout.

A Missed Opportunity


The thing is, with new technology and advanced workflow redesign, physicians could significantly increase their production while reducing the number of hours they work, achieving real work-life balance. And the increased productivity would provide increased health system revenues to improve financial performance. Think of it as "Organizational Resilience".


It’s a win/win for those forward-thinking health system leaders who pursue this. And it will give them a true competitive advantage over those systems that don’t understand this.


In many health systems the physicians are frustrated by the lack of investment in the support staff and systems they need. The health system not only sets physician compensation rates per wRVU, it also underinvests the resources available to the physicians to improve their production, due to a perceived lack of financial capacity to make the investments. This imbalance of power is one of the factors driving the trend in physician unionization.


To summarize:

·      The formulas to compensate health systems and physicians depend on RVU productivity.

·      There is a new opportunity to improve productivity while improving work-life balance for physicians by combining tech innovations and workflow redesign.

·      In many healthcare systems, administration is pushing physicians to produce more while not making the investments that would enable physicians to do so without burning out.

·      Those systems that understand this and make the investments to reduce wasteful administrivia will have a real competitive advantage, being able to recruit and retain the best physicians.


I’d love to hear what you think about this, whether you’re a practicing physician or a senior executive. Feel free to share your thoughts in the comments.


I’d welcome the opportunity to help senior executives and/or physicians who are ready to pursue significant change. You can schedule a call here.






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