Let’s Shift How Palliative Care Teams are Measured and Valued

This post makes the case that Relative Value Units (RVUs) are not the most appropriate method for measuring the impact of the work of palliative care teams. And yet, the reality is that today, many palliative care programs are evaluated (at least in part) based on RVU targets. To better understand how to work within the world of RVUs, even as we advocate to change it, reference Lynn Spragens and Allison Silvers’ article from March 2023.

Relative Value Units, or RVUs, are the currency by which payers measure health care work. RVUs exist to try to compare—relatively of course—the effort and cost of performing a 12-level spinal fusion, a 35-minute inpatient visit for heart failure management, and a 5-minute outpatient nursing visit to check blood pressure. Historically, procedural work like surgeries, colonoscopies, and cardiac catheterizations has been (and continues to be) reimbursed significantly better than cognitive work like that done in palliative care. Until we invent the Pallioscope, we’re relegated to the land of the paupers and the cogitators.

It comes as no surprise to any of us that palliative care is a growing specialty. As our clinical and administrative workforce has increased, so too have the budgets needed to run adequately staffed palliative care programs. Now that palliative care programs number a dozen clinicians or more in some health systems, administrators have rightly been trying to understand and quantify teams’ return on investment. Working within their zones of expertise, many health system leaders ask for production benchmarks from their palliative care teams, and RVUs are familiar territory.

Let us consider two cases that should resonate with palliative care teams:

Case 1: A palliative care nurse practitioner visits a patient with cancer pain. He titrates the patient-controlled analgesia device and talks for 17 minutes about the patient’s goals, values, and preferences.

Case 2: A 35-year-old woman with two children under the age of six is actively dying of metastatic breast cancer. The palliative care team’s pharmacist visits for 30 minutes, making recommendations to the primary team to titrate opioids based on nonverbal signs of pain and grunting. She is also visited by the palliative care social worker, who spends two hours on a legacy project with thumbprints and recording the dying woman’s heartbeat for her children. The team’s chaplain sits for 90 minutes with the woman’s wife, unpacking the unfairness of the situation and reflecting on the abandonment she feels from God. The palliative care nurse offers 30 minutes of support to the tearful, newly-graduated RN tasked with caring for the dying woman while the child-life specialist spends 75 minutes with the family to help break the news to the children of their mother’s dying. Lastly, the team’s psychologist offers a lunch-hour debriefing for the floor staff, many of whom have come to love the woman and her family over the prior few months, and are grieving her upcoming death.

In a quote often misattributed to Einstein, it is said that “Everyone is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid.” In the first case above, the palliative care clinician will have spent around 35 minutes in total. This bread and butter visit by a palliative care provider is valued at 3.9 work RVUs, 2.4 for the high-level subsequent medical care, and 1.5 for the advance care planning. The second case, illustrating 6.75 hours of work by six clinicians with at least 30 years of collective post-high school education, is valued at 0 RVUs.

Due to unfortunate inequities in the Medicare fee structure, palliative medicine stands as a reimbursable service while true interdisciplinary palliative care does not. The work of colleagues in nursing, social work, spiritual care, pharmacy, and several other fields—work central to high-quality, patient-centered palliative care—is almost never reimbursed. If you measure the second palliative care team by its ability to climb the RVU tree, it will always fail.

As we struggle to respond to health system leaders, we wonder whether we are using the wrong unit of measure (the RVU) or whether we are asking the wrong question entirely. The request for productivity data measured in RVUs is really a request to show our value to systems, which must be good stewards of their ever-tighter dollars. Unfortunately, the benefits realized by health systems from palliative care involvement (fewer hospital admissions, avoided emergency department visits, shortened length of stay, fewer readmissions) all exist off the balance sheet. Arguments for the benefits of palliative care must be data-based but cannot be dollar-based. How do you count the unspent dollar?

Because we can’t measure much (or for some teams, most) of the work done using this currency, we urge the palliative care field to stop using RVUs to measure palliative care team productivity. While program-level data must be incorporated into presentations to leaders, patient stories like the one in Case 2 must also be highlighted to show the true value palliative care brings. In addition, our field must work together with all stakeholders to create ways to quantify and benchmark palliative care team productivity outside of RVUs. Initiatives like the Palliative Care Quality Collaborative (PCQC) and the American Academy of Hospice and Palliative Medicine (AAHPM)-led Palliative Care Measure Projects are showing the way to a future where we can tell a nuanced, data-informed story about the impact of team-based palliative care on the lives of individuals with serious illness, and their caregivers.

We must define our value and create our currency if we are to separate ourselves from the RVU. Many palliative care teams are valuable schools of busy fish; we must ensure that our absence from the forest canopy is not viewed as a reflection of our limited worth but of the genius of our ongoing, continuous, interdisciplinary, and high-impact swimming against suffering’s current.

• Optimizing Billing Practices, a billing and coding toolkit, which has been updated to reflect significant Medicare fee schedule changes that took effect January 1, 2023.
• Demonstrating Value to Stakeholders, a toolkit that can be used to learn about the evidence for the impact of palliative care on quality and costs in all care settings, and for downloading tools and templates for making the case.
• Everything You Always Wanted to Know about RVUs But Were Afraid to Ask, an article that explores the history and mechanics of RVUs to demystify and support constructive use.