Neonatology's race to the bottom: RVUs, cFTEs, and physician time

The clinical productivity of neonatology divisions is often defined as relative value units (RVUs) produced per clinical full-time equivalent physicians (cFTEs). Based on the realities of neonatology clinical billing, commonly daily bundled charges, and one cFTE defined as a fixed number of clinical hours per year, the RVU:cFTE ratio will inevitably be proportional to the number of NICU patients per physician clinical hour. As a result, increasing productivity defined as the RVU:cFTE ratio, a commonly incentivized goal in neonatology, requires decreasing physician time per patient. As neonatology groups seek to surpass RVU:cFTE benchmarks based upon productivity of peer institutions, they end up in a "race to the bottom," each striving to spend less time per patient than their peers. This definition of physician productivity fails to consider the importance of time itself as an essential "product" provided by physicians, and can undermine the clinical mission and quality of care.