Implementation of Relative Value Unit-Based Physician Compensation in Emergency Physicians: Operational Evidence From...

We study the effects of changing from hourly-based to relative value unit (RVU)-based clinician compensation models on billing intensity, productivity, and several secondary outcomes.

We used data from general emergency departments (EDs) from January 2019 to December 2024. Primary outcomes were site-level RVUs per patient, patients per hour (PPH), and left without being seen rates. Secondary outcomes included staffing patterns (physician and advanced practice provider hours), operational efficiency (length of stay for discharged patients, admission rates), clinician satisfaction (net promoter score, clinician attrition rates), patient safety (72-hour returns with admission), computed tomography usage rates, and percentage of visits for which critical care was billed. We used 2-way fixed effects and 2 staggered difference-in-difference models to assess outcomes in sites that changed from an hourly to an RVU model compared with those remaining hourly. Covariates included indicators of patient acuity, boarding hours, ED volume, and payor mix.

The sample included 167 EDs and 2,191 site-quarters of data. Changing to RVU-based compensation had no significant effect on RVUs per patient, PPH, or left without being seen rates. Advanced practice provider hours increased relative to physician hours in some models. A transition to RVU-based compensation was not associated with changes in other secondary outcomes.

Changing from hourly to RVU-based compensation was not associated with measurable changes in billing intensity, productivity, or secondary outcomes of clinician hours, clinician satisfaction, operational quality, or efficiency.