In medicine, when something isn’t working, we tend to fix it. Whether it’s a treatment plan that isn’t delivering results or a clinical process that’s creating inefficiencies, we identify the problem, adjust the approach, and find a better solution. But when it comes to the RVU (relative value unit) system—the very framework that dictates how physicians are compensated—we seem to be stuck. Despite growing evidence of its flaws, its inherent biases, and the fact that health care costs are rising while outcomes are stagnating or worsening, we’ve done little to fix the system.
At the heart of the issue lies the relative value scale update committee (RUC), the body responsible for assigning value to different medical services through the RVU system. This committee is composed of well-meaning professionals, but its structure disproportionately favors high-revenue procedures and specialties, employed hospital-based physicians, while it lessens input from critical areas of care—like primary care, mental health, and chronic disease management—the undervalued and under-compensated. As a result, the RVU system incentivizes revenue and volume over the very outcomes health care is meant to achieve.
Yet despite these clear shortcomings, the RVU system remains largely unchanged. Costs continue to rise, physician burnout worsens, and the system’s focus on revenue generation pulls us further away from the true goals of health care—the quadruple aim: improving population health, enhancing the patient experience, reducing costs, and supporting provider well-being.
So, the question is: Is it time to do away with the RUC and the RVU system altogether? If we truly want to build a health care system that rewards value over volume, better outcomes over more procedures, and long-term health over short-term revenue, we must ask ourselves if the current system is still serving us. Or is it time for a bold transformation that aligns incentives with the results we actually want to achieve?
1. A historical perspective: How the RVU system created salary disparities
When the RVU system was introduced in 1992, its goal was to establish a more equitable way to reimburse physicians based on the complexity and time involved in providing medical services. At its core, the RVU system was meant to reflect the “relative value” of different medical services, with the idea that physicians performing more complex or resource-intensive procedures would be reimbursed at a higher rate. However, over time, the system has disproportionately rewarded procedural specialties at the expense of cognitive and primary care services.
The changing landscape of physician salaries
Since the inception of the RVU system, physician salaries have diverged dramatically. Proceduralists—such as surgeons, cardiologists, and radiologists—have seen significant salary increases, while primary care physicians and those in specialties focused on cognitive services (e.g., psychiatry, internal medicine) have experienced relatively stagnant growth.
Specialist salaries on the rise
According to data from the Medical Group Management Association (MGMA) and other salary surveys, procedural specialists’ salaries have consistently risen over the past three decades. For instance, in 1991, general surgeons earned an average of about $143,000 annually, but by 2023, that figure had ballooned to over $400,000. Similarly, orthopedic surgeons, cardiologists, and radiologists routinely command salaries well above $500,000 per year. This reflects the RVU system’s emphasis on high-revenue-generating procedures like surgeries, diagnostic imaging, and interventions, which carry high RVU assignments.
Primary care: stagnant compensation
In stark contrast, primary care physicians—who provide ongoing, longitudinal care, manage chronic diseases, and offer preventive services—have seen only modest increases in salary. Family medicine doctors, for instance, earned an average of $108,000 in 1991, compared to roughly $250,000 today. While this growth is notable, it has not kept pace with inflation or with the rising costs of medical education and practice. More importantly, it pales in comparison to the salary growth seen by procedural specialists. The RVU system undervalues the critical work of primary care providers, offering far fewer RVUs for services that require time, expertise, and relationship-building with patients but don’t generate the same short-term revenue as procedures.
Why it’s about revenue, not value
The disparity in physician salaries highlights a fundamental flaw in the RVU system: it equates value with revenue generation, not patient outcomes or the broader benefits of holistic, preventive care. This revenue-centric model has led to a significant income gap between those who perform high-paying procedures and those who focus on primary care, mental health, and chronic disease management. The system not only fails to reward these essential services, but it actively discourages physicians from entering these fields, exacerbating workforce shortages in critical areas of care.
2. The consequences: physician burnout and the decline of the quadruple aim
The salary disparities created by the RVU system have far-reaching implications beyond income inequality. The emphasis on revenue generation over value has also contributed to rising levels of physician burnout, particularly among primary care providers who must see more patients to compensate for lower RVU reimbursements. Burnout has become so prevalent that it now threatens the very viability of the health care system.
Burnout: the human cost of the RVU system
Physician burnout, characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, has reached epidemic levels in the U.S. health care system. The RVU model plays a significant role in this crisis by incentivizing volume over quality, forcing physicians to churn through patients to meet productivity quotas. According to a 2022 Medscape report, over 50 percent of physicians report feeling burned out, with primary care physicians, internists, and emergency medicine doctors being among the hardest hit.
Primary care: the strain of undercompensation
Primary care physicians, who are already undercompensated relative to their specialist counterparts, face intense pressure to increase their patient volume to meet RVU targets. This results in shorter appointments, less time for meaningful patient interactions, and a growing sense of frustration. Many physicians feel like they are being forced to choose between providing high-quality care and meeting RVU quotas. This constant balancing act between patient care and productivity is unsustainable and directly contributes to the high rates of burnout in the field.
Specialists: overworked and under pressure
Even specialists who benefit from high RVU reimbursements are not immune to the pressures of the system. The demand to produce more RVUs means that proceduralists are also working longer hours, performing more surgeries, and managing more cases to maintain their income levels. While their salaries may be higher, their work-life balance is often equally strained, contributing to burnout across the board.
The shift away from the quadruple aim
Burnout and income disparity are symptomatic of a larger shift in health care: the move away from the quadruple aim’s patient-centered focus toward an RVU-centric, fee-for-service model that prioritizes volume and revenue over care quality. Instead of improving population health, enhancing the patient experience, and reducing costs, the system is incentivizing physicians to perform more procedures and see more patients in less time—all in pursuit of higher RVU generation.
3. Moving toward true value: Developing the OVU and OVC?
To address these disparities, reduce burnout, and realign health care with the quadruple aim, we must fundamentally restructure the system, starting with the RVU framework and the RUC. The current relative value unit (RVU) system is misaligned with the goals of health care; it rewards activities based on revenue generation rather than real health improvements.
The solution is a complete transformation—one that replaces RVUs with outcome-based value units (OVUs) and rethinks the RUC as the outcome-based value committee (OVC). These changes would shift the focus toward rewarding services that lead to better health outcomes, improving the patient experience, and reducing long-term costs, while also supporting physician well-being.
Balanced representation
The OVC should include a more equitable balance of primary care physicians, specialists, private practice and employed physicians, and both academic and full-time clinicians. This broader representation would ensure that decisions about OVUs reflect the full spectrum of medical practice, not just high-revenue procedures. In addition, it would help align incentives across a wide variety of medical fields, making specialties that have historically been undercompensated—such as geriatrics, family medicine, and mental health—more attractive to future physicians.
Revising OVU assignments
OVUs should be assigned to place greater value on the time-intensive, cognitive, and relationship-based care that is essential to improving population health. Services like chronic disease management, mental health care, and preventive services must be rewarded in line with their long-term benefits to patients and the health care system. A shift away from procedural dominance would encourage a more balanced physician workforce, reducing the shortages in undercompensated specialties that are critical to achieving better outcomes.
Incentivizing value over volume
Finally, we must move away from fee-for-service models that reward volume and instead adopt value models that prioritize outcomes. This could involve expanding the use of population health, continual improvement, and metrics that incentivize and align physician compensation with patient outcomes, not the number of procedures performed. By restructuring how OVUs are assigned and shifting toward value models, we can ensure that physicians are rewarded for the long-term health outcomes of their patients, not just the quantity of services delivered. This shift would not only encourage more thoughtful, patient-centered care but also reduce unnecessary procedures and overutilization, driving down costs while improving patient and physician satisfaction and overall health outcomes.
Conclusion: a call for outcome-based value
The RVU system, and the structure of the RUC, has contributed to wide disparities in physician salaries, contributed to rising levels of burnout, and pushed the health care system further away from the quadruple aim. Instead of promoting true value in health care, it has turned medicine into a volume-driven business where revenue generation trumps patient care. If we are to move toward a system that values health, wellness, and care quality, we must reform both the RUC and the RVU system to reflect these priorities.
By transitioning from the outdated RVU system to outcome-based value units (OVUs) and empowering an outcome-based value committee (OVC) to oversee this shift, we can realign physician compensation with meaningful health outcomes, not just procedural volume or revenue generation. This new structure would reward physicians and health care organizations based on their ability to improve patient health, reduce long-term costs, and enhance the patient experience—all while addressing the root causes of physician burnout.
The time for reform is now. Incremental changes won’t be enough to solve the systemic problems that the current RVU model has created. To achieve the quadruple aim, we need bold, systemic transformation that places value where it truly belongs: on better health outcomes for patients, sustainable costs, and the well-being of health care providers. With outcome-based value units and a restructured outcome-based value committee, we can build a health care system that rewards what truly matters—better care, better health, and a brighter future for all.
Mick Connors is a pediatric emergency physician.
