ZDoggMD on RVUs: How Physician Pay Works and Why It's Destroying Physician Practice

This article discusses ideas from ZDoggMD — Dr. Zubin Damania, MD , Stanford/UCSF-trained internist, founder of the Health 3.0 movement. Full archive: zdoggmd.com | YouTube @zdoggmd

Most physicians are paid based on RVUs — relative value units — without fully understanding how the system works or what incentives it creates. ZDoggMD has explained the RVU model clearly and criticized it sharply: it's a productivity metric masquerading as a quality metric, and it's one of the core engines driving physician burnout.

What RVUs Actually Are

Every medical service — an office visit, a procedure, a consultation — is assigned a relative value unit by the Centers for Medicare and Medicaid Services. The RVU is composed of three components: physician work (the time, skill, and intensity of the service), practice expense (overhead costs), and malpractice expense. The physician work component is what employed physicians are typically measured and paid against.

A level 4 established patient visit (99214) generates more physician work RVUs than a level 3 (99213). A colonoscopy generates more than a primary care visit. A cardiac stent placement generates substantially more than six months of managing the patient's risk factors that might have prevented the stent from being necessary. The RVU system systematically undervalues cognitive work and overvalues procedural work — which is why primary care physicians earn dramatically less than proceduralists despite comparable training.

How RVU Targets Drive Burnout

When employed physicians are paid based on RVU production relative to targets, the incentive is volume. See more patients, generate more RVUs, earn more or avoid earning less. The 15-minute appointment isn't a patient care optimization — it's an RVU optimization. The physician who spends 45 minutes with a complex patient having a real conversation about their health is generating the same or fewer RVUs than three 15-minute visits.

ZDoggMD identifies RVU pressure as a direct driver of the documentation crisis: physicians who are running an RVU-optimized schedule have less time per patient, which means less time to chart during the visit, which means notes get pushed to after hours. The RVU system generates the documentation debt that becomes midnight charting.

What Would Replace It

ZDoggMD's Health 3.0 framework calls for value-based payment models that reward health outcomes rather than visit volume — capitated arrangements, shared savings programs, or direct primary care subscription models that remove the per-visit incentive entirely. None of these are simple to implement at scale. All of them point in a better direction than a system that pays for volume and calls it healthcare.

ZDoggMD on RVUs and physician payment models:

The RVU System Won't Change Tonight

But midnight charting can. NoPajamaTime eliminates the documentation debt that RVU-optimized schedules create. Notes done before the patient leaves — whatever your payment model.