Many physicians believe the work relative value units, or wRVU, model was built for a different era — one that didn’t account for burnout, cognitive work, care coordination or the slow erosion of clinical judgment that comes from optimizing for volume over value.
Nine physician leaders joined Becker’s to discuss how compensation models should evolve to balance productivity with sustainability. The answers ranged from hybrid base-plus-outcomes structures to a fundamental rethinking of what the current system is actually rewarding.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: How should compensation models change to balance productivity and physician wellbeing?
Richard Chazal, MD. Medical Director at Lee Health Heart Institute (Fort Myers, Fla.): Most current clinician reimbursement models are focused on wRVUs/volume. While this approach supports time spent and hard work, such programs are weighted heavily toward procedures … and inadequately addresses quality and cognitive work, particularly related to prevention. While measurement of quality is an evolving science with substantial gaps, an increasing number of measurements is available in many fields.
The need to migrate toward prevention of disease rather than focusing principally on treatment of disease, for both medical and fiscal reasons, necessitates a reevaluation of reimbursement models that fail to properly reward/incentivize clinician efforts. Some institutions are utilizing hybrid reimbursement models that continue to have an element of volume/time measurement, while increasingly weighing quality metrics. The incorporation of base salary can be utilized to provide practitioners with more appropriate reimbursement for patient interactions and counseling by reducing the “volume pressure.” Providing physicians with compensation packages that fairly reward quality of care and all efforts toward improving patient well-being is a strong step toward improved physician well-being.
Matt Cronin. Founder and CEO at Somnus Technologies (Denver): The RVU-heavy model sends a clear message that volume equals value, and that takes a toll. I’d like to see a blended approach that still rewards clinical effort but also accounts for outcomes, mentorship, care coordination, and protected non-clinical time. The goal isn’t to remove productivity incentives — it’s to stop penalizing the things that sustain a physician over a full career, not just a quarter.
Triwanna Fisher-Wikoff, MD. Family Medicine Physician at Texas Health Care (Fort Worth): I would like to see compensation models evolve to better reflect the true value of primary care and restore a sense of humanity to physician work. Strong primary care improves quality, reduces mortality and lowers healthcare costs, yet many physicians are expected to deliver complex care within short visits while completing significant administrative work that is often uncompensated.
Future models should recognize the full scope of physician responsibilities, including care coordination, patient communication and documentation, and ensure that team-based care expectations are supported by realistic staffing and workload capacity. Additionally, physicians should not be financially penalized for factors outside their control, such as patient non-adherence, particularly when patient autonomy and access to care options have been addressed.
Ultimately, compensation models must balance productivity with sustainability by valuing physician time, supporting care teams, and aligning incentives with outcomes physicians can reasonably influence.
Michael Gagnon. Founder and CEO of the Academic Orthopaedic Consortium and Chief Administrative Officer- Emeritus at Duke University Orthopaedics (Durham, N.C.): I can best answer this from the perspective of someone who has spent a career in academic medicine, including leadership roles at Harvard and Duke, and through my work with academic orthopaedic departments nationally.
Academic orthopaedic compensation models are fundamentally different from private practice because they depend on multiple revenue streams beyond clinical income. These models require meaningful funds flow from hospitals, health systems and schools of medicine to sustain the tripartite mission of clinical care, education, and research.
The challenge is that clinical reimbursement continues to decline year over year, while the cost structure of academic departments remains high due to teaching and research obligations. This creates increasing pressure to tie compensation more directly to productivity, often at the expense of physician wellbeing and academic engagement.
To move forward, compensation models must evolve in two important ways:
- Rebalance incentives so that productivity is one component, but not the dominant one, alongside meaningful recognition of teaching, research, and leadership contributions.
- Strengthen institutional support, particularly from health systems that rely heavily on orthopaedics as a primary economic engine.
Orthopaedics is a major driver of health system revenue through procedural volume and downstream ancillary services. As health systems continue to expand and manage orthopaedics as a strategic service line, they must take a more active role in financially supporting academic departments, not just covering deficits, but making proactive investments.
This includes:
- Sharing in ancillary revenue streams such as DME, imaging and ASCs
- Structuring co-management or gainsharing models
- Supporting growth through aligned investments in surgeons, APPs, and infrastructure
Ultimately, the future model should be more entrepreneurial and aligned, with shared risk and shared reward between academic departments and health systems. This is essential not only for financial sustainability, but also for preserving physician wellbeing by reducing over-reliance on pure productivity metrics.
Brandon Ortega, MD. Orthopaedic Spine Surgeon at Long Beach (Calif.) Lakewood Orthopaedic Institute: The wRVU model served a purpose, but it was designed for a different era of medicine. As it stands, it systematically undervalues cognitive work, penalizes surgeons who pursue less invasive or motion-preserving procedures over higher-volume, simpler cases and creates perverse incentives that can quietly erode clinical judgment. I’d like to see a hybrid model emerge, one that weights outcomes, patient-reported outcomes and implant stewardship alongside productivity. Compensation should reward surgeons for choosing the “right” operation, not just the next one. Tying a meaningful portion of compensation to quality metrics, peer benchmarking and long-term patient outcomes would begin to realign incentives with what actually constitutes good medicine. Physician wellbeing follows naturally when clinicians feel their judgment is both respected and rewarded.
Mukesh Sharma, MD. General and Interventional Nephrologist at Sierra Nevada Nephrology Consultants (Reno): I would love to see the payors shift from the antiquated “fee for service” model toward “value and quality-based service” model. The fee-for-service model is the root cause forcing practices and providers to see more and more patients in the same allotted time causing burn-out and frustration both for the patient and providers. Moving towards a payor model that values quality more than quantity and incentivizes value savings may serve as a catalyst for shared savings and lowering the overall costs for the entire U.S. healthcare industry.
Fred Watkins. Plastic Surgeon at Inova Fairfax Hospital (Rockville, Md.): All physicians should be paid the same for the same outpatient visit. RVUs should be the same. Eliminate the time factor.
Example: Board-certified family medicine physician gets $132 for skin screening exam and cryotherapy of benign lesions but dermatologist gets almost $500 for same visit due to getting more RVU’s. But, the dermatologist does not check blood pressure or any vital signs and does not screen for any other medical conditions or review list of current medications or review any need for recommended health screening procedures.
Example: Cardiologist in Riverside, Calif., states on every patient note that he spent 40 or more minutes with every patient to pad billing, since he sees 24 patients a day that means he spent 24 x 0.67 hours = 16 hours seeing patients. But, he is only in his office 8 hours/day. Time spent on statements leads to massive fraud.
Example: Family medicine physician obtains shoulder X-ray and performs intra-articular steroid injection and receives $173, but orthopod performing exact same visit is paid $421 based on RVU’s.
David Weiner, MD. Assistant Professor of Orthopedic Surgery at MedStar Health (Columbia, Md.): As productivity-focused models expand, it’s crucial to strike a balance between appropriate surgeon compensation and a sustainable workforce. Our ability to rapidly advance the medical field and lead the world in quality care hinges on recruiting the most qualified applicants. Unfortunately, dwindling reimbursements have a significant impact on this. Some potential solutions include increasing Medicare reimbursement rates, solidifying the legislation around arbitration models for collection-based physicians and imposing financial penalties on commercial payers for denying appropriate care. These measures would help alleviate the administrative burden of providing care, increase average reimbursement and reduce burnout rates.
Aqib Zehri, MD. Neurosurgeon at The Oregon Clinic (Portland): I think physician pay needs to become more balanced. Right now, many models focus too much on volume alone. That pushes doctors to see more patients, do more cases and keep working at a pace that is hard to sustain over time. From a finance perspective, that may look good in the short term, but it can create bigger problems later. Burnout, turnover, poor morale and rushed decision making are all costly.
A better model would include three things. First, a solid base salary that gives physicians some stability. Second, incentive pay for productivity, because work output still matters. Third, extra recognition for things that also create value, like good outcomes, taking care of complex patients, improving efficiency, helping grow a service line, and being a strong team member.
If we want doctors to stay productive and healthy over the long run, compensation has to reward more than just speed and volume.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
