EP403: The Mix & Match With the How Doctors Get Paid, With Rachel Reid, MD, MS

Health systems increasingly get paid through value-based or capitated contracts — but the individual physicians actually seeing patients inside those systems are still, more often than not, paid the old-fashioned way: fee-for-service RVUs with a thin layer of quality bonuses on top. In this episode, Stacey Richter talks with Rachel Reid, MD, MS, a physician policy researcher at RAND Corporation and primary care physician at Brigham and Women's Hospital, about a study she co-authored looking at exactly how U.S. health systems compensate and incentivize their physicians — and the five reasons that misalignment persists even when everyone agrees it's a problem. WHAT YOU'LL LEARN ✅ Why most physicians — including PCPs — are still paid primarily on RVU-based productivity, even when the health system employing them is being paid through value-based or capitated contracts ✅ The five reasons Dr. Reid identifies for why physician compensation models rarely change to match how the organization itself gets paid: insufficient payment size, a fee-for-service "chassis" already baked into most value arrangements, the difficulty and risk of overhauling comp models, plain inertia, and lack of consensus on what to actually incent ✅ Why misaligned compensation is a real driver of physician moral injury — wanting to do right by a patient but not getting paid, or getting in trouble, for doing so ✅ How this plays out for self-insured employers specifically: a plan can pay a health system a value-based or capitated rate for a "medical home," while the PCPs actually seeing members are paid fee-for-service underneath that arrangement, with the difference pocketed upstream ✅ What Dr. Reid recommends plan sponsors actually do about it: write physician compensation expectations directly into the contract, rather than assuming a value-based payment to the organization trickles down to the doctor WHY THIS MATTERS "There's no current gold standard for how to pay doctors," Dr. Reid says — which means the industry is left guessing at both halves of the equation: what counts as high-value care, and how to actually pay for it. Until physician compensation is explicitly tied to the same goals a health system's own contract is being paid to achieve, plan sponsors buying "value-based care" or a "medical home" risk paying for an outcome the doctor on the other end has no financial reason to deliver. MENTIONED IN THIS EPISODE Study: "Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems" (JAMA Health Forum) EP295 with Rebecca Etz, PhD: Apple Podcasts | Spotify | Other Apps === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction. 08:11 Why Dr. Reid decided to do the study in the first place. 09:49 What are the main foundations of what doctors are paid on? 10:31 Why is value-based compensation still just the "icing" on the cake? 13:08 What is the biggest value add for doctors, and does it vary between specialties? 14:32 Why wouldn't a physician organization change their comp models? 19:55 Are we at a moment of evolution? 20:20 "Tying dollars to measured quality gaps doesn't necessarily produce results." 22:04 "I don't think there's a current gold standard for how to pay doctors." 25:37 Job one: What are we trying to incent? 31:28 From the payer or insurer perspective, what's the leverage they have to change doctor compensation?