There is something strangely captivating about the RVU (relative value unit) system in medicine. It’s as if it has become our own “precious”—a golden ring that offers power and financial viability, yet comes at a great cost. Just like the One Ring in Tolkien’s The Lord of the Rings, the RVU system exerts a powerful, almost mesmerizing hold on the medical profession. It promises us control—of our practices, our autonomy, our livelihoods. But, like the One Ring, it is also deeply flawed and corrupting. It is both our source of power and our burden, pulling us further away from what truly matters in health care.
Despite the rising costs of health care, worsening patient outcomes, and alarming levels of physician burnout, many doctors are still desperately defending the RVU system. Physicians are the biggest resistance to changing this system and spend tons of time asking the government for incremental tweaks to increase payment rather than questioning the very structure that has gotten us here. We cling to our “precious,” believing that if only the government could legislate higher payments and we all could get paid more per RVU, everything would be better. But is this really true? Why are we so attached to a system that clearly isn’t working? And why can’t we see the ways in which others—from for-profit companies to health care disruptors—have adapted, while we continue to ask for external solutions?
The RVU’s power: What makes it so precious?
The One Ring in Tolkien’s world was forged to control, to corrupt, and ultimately to dominate those who wielded it. In much the same way, the RVU system was initially created to bring order—to standardize reimbursement based on the complexity and effort required for medical services. Over time, however, it has morphed into something far more powerful, dictating nearly every aspect of how we practice medicine. The RVU has become our golden ring—something that feels impossible to give up, despite the toll it takes.
A false sense of security: The RVU offers a form of power, allowing physicians to track productivity, justify reimbursement, and create a predictable framework for financial survival. But like the power offered by the One Ring, this sense of control is deceptive. In chasing RVUs, physicians often lose sight of what really matters—patient care, meaningful outcomes, and the joy of practicing medicine. The RVU system measures value in terms of volume and procedural complexity, not in terms of the health and well-being of our patients.
A reluctance to let go: Just as Gollum in The Lord of the Rings is obsessed with the Ring, calling it “My precious,” many of us in health care have become unwilling to imagine a world without RVUs. We hold onto this system because it is what we know—it’s comfortable, it’s predictable, and it offers a sense of legitimacy. Asking for legislative fixes or higher reimbursement rates is akin to Frodo and the Fellowship trying to use the Ring for good, believing they can wield it without being corrupted. But the truth is that the Ring—like the RVU system—was never meant to serve our true purposes. It was designed with different priorities, and its power over us prevents us from embracing real change.
The quest for legislative solutions: Are we the Fellowship or are we Gollum?
In The Lord of the Rings, the Fellowship sets out with the intention of destroying the Ring because they understand that, despite its allure, its power cannot be used for good. In contrast, many physicians today are trying to wield the RVU system for their own benefit, seeking legislative solutions to increase RVU values and boost reimbursement, all while health care costs rise, outcomes decline, and burnout becomes widespread.
The government as our fixer: Rather than throwing the Ring into Mount Doom, many physicians instead hope that legislation can make the RVU system work in their favor. The idea is that if the government would just mandate higher reimbursements or adjust how RVUs are calculated, then all the problems in health care would be solved. But much like the Ring, the RVU system corrupts—it prioritizes volume, short-term gains, and procedural care over long-term outcomes, prevention, and patient-centered approaches. Adjusting the reimbursement rates without addressing the deeper issues will only perpetuate the same cycle of misaligned incentives and unsustainable practices.
For-profit companies as the new power brokers: Meanwhile, an entire cast of other players—private equity firms, telehealth startups, insurers, and retail health care clinics—have adapted, thrived, and taken advantage of the RVU system without waiting for legislative intervention. They have mastered how to leverage RVUs to create efficient, profitable models. Telehealth companies are using RVU billing to rapidly expand access, insurers are exploiting RVU codes to negotiate favorable contracts, and private equity-backed management firms are setting up shop to maximize the profitability of physician practices by offering diluted care.
These companies are thriving while physicians are struggling. And unlike physicians, they are not asking for government help—they are adapting, evolving, and finding ways to use the existing system to their advantage. It begs the question: Are we as a profession acting more like Gollum—clinging to “My precious”—instead of acknowledging that perhaps we need to let go and seek a fundamentally different approach?
The courage to let go: Finding a new path
If the RVU system is our One Ring, then the real question becomes: Do we have the courage to let it go? Can we, as a profession, envision a health care system that doesn’t revolve around productivity metrics but instead rewards the outcomes we want to see—better health, lower costs, enhanced patient experiences, and improved well-being for providers?
Redefining value: The call for outcome-based care. Instead of asking for higher RVU reimbursements, what if we questioned whether RVUs are the right metric at all? What if we moved towards something akin to an outcome-based value unit (OVU) that incentivizes true health improvements rather than the number of procedures completed? We need a new definition of value in health care—one that measures success by how well we keep patients healthy, how effectively we reduce the need for expensive interventions, and how well we create an environment where physicians can thrive rather than burn out.
Physicians as leaders of change: In Tolkien’s world, it took an unlikely group of heroes—the Hobbit-led Fellowship Team—to make the decision to destroy the Ring and rid Middle-earth of its corrupting influence. Likewise, it may take a collective movement within the medical community led by primary care to let go of our attachment to RVUs and pursue a system that is better for patients and providers alike. We need to stop waiting for the government to solve this problem and start recognizing our own power to drive change. We must redefine what autonomy means, embrace outcome-based care, and take control of the future of our profession.
Conclusion: It’s time to let go of “My precious”
The RVU system, much like Tolkien’s One Ring, holds a powerful sway over the medical profession. It has become “My precious,” something we cling to out of habit, fear, and a belief that it offers security. But its power is illusory—it has corrupted the way we measure success in health care, driving us away from the outcomes we truly care about and into a cycle of rising costs, declining quality, and burnout.
The path forward requires courage. We must let go of the RVU, stop looking for legislative solutions to patch a broken system, and instead embrace the opportunity to create something new. Physicians are uniquely positioned to lead this change, but only if we are willing to stop defending the golden ring that binds us to a flawed model of care. It’s time to leave “My precious” behind and build a health care system that reflects the values we hold as healers—caring for our patients, improving health, and ensuring a sustainable, fulfilling future for ourselves and those who follow us.
Mick Connors is a pediatric emergency physician.
