PHysician Compensation

[PrincessFiona]

This is sort of an interesting topic that has been blowing through our house for the last few months.

There is a national trend going on that is a bit of a backlash against the radiologists and surgeons, etc....they call it RVUs here...I don't know if that is what it is called everywhere?

But many of the non-surgical/non-procedural specialists are up in arms because (and no offense to the radiology people here, btw!) they say that they spend 45 minutes with a complicated medical patient and are limited in their ability to bill...while a procedural specialist might spend half that time and bill 3 times as much. Example, as an ID doc, Thomas went in at 12.30am and saw a young woman who was in the ICU. He was in the ICU/at the hospital for 1.5 hours doing an indepth exam/consultation and determining the right course of treatment. For that, he would have been able to bill (if she had had insurance) a couple hundred dollars. Certainly nothing to snear at...BUT..then he has his radiology buddies who brag about spending under 5 minutes on a chest x-ray and billing $70 a pop.

In any case...this whole RVU system has been creeping around the country and is finally landing here.....RVUs basically mean that you are able to bill by patient complexity. If you have a patient with multiple medical problems that requires more time and a more complicated work-up, you are able to bill for that. If you see a regular check-up (for example) you would be able to bill less.

This is good news for specialists, but bad news for generalists...particularly pediatricians who are already swamped.

On the one hand, I can certainly understand the backlash....it takes less time to stitch a wound, for example, than to examine someone/begin treatment for systemic meningitis...but if you stitch, you get paid. Procedure=$. It even encourages doctors to spend an adequate amount of time with their very sick patients because they will be compensated. The problem, however, is that healthcare dollars are limited....and it means that people in specialties like family practice and peds that are already seeing lower incomes will struggle even more.

In the hospital practice that Thomas is in, the docs are salaried by specialty...regardless of the income that they bring in. So...some of these guys would be motivated to step things up again and pull their weight...but it brings up a real moral dilemna.

How do you compensate physicians appropriately so that all physicians are compensated adequately for seeing/treating their patients without creating a system where the patient becomes a commodity? It seems to me that there are inherent flaws in the system as it is right now...billing for procedures= unnecessary procedures/surgeries, etc., excessive compensation for some specialties and turns patients into money-making machines.....billing for complexity of patients might mean more 'iffy' diagnoses and lower salaries for general practice specialties unless they start churning out a patient every 5 minutes....

Anyone have any thoughts?

kris

This is a very interesting topic. Don has gotten many job offers from Emergency departments who pay based on RVU's. They tell him the physicians currently make a certain amount but that is not guaranteed. For Don that was just a little too scary. Of course the ER is always unpredictable. We have seen the smaller community hospitals turning to RVU reimbursement as the volumes tend to be on the lower side, therefore, less patients= less compensation. If they did this at his current place of employment, being a Level 1 trauma center, we would be swimming in it!! Boy wouldn't that be nice? As it is his group pays an hourly wage and sets a shift. If he is scheduled to work 8a-6p he's paid for 10 hours and not a minute more even though he might be there for an extra couple of hours wraping up the patients he has.

[Rapunzel]

I've never heard of it and quite frankly I don't want to know much about medical billing :P My understanding of the radiology side of things, however, is that very little can get done without the radiologist. Jon tells me that call for him consists of a loooong line of physicians waiting to ask him a)what's wrong with their patient and b)how does he recommend they be treated. The radiologists basically see themselves as the brains in the basement of the entire hospital operation. So, I don't know nothing about no billin' but I do know that radiologists feel they are compensated on par with their importance in the grand scheme of things - take that for what it's worth (and it's not necessarily my personal opinion on things - I don't feel I know enough to even have an opinion, just my observations). :P

Of course, to throw it all into perspective: We have very, very good friends who came over for dinner last night and they pointed out that my husband makes more as an active duty physician in a civilian sponsored residency than the husband of the duo will make as a police officer. Made me think....

[PrincessFiona]

compensation

My understanding of the radiology side of things, however, is that very little can get done without the radiologist. Jon tells me that call for him consists of a loooong line of physicians waiting to ask him a)what's wrong with their patient and b)how does he recommend they be treated. The radiologists basically see themselves as the brains in the basement of the entire hospital operation.

Jon cracks me up...actually, doctors crack me up in general...because I can just hear the responses of our dear spouses:

the surgeon: Ack...just let an Internist (surgeon literally spits out the word as if it is evil) try and 'cure' a patient...I mean, we all know that surgeons are the only ones that can 'cure' illnesses...said as sugeon hands off latest surgical 'victim' to despised internist to have blood sugar stabilized, blood pressure monitored, and infection properly treated.

The internist: Sure, the surgeon 'thinks' he's all that...but if it wasn't for us managing these patients medically and taking all of the time to diagnose and properly manage their out of control diabetes, lung disease, infections, etc then said patient wouldn't even make it to the operating table for miraculous (said with a gasp and a roll of the eyes) 'cure'. And besides, the internist adds...being a surgeon doesn't require any actual thinking..it's like being a ...mechanic...you can train a monkey to do a procedure

ID Physician (Just have to throw this one in): Yah...well..the surgeons and internists 'think' that they know how to treat infections...which is why I'm called to the ICU in the middle of the night for septic hips after surgery...yawn....ID is the most..intellectual field You have to really think..and come up with the answers that no one else could. (yawn)

All together: Sure, the radiologist can 'read' an x-ray, but 1/2 the time they just list the myriad of possible differential diagnoses that could exist to cover their butts just in case....and hey....try and get them to treat a patient....

Of course, we all know what the truth is...Internist suspects a problem he needs help with and consults ID doc who suspects a particular illness after a workup/history and knowledge of specific infectious illnesses, sets up appt with radiologist for MRI (or whatever) to prove/disprove diagnosis, begins treatment and sends patient off to see the surgeon to have further work done when necessary...Team Work!

Medical snobbery...will it ever end At the end of the day, every specialty has a long line of docs waiting to find out what's wrong with their patients...

kris

PS...this was meant to be humorous, and of no offense to any single specialty. If your specialty isn't in there, feel free to add on to the responses I think its' a hoot to hear them all talk!

[Rapunzel]

Isn't there a joke about this somewhere? :P

[Cumberland]

RVU

Maybe I missed it- but what does RVU stand for?

This is reminding me of the joke about who is in charge of the body.....maybe GI is the most critical specialty?

By the way, I mentioned this to Eric....and he said that a dermatologist is not the most needed specialist and that he's pretty happy about that! Which would probably start the debate of what the "best" specialty is.... But he did throw in that derms get to take care of the biggest and best-looking organ (depending on what is wrong with it, I would guess!).

[houseelf]

Kris,

I know that you and I don't see eye to eye on this, but I think that this whole RVU thing is a slippery slope. While you may think that my view stems from the fact that I'm the wife of the surgeon (i.e. procedure intensive= $$$), my thougths are actually grounded more in ethics. While it certainly seems fair for the powers-that-be to apportion more salary or bonuses based on patient volume or hours worked or the physician who is really keeping the hospital afloat, RVUs sound eerily like "billable hours" and drive through medicine.

I know a pediatrician whose practice told her to think as her examining room as a "revenue generating room" and to always think about the most profitable way to bill each patient. Each month, the practice delivers charts which plot all of the pediatricians on a graph in terms of who is generating the most income. In other words, if she spends time reassuring a first time mom or taking time to console one of her reticint patients, this generates no income for the practice. Is this the group that any of us really want to send our children to? In another example, dh spent an hour this weekend with the mother and father of an eighteen year old patient. He held the mother's hand and told them that their eighteen year old daughter was brain dead, she felt no pain, and explained the process of organ donation as an option. In my mind, these "non-revenue generating practices" are the highest forms of practicing medicine.

I *really* don't mean to start a debate (coward that I am). I do realize that the system is fundamentally flawed as it is now. Certain people are overcompensated (especially the HMO administrators) and others are undercompensated (nonprocedure docs). But let's not scrap one system to make a change for the worse.

Kelly

[PrincessFiona]

RVU discussion

I don't know that our views are far apart, Kelly...and I'm open to the debate/discussion. I think that there is a real problem with the RVU system (though I understand it is nation-wide now). Though RVUs themselves do not cause docs to see more and more patients...they actually take more time with their complicated cases and are compensated for it.....it affects specialties like FP and Peds that see relatively healthy patients....and results in overbilling and that drive-thru patient mentality. If you can't bill for a more complicated consult then you have to see more patients...For the doctor seeing more complicated cases, the RVUs mean that they can spend more time with each patient.

On the other hand, should specialties that see more complicated patients or do more complicated procedures earn more than specialties like FP/Peds that tend to do well-people check-ups? How much more should a specialist earn commensurate with their training and the additional time in the hospital that they spend?

I have to say that here the FPs don't see their patients in the hospital...they refer them to the hospitalists...and they tend to not take call on their patients...ie working 9-5...maybe they shouldn't be earning as much as they are? Their salaries are only $20k apart from their internist colleagues who round every day in the hospitals and take call regularly.....How do we define fair compensation? Should a surgeon who had to go in and operate at night when he's on call earn more than a family practitioner or pediatrician even if it means that to earn a good salary the fp or ped docs have to see more and more patients? At the end of the day, it often is the patient that suffers...and yet I don't see the surgeons out there saying "hey...cut my salary by 20% so those health care dollars can go to the generalists who can't see as many patients" And after the investment financially and the lifestyle issues, I can't imagine that you would be willing to hear that either.

I wonder what the solutions is...to me it seems only fair that they scrap RVUs AND that they also reevaluate the salaries earned for procedures....There is no excuse, for examaple for a 15 minute GI procedure to net a $1500 bill to the doc....know what I mean?

For Alex's teeth, the anesthesiologist billed nearly $5000!!! For an HOUR! I'm all for compensation...but where and how do we draw the line.

On the other hand, are we willing to embrace an almost communist economic policy in terms of our healthcare dollars...ie...all docs earn the same or close to the same to make sure that the dollars are spread out most equitably amongst all specialties?

Debate is exactly what should be happening. How do we fairly compensate all physicians...not just those who happen to do a procedure? And how do we do it in such a way that the patient does not become a commodity?

kris

Sort of off the subject....I just read that pediatricians are receiving recommendations to check the BMI of children as well as to educate on the proper fit of bike helmets. I think both of these are very important to kids' health and well-being....but that just seems to add that many more items to a well-child visit. It doesn't sound like RVUs would account for that as a well child would not be a complicated patient (depending on how they behave during the exam!).

I do think there is justification for salary difference between physicians based on level of training -- a IM doctor who does a fellowship in a sub-specialty should get paid more, IMO, and same for other sub-specialties.

Not an easy problem to solve though.

[PrincessFiona]

salaries...

OK...so here's one for the books:

60% Nuc Med/ PET Imaging
Perform 60% Nuc Med / PET Imaging and 40% body work. No Mammo No IR. Several outpatient centers and no hospitals, therefore, no call!

Typical day is 8:30/9:00 to 5:00. You'll perform 6-7 PET cases per day. Digital system allows scans to come in from other locations for you to get all the Nuc Med. Strong Collegial Group of 35 Radiologists.

Starting compensation is $300,000 to $350,000 and 1 year to partnership. Compensation as a partner is in excess of $600,000.

Benefits include: 7 weeks vacation; 2 weeks for CME; $5,000 stipend; full health, medical dental, optical, disability & life; tax shelters & Pension plans; salary deferral plans, too.

To apply for this position, or for more details, send your CV to XXXXXXX.

It must be nice...but how do we justify this? Maybe the problem isn't with RVUs and paying specialists for their time...maybe it is with positions like this? Nice for the radiologists and their families...but not for the pediatricians and family practitioners..I mean come on!....600K/yr? 300k to start??? 9-frickin' 5?

I read job ads like this and it really gets my goat...there is no justification for that kind of salary for reading 6 PETs a day..there isn't...reading a PET scan is just as important to the health of a patient and diagnosis of illness as analyzing a complicated set of a pathology data (pathologist), testing blood and reading cultures/starting the right therapies (ID)..and we're talking going in at 12.30am, not 9-5 , operating on an accident victim in the middle of the night (surgery), treating a complicated diabetic patient (endocrinologist). How the hell do you come up with 600k for reading 6 PET scans a day?

The problem is that for fair change to happen that would be beneficial to the patients, some specialists would simply have to take a pay cut...and that will never happen..so I think the patient will continue to be the commodity and the doctors will continue to fight over the healthcare dollars. I can understand now after reading this why one of the hospitalists is leaving to do a new residency in Radiology. After 2 eyars in practice he said "I'm as smart as them, I work harder, and I earn less..." He applied and is going to Rochester in July....

Sad that it all ends up being about money.


:!

alright...rant over

kris



PS..sorry Jennifer

[Rapunzel]

Oh boy, I really, really hope that job is still around when Jon gets done serving his time in the Air Force! :P

Seriously, though, I think that radiology has brilliantly engineered their specialty to maximize profits while the nature of the specialty minimizes time.

For example of the former (maximizing profits) there is tight reign kept on how many radiology residents are chosen in the match. Radiology keeps those numbers down and I see no desire in the literature Jon receives for that trend to change. Fewer radiologists see more cases - get more compensation.

Which leads to the next thing: The nature of the specialty minimizes time. Radiologists can easily read many, many films in a day and can control (once they are done with residency and in practice) exactly how many cases they want to read everyday. We know of radiologists that choose to focus on making a ton of money and work themselves like dogs. We also know radiologists that decide to take it slow and work less in order to "smell the roses" in life - but, of course, get less compensation. Radiologists are different than clinicians in that they do not "see" patients - they read films and cases. Their jobs are quite different than the average clinicians in that they have so much more control over their own use of time as well as their schedules.

As another example of these extreme differences: Call for many radiologists is now home-call in a literal sense. They read films from a professional-level (expensive) computer screen on their own computers. So, we know radiologists who have brought in extra income by taking call while on vacation - because they can sit on a beach and read films at the same time. You simply cannot do that as a Family Practitioner. Of course, the radiologist vacationing and also taking call is compensated for his services. The nature of the specialty lends itself to being a money-making one with ultimate control over one's schedule.

So, I don't know that comparing the compensation of a radiologist to a surgeon or an internal medicine specialist is very accurate because of these fundamental differences.

Jennifer

[Rapunzel]

From Jon:

"The thing to realize in all of this is that the technology itself is very expensive. Equipment to process requests, equipment to take the images, equipment to retrieve images, archive images, transcription costs, paying the technologists (and their benefits), high liability insurance (especially for mammography), and paying the salaries of the highly-specialized physicians for example."

Thus the tools of a radiologist are incredibly expensive - some of the most expensive tools in the medical world, in fact, and must be paid for. This is part of the answer to higher costs of compensation for radiology. Jon added:

"Not everyone can be a radiologist and sit in a dark room all day with little patient, let alone, people interaction."


Here's a quote that Jon really loves and insisted I share:


The diagnostic radiologist is a clinician who has sacrificed one of the greatest glories of the practice of medicine and its greatest responsibility - the daily contact with the ill and their families - in order to concentrate more on the essence of our profession, the pathology of the living. This he sees through the medium of shadows which has left him open to the charge of not quite being a real clinician.
But shadows, after all, are real. What are we to one another and what is the world to any of us but an inverted image on the retina? Seeing is done with the mind. The camera does not see; it records. The radiologist perceived the shadow, sees a lesion, and imagines the man. The bedside physician sees the man, perceives the signs and imagines the lesion. They practice from the outside in and we from the inside out. Both are clinicians for in truth there is no other kind of doctor worthy of the name. The decisive test for all is finally and always the bedside. This, then, is one concept of the radiologist - with a film on the viewbox but the bedside in his mind.


Harry Z Mellins, MD
Professor of Radiology
Harvard Medical School
Former Program Director
Residency Program
Department of Radiology,
Brigham and Women's Hospita

Jennifer

Here's a quote that Jon really loves and insisted I share:

[b]The diagnostic radiologist is a clinician who has sacrificed one of the greatest glories of the practice of medicine and its greatest responsibility - the daily contact with the ill and their families - in order to concentrate more on the essence of our profession, the pathology of the living.

Some of the radiology folk we know see this as a huge plus (not having to see patients) -- not a sacrifice!

[Rapunzel]

Here's a quote that Jon really loves and insisted I share:

[b]The diagnostic radiologist is a clinician who has sacrificed one of the greatest glories of the practice of medicine and its greatest responsibility - the daily contact with the ill and their families - in order to concentrate more on the essence of our profession, the pathology of the living.

Some of the radiology folk we know see this as a huge plus (not having to see patients) -- not a sacrifice!

Very true - but the sacrifice is being seen as not "real" doctors by other specialists and generalists.