RVU based salary

[j48seconds]

I wanted to ask all the psychiatry docs out there for some opinions about compensation models. Would you prefer a wRVU based compensation or a straight salary, especially when first starting out from residency? I can see the advantages to both, but having spent my residency getting a fixed salary, I'm nott as knowledeable about the wRVU model. There seems to be more uncertainty with it and I would want to make sure that I'm going to get my target income before picking that model.

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[cookymonster]

It totally depends on your salary and the number of patients you're expected to see, or conversely how much you're paid per RVU. However, all things being equal, I feel a lot more satisfied when I'm incentivized to work than incentivized to avoid it.

If you don't hit your target income on an RVU model, assuming you are getting compensated reasonably per RVU, you either need to see more patients, or improve your coding. I think that's easier to fix than the problems you could have with working on salary (getting hit with extra patients you aren't compensated for).

 

[j48seconds]

Do you ever feel pressured to see more patients to maintain a certain salary or has your salary been fairly stable over time. Also, with healthcare moving to value instead of volume models, would that negatively impact models based on rvus.

 

[WingedOx]

RVU minimums + no bonus for increased productivity makes WingedOx go work for someone else...

Though I looked at a private multispecialty group who had a deal where something like 70% of the income generated beyond your minimum requirement is bonus cash in your pocket (no public aid accepted). I considered it, but I still enjoy "saving the world" so I went somewhere else that will be salaried with not a whole lot less base income

 

[cookymonster]

Do you ever feel pressured to see more patients to maintain a certain salary or has your salary been fairly stable over time. Also, with healthcare moving to value instead of volume models, would that negatively impact models based on rvus.

Good questions. I'm in my first job, not even a year out of residency, so I've been growing into it. Now I'm trying to find ways to work less, as more and more of my income is taxed at 33%.

 

[heyjack70]

I like RVUs in the hospital because you are compensated if there is a lot more work, such as tons of consults on top of your regular inpatients. You don't resent the 5 extra consults that day. Though you may not want to stay until 7pm working, at least you are getting paid for the work you are doing. If it was salary you would be doing all of that for free. In the hospital there are no "no shows." The no shows in clinic are what make me hesitant to do RVUs there because you don't have control of someone not being at the appointment, and a no show often means phone calls or faxed rx refills that are not compensated. If I was going to do outpatient it would probably make more sense financially to just start or join a private practice group where you get your collections minus overhead. An employed position at Kaiser would be okay because I hear their retirement benefits are amazing.

 

[wolfvgang22]

I get paid a good set salary in the VA, but they still track my productivity using RVUs among other metrics such as time spent actually face to face with a patient. I do a lot of consults I'm not compensated extra for, its considered part of the base job. If no shows persist for a while they are going to want to renegotiate my salary next year, even though I don't get paid based on RVUs.
When I was in fellowship I had a faculty member attending get asked to resign due to poor RVU production, despite getting paid a set salary.

 

[Achillees]

Good questions. I'm in my first job, not even a year out of residency, so I've been growing into it. Now I'm trying to find ways to work less, as more and more of my income is taxed at 33%.

What would be the benefit of working less?
Pardon my ignorance.

 

[smalltownpsych]

What would be the benefit of working less?
Pardon my ignorance.

That's a good one. Which specialty are you going into? Surgery? I hear they work long hours. Some of the people in psych actually want to have a balanced life and that is one of the benefits. Of course, the infamous Vistaril who rarely posts anymore has this philosophy...

 

[Achillees]

That's hilarious.
You couldn't pay me enough to be a surgeon. I'm apply to Psychiatry. My question was in the context of his statement about 33% income taxes.

 

[Achillees]

That's a good one. Which specialty are you going into? Surgery? I hear they work long hours. Some of the people in psych actually want to have a balanced life and that is one of the benefits. Of course, the infamous Vistaril who rarely posts anymore has this philosophy...
View attachment 192638

That's hilarious.
You couldn't pay me enough to be a surgeon. I'm applying for Psychiatry. My question was in the context of his statement about 33% income taxes.

 

[WingedOx]

I get paid a good set salary in the VA, but they still track my productivity using RVUs among other metrics such as time spent actually face to face with a patient. I do a lot of consults I'm not compensated extra for, its considered part of the base job. If no shows persist for a while they are going to want to renegotiate my salary next year, even though I don't get paid based on RVUs.
When I was in fellowship I had a faculty member attending get asked to resign due to poor RVU production, despite getting paid a set salary.

How have you fared with the VA bonus system?

 

[WingedOx]

What would be the benefit of working less?
Pardon my ignorance.

Graduated income tax brackets do not work that way!

 

[smalltownpsych]

That's hilarious.
You couldn't pay me enough to be a surgeon. I'm apply to Psychiatry. My question was in the context of his statement about 33% income taxes.

Doh.
I actually wondered what he meant about that statement as well. My thought was "real estate".

 

[cookymonster]

What would be the benefit of working less?
Pardon my ignorance.

I'm extremely fortunate in that I got out of med school with minimal debt. I also moonlit a lot during residency. So it feels really weird to slow down, and I'm still learning how to do it after plowing through college, med school, and residency with zero time off in between, but I'm definitely at the point where time is more valuable than additional income.

$189,00 is the threshold for 33% federal income taxes. A third of any income over that goes to the federal government (excluding what goes to your state). If you make over $200,000, you also pay higher capital gains taxes.

http://www.efile.com/tax-service/tax-calculator/tax-brackets/

Also, this is a worthwhile read:
http://whitecoatinvestor.com/14-reasons-why-you-shouldn’t-retire-early/

Bottom line, unless you have a lot of debt or other expenses to worry about you're better off deferring income and enjoying your free time while you can.

 

[wolfvgang22]

How have you fared with the VA bonus system?

No problems so far.

 

[Achillees]

I'm extremely fortunate in that I got out of med school with minimal debt. I also moonlit a lot during residency. So it feels really weird to slow down, and I'm still learning how to do it after plowing through college, med school, and residency with zero time off in between, but I'm definitely at the point where time is more valuable than additional income.

$189,00 is the threshold for 33% federal income taxes. A third of any income over that goes to the federal government (excluding what goes to your state). If you make over $200,000, you also pay higher capital gains taxes.

http://www.efile.com/tax-service/tax-calculator/tax-brackets/

Also, this is a worthwhile read:
http://whitecoatinvestor.com/14-reasons-why-you-shouldn’t-retire-early/

Bottom line, unless you have a lot of debt or other expenses to worry about you're better off deferring income and enjoying your free time while you can.

Ah, thanks for responding.
I didn't need more reasons to value my time over more money, but you've given me another.
How much student loans are you in the hole for, if you don't mind me asking? I'm a 3rd year projected to graduate with just under 250K. I'd made up an arbitrary idea where I need to make at least my principal yearly. I'm unsure exactly how easier it is, relatively, to pay off while making less.

 

[Achillees]

Graduated income tax brackets do not work that way!

Please enlighten us.

 

[Merovinge]

Please enlighten us.

Graduated tax brackets are created specifically to not disincentive hitting a higher bracket and thus make less take home. Only the money you make past a point, in this case 180k ish is at the 33%, the first 180k don't magically jump to that number. This difference is being heavily overstated here as the bracket below is 28%, so you are "only" getting paid 67% instead of 73%.

 

[cookymonster]

Ah, thanks for responding.
I didn't need more reasons to value my time over more money, but you've given me another.
How much student loans are you in the hole for, if you don't mind me asking? I'm a 3rd year projected to graduate with just under 250K. I'd made up an arbitrary idea where I need to make at least my principal yearly. I'm unsure exactly how easier it is, relatively, to pay off while making less.

I paid off my student loan debt not far into intern year. I took it because it was interest-free for six months. So I don't have a lot of helpful advice about paying them off. I hate debt, however, so given that the interest rates from loans are higher than the differences in tax rates between tax brackets (in most states), if I had a lot of loan debt, it would probably incentivize me to work more than taxes would deter me. I would still maximize all the retirement tax breaks I had available and then use the remaining free money to pay off the loans.

 

[WingedOx]

Please enlighten us.

I actually understand Cooky's point better after he clarified it. I only about 20% agree with it, but I understand it better.

But right or wrong, it's never a bad time to post a Futurama pic.

 

[cookymonster]

After doing my taxes on paper for the last three years, and doing them for three states in 2014, I can assure everyone I fundamentally understand how our progressive income tax system works. I'm well aware that you don't lose take-home pay as you move to a higher bracket, but that doesn't mean higher marginal rates don't deter you more from doing more marginal work. Especially when the alternative is to work longer, get taxed at a lower marginal rate, and have more years to contribute to tax-advantaged retirement accounts. Once you have your loans paid off, I'd say doing the minimum to save for retirement, maintain comfortable lifestyle, and still get full-time benefits is the way to go.

 

[WingedOx]

Especially when the alternative is to work longer, get taxed at a lower marginal rate, and have more years to contribute to tax-advantaged retirement accounts.

Like I said, I appreciate what you're saying but I'm not sure that's exactly a zero-sum alternative. I'm certainly making a mild sacrifice on salary to have a better lifestyle myself, but for those who want it, having additional cash on hand early in the career to let grow through investments can be worthwhile, especially if you're at the part of your life where you're not popping out kids yet. The opportunity to slow down and work longer will always be there... we're psychiatrists after all.

 

[honsano]

Wanted to bump an old thread.

Anyone know of the average $$$ reimbursement per wRVU in the midwest? Is there a website or some resource to consult for this? Also, without adding a salary onto it, do you guys think 4600 wRVUs is reasonable at about 90% full time for outpatient work?

 

[heyjack70]

Wanted to bump an old thread.

Anyone know of the average $$$ reimbursement per wRVU in the midwest? Is there a website or some resource to consult for this? Also, without adding a salary onto it, do you guys think 4600 wRVUs is reasonable at about 90% full time for outpatient work?

I think 4600 RVUs is a full time job. Many psychiatrists certainly see more but that's a solid year. There are two income survey companies that publish books with physician income by RVU number and $$ broken down by region and specialty. MGMA and AMGA. I'm not sure what the difference is if any. The books are expensive but I've heard a graduating class might pool money to buy a copy to help with job negotiations. Also your residency hospital might have a copy you could look at.

 

[Jester25]

4600 sounds very high to me.

 

[chicagochildpsych]

I work hard and do about 1000 rvu a month, it depends on how hard you can work.

 

[heyjack70]

If you're in a place with good ancillary support, e.g. social work and therapists doing significant amounts of phone calls, gathering collateral, creating discharge plans, etc, you can revert to very basic "medication management" you can generate many more RVUs. In this setting it almost seems like the patient belongs to the unit and the team of RNs, MD, and social workers are carrying the responsibility for the patient. The problem with it to me is the MD is the one who is really in charge and I don't know how you can really know what's going on with 16-20 inpatients a day. .

 

[chicagochildpsych]

In our residency we saw 17 inpatients by noon (notes done), and often admitted 12+ on night float (as unsupervised interns) and covered 50+ people on the floor. I was trained to handle real work, it sucked at the time, but now I know how to provide expert care and delegate nonsense beurocracy.

 

[heyjack70]

I've seen doctors who work that fast and it's not good psychiatry. No offense to you specifically Chicago because I don't work with you, but I'm skeptical. The doctors I've seen are efficient but they miss a lot by not talking more with the patients.

 

[honsano]

Yeah I know on an inpatient setting 4700 can be done. I mean you only just saw the person the day before and often the people are lined up for you.

My thing will be outpatient with limited inpatient work (maybe 10 to 20%). That makes a bit more difficult to generate similar RVUs even with the psychotherapy add-ons because you are dealing with things like no shows.

 

[chicagochildpsych]

The people who fly in from thousands of miles away to see me at my office may disagree that I'm not practicing good psychiatry. I work in a facility where collateral is gathered by a psyD before I get there, every single one of my patients gets weekly psychotherapy from a psyD/phD, and I handle ECT, meds, tms etc. it's a novel approach where people get better and have wrap around services. But you don't have to like my style, the great salary combined with living in civilization is enough for me.

 

[heyjack70]

It's not about not liking your "style." I dig how much money you're making. How many patients do you see a day and how much time on average do you spend with each followup and intake? That's where the rubber meets the road. If people are flying 1000 miles to see you I assume you're at a tertiary referral hospital where people think they're getting better care, your hospital/clinic has significant branding and claims to offer something it really doesn't, you're at some type of Amen-like clinic where people are being duped out of their cash, or some other niche setting. Otherwise I can't imagine why anyone would fly a thousand (or "thousands" of miles like you said implying multiples of a thousand) miles to see a psychiatrist.

 

[chicagochildpsych]

I see about 25-30 patients a day, work at least 6 days a week, I am at a tertiary referral center that treats school anxiety, autismeating disorders, self injury, and also has a research division. We are an affiliate of rush university, northwestern, and Loyola. Also the 6th largest provider of mental health in America. And since I had a patient fly in from Europe yesterday, I do believe that qualifies as thousands of miles. I know the idea that a guy that works hard (12-14 hours a day) may actually have clinical acumen and marketability is tough, I assure you that it is possible.

 

[heyjack70]

So you're not generating a lot of RVUs by working fast, you're working for 12 to 14 hours a day. Oh my god that's a lot of work. 1.4 to 1.6 FTE if it was just 5 days a week. Add a sixth and it's basically 2 full time jobs. Good for you.

 

[chicagochildpsych]

Yup, sill trying to provide quality care, pay off Sallie Mae and set up my kids so they never need to take student loans.

 

[hamstergang]

I work in a facility where collateral is gathered by a psyD before I get there, every single one of my patients gets weekly psychotherapy from a psyD/phD

And since I had a patient fly in from Europe yesterday, I do believe that qualifies as thousands of miles.

Patients fly thousands of miles for the weekly therapy too, or am I just taking this too literally/simplistically?

 

[chicagochildpsych]

That patient came for a php program, and will follow up in europe

 

[F0nzie]

Yup, sill trying to provide quality care, pay off Sallie Mae and set up my kids so they never need to take student loans.

I am amazed that you can work this much in our field without going bonkers. Good for you. Don't forget carve out time for yourself and the kids-- they probably want you more than a free loan.