APC charts

[Groove]

How are you guys handling APC chart distribution among your physicians?

At our CMG, APC charts probably add or subtract an additional ~$25/hr at the end of the month (or more) but we have no organized system for an even distribution among the physicians. So, it ends up being a lot of favoritism and psychological games being played in the ED. i.e. (If you don't give me a hard time, I'll send you my charts, etc..) I've touched on it with medical directors in the past but nobody seems very interested in doing anything about it and rightly so, because who gets the most charts sent to them at the end of the month? You guessed it, the medical director. Sometimes almost twice as many charts are sent to him at the end of the month.

Before I make a big deal about it, I'm just curious as to what everyone else does? Do you guys have a system in place and if so, how does it work exactly? Or does everyone have something similar to ours? It's just really frustrating and can sometimes significantly decrease your compensation at the end of the month. It's a constant source of frustration for me and sometimes makes other gigs in town seem attractive when they probably wouldn't be if issues such as this one were handled fairly. It's hard enough to guess compensation in a total RVU environment from month to month let alone having APC charts be yet another completely uncontrollable variable.

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[southerndoc]

We have a list of docs on our call sheet (below all the cards, neurosurg, hand surg, etc. names/numbers). It's organized by shift (2 6a's, 1 7a, etc.). The APC goes down that list if they are in fast track. If a doc isn't there, then they skip them (i.e., the ones who are scheduled to come in later). Once those docs come in, they start in the rotation. As docs end their shift, they fall off the rotation. It seems to work very well.

We split our ED into zones. They do the same thing for zones (the providers covering those particular zones).

I believe patients who are screened in triage but who leave against medical advice are assigned to the medical director.

 

[namethatsmell]

At one group I used to work at the PAs could send their charts to any doc whose shift overlapped with theirs.

A few other places and CMG I worked for would have them send the charts to the doc whose shift most-closely aligned with theirs.

One place I work doesn't have us sign their charts unless we actually see the patient. On average I'm asked to see a PA pt there like once every 6 or 7 shifts. This is my favorite setup when working with midlevels.

I've never been paid more or less for seeing midlevels patients as I've always been fed the line of "your pay for supervising them is built into your general overall pay."

Am I understanding it correctly that you basically don't have to sign PA charts and in exchange take a $25/hr paycut? Frankly, this seems like a fairer way to handle this than most other set-ups. You should get paid more for signing their charts. The rub though is that since you're getting paid directly for signing them you'd probably be even more hard-pressed (than it already is) to separate yourself from a suit filed against a midlevel chart you sign.

 

[Janders]

We assign the money to whomever supervises or cosigns or sees the patient (or all of the above).

We assign each PA a specific MD they are working with at given point of their shift. On rare occasion they will ask a different doc to supervise a specific patient (i.e. the assigned doc is in a prolonged code, can't get out). 98% go to the doc they are working with.

 

[GonnaBeADoc2222]

Honestly.....I personally would consider sacrificing that income to not have to deal with midlevels.

 

[emergentmd]

Charts assigned depending on what shift you work.

Pay is assigned equally. So if there is 100K made from ML charts and you worked 10% of the shift, then you get 10K, if you work 50% then you get 50K.

OPs set up is stupid and any fair group would get rid of this set up. It does nothing but create distrust and animosity throughout the whole system.

OP needs to either ignore it and take lower pay or play the game. Buy the MLs some Gift cards every month and you will see your charts sky rocket.

 

[Hercules]

We assign the money to whomever supervises or cosigns or sees the patient (or all of the above).

We assign each PA a specific MD they are working with at given point of their shift. On rare occasion they will ask a different doc to supervise a specific patient (i.e. the assigned doc is in a prolonged code, can't get out). 98% go to the doc they are working with.

We do the same in our group. We actually see every midlevel patient though so it makes it pretty obvious who they should be assigned to.

 

[Groove]

We have a list of docs on our call sheet (below all the cards, neurosurg, hand surg, etc. names/numbers). It's organized by shift (2 6a's, 1 7a, etc.). The APC goes down that list if they are in fast track. If a doc isn't there, then they skip them (i.e., the ones who are scheduled to come in later). Once those docs come in, they start in the rotation. As docs end their shift, they fall off the rotation. It seems to work very well.

We split our ED into zones. They do the same thing for zones (the providers covering those particular zones).

I believe patients who are screened in triage but who leave against medical advice are assigned to the medical director.

So, each consecutive chart is assigned to the next doctor on your list?

 

[Groove]

Am I understanding it correctly that you basically don't have to sign PA charts and in exchange take a $25/hr paycut? Frankly, this seems like a fairer way to handle this than most other set-ups. You should get paid more for signing their charts. The rub though is that since you're getting paid directly for signing them you'd probably be even more hard-pressed (than it already is) to separate yourself from a suit filed against a midlevel chart you sign.

We get their RVUs applied to our overall RVU/hr and are paid for the extra RVUs generated. If you don't sign the chart, you don't get paid any extra. The amount oscillates but it's roughly $25/hr or so when said and done at the end of the month.

 

[namethatsmell]

We get their RVUs applied to our overall RVU/hr and are paid for the extra RVUs generated. If you don't sign the chart, you don't get paid any extra. The amount oscillates but it's roughly $25/hr or so when said and done at the end of the month.

Sounds reasonable to me. Then again I'm a guy who would like the freedom to opt out and forgo the extra $25/hr to not sign their charts unless I'm actually seeing their patients or perhaps if I was a partner in a true SDG where I had hiring/firing/legit (re)training power over them and they practiced within well defined parameters that the group agreed on.

 

[GeneralVeers]

Sounds reasonable to me. Then again I'm a guy who would like the freedom to opt out and forgo the extra $25/hr to not sign their charts unless I'm actually seeing their patients or perhaps if I was a partner in a true SDG where I had hiring/firing/legit (re)training power over them and they practiced within well defined parameters that the group agreed on.

$25/hour? Where's all that money they are generating going? Typically on my shift I'll work with 1-2 midlevels (they stagger the docs they work with )and they add between 15-30 patients to my total depending on how busy we are and how fast the midlevels are. That adds between $100-$150/hr to my work salary. We pay them about $100/hr. So anywhere from 30-50% of my salary comes from midlevels. Not a small chunk of change.

 

[southerndoc]

So, each consecutive chart is assigned to the next doctor on your list?

Correct. The fast track midlevel runs the list. Those in the main ED assign to the docs that are working that particular zone (they also run the list, some zones have 3 active docs). They stop assigning about 2 hours before the end of a doc's shift because all patients except level 4's are seen by an MD as well.

It really is a fair system how they do it.

 

[RustedFox]

Correct. The fast track midlevel runs the list. Those in the main ED assign to the docs that are working that particular zone (they also run the list, some zones have 3 active docs). They stop assigning about 2 hours before the end of a doc's shift because all patients except level 4's are seen by an MD as well.

It really is a fair system how they do it.

This makes a LOT of sense. I hate coming into the next shift, logging in, and seeing 30-40 MLP charts all waiting for my signature - all submitted after I went home for the night.

This is how I got my second lawsuit. Never saw the patient. MLP had OtherDoc see the patient, but chart came to me for signature.

No, I'm not being dropped - before you ask.

 

[namethatsmell]

$25/hour? Where's all that money they are generating going? Typically on my shift I'll work with 1-2 midlevels (they stagger the docs they work with )and they add between 15-30 patients to my total depending on how busy we are and how fast the midlevels are. That adds between $100-$150/hr to my work salary. We pay them about $100/hr. So anywhere from 30-50% of my salary comes from midlevels. Not a small chunk of change.

Do you get an actual RVU breakdown to determine your vs the midlevels RVUs that make up your pay?

My two main gigs these days pay reasonably well—as well as with groups where I’ve had to blindly sign midlevel charts whom I had no real control over—yet I now don’t have any midlevel shenanigans to deal with. An extra $25/hr wouldn’t entice me personally, but an extra +100/hr would though if I had input into their hiring/firing/scope of practice or I was briefly seeing all their patients.

 

[Groove]

$25/hour? Where's all that money they are generating going? Typically on my shift I'll work with 1-2 midlevels (they stagger the docs they work with )and they add between 15-30 patients to my total depending on how busy we are and how fast the midlevels are. That adds between $100-$150/hr to my work salary. We pay them about $100/hr. So anywhere from 30-50% of my salary comes from midlevels. Not a small chunk of change.

I work for a CMG with closed books. Very fuzzy math and a compensation formula that could only be deciphered by Rain man. The APCs do a lot of MSE screening shifts which don't generate any money, or generate very little. We are continuously told during quarterly meetings that the APCs function at a net loss when considering MSE shifts with regular shifts which I've always found difficult to believe but I can't disprove outright. We DO have a horrible payer mix at my current shop and are requiring a hospital subsidy because of it so maybe there is some truth in that explanation. Regardless, the APC component of our compensation formula seems to be round about $25/hr. There is little interest in the past from medical directors to control or organize APC chart distribution, likely because administration typically benefits as the APCs fall over themselves to send them to a director if he/she is on shift. Lots of favoritism, lots of psychological games (if you correct me/criticize my management, I'll just send my charts to someone else, etc..) It's a huge mess.

 

[BoardingDoc]

I work for a CMG with closed books. Very fuzzy math and a compensation formula that could only be deciphered by Rain man. The APCs do a lot of MSE screening shifts which don't generate any money, or generate very little. We are continuously told during quarterly meetings that the APCs function at a net loss when considering MSE shifts with regular shifts which I've always found difficult to believe but I can't disprove outright. We DO have a horrible payer mix at my current shop and are requiring a hospital subsidy because of it so maybe there is some truth in that explanation. Regardless, the APC component of our compensation formula seems to be round about $25/hr. There is little interest in the past from medical directors to control or organize APC chart distribution, likely because administration typically benefits as the APCs fall over themselves to send them to a director if he/she is on shift. Lots of favoritism, lots of psychological games (if you correct me/criticize my management, I'll just send my charts to someone else, etc..) It's a huge mess.

You guys have dedicated MSE shifts? e.g. they basically see the person and say "you're not having an emergency. Bye."? Or are they just running a fast track and doing whatever low acuity stuff rolls in.

If the former, that's really interesting as I've never really heard of that happening in practice.

 

[Groove]

You guys have dedicated MSE shifts? e.g. they basically see the person and say "you're not having an emergency. Bye."? Or are they just running a fast track and doing whatever low acuity stuff rolls in.

If the former, that's really interesting as I've never really heard of that happening in practice.

Yes, dedicated MSE shifts. In theory, it improves TATs d/t MSE orders can be entered and blood drawn in RAZ prior to placement in the ED. In practice, it does none of the above except to cook the numbers (decrease door to doc times, decrease LWOT, Elopements, etc..) In fact, the departmental management has created an "Internal WR" which is nothing more than a arbitrary logical WR that exists on the tracking board that stops the time and decreases (time to bed) times. In reality, the pt's are still in the "waiting room" but are labeled IWR on the tracking board. We don't have enough techs in RAZ to facilitate appropriate blood draws and so most of the time the pt's sit out there with MSE screening orders, and don't have anything done until they get placed back in the room. However, it cooks the metrics in a remarkable way thereby making upper admin very happy with the process.

In my old gig (busy level 2 trauma center), we started doing physician MSE shifts where we ran a RAZ/POD area and would screen, enter orders, dump complicated pt's to the main ED, rapid discharge pt's and/or put lac/I&D's in a set of rooms that we had set aside for pt's that might require a few labs and/or procedures. It was extremely busy and sometimes we'd see 40 pt's a shift, but it was very lucrative and really increased your RVUs. That was a Schumacher site at the time. It seemed to work well but most docs don't really have any interest in doing those types of shifts and most of our guys voluntarily chose not to work them. It was a little known secret among the rest of us that it significantly increased RVU so we kept that information to ourselves and would volunteer for the shifts.

 

[GeneralVeers]

You guys have dedicated MSE shifts? e.g. they basically see the person and say "you're not having an emergency. Bye."? Or are they just running a fast track and doing whatever low acuity stuff rolls in.

If the former, that's really interesting as I've never really heard of that happening in practice.

At my newish job, we never have available beds to see patients, so the prior group had the midlevels out front doing an "RME" whereby they wrote a quick note and just put some crappy orders in. For this we were paying $100/hr plus benefits. The doctors would typically sit at the back and read internet news until a bed opened miraculously opened up and a patient would be put back that had been RMEd, all the labs were back, and had been waiting 2-3 hours in the waiting room.

I put a stop to that, and I'm trying to get everyone on board. I sit out front and see/treat people from the waiting room. I see the higher acuity ones myself. I give the lower acuity ones to the midlevels with instructions to finish their workup and disposition. It works great, but bad habits are hard to break in a lot of the doctors.

At my other job where we use midlevels far more efficiently I'm given a breakdown every month of all the patients I've seen, all the midlevels have seen in my name as well with a total RVU breakdown. With those numbers it's very easy to calculate how much they contribute to my bottom line.

 

[deleted836128]

Interesting thread!

In my group, for years we would have to forward ALL charts for cosignature, whether we discussed them or not. There are two PA shifts a day so that could be fifty charts. It’s a lot. We just sent the charts to whatever physician we wanted who was on shift at the time the patient was in the ER. Didn’t really hear complaints about this but we realized it was redundant and pointless after a while. Some docs would put something like “I was available in the emergency department” and others would put “I was available and agree with the APP’s work up and plan” and I suspect they didn’t even look much at the chart (they trust us but this is too nonchalant and risky if you ask me). Something changed - maybe because of the concern about wasting time putting in attestations and maybe because of liability concerns - now we don’t require a co-sig / attestation so we don’t technically have to forward any charts to the docs. I still do if I talked to the doc about the case or obviously if the doc sees the patient.

 

[deleted836128]

By the way - we did the provider in triage thing for a while now. Those were... awful days. Eight hours of nonstop patients flowing in... the triage nurse would lead the encounter, and I would just stand there and desperately try to interject to get questions in and do a half ass exam while the patient sat in the chair. Seconds later the triage nurse would get up and pul the NEXT patient leaving me twenty seconds to get as much history as possible. I would be thinking about orders and putting those in while at the same time listening to the complaint of the next patient. It was awful. What was even more awful was when spooky sick patients were sent back to the lobby and there’s nothing I could do. My hospital also found that it wasn’t very cost effective. It was a waste of an APP who could otherwise be turning and burning patients in the fast track or working up belly pains in the main ED. Plus we realized putting in triage protocols is generally all that is needed 80 percent of the time. Many you’d order stuff and it would be the exact work up the doctor would want - but then no one would pull the patient for labs and imaging so when the patient was pulled back to a room nothing was done ahead of time anyway. Then some docs / fellow APPS would get irritated about some of the stuff the APP in triage would order like a D Dimer in a chest pain patient if they themselves wouldn’t have gotten a D Dimer in that case. It was hard to guess what the docs / APPs would want and it was kinda a nightmare. Never again!

 

[namethatsmell]

Then some docs / fellow APPS would get irritated about some of the stuff the APP in triage would order like a D Dimer in a chest pain patient if they themselves wouldn’t have gotten a D Dimer in that case.

Having a D dimer you don’t want sent on a patient you have to see is like the blind date of emergency medicine. The person who sets things up usually thinks they’re doing somebody else a favor. In reality it rarely works out as planned and causes a lot of angst and wasted resources along the way.