Comparing Unit Reimbursement Models

[Amnesiator]

I’ll be entering PP next year, and I’m trying to learn about billing and reimbursement. One thing I’ve noticed is many groups seem to have their own custom model. Can anyone help me figure out how to compare? For example, at what dollar per unit rate would each of these be equivalent?

- standard ASA start up and 4 units per hour
- standard start up and 5 per hour
- ½ start up and 5 per hour
- ½ start up and 6 per hour

Let’s say the first option is $50/unit. What would the others need to be for all to be equal? I realize it depends on how many and what type of cases you’re doing, but is there a way to generalize? Thanks for the help wrapping my mind around this.


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[IMGASMD]

Are you making this more complicated than it has to be?

 

[nimbus]

I’ll be entering PP next year, and I’m trying to learn about billing and reimbursement. One thing I’ve noticed is many groups seem to have their own custom model. Can anyone help me figure out how to compare? For example, at what dollar per unit rate would each of these be equivalent?

- standard ASA start up and 4 units per hour
- standard start up and 5 per hour
- ½ start up and 5 per hour
- ½ start up and 6 per hour

Let’s say the first option is $50/unit. What would the others need to be for all to be equal? I realize it depends on how many and what type of cases you’re doing, but is there a way to generalize? Thanks for the help wrapping my mind around this.


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Option 2 is better than option 1 and option 4 is better than option 3 because you’ll be generating more units.

The rest of the answer really depends on the case mix. If the practice does a bunch of complex cases with high startups like hearts and liver transplants, option 1 and 2 are much better than 3 and 4. If they do mostly low startup cases like knee scopes and breast biopsies, option 3 and 4 are better.

To simplify things, ask the average unit value and average monthly production unit wise within the system they use. Then you can do the arithmetic.

Options 3 and 4 are prioritizing time on the stool over case complexity, lines, and blocks.

 

[deleted875186]

I don’t understand. Isn’t the standard base units Standard across the country? I thought the amount per unit was The only thing that varied based on the insurrances accepted.

 

[deleted162650]

I don’t understand. Isn’t the standard base units Standard across the country? I thought the amount per unit was The only thing that varied based on the insurrances accepted.

You bill at the standard ASA unit scheme. We are talking about the various ways for groups to divvy up the collection money amongst themselves.

 

[Amnesiator]

I’m not trying to make it complicated. These are actual models that real groups I’ve talked to use. I’m trying to compare apples-to-apples to see how much people at group A make compared to group B for the same amount of work (in theory).


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[Mikkel]

You don't want to over emphasize time in a case because it incentivizes slowness, leading to unhappy surgeons and a future in jeopardy.

The worst I've seen is AMC groups that just salary the employees, then they couldn't give a crap if their turnovers are an hour long.

 

[nimbus]

You don't want to over emphasize time in a case because it incentivizes slowness, leading to unhappy surgeons and a future in jeopardy.

The worst I've seen is AMC groups that just salary the employees, then they couldn't give a crap if their turnovers are an hour long.

Yep there have been people who routinely game that system with 20minute wakeups.

 

[deleted162650]

I’m not trying to make it complicated. These are actual models that real groups I’ve talked to use. I’m trying to compare apples-to-apples to see how much people at group A make compared to group B for the same amount of work (in theory).


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You’re thinking about this all wrong.

I’ll explain later.

 

[Maverikk]

You should look at what cases they’re doing which probably reflects their billing model modifications. It may be they do 8/9 hour cases and try to equalize the payment to people who cover these which are sometimes sub-specialized. Large group policies are hard to game for a whole group. If turnovers are 20 min at one place vs 50 min at another you’ll care more about that than how the billing is split unless it’s some outrageous scheme.

One of my co-residents works for an AMC. Per hour pay with OT that’s semi decent, so-so bennys in a desirable city. I’ve been working in PP, busting my hump trying to get my patients ready in preop, being sweet to the prep/circulator so that when shift change comes they actually do some work to get the room turned over.
More stress/hours for a modest pay bump, more self satisfaction less employee mentality. I say this so you think about it, I’ve had my doubts, my payor mix is decent, vacation is good but when I have to wait for a 40 minute turnover and it irks me I wonder.

 

[IMGASMD]

2 is better than 1.
4 is better than 3.

the question is how’s 2 compare to 4.
Option 2
A. If I do hernia all day and quick turn overs.
4 (base unit) + 12min * 3 = 7
6 cases before 1pm. 42 units pack up go home.

B. If I am at a place with residency and slow union hospital do hernia all day.
4 (base unit) + 12min* 6 = 10
4 cases by 2pm. 40 units pack up and go home.

Option 4
A. 2 + 3.5 = 5.5
33 units. Home by 1
B. 2 + 7 = 9
36 units. Home by 2

———————————-
Now the fun one. Something that a gen anesthesiologist can potentially do all day.
Cervical spine, let’s say.
Option 2
A. 10 (base unit) + 10 units (2 hours) = 20
2 cases. 40 units by 1pm
B. 10 + 20 (4 hours)= 30
1 cases. 30 units by 2 pm

Option 4
A. 5 + 12 units = 17
2 cases. 34 units by 1pm
B. 5 + 24 units = 29
1 cases. 29 units by 2 pm.

——————————
Just like everyone is saying. Depends on what kind of cases and how much you value your time and stress level you are welling to put up with. No magic here.

 

[NICMAN]

Here’s the best scheme. You own the business, everybody works the same diversity of cases and the same amount of time, and then you split the profits equally.

 

[Mikkel]

Here’s the best scheme. You own the business, everybody works the same diversity of cases and the same amount of time, and then you split the profits equally.

How do you ensure diversity and equal time?

 

[Mikkel]

How do you ensure diversity and equal time?

And what's your timescale? Even after 1 week? 1 month? 3 months? 1 year? This sounds like a nightmare for your scheduler, especially if the scheduler is not employed by your group.

 

[IMGASMD]

And what's your timescale? Even after 1 week? 1 month? 3 months? 1 year? This sounds like a nightmare for your scheduler, especially if the scheduler is not employed by your group.

We used to have a junior partner that would assign rooms. But still at the end favoritism and seniority plays a part. Not the easiest job.

Or like one of the other thread is talking about.... first call gets to pick. More calls you take, more you get the pick the juicy ones.

 

[Southpaw]

Here’s the best scheme. You own the business, everybody works the same diversity of cases and the same amount of time, and then you split the profits equally.

The incentive in this system, where everyone gets paid regardless of amount worked, is to not work or do as little work as possible. In my opinion, compared to pure fee for service eat what you kill, this turns otherwise decently working people into lazy and entitled. Note that I’m not saying eat what you kill is better, just different, and with its own set of issues.

I haven’t found a best scheme. I do know that regardless of the scheme, the system works best with honest, hard-working people. Unfortunately, within the anesthesia world, I haven’t seen a group composed entirely of that. There’s always a squeaky wheel with someone trying to game the system. Your hope is to minimize the number of squeaky wheels as much as possible.

 

[deleted162650]

I’ll be entering PP next year, and I’m trying to learn about billing and reimbursement. One thing I’ve noticed is many groups seem to have their own custom model. Can anyone help me figure out how to compare? For example, at what dollar per unit rate would each of these be equivalent?

- standard ASA start up and 4 units per hour
- standard start up and 5 per hour
- ½ start up and 5 per hour
- ½ start up and 6 per hour

Let’s say the first option is $50/unit. What would the others need to be for all to be equal? I realize it depends on how many and what type of cases you’re doing, but is there a way to generalize? Thanks for the help wrapping my mind around this.


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OK, so as I said earlier, you're thinking about this wrong. You cannot compare one group to another based on the particular unit scheme they run. You're operating under the false assumption that in a blended unit practice, your income = number of units worked x blended unit value. In reality, that's not how it works at all. In a blended unit eat what you kill practice, the number of units you generate is used to calculate the percentage of the total amount of units generated by the group that you were responsible for. Your percentage is then multiplied by the total collections for the month, and that is what your income will be.

Greatly simplified example:

4 person MD only group. Total group revenue for the month = $160,000.
Partner A worked 1000 units that month
Partner B also worked 1000 units that month
Partner C is an old timer that's slowing down. He only worked 800 units that month by giving some call to the young hungry Partner D
Partner D worked 1200 units for the month.

Grand total of 4000 units for the group.
Partner A = 25%
Partner B = 25%
Partner C = 20%
Partner D = 30%

So income:

Partner A 25% x $160k = 40k
Partner B 25% x $160k = 40k
Partner C 20% x 160k = 32k
Partner D 30% x 160k = 48k

In reality, it's even more complicated than that, because your income in a given month is actually a composite of many months worth of collections, each multiplied by the percentage of total units you worked for that given month. Follow me?

It is extremely difficult to calculate a blended unit value in real time (it's a calculus problem). The unit value actually fluctuates month to month, pay period to pay period. You really can only get an accurate picture by taking the average over the whole year.

Do you see why the actual unit scheme for each group cannot be cross compared between groups. All that matters is that everybody within a group is operating under the same scheme. If that isn't the case, then that would be huge red flag.

Schemes B and D in your example put more weight on stool time over case selection. This is an an attempt at a more egalitarian way to run the schedule so people care less about what cases they are doing.

When comparing groups, you need to focus on 2 things:
1) What is the payer mix - i.e. what is the percentage of commercial insurance vs government pay
2) How is the schedule run. Is it fair. Do you have an equal opportunity to generate units as the next guy?

 

[Mman]

And what's your timescale? Even after 1 week? 1 month? 3 months? 1 year? This sounds like a nightmare for your scheduler, especially if the scheduler is not employed by your group.

we make our own schedule. Call is spread out equally and randomly by a computer system. If you want to pay someone to pick up a weekend or a shift or holiday or whatever, the two of you can work out whatever payment you want. Everybody gets paid the same. We also dole out cases on each day as equal as possible. We all work about as equal in hours and difficulty as you can get and we all get paid the same. Everybody wins. If someone is really hungry for cash, then can pick up shifts from people willing to sell them.

 

[nimbus]

we make our own schedule. Call is spread out equally and randomly by a computer system. If you want to pay someone to pick up a weekend or a shift or holiday or whatever, the two of you can work out whatever payment you want. Everybody gets paid the same. We also dole out cases on each day as equal as possible. We all work about as equal in hours and difficulty as you can get and we all get paid the same. Everybody wins. If someone is really hungry for cash, then can pick up shifts from people willing to sell them.

It makes a big difference if one is MD only vs. ACT.

I could see how counting units could get way too complicated if the practice is a care team, and if you are supervising some of the time and doing your own cases some of the time. In that situation it makes sense to count shifts.

 

[Mman]

It makes a big difference if one is MD only vs. ACT.

I could see how counting units could get way too complicated if the practice is a care team, and if you are supervising some of the time and doing your own cases some of the time. In that situation it makes sense to count shifts.

as long as you rotate the case types around for physician only it has the same effect. I mean we are all going to be here for decades, some days it's hard and some days it's easier and in the end it all evens out.

 

[nimbus]

as long as you rotate the case types around for physician only it has the same effect. I mean we are all going to be here for decades, some days it's hard and some days it's easier and in the end it all evens out.

I’m in MD only eat what you kill based on units generated. Qgenda assigns us all an even amount of call and we all pick our own cases the day before based on our call position. But people have different priorities. We do a lot of call trading and some people just want a chill lineup and short days and don’t care so much about income. Others try to maximize every opportunity to be more productive. So our spread is pretty wide. I’d guess our top earners make 2x the lowest earners even though we work in the same hospital and are all considered full time.

 

[deleted162650]

as long as you rotate the case types around for physician only it has the same effect. I mean we are all going to be here for decades, some days it's hard and some days it's easier and in the end it all evens out.

You underestimate the diabolical nature of some folks and the effort they will put in to game the system.

For example, in my last gig there was a particularly pathological guy that would review the scheduled cases weeks in advance, and then call patients and ask them to request him for their high value cases.

 

[Mman]

You underestimate the diabolical nature of some folks and the effort they will put in to game the system.

For example, in my last gig there was a particularly pathological guy that would review the scheduled cases weeks in advance, and then call patients and ask them to request him for their high value cases.

that type of person would never become a partner in our group and if they did, we'd vote them off the island.

 

[deleted162650]

that type of person would never become a partner in our group and if they did, we'd vote them off the island.

Same at my current gig.

There was a very unique set of circumstances that allowed him to persist at that last job. Shortly after I left, he was actually booted off the medical staff for other behavior related issues.

 

[2Fast2Des]

I think the eat what you kill is a great model, if run fairly. It really incentivizes work to get done quickly and efficiently as there's never a shortage of someone trying to get units. That being said, I'm in a group where cases and centers don't get divied fairly, so it certainly breeds animosity to the senior guys gaming the system, not respecting the daily relief order list, or only partners assigning themselves the best rooms all the time and giving non partners crappy rooms (even though we are productivity based as well). Unfortunately human nature breeds unfairness and greed which drives this. When I see people in other facilities who are salaried, there is no sense of urgency or motivation to get cases done, cancelling over trivial issues, etc.

 

[Pharmado]

Even in employee situations there are those gaming the system. I’m currently working as a hospital employee as 1 of 6 anesthesiologists. Management swears we all have the same contract (an absolute lie), yet one guy games the system such that he gets all the cases that get blocks and does most of the epidurals (daytime hours only). He will start a case then force someone to get him out of the case so he can place epidurals. He insists on starting cases at the end of the day then getting relieved by the call person. He works fewer hours than the rest of us, but generated 3k units more than the next highest person (me) last year. It is unfortunate that such greed occurs so regularly in a profession where our primary goal should be the welfare of the patient.

 

[jwk]

Even in employee situations there are those gaming the system. I’m currently working as a hospital employee as 1 of 6 anesthesiologists. Management swears we all have the same contract (an absolute lie), yet one guy games the system such that he gets all the cases that get blocks and does most of the epidurals (daytime hours only). He will start a case then force someone to get him out of the case so he can place epidurals. He insists on starting cases at the end of the day then getting relieved by the call person. He works fewer hours than the rest of us, but generated 3k units more than the next highest person (me) last year. It is unfortunate that such greed occurs so regularly in a profession where our primary goal should be the welfare of the patient.

One greedy guy vs five hungry. Hmmm, -That seems like it should be a solvable problem, whether done through management or a quiet five on one conversation behind closed doors.

 

[IMGASMD]

Even in employee situations there are those gaming the system. I’m currently working as a hospital employee as 1 of 6 anesthesiologists. Management swears we all have the same contract (an absolute lie), yet one guy games the system such that he gets all the cases that get blocks and does most of the epidurals (daytime hours only). He will start a case then force someone to get him out of the case so he can place epidurals. He insists on starting cases at the end of the day then getting relieved by the call person. He works fewer hours than the rest of us, but generated 3k units more than the next highest person (me) last year. It is unfortunate that such greed occurs so regularly in a profession where our primary goal should be the welfare of the patient.

Hahaha. Gotta hand it to some of these people.

Also speaks volume how sometimes we let it go..... isn’t it how seniority works and the hope it “may be me one day” mentality?

I digress.

Happy Turkey Day for those who celebrate it.

 

[psychbender]

One greedy guy vs five hungry. Hmmm, -That seems like it should be a solvable problem, whether done through management or a quiet five on one conversation behind closed doors.

Good 'ole wall-to-wall counseling session.

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