Envision RVU model

[Birdstrike]

Curious your thoughts.

lets assume a busy ED 100k visits, a common chart rack and 10 shifts a day, assume everyone works a square (aka equal schedule). Would RVU based pay be fair. (Note numbers are made up)

In an ideal world and ideal system, it would be fair. In some systems a hybrid might be more fair, in some groups, maybe straight hourly works. In others, perhaps 100% production based pay, is fair. In some places, it's probably not. I don't think it has to be a one size fits all, approach.

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[Backpack234]

PM me, amigo.
It won't let me PM you.

Done

 

[Rekt]

I’m glad there’s a lot of debate about this. As much as I like my flat rate gig, I’m ok with going to a CMG to get closer to family. If it’s 10-20% worse than the local amazing unicorn SDG, it’s probably 5% worse than my current gig.

I appreciate the responses in this thread. Its helped a lot!

Except you're making a false assumption that you will have job security at the CMG. You could land an SDG in a not so desirable area or not specific to you geographic needs and be close to FIRE and have stability as long as you need or you go with the CMG and your option 5-10 years from now is a 50-75% paycut or they replace you with one of the million surplus EM docs. Especially more so if you live in a desirable area. They will be prime for the reaping.

If you learn anything from this thread, it should be that CMGs are corporations and not groups. Every single move they make is to pay you less and pay themselves more. They don't care about you or your family. You can be fired by a guy with a business degree from University of Phoenix online from five states away.

 

[EctopicFetus]

Everything you say is true. But in my situation, I’m working directly for a hospital which turns out to not be so different from working for a CMG.

If there was a unicorn job with an opening near my family I would take it in a heartbeat (although even those aren’t guaranteed job security), and I’ll keep trying to get into those even with a CMG gig.

Could we get to FI in the next 5 years at our current place? Probably.

But then when I move back home am I more likely to land the local SDG from across the country or from down the street at CMGs R US?

If 50% of the em jobs currently employed by CMGs cut pay by 50-75% I think there will be much bigger problems and life changes to consider.

I think a 25% pay cut at SDG sites is coming at places where they haven’t already screwed docs like Denver.
yes to those who commented. Different discussions being had. I think the RVU model in an open book situation makes sense with between 25-50% base pay. Much of this depends on what people will make. If you make 300/hr then base pay between 120-150 makes sense to me.

 

[Torsion]

I think a 25% pay cut at SDG sites is coming at places where they haven’t already screwed docs like Denver.
yes to those who commented. Different discussions being had. I think the RVU model in an open book situation makes sense with between 25-50% base pay. Much of this depends on what people will make. If you make 300/hr then base pay between 120-150 makes sense to me.

What would prompt that kind of pay cut in a democratic group?

 

[drerp88]

What would prompt that kind of pay cut in a democratic group?

Surprise billing law that’s going into effect this January. Big pay cuts coming that’s going to hit everyone.

 

[Backpack234]

Surprise billing law that’s going into effect this January. Big pay cuts coming that’s going to hit everyone.

Is there a good resource to better understand why? I’ve seen a few articles saying it’s going to cut er doc pay by 50% but haven’t seen anything explaining why.

Where I work, we don’t see many out of network and seem to be doing just fine. Pretty sure we make average dollars per rvu.

 

[Jabbed]

Is there a good resource to better understand why? I’ve seen a few articles saying it’s going to cut er doc pay by 50% but haven’t seen anything explaining why.

Where I work, we don’t see many out of network and seem to be doing just fine. Pretty sure we make average dollars per rvu.

If out-of-network rate become cheaper than in-network rates, insurance companies have no incentive to negotiate contracts and everybody pays out-of-network by default.

 

[Rekt]

If out-of-network rate become cheaper than in-network rates, insurance companies have no incentive to negotiate contracts and everybody pays out-of-network by default.

So are we just ignoring it this time? Seems like there was way more freak out before with the 100x it's been proposed in past. Haven't heard much this round

 

[EctopicFetus]

What would prompt that kind of pay cut in a democratic group?

I did mean CMG but there will be some pain for sure with the SMB laws.

 

[EctopicFetus]

Is there a good resource to better understand why? I’ve seen a few articles saying it’s going to cut er doc pay by 50% but haven’t seen anything explaining why.

Where I work, we don’t see many out of network and seem to be doing just fine. Pretty sure we make average dollars per rvu.

There is more to come but the last set of guidance released at the end of the September will allow the arbiter to take into account the average in network rate. We wanted them to have to consider billed charges.

Also keep in mind the arbiter doesn't get to pick an amount, they have to pick between the ED offer of the insurance offer.

50% is silly but over time why would an insurer sign a contract higher than their average. As such they will push the rates down. ALso, consider this and this is what I would do if I was an insurer. Find a small ED group and make them an offer like this. NO copay or deductible for you tocollect. I the insurer will pay you $300 for every patient who comes into your ED. NO co pay no deductible. We wont even read your charts. Doesnt that sound awesome. Very few groups collect that much even when contracted rates are higher. Now assuming the average patient is 4 RVUs or so you are looking at about 200% of medicare. Now you tell envision to bite it and you offer your in network rate plus a little offer them $350/pt. When you end up at the arbiter you say hey in network we are at $300 so we are actually paying these guys more. Pretty good argument. NOw in reality the ED group now has to collect the co pay and deductible. Many patients cant afford this. In general ED groups are getting 70-80% of their billed allowable. Over time they whittle the 200% down bit by bit.

There are other ways for them to make it work but this is one option I am sure they will implement if they are smart.

 

[Groove]

I’m glad there’s a lot of debate about this. As much as I like my flat rate gig, I’m ok with going to a CMG to get closer to family. If it’s 10-20% worse than the local amazing unicorn SDG, it’s probably 5% worse than my current gig.

I appreciate the responses in this thread. Its helped a lot!

Yeah...not everything is about the money. I gave up a sweet SDG gig about 2 hours away in my home town for a string of CMG gigs in a larger city closer to family and friends. I ended up sacrificing about...$50-60/hr. I have occasional regrets but I still think I made the right decision.

 

[DocEspana]

Surprise billing law that’s going into effect this January. Big pay cuts coming that’s going to hit everyone.

Is there a good resource to better understand why? I’ve seen a few articles saying it’s going to cut er doc pay by 50% but haven’t seen anything explaining why.

Where I work, we don’t see many out of network and seem to be doing just fine. Pretty sure we make average dollars per rvu.

wait... isnt the surprise billing law including arbitration for cost discrepancy? I admittedly stopped paying attention to it at some point, which is my fault because I should have cared more but personal life has been requiring my attention the last 6-9 months, but I thought it included arbitration.

And arbitration has been the case in NY for a while and it generally benefits physicians/hospitals because insurance companies don't know how to play ball and are not used to someone neutral saying to them 'your bid is absurd lowballing.' Its not like its anything close to a pay raise, its still a pay cut to hospitals and eventually a pay cut to us by reflex - but its also probably the single best case scenario for physicians and hospitals barring fantasy scenarios like payers just going "eh, **** it. charge whatever you want." Because as nuts as hospital charges are, they have shown in NY to be less nuts than insurance carrier's lowball offers.

all of this is irrelevant if arbitration didnt make it into the final law, or if it got kneecapped somehow.

 

[southerndoc]

Surprised billing law unfortunately uses the median in-network payment rate thanks to an interim rule (I will leave out the politics). As insurers hardball groups, it will drive reimbursements per group down, which will drive the median in-network rate down. This will likely make reimbursement rates only slightly more than Medicare.

Groups -- including CMG's -- need to remain strong. Either an increase or don't sign. Go out-of-network instead of accepting a lower reimbursement to protect the median in-network rate.

The insurance industry has its hands in the majority of politicians pockets, and ER docs did not have as much of a "grassroots" effort as we had hoped. Much more than I expected, but still not enough.

The doom and gloom of emergency medicine is not as much residency explosion as it is threats to reimbursement. Instead of increasing payments to keep up with inflation, we're going to have reimbursements cut in the next 10-20 years unless things change. The FAIR Health Database was the best option to benchmark reimbursement rates.

 

[Porfirio]

My understanding of the bill is that now “Out of Network” for emergency medicine is dead. Can only bill “In Network” rates.

 

[southerndoc]

My understanding of the bill is that now “Out of Network” for emergency medicine is dead. Can only bill “In Network” rates.

Can still be out of network. When out of network, you can only bill the median in-network rate for all the groups in your region.

Consider these examples (obviously simplified):

• Group A: $150 per 99285 chart
• B: $120
• C: $100
• D: $80
• E: $60

You're out of network. The insurer will reimburse you at $100 since that's the median.

Two years pass, and groups have renegotiated so they can get the easy billing of being in-network.

• A: $150 (no change)
• B: $120 (no change)
• C: $90
• D: $80 (no change)
• E: $60 (no change)

The median rate is now $90, so out of network charges going through arbitration get the median in-network rate. So you get $90.

Now, two more years go by, and insurers have hard-balled those at the top and also those in the median. They care nothing about the lower end of the scale for now. Now it's:

• A: $110 (the insurer says it's more than you get for being out-of-network, and you're still above the mean/average for reimbursements)
• B: $92 (insurer says you're above the new mean now)
• C: they refused an offer of $80 and went out of network; they're no longer used to calculate the median
• D: kept their $80
• E: kept their $60

Now the median is between $80 and $92 ($86), so the out-of-network median rate has now shifted to $86.

Keep this cycle going for a while, and soon you have some significantly lower reimbursements. Coupled with the fact that most out-of-network reimbursements are checks to the patient and not the group/provider, well, it's a well-played move by the insurance industry to reduce their reimbursements. A penalty for not being in-network is that you may not get paid at all if the patient keeps the money, or you're forced into litigation with the patient to get paid (you suffer the bad PR when they talk to their friends that you're suing them because they won't say they kept the big fat check that was sent to them by the insurance company).

 

[EctopicFetus]

Surprised billing law unfortunately uses the median in-network payment rate thanks to an interim rule (I will leave out the politics). As insurers hardball groups, it will drive reimbursements per group down, which will drive the median in-network rate down. This will likely make reimbursement rates only slightly more than Medicare.

Groups -- including CMG's -- need to remain strong. Either an increase or don't sign. Go out-of-network instead of accepting a lower reimbursement to protect the median in-network rate.

The insurance industry has its hands in the majority of politicians pockets, and ER docs did not have as much of a "grassroots" effort as we had hoped. Much more than I expected, but still not enough.

The doom and gloom of emergency medicine is not as much residency explosion as it is threats to reimbursement. Instead of increasing payments to keep up with inflation, we're going to have reimbursements cut in the next 10-20 years unless things change. The FAIR Health Database was the best option to benchmark reimbursement rates.

In general you are right but there is a major flaw here which shouldn’t go by unchallenged. You stated “The doom and gloom of emergency medicine is not as much residency explosion as it is threats to reimbursement.”
this is true for SDGs as it impacts their pockets.
for CMGs or employed physicians be clear it doesn’t matter one iota. To pretend otherwise means you aren’t looking at the facts of CMG pay across the nation. Is the rate in Denver and Chicago around $150/hr because the reimbursement there sucks? Nope. I’m sure it’s better than a Ton of other cities. When u are working for a CMG or hospital their goal is to pay you as little as possible. Using an analogy like yours. Let’s say there are 3 docs for 1 spot. The group gets $500/hr on average in collections per “provider”. They have 3 options. 1) pay the experienced em doc $200/hr 2) pay the new grad $160/hr or 3) hire Jenny mcjennyson with no experience who is willing to work for $50/hr since the np market is also saturated (assuming the rn market normalizes)

it’s not hard to see option b is way better than option a. At some point they will figure out staffing to maximize option c. Whether reimbursement drops to $400/hr doesnt matter. The goal is profits.

I know you know this southern doc but for places that generate less than compen for docs they just get a hospital subsidy and we know that’s not gonna go away But the goal is to minimize that as well hence option c above.
that’s the real issue for non SDG jobs. The glut of docs will hammer what we are paid and we will see the delta between mlps and docs shrink so the extra grads can find work. They will have no other choice.

 

[Torsion]

Can still be out of network. When out of network, you can only bill the median in-network rate for all the groups in your region.

Consider these examples (obviously simplified):

• Group A: $150 per 99285 chart
• B: $120
• C: $100
• D: $80
• E: $60

You're out of network. The insurer will reimburse you at $100 since that's the median.

Two years pass, and groups have renegotiated so they can get the easy billing of being in-network.

• A: $150 (no change)
• B: $120 (no change)
• C: $90
• D: $80 (no change)
• E: $60 (no change)

The median rate is now $90, so out of network charges going through arbitration get the median in-network rate. So you get $90.

Now, two more years go by, and insurers have hard-balled those at the top and also those in the median. They care nothing about the lower end of the scale for now. Now it's:

• A: $110 (the insurer says it's more than you get for being out-of-network, and you're still above the mean/average for reimbursements)
• B: $92 (insurer says you're above the new mean now)
• C: they refused an offer of $80 and went out of network; they're no longer used to calculate the median
• D: kept their $80
• E: kept their $60

Now the median is between $80 and $92 ($86), so the out-of-network median rate has now shifted to $86.

Good analogy. On the flip side I would think that best thing to do for those on the lower end would be to leave the network for higher reimbursement in this scenario, right? Why would a provider accept option E: 60$ when they could be out of network collecting double at a new median $120? Is it lack of ability to negotiate? This is the argument put forth by the payor side that without a starting point for negotiating their will be reimbursement inflation.

Do you believe that this issue will get resolved favorably? The legislation as written seemed to be an overall win and the new rule goes against congressional intent and has angered both the stakeholders on the hospital/physician side as well as the original sponsors of the bill in congress.

 

[southerndoc]

@EctopicFetus I'm not saying that residency proliferation doesn't matter; I'm saying there is a bigger threat in reimbursement. The markets you cite were paying well below national rates for quite some time now. People are choosing living there and accepting that wage, and have done so for years. Residency proliferation, in my opinion, will even itself out. I think in a few years you're going to find many spots going unfilled. I could be wrong, but I can see it. I do believe that a bigger threat than residency expansion is in more use of NP's and PA's.

@Torsion Two things will keep lower reimbursement groups from leaving: First, the payments for most major insurers are not paid directly to the out of network provider and are paid to the patient instead. Second, there may be steep penalties to leave mid-contract. Also, keep in mind, that the payment isn't automatic -- it's after arbitration. The insurer can pay you whatever they want (including your previous rate) until you go into arbitration.

 

[Torsion]

@Torsion Two things will keep lower reimbursement groups from leaving: First, the payments for most major insurers are not paid directly to the out of network provider and are paid to the patient instead. Second, there may be steep penalties to leave mid-contract. Also, keep in mind, that the payment isn't automatic -- it's after arbitration. The insurer can pay you whatever they want (including your previous rate) until you go into arbitration.

What do you think will be the most likely outcome with the current rule change? It seems members of congress who sponsored the legislation agree this was a bait and switch and several hospital and physician organizations are fighting it .

 

[Old_Mil]

I’ve been hearing that envision recently changed from a base salary to a base plus rvu model. What have your experiences been with this change?

I've never taken an RVU job, and never will. All that does is allow other factors I have no control over adversely affect my paycheck. It's one thing to eat what you kill in private practice or even in a clinic practice. In the ED, with your productivity being dependent on everything from the speed of the computers IT puts in your shop to the willingness of the floor nurses to board patients in your department it's not worth it.

 

[Arcan57]

I've never taken an RVU job, and never will. All that does is allow other factors I have no control over adversely affect my paycheck. It's one thing to eat what you kill in private practice or even in a clinic practice. In the ED, with your productivity being dependent on everything from the speed of the computers IT puts in your shop to the willingness of the floor nurses to board patients in your department it's not worth it.

RVU and eat what you kill are very similar in that they both have the downsides you mention regarding external factors affecting productivity. Eat what you kill is generally more transparent, but a SDG could easily implement a fair RVU system. Main difference is eat what you kill incentivizes care for resourced patients over non-resourced. There's literally no incentive to see non-emergent self-pay because you know you're making no money off of it. RVU at least divides the total pool of money then distributes it according to productivity. Unfortunately, that also lends a layer of obfuscation in that if you don't know how much group is collecting and what your overhead is then the RVU/hr can be artificially suppressed. Ultimately, in an open book model RVU pay is "fairer" than eat what you kill but in a closed book model it's generally less fair.

From a CMG perspective, assuming a contract is mostly stable from a volume/staffing standpoint they legitimately don't care whether it's RVU or hourly pay. Given sufficient billing data, they can pretty accurately predict collections from a site and are happy to divvy that pot out to its docs in whatever way makes the docs more satisfied. They don't like RVU model when volume is rapidly growing and there's any shift in payor mix. In this scenario, they can't predict payroll and it's one of the few times they can find themselves upside down if a substantial part of the volume increase is self-pay in a shop with a previously heavily private population. The other time they're commonly upside down is immediately after acquiring an understaffed contract when they have to pay $$$ to staff the contract as they backfill open spots with new grads/recruits. (source: 7 years in CMG leadership positions)