Group compensation

[Dr.Evil1]

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My small democratic ED group is currently considering changing the way we pay ourselves. Currently we work a 50/50 split between hourly and RVU based compensation. In short money comes in, we pay overhead (billing, insurance, etc) then divide the money up into two pots. This is then distributed to the physicians according to # of hours worked and RVUs earned (two pots). We are paid each month a draw and then get a catch-up check (or very rarely a bill) every 6 months.

We are considering moving to a 100% RVU based system. We hope that this will increase everyone's desire to see more patients and help with our time to greet metrics if people are actively competing for patients.

Wondering what other systems may be out there and what other people's experience may be.

Thanks

 

[EctopicFetus]

My group currently works on a strict hours worked basis. It is far from perfect and I prefer some measure of performance.

The issue for us is we have some spots with PAs, some without, some with scribes some without. This makes it a little harder to make it fair.

Also, shouldnt you compensate for other factors like Patient satisfaction, quality, involvement in hospital affairs (aka things that keep your contract strong) etc? FWIW, these are the issues we are dealing with.

 

[GeneralVeers]

My group currently works on a strict hours worked basis. It is far from perfect and I prefer some measure of performance.

The issue for us is we have some spots with PAs, some without, some with scribes some without. This makes it a little harder to make it fair.

Also, shouldnt you compensate for other factors like Patient satisfaction, quality, involvement in hospital affairs (aka things that keep your contract strong) etc? FWIW, these are the issues we are dealing with.

How do you get people to work hard? If you're paying me a strict hourly rate, I'm going to figure out the minimum work needed to not get fired and work at that pace. It wouldn't motivate me to see that extra patient, come in a few minutes early, or stay late after my shift.

 

[shopsteward]

How do you get people to work hard? If you're paying me a strict hourly rate, I'm going to figure out the minimum work needed to not get fired and work at that pace. It wouldn't motivate me to see that extra patient, come in a few minutes early, or stay late after my shift.

The evidence is that performance pay for employees works in relation to quantity, and also in relation to quality in straightforward cases such as production-line jobs (eg numbers of good widgets produced per shift). There is little or no evidence to show that performance pay for employees works, long-term, in relation to quality where a job involves judgement issues, such as medicine, law, management, etc. Mostly in these cases performance pay for employees turns out over the long term to be demotivating for the majority of employees. There is a sizeable management industry devoted to creating performance pay systems for large firms, but it's all smoke and mirrors with little or no reputable research behind it and a lot of reputable research the other way.

Payment for results may work better for the self-employed, or for a group of the self-employed such as partners. But if your concern is to be in a partnership where everyone is motivated to produce both quality and quantity, you are better off making sure that you take the right people into the partnership (ie those who are self-motivated to do a good job). After that, it's a matter of making sure that people have the right conditions to carry on working happily, get the information they need to make sure that they are meeting the necessary performance standards, are paid fairly and have a way out if they need it.

 

[WilcoWorld]

How do you get people to work hard? If you're paying me a strict hourly rate, I'm going to figure out the minimum work needed to not get fired and work at that pace. It wouldn't motivate me to see that extra patient, come in a few minutes early, or stay late after my shift.

There are other motivators than money. I've worked at 2 places where the prevailing culture was to stay late to help out the other docs when needed. Both of these places were salaried jobs. Were we acting out of pure altruism? No, we were motivated by a desire to be judged favorably by our coworkers.

 

[Mighty Mouse]

I currently work for a group at an academic hospital. Base salary, twice yearly bonus based on academic contribution, and hourly moonlighting rate for extra shifts. Paid vacation.

I personally would never work for a group that was 100% RVU based. I feel like its hard to plan financially when your potential income is too variable. A few low volume days, a week of vacation, or some other variable could make for some lean checks. I think your present model of 50/50 is a good mix. You know at the very least that you're getting X dollars, and those who are proactive and see more patients, etc will generate more RVUs for themselves and still be compensated better than those who don't do the same.

 

[GeneralVeers]

I currently work for a group at an academic hospital. Base salary, twice yearly bonus based on academic contribution, and hourly moonlighting rate for extra shifts. Paid vacation.

I personally would never work for a group that was 100% RVU based. I feel like its hard to plan financially when your potential income is too variable. A few low volume days, a week of vacation, or some other variable could make for some lean checks. I think your present model of 50/50 is a good mix. You know at the very least that you're getting X dollars, and those who are proactive and see more patients, etc will generate more RVUs for themselves and still be compensated better than those who don't do the same.

We do 50/50 and I think it's a good mix. There is still reasonable compensation if you have a light shift, but if you put in that extra effort then there is at least some reward. It motivates even our slow-pokes to at least work a little harder.

The hourly difference between our top earner and low earner is about $30/hour.

 

[BADMD]

My small democratic ED group is currently considering changing the way we pay ourselves....

You know how I get paid and I think this is likely the best mix. Pay for RVUs exclusively can create some weird incentives.

One of the issues is how the patients are distributed. In a pure "you eat what you kill" model, if you see an uninsured patient, that sucks for you. Two easy, blue cross level 4 chest painers can pay you way more per hour than one critical care medicare (or worse medicaid). A little cherry picking can make a huge difference in work load and pay. Hopefully it would be a matter of adding up all the RVUs and then dividing pot, however to use that model, you have to create a time period over which the RVUs count in order divide out the pot, as insurers like to delay payment as much as possible. New people also tend to have a few very lean months under the "You eat what you kill model."

So, I like an hourly with an RVU based deferred compensation package. I think it is the best way to ensure steady income and give billing incentives.

 

[NinerNiner999]

I think determining a pay model is dependent on several variables, none of which can be answered here. Payer mix, accounts receivable, time in AR, and expected group reimbursement should all come into play.

In general, a mix of base pay and RVU/CPT productivity seems to work best IMO, but that ratio can only be determined by your group's profit and margin. A pure per-patient minimum is also a neat idea. In this model, each physician can get a minimum for each patient he/she sees (i.e. $40 per patient) PLUS a RVU/CPT multiplier to be determined by looking at the monthly collections and considering the outstanding AR. This would be based on expected collections (i.e. each physician is compensated regardless of what the group actually collects). Factor in a margin for the group and you also have room for a quarterly bonus pool. This would do two things:

1) Physicians who are happy with earning a "minimum" can see 2-3 patients per hour for a "base salary" of $80 - $120 per hour based on this example.

2) RVU/CPT potential could increase each patient's pay by $30-40 per patient based on level of acuity (levels 4 and 5), effectively doubling one's pay. Alternatively, a dollar amount per RVU ($5 per RVU per hour) can add up pretty quickly.

This also allows the group to absorb the "cost" of no pay charts and medicare reibursement. Again, highly dependent on your mix. Assuming you have calculated your base and productivity correctly, this would allow the group to retain a profit while buffering one month ahead for future collections. This would allow for a bonus pool as above.

One interesting point to consider - for a 45k volume department, every 1% LWOT or LWBS, costs the group $90,000 if you collect $200 per chart. Obviously, any system that promotes proactive physician practice to reduce these numbers adds serious revenue to the group.

 

[pinipig523]

Thanks for a good thread, guys.

 

[StevieStud]

There are other motivators than money. I've worked at 2 places where the prevailing culture was to stay late to help out the other docs when needed. Both of these places were salaried jobs. Were we acting out of pure altruism? No, we were motivated by a desire to be judged favorably by our coworkers.

The first time you get asked to come in early to clear out the waiting room and you hesitate or do a few errands before you casually stroll into the dept.......

....or the shift that you leave the next guy with 19 hanging around the admitting desk as you smile and depart for your warm bed.....

..... just remember, what goes around comes and around and payback is going to be a real bytch.

 

[docB]

We are all RVU. I like it. When I'm getting pummeled I can take solace in the bigger check I'll get. If I have an easy shift, hey, I had an easy shift and I'll take it.

I think the worst part is that many of my partners want to keep staffing so lean that we have to see what, in my opinion, is too many patients. They want the money and it's hard to get them to accept less money per hour to boost the staffing.

Another important point, we pay based on billing, not collections. That way there's no disincentive to see the uninsured.

 

[GeneralVeers]

I think some are confusing RVU-incentive with "eat what you kill". In almost every RVU model the insurance of the patient is irrelevent. All of the collections goes into one pot of money for the group that month (or quarter) then gets divided up equally based on RVU production. If I admit a self-pay chest pain, I get paid the same as if I admit a BC/BS chest pain.

This drastically reduces cherry picking and is reasonably fair.

 

[EctopicFetus]

As what seems like the only one working in a communist system I can say that motivation is an issue especially for a number of the older partners who trained in a different era.

In order to change our pay we need a 75% vote which would be quite difficult. We have talked about tons of different systems to get this in to provide some incentive to people.

On another note our young guys tend to behave well because no one wants to be labeled a douche. The older guys either dont care or are oblivious. This has long been discussed but the older (and louder) culture is to hide all sorts of data. Instead of giving us the productivity data we have to seek it out. This is def frustrating.

I think a mixture of a base plus RVU sharing is the fairest.

 

[GeneralVeers]

As what seems like the only one working in a communist system I can say that motivation is an issue especially for a number of the older partners who trained in a different era.
.

Even with productivity component it's hard to motivate some people. Every month we get the list of everyone's productivity. The lowest earners are ~ 9 RVU/hour while the top guy is ~14. If we didn't have the productivity component, would any of us be happy working 50% harder than the guy next to us for the same pay? I certainly wouldn't do it.

 

[DrQuinn]

we staff five hospitals, two of which are FFS. three of them are hourly rates paid for by the hospital. All of us work a mixture of FFS and hourly rates, so there's a little more standardization for pay.

For FFS, its based on BILLING and not collections. So there is no cherry picking. If I bill 5% of the groups charges for six months, then after all expenses are paid and my salaries are paid off and the leftover cash, basically I get 5% of the kitty.

Q

 

[deleted109597]

snip...Also, shouldnt you compensate for other factors like Patient satisfaction

No, at least not until we get a better way of doing it. Remember, none of the patients you admit count in your satisfaction scores. Thus, anybody that comes in really sick and you make a huge difference, you've lost that one.
Also, anyone that wants something and doesn't have a legitimate reason(CT/MRI/Narcotics/Admission), is going to screw you in your score.
One of the best PG scores at my shop is someone who has some of the worst clinical medicine, but will bend over backwards for the patients. I don't want to be that guy.
I'm not saying everyone should be a dick, but at the same time, we aren't the concierge either.

 

[Arcan57]

Having worked in base-pay only and RVU-only systems, I'm not sure my productivity changed that much based on pay system. I can tell you that I was constantly pissed off in the base-pay system that I was making the same as a couple of docs who had half the productivity (and probably billed 30-40% of what) I did.

The group that had the contract at my current shop prior to us was hourly and ended up losing the contract because their docs would go to lunch during crunch hours and leave patients sitting in rooms for hours before they were seen. I doubt changing the compensation model would have changed that behavior, but it may have helped prevent it from becoming entrenched. Also, this is what is wrong with saying the ideal model for physician employment is the salaried, hospital-employee model.

 

[dotcb]

I'm salaried in academics, which I like because I have no conflicts of interest, and charting is one of my least favorite activities. That said, I try to chart well and bill appropriately because it's good medicine and good for our group. If I were in a private group, I'd want a mix of base pay and RVU.

 

[GeneralVeers]

No, at least not until we get a better way of doing it. Remember, none of the patients you admit count in your satisfaction scores. Thus, anybody that comes in really sick and you make a huge difference, you've lost that one.
Also, anyone that wants something and doesn't have a legitimate reason(CT/MRI/Narcotics/Admission), is going to screw you in your score.
One of the best PG scores at my shop is someone who has some of the worst clinical medicine, but will bend over backwards for the patients. I don't want to be that guy.
I'm not saying everyone should be a dick, but at the same time, we aren't the concierge either.

We've already lost this one. My group (large, national) already bonuses for Press-Ganey performance. If you hit the 50th percentile you get $5/hour and if you hit 90th percentile you get $10/hour.

I've asked the question before about grade inflation. We cannot ALL be above the 50th percentile, as the percentile bar will get moved if people do better. As it is, you essentially need all 5s on all your surveys just to get above 75th percentile.

 

[EM_Rebuilder]

We are a mix.. probably 60% base rate, 30% RVU, and 10% that is a mixture of PG scores and core measures being met.

I liked the mixed ratio... if you want to work harder, you get a bit more reward.

I think the main key is a group of like minded individuals with common goals in mind...

 

[BADMD]

Also, shouldnt you compensate for other factors like Patient satisfaction, quality

Once there is a way to actually measure these things in an objective fashion, I'll consider it. As much as I would like my patients to be satisfied, it sure would be easy to give every viral syndrome a penicillin prescription and every painer an opioid. Patients often like the nice doctor, who isn't necessarily giving the best care.

involvement in hospital affairs (aka things that keep your contract strong) etc?

My deferred compensation package does have some non-patient care, but measurable factors, such as hospital committee membership and hospital related community service.

 

[EctopicFetus]

We are looking at systems to give us quality info. As a group of 40 private EM docs this is a challenge. We have some guys who practice in their own unique way.

Simply I think that while PG scores are crap we 1) tease out anyone with a dx of chronic pain and some other select diagnoses.

I despise patient satisfaction especially since I work at night and one of the strongest correlations is wait over which when I show up for my shift I have no control.

All that being said as much as we hate it (myself included, though my scores were/are really good) the hospital cares and since they are our "customer' we have to find a way to reward this as well.

Personally, I am for any change to our current total communist system at my shop. I just think that things are going well and no one wants to rock the boat too hard.

 

[deleted109597]

All that being said as much as we hate it (myself included, though my scores were/are really good) the hospital cares and since they are our "customer' we have to find a way to reward this as well.

I don't see it being a way to reward in the future. It will go from being a carrot to being a stick. If they would reward "good doctoring" I would be all for it. Instead, they reward "good charting" so much that I make more in extra RVUs then I spend on my scribe. I see that as a good tradeoff.
ACEP has already made a statement against Press Ganey, and if more groups would take a stand, the hospital wouldn't be able to use it.

 

[deleted65604]

I used to work for a pseudodemocratic group (it was just a dictatorship). The advertised pay was much less than the actual pay. The group gave bonuses every 6 months that were really random, and we were blinded as to how much we all got bonused. The bonuses were 50% of hourly wage. I don't think RVUs where used to determine the bonuses.

My current shop does have a bonus system where high-performers make more money hourly. But nothing is guaranteed in the contract and the mother company could easily take that away.Looking at the numbers and my pay-check, it looks like 90/10 hourly wage to bonus. However, our payor-mix sucks. Something like 30% medicaid, 30% self-pay, 30% medicare, and 10% private insured. Great contract, huh?

 

[EctopicFetus]

I don't see it being a way to reward in the future. It will go from being a carrot to being a stick. If they would reward "good doctoring" I would be all for it. Instead, they reward "good charting" so much that I make more in extra RVUs then I spend on my scribe. I see that as a good tradeoff.
ACEP has already made a statement against Press Ganey, and if more groups would take a stand, the hospital wouldn't be able to use it.

I dont know how a group could really take a stand without red flags going up. The hospital cares about this. The only other option is using some other system to "poll" patients. PG is bad news and the spreads are so tight im unsure if it matters at all.

 

[Apollyon]

I used to work for a pseudodemocratic group (it was just a dictatorship). The advertised pay was much less than the actual pay.

So they actually paid more than they told you they would?

 

[GeneralVeers]

I dont know how a group could really take a stand without red flags going up. The hospital cares about this. The only other option is using some other system to "poll" patients. PG is bad news and the spreads are so tight im unsure if it matters at all.

That's exactly my point. The difference in a doctor at the 99th percentile and one at the 75th percentile is often just one survey with a "4" on it. Is that doctor at the 99th percentile that much better at customer service? No, not necessarily, though I can guarantee you that the ones consistently at that level are doing some bad medicine to appease patients.

If ACEP made it official policy that reimbursement should not be tied to Press-Ganey, and if every group made a pact not to do it, then we wouldn't be doing it.

Basically if EmCare, Teamhealth, Schumacher, EMP, and CEP would band together and stop being the corporate ****** of medicine, we would be able to get rid of some of this crap.

 

[xaelia]

Supposedly my academic group got bonuses based on productivity/service to the department last year. I'd only been here a month, so I have no idea how substantial they were.

Seemed reasonable - the published patients per hour/RVU per hour had a metric ton of variability between the high productivity and low productivity, even in our relatively inefficient, high acuity environments where the residents bear the brunt of the gruntwork....

 

[TysonCook]

...at one of my sites we're 100% ffs, including bonus, based on Billing, no PG involved. People that aren't partner yet are paid an hourly rate, no bonus.

Definitely improved the "older" workers and those that are less productive to move, as it was a serious problem before.

At my academic site the whole group bonuses based on department (not individual) RVU's, with a base salary, no PG involved.
-------------------------------------------------
On another note, how do you guys handle the night differential? In particular those that agree to only do nights? One of my shops does a shift reduction, the other a modest increase in hourly rate, but in particular I'm looking for hard numbers (e.g. 20% less shifts, paid X % more per shift, get to pick schedule, no weekends etc).

Thanks!

 

[EctopicFetus]

Tyson,

At my place we do a $40/hour pay differential for nights. We researched this and there was some data out there that the avg is $50/hr.

Hope this helps. On another note our PAs who only work nights 2 of them, get a 25% reduction. They work the same number of shifts but for 9 hours of work they get 12 hours of pay.

 

[pinipig523]

Tyson,

At my place we do a $40/hour pay differential for nights. We researched this and there was some data out there that the avg is $50/hr.

Hope this helps. On another note our PAs who only work nights 2 of them, get a 25% reduction. They work the same number of shifts but for 9 hours of work they get 12 hours of pay.

Dang.... 40$/h differential for nights??

I only get $8/h differential... lol.

 

[deleted65604]

So they actually paid more than they told you they would?

Yeah, $80,000-$100,000 more a year than advertised.

 

[pinipig523]

Yeah, $80,000-$100,000 more a year than advertised.

So, if it's not rude, why did you transfer from your prior job?

 

[The White Coat Investor]

Our night diff is 50%, so sometimes $100 or greater. I don't know if anyone in the group would do it for a measly $40 an hour. I doubt we could cover all the nights that way.

Our group is strictly hourly (well, divide the pot, then split it by hours worked). Want to make more? Work more shifts or work at night.

 

[UnderwaterDoc]

Our night diff is 50%, so sometimes $100 or greater.

😱!!!

Woah, if you don't mind me asking, which area of the country are you?

 

[docB]

So they actually paid more than they told you they would?

I've seen this before. My impression is that some groups want to low ball applicants for various reasons. They want someone who is coming based on lower expectations. They want someone who cares less about $$$ and more about other stuff. They don't want anyone complaining they aren't making as much as promised. They only want to promise what the lowest producing person is making or what is in the contract without bonuses to ensure they can't be accused of inflating the offer.

 

[TysonCook]

Emailed several of my buddies in other groups and the lowest I've seen is $20/hr and that is without a pure nights only situation (everybody gets paid more for the nights). The rest are right around $40-$60hr.

Anyone else that can weigh in on how their groups do nights only staffing and compensation?

 

[la gringa]

Tyson Cook,

i am starting in your neighborhood... $10/hr regular nts, $20/hr if you do all nights. by telling you that, you probably know where i'll be working 😉

former job paid nothing extra for nights unless you did all nights, and they were vague about how that changed things (though those people did seem to make junior partner faster). come to think about it, they were vague about a lot of things... one reason i left! that, and the absurd cost of living compared to pay...

 

[The White Coat Investor]

I've seen this before. My impression is that some groups want to low ball applicants for various reasons. They want someone who is coming based on lower expectations. They want someone who cares less about $$$ and more about other stuff. They don't want anyone complaining they aren't making as much as promised. They only want to promise what the lowest producing person is making or what is in the contract without bonuses to ensure they can't be accused of inflating the offer.

Yes, my group definitely didn't want to talk about money when I was interviewing. In fact, it's pretty stupid to bring money up. I'd just concentrate on being treated fairly. If you're joining a democratic group, you'll be getting what everyone else is getting anyway. Trust me, you'll be no happier making $250K instead of $200, or $350K instead of $300. Choose your job based on the quality of the people you'll be working with. Your initial contract will only be 1-3 years anyway until you make partner.

If you want a big night diff, join a group where everyone wants day shifts. It helps if you pick a group that is very lifestyle oriented rather than money oriented. For $20 an hour, I wouldn't work a single night shift. Most of my group feels the same way.

 

[robin082006]

Sh--

I am a nocturnist and recently I found out that they pay me the same as daytime hospitalist (5$/h different). Because I don't round so I see less patients than daytime people, so my RVU is 1/3-1/2 in compared with daytime guys.

Then I was shocked again because my total income is less than daytime guys because I get the minimum bonus and lowest RVU.

I volunteer to do night shifts which everyone refuses to do, now I understood why they refused (work like a resident but get the least). Bull-sh..

I am looking for another nocturnist position.

Where do they pay 40-50$/h different? I will do night shift in that place.

 

[Apollyon]

Sh--

I am a nocturnist and recently I found out that they pay me the same as daytime hospitalist (5$/h different). Because I don't round so I see less patients than daytime people, so my RVU is 1/3-1/2 in compared with daytime guys.

Then I was shocked again because my total income is less than daytime guys because I get the minimum bonus and lowest RVU.

I volunteer to do night shifts which everyone refuses to do, now I understood why they refused (work like a resident but get the least). Bull-sh..

I am looking for another nocturnist position.

Where do they pay 40-50$/h different? I will do night shift in that place.

Your post sounds like IM. Also, I've only heard the term "nocturnist" referring to IM.

 

[EctopicFetus]

Your post sounds like IM. Also, I've only heard the term "nocturnist" referring to IM.

What he said...

 

[Hamhock]

How do you get people to work hard? If you're paying me a strict hourly rate, I'm going to figure out the minimum work needed to not get fired and work at that pace. It wouldn't motivate me to see that extra patient, come in a few minutes early, or stay late after my shift.

pathetic

animalistic

like a beast

HH

 

[docB]

pathetic

animalistic

like a beast

HH

But he's right. That is what many groups degenerate to without any incentive to go the other way.

 

[GeneralVeers]

pathetic

animalistic

like a beast

HH

You deny the true nature of humans. Very few of us are altruistic. Whether we admit it or not, we all perform based on selfish goals and wants. That is why communism has never worked, and any system where you deny the true nature of human motivation is doomed to failure.

 

[Birdstrike]

.

 

[Lokhtar]

Well a lot of companies pay their employees salaries or a set hourly rage and have developed metrics to make sure the employees are sufficiently productive. At one of my dads jobs he'd get a letter every month ranking him on a percentile basis in terms of quality and another ranking on quantity. Being in the bottom 10% got you a meeting with the boss - and continually being there got you canned.

 

[GeneralVeers]

Well a lot of companies pay their employees salaries or a set hourly rage and have developed metrics to make sure the employees are sufficiently productive. At one of my dads jobs he'd get a letter every month ranking him on a percentile basis in terms of quality and another ranking on quantity. Being in the bottom 10% got you a meeting with the boss - and continually being there got you canned.

Agree completely. This is how we should conduct business. If you're a low producer, you should move to a slower environment or you should speed up.