How does the RVU model work?

[Backpack234]

I've seen a few EM practices that pay different variations of RVU-based pay and somehow end up with similar or extremely different annual salaries. For example:

Base only: 225/hr
RVU only: 200/hr
Base + RVU: 175/hr + RVU "Our guys average around 240/hr"
Base + RVU incentives: 200/hr + RVU "Our guys average around 225"

I'm not sure how RVU can equal $200/hr but can also equal $75/hr, $25/hr, and seemingly everything else.

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[BoardingDoc]

I've seen a few EM practices that pay different variations of RVU-based pay and somehow end up with similar or extremely different annual salaries. For example:

Base only: 225/hr
RVU only: 200/hr
Base + RVU: 175/hr + RVU "Our guys average around 240/hr"
Base + RVU incentives: 200/hr + RVU "Our guys average around 225"

I'm not sure how RVU can equal $200/hr but can also equal $75/hr, $25/hr, and seemingly everything else.

You can't look at each of these offers and figure out what the RVUs you generate are worth.

Job 1: base pay only. Anything you generate over your base goes to mgmt.
Job2: This may or may not be a purely keep what you kill model. You can't advertise an exact rate with a pure RVU model as everyone's productivity is different. The 200/hr you're seeing may be the base, or it may be what the group averages.
Job3: Your base is 175/hr, so even if you have a super slow run of shifts, you will always make that amount. That said, your comp is likely around 240/hr. This is either because 240/hr is what they're actually bringing in, or it's because they bring in more than 240/hr on avg and corporate keeps some and gives out enough to get you to 240.
Job 4: You always make at least 200/hr. Basically everyone is generating significantly more than 225/hr. Mgmt gives you a cut of your productivity and keeps the rest.

There will always be variation in what your RVUs are worth from one site to another, but you're misconstruing base + RVU to mean "you get what you generate, plus a base pay." It doesn't. It means "we will pay you X amount of dollars even if you don't generate that much. If you generate more money than your base, you will get some of that excess as a bonus."

 

[southerndoc]

I work in an RVU-based place. We have an hourly minimum plus shift differentials if we're working a really slow shift/month. We're paid so much per RVU.

You should ask the jobs that pay RVU's how much per RVU you'll be paid and what the group average RVU is per hour/shift.

You basically get so many RVU's for seeing the patient based on level of acuity (1-5) plus RVU's for procedures, EKG interpretations (if your group bills for them), etc.

 

[deleted109597]

Poorly in my experience with CMGs.
You have to stay on top of them to make sure you are getting credit for your work. This means keeping stickers in a log so at the end of the month when that check is less than you expect, you can ask them for all the charges in your name, and then compare them.
The slower people in your group will complain that you're stealing from them. Because you took a chart out of the rack when it was "their turn" or some nonsense. They will often complain to the point that the CMG will simply get rid of it at the site. I've seen this happen at 2 places in the last 7 years.
Hell, I saw them put a cap on one physician because his paycheck would routinely be 2x the slowest person. And we all know medicine is supposed to be socialist, and we should all get paid the same regardless of how hard we work, etc.

 

[Groove]

If you work for a CMG like myself then forget about being able to obtain any semblance of transparency with the compensation. In the CMG world, RVU based practice simply means that you will likely get compensated more for increased productivity (usually most easily translated to higher pph). Sometimes there are group averaging modifiers which bring up the low producers and bring down the high producers so that everyone averages out and it reigns in the standard deviations. Regardless, the math is never shared with the docs. They will give you access to a lot of cooked numbers and moving variables where the arbitrary variables that change each month can't be explained very well. Trust me, I've tried making sense of it and applying various algorithms to the process and it's virtually always a bunch of fuzzy math. My questions have never been answered to my satisfaction. Regardless, hey....its a CMG so how much transparency can you really expect? At the end of the day, if you work for one of these guys you just have to relax and the ultimate question is whether you feel fairly compensated at the end of the month. Most CMGs will try to stay competitive with the local market and raise or lower compensation accordingly. Most will reward the higher producers within reason to incentivize productivity and penalize the lower producers by lowering their compensation. They don't want to lower the compensation too much, or else you might suffer a mass exodus of docs. They don't want to pay you too much, or else the company loses profits. They'd ideally like to pay you slightly more than the rest of the jobs in town so that you will stay right where you are...

The disadvantage is that on slow days...there is a lot of sniping. There's an underlying competitive aggressive drive that permeates your shift (if you let it) where you are worried that you won't see enough patients and are anxious that your partner on shift is going to steal or cherry pick all the good charts. This can really ruin your attitude and stress level if you pander to the mentality. What I've found is that if you just relax, do your job, go at a reasonable level and stop worrying about it all...things generally work out because like I said, the CMG doesn't want to lose you at the end of the day. They aren't stupid and they want to at the very least make you feel like you are being compensated fairly for your market.

All this might make a fixed hourly compensation sound much better but then you would likely be pissed off because you're seeing 3pph and your partner is AWOL taking snack breaks and seeing 1pph while still making the same amount of money. I think the ideal compensation model is somewhere in the middle but if I had to choose, I'd go with RVU as if I'm working hard, I can rest in the knowledge that I'm getting paid for my work. Also, there is much less sniping if you have a reasonably staffed ED without too many scheduled physician hours and without too many MLPs.

 

[Groove]

At the end of the day, simplify your questions to the CMG and just ask them what the average compensation is for their docs (along with average pph). Also ask them what the compensation is for their lowest and highest producers (as well as pph for these docs). This will give you the realistic range volatility that you can expect. They should at the very least be willing to give you this information. If they aren't willing to cough up that information, then I wouldn't work for them.

Also, for a lot of you guys coming out of residency, I can't stress enough to inquire adequately as to the pph and quit focusing so much on the hourly compensation. A lot of us have said before, and I can't say enough...but $260/hr at 2.6pph is MUCH different than $240/hr at 1.8pph. For the right market, all things otherwise being equal, I'd choose the latter job virtually every time.

 

[Brigade4Radiant]

If the books are closed (like many RVU CMG) then it doesn't matter you can see 2.7 pph and still be capped at 230. Also you'll compete with other docs and see things like seeing patient's in the ambulance bay. However there a lot of things like holding, bed turnover, transferring patient's out, being on diversion, working night shifts, working with docs who want to see everything. That in my opinion isn't worth it unless you have pods or are single coverage.

 

[Backpack234]

You can't look at each of these offers and figure out what the RVUs you generate are worth.

Job 1: base pay only. Anything you generate over your base goes to mgmt.
Job2: This may or may not be a purely keep what you kill model. You can't advertise an exact rate with a pure RVU model as everyone's productivity is different. The 200/hr you're seeing may be the base, or it may be what the group averages.
Job3: Your base is 175/hr, so even if you have a super slow run of shifts, you will always make that amount. That said, your comp is likely around 240/hr. This is either because 240/hr is what they're actually bringing in, or it's because they bring in more than 240/hr on avg and corporate keeps some and gives out enough to get you to 240.
Job 4: You always make at least 200/hr. Basically everyone is generating significantly more than 225/hr. Mgmt gives you a cut of your productivity and keeps the rest.

There will always be variation in what your RVUs are worth from one site to another, but you're misconstruing base + RVU to mean "you get what you generate, plus a base pay." It doesn't. It means "we will pay you X amount of dollars even if you don't generate that much. If you generate more money than your base, you will get some of that excess as a bonus."

Thanks for the reply. I'm definitely thinking that RVU means you get base pay plus a % bonus for what you generate. Thinking about that from the business/employer side though, that would mean docs would end up making way more than I could get away with paying them and they'd be eating into my profits

 

[Backpack234]

I work in an RVU-based place. We have an hourly minimum plus shift differentials if we're working a really slow shift/month. We're paid so much per RVU.

You should ask the jobs that pay RVU's how much per RVU you'll be paid and what the group average RVU is per hour/shift.

You basically get so many RVU's for seeing the patient based on level of acuity (1-5) plus RVU's for procedures, EKG interpretations (if your group bills for them), etc.

This is where I see a ton of potential for RVU vs non RVU. I've been reading up on it and it seems like there's an insane amount of RVUs for just being an ER doctor. CXR interpretation? That's $10 that I generate about 5 times per hour. EKG read? $10 every 5 minutes. Then there's the actual RVUs for acuity level and I see a ton of missed potential income in a non RVU model.

 

[Backpack234]

Poorly in my experience with CMGs.
You have to stay on top of them to make sure you are getting credit for your work. This means keeping stickers in a log so at the end of the month when that check is less than you expect, you can ask them for all the charges in your name, and then compare them.
The slower people in your group will complain that you're stealing from them. Because you took a chart out of the rack when it was "their turn" or some nonsense. They will often complain to the point that the CMG will simply get rid of it at the site. I've seen this happen at 2 places in the last 7 years.
Hell, I saw them put a cap on one physician because his paycheck would routinely be 2x the slowest person. And we all know medicine is supposed to be socialist, and we should all get paid the same regardless of how hard we work, etc.

Hadn't thought about the issue with non-transparency, but I always imagined that a group RVU model might be better than individual RVU. Rather than the game of slow playing low RVU patients and quickly grabbing high RVU charts, we could all just work together in the department and see the same benefit. Also have incentives to see more people since more pt's = more RVUs.

 

[BoardingDoc]

This is where I see a ton of potential for RVU vs non RVU. I've been reading up on it and it seems like there's an insane amount of RVUs for just being an ER doctor. CXR interpretation? That's $10 that I generate about 5 times per hour. EKG read? $10 every 5 minutes. Then there's the actual RVUs for acuity level and I see a ton of missed potential income in a non RVU model.

An EM doc does generate a lot of RVUs, however, your estimates are extremely off. 5 CXRs an hour? An EKG every 5 minutes? You're getting 40 CXRs a shift and 96 EKGs a shift? In reality, you're doing maybe 10 CXRs a shift tops and maybe 10 EKGs. That's 200 bucks total. Not a lot of money.

Yes, everything you do does add up, but not quite the way you're thinking.

 

[BoardingDoc]

Hadn't thought about the issue with non-transparency, but I always imagined that a group RVU model might be better than individual RVU. Rather than the game of slow playing low RVU patients and quickly grabbing high RVU charts, we could all just work together in the department and see the same benefit. Also have incentives to see more people since more pt's = more RVUs.

If you have a group pool of RVUs, you will always be dragged down by the slower docs. Your incentive to go faster also rapidly vanishes seeing as you're now splitting your gains with everyone else. In a perfect world, it would work like you say. In the real world, game theory wins and people realize that they get a chunk of cash regardless of whether they work harder or not... so they opt for "not".

 

[Backpack234]

If you work for a CMG like myself then forget about being able to obtain any semblance of transparency with the compensation. In the CMG world, RVU based practice simply means that you will likely get compensated more for increased productivity (usually most easily translated to higher pph). Sometimes there are group averaging modifiers which bring up the low producers and bring down the high producers so that everyone averages out and it reigns in the standard deviations. Regardless, the math is never shared with the docs. They will give you access to a lot of cooked numbers and moving variables where the arbitrary variables that change each month can't be explained very well. Trust me, I've tried making sense of it and applying various algorithms to the process and it's virtually always a bunch of fuzzy math. My questions have never been answered to my satisfaction. Regardless, hey....its a CMG so how much transparency can you really expect? At the end of the day, if you work for one of these guys you just have to relax and the ultimate question is whether you feel fairly compensated at the end of the month. Most CMGs will try to stay competitive with the local market and raise or lower compensation accordingly. Most will reward the higher producers within reason to incentivize productivity and penalize the lower producers by lowering their compensation. They don't want to lower the compensation too much, or else you might suffer a mass exodus of docs. They don't want to pay you too much, or else the company loses profits. They'd ideally like to pay you slightly more than the rest of the jobs in town so that you will stay right where you are...

The disadvantage is that on slow days...there is a lot of sniping. There's an underlying competitive aggressive drive that permeates your shift (if you let it) where you are worried that you won't see enough patients and are anxious that your partner on shift is going to steal or cherry pick all the good charts. This can really ruin your attitude and stress level if you pander to the mentality. What I've found is that if you just relax, do your job, go at a reasonable level and stop worrying about it all...things generally work out because like I said, the CMG doesn't want to lose you at the end of the day. They aren't stupid and they want to at the very least make you feel like you are being compensated fairly for your market.

All this might make a fixed hourly compensation sound much better but then you would likely be pissed off because you're seeing 3pph and your partner is AWOL taking snack breaks and seeing 1pph while still making the same amount of money. I think the ideal compensation model is somewhere in the middle but if I had to choose, I'd go with RVU as if I'm working hard, I can rest in the knowledge that I'm getting paid for my work. Also, there is much less sniping if you have a reasonably staffed ED without too many scheduled physician hours and without too many MLPs.

I like your perspective. If I remember right from a previous post, you work with Apollo, correct? I've been strongly considering one of their locations for my next job. Interestingly though, I haven't yet run into a lazy partner. Every doc I work with now seems to be seeing patients as soon as possible and we cover for each other which has been nice. That's why I imagine a group RVU bonus model would be good.

 

[Backpack234]

At the end of the day, simplify your questions to the CMG and just ask them what the average compensation is for their docs (along with average pph). Also ask them what the compensation is for their lowest and highest producers (as well as pph for these docs). This will give you the realistic range volatility that you can expect. They should at the very least be willing to give you this information. If they aren't willing to cough up that information, then I wouldn't work for them.

Also, for a lot of you guys coming out of residency, I can't stress enough to inquire adequately as to the pph and quit focusing so much on the hourly compensation. A lot of us have said before, and I can't say enough...but $260/hr at 2.6pph is MUCH different than $240/hr at 1.8pph. For the right market, all things otherwise being equal, I'd choose the latter job virtually every time.

Excellent thought here and something i agree with completely. I've been trying to find the my true value and what hourly rate I could command based on what I actually generate. That's what prompted this whole thought process on RVUs. Now, I would say that at least in my area, there's $260/hr at 2.6pph but the 1.8pph is closer to $180-200/hr. As the numbers diverge more, the $ starts to look more important than pph at times.

 

[Backpack234]

An EM doc does generate a lot of RVUs, however, your estimates are extremely off. 5 CXRs an hour? An EKG every 5 minutes? You're getting 40 CXRs a shift and 96 EKGs a shift? In reality, you're doing maybe 10 CXRs a shift tops and maybe 10 EKGs. That's 200 bucks total. Not a lot of money.

Yes, everything you do does add up, but not quite the way you're thinking.

Those estimates were more example (re: exaggeration?) than anything, but you're right that I would have to crunch the actual numbers if I were doing the real calculations.

 

[Backpack234]

If you have a group pool of RVUs, you will always be dragged down by the slower docs. Your incentive to go faster also rapidly vanishes seeing as you're now splitting your gains with everyone else. In a perfect world, it would work like you say. In the real world, game theory wins and people realize that they get a chunk of cash regardless of whether they work harder or not... so they opt for "not".

Haven't thought about docs applying game theory in the department. At least where I work and through my residency everyone seemed to work at their fastest pace. Some people are definitely slower than others for whatever reason, but I don't know if I've seen anyone try to actually game the system and use their partners like that. At least not yet.

 

[EctopicFetus]

Haven't thought about docs applying game theory in the department. At least where I work and through my residency everyone seemed to work at their fastest pace. Some people are definitely slower than others for whatever reason, but I don't know if I've seen anyone try to actually game the system and use their partners like that. At least not yet.

Human nature is human nature. Just because you havent noticed it doesnt mean it is not happening. Believe that it is happening. Open your eyes. If you had open books you would realize it is happening all the time.

 

[Groove]

I like your perspective. If I remember right from a previous post, you work with Apollo, correct? I've been strongly considering one of their locations for my next job. Interestingly though, I haven't yet run into a lazy partner. Every doc I work with now seems to be seeing patients as soon as possible and we cover for each other which has been nice. That's why I imagine a group RVU bonus model would be good.

Yes, I’ve worked for Apollo for 5 yrs. No big complaints other than ones that can be applied to any CMG. They’ve treated me fairly but I’m careful not to hold any loyalty to a CMG. If a better opportunity showed up in town, I would probably take it. Luckily they have remained fairly competitive for our market. I also work with a good crew of docs and enjoy the company. All in all it’s a pretty good gig. Feel free to PM me if you ever want details regarding Apollo in the future.

 

[thegenius]

Poorly in my experience with CMGs.
You have to stay on top of them to make sure you are getting credit for your work. This means keeping stickers in a log so at the end of the month when that check is less than you expect, you can ask them for all the charges in your name, and then compare them.
The slower people in your group will complain that you're stealing from them. Because you took a chart out of the rack when it was "their turn" or some nonsense. They will often complain to the point that the CMG will simply get rid of it at the site. I've seen this happen at 2 places in the last 7 years.
Hell, I saw them put a cap on one physician because his paycheck would routinely be 2x the slowest person. And we all know medicine is supposed to be socialist, and we should all get paid the same regardless of how hard we work, etc.

I work at a 100% RVU place and in the bottom 1/3 to 1/2 of pay, we all work hard we never lollygag around during work. Some make more than others because
1) they are more efficient
2) they run more tests
3) they don't think as much as others, e.g. spending time on whether to run test x or y. they just do it
4) they bill / chart better
5) they lie on their chart and bill for CC when it's not applicable

It's mostly 1-3 above.

In my experience those who excel at RVU payment practice bad medicine. They are not necessarily bad doctors, but they practice medicine with an aim to make as much money as possible. I know this will generate lots of criticism, but that's my experience where I work.

You are not paid for your time spent with patients. Not in the ER, not in an outpatient office. You will run the 5th CT Head scan in 1 month for headache because you don't bother to look at the history.

 

[thegenius]

If you work for a CMG like myself then forget about being able to obtain any semblance of transparency with the compensation. In the CMG world, RVU based practice simply means that you will likely get compensated more for increased productivity (usually most easily translated to higher pph). Sometimes there are group averaging modifiers which bring up the low producers and bring down the high producers so that everyone averages out and it reigns in the standard deviations. Regardless, the math is never shared with the docs. They will give you access to a lot of cooked numbers and moving variables where the arbitrary variables that change each month can't be explained very well. Trust me, I've tried making sense of it and applying various algorithms to the process and it's virtually always a bunch of fuzzy math. My questions have never been answered to my satisfaction. Regardless, hey....its a CMG so how much transparency can you really expect? At the end of the day, if you work for one of these guys you just have to relax and the ultimate question is whether you feel fairly compensated at the end of the month. Most CMGs will try to stay competitive with the local market and raise or lower compensation accordingly. Most will reward the higher producers within reason to incentivize productivity and penalize the lower producers by lowering their compensation. They don't want to lower the compensation too much, or else you might suffer a mass exodus of docs. They don't want to pay you too much, or else the company loses profits. They'd ideally like to pay you slightly more than the rest of the jobs in town so that you will stay right where you are...

The disadvantage is that on slow days...there is a lot of sniping. There's an underlying competitive aggressive drive that permeates your shift (if you let it) where you are worried that you won't see enough patients and are anxious that your partner on shift is going to steal or cherry pick all the good charts. This can really ruin your attitude and stress level if you pander to the mentality. What I've found is that if you just relax, do your job, go at a reasonable level and stop worrying about it all...things generally work out because like I said, the CMG doesn't want to lose you at the end of the day. They aren't stupid and they want to at the very least make you feel like you are being compensated fairly for your market.

All this might make a fixed hourly compensation sound much better but then you would likely be pissed off because you're seeing 3pph and your partner is AWOL taking snack breaks and seeing 1pph while still making the same amount of money. I think the ideal compensation model is somewhere in the middle but if I had to choose, I'd go with RVU as if I'm working hard, I can rest in the knowledge that I'm getting paid for my work. Also, there is much less sniping if you have a reasonably staffed ED without too many scheduled physician hours and without too many MLPs.

This sums it up perfectly, I agree with everything here, sentiment and all.

I'm one of those who is bothered that I work as hard as the other guy and don't paid as much in an 100% RVU model. I also understand the problem with hourly pay and being lazy...and that was solved at one of my workplaces by having a computer assign patients a doctor on a cycle. So there is an even distribution of patients to docs. That seemed to solve that issue.

Lastly, there are people I work with who sign up for a patient then don't see them for 45-60 minutes. That's the kind of crap you sometimes experience.

 

[thegenius]

Thanks for the reply. I'm definitely thinking that RVU means you get base pay plus a % bonus for what you generate. Thinking about that from the business/employer side though, that would mean docs would end up making way more than I could get away with paying them and they'd be eating into my profits

no..no..no......There are all sorts of models

I'm 100% RVU. Meaning if I go to work and see 0 patients, I make no money.

You have hybrid models
- 75% hourly, 25% RVU
- 50% hourly, 50% RVU
- etc.

then there are 100% hourly. Sometimes in these cases there are quarterly or EOY bonuses based on productivity


The RVU multiplier ($15/RVU, $20/RVU, $30/RVU, etc..) in all these cases are different, so it's really meaningless to compare one site to another if they have different payment schemes.

 

[thegenius]

This is where I see a ton of potential for RVU vs non RVU. I've been reading up on it and it seems like there's an insane amount of RVUs for just being an ER doctor. CXR interpretation? That's $10 that I generate about 5 times per hour. EKG read? $10 every 5 minutes. Then there's the actual RVUs for acuity level and I see a ton of missed potential income in a non RVU model.

On some level that is correct, but remember that you are billing insurance companies CPT codes with reimbursement. So if you are 100% hourly and your group is good at recording EKGs, splints, procedures, CC time your hourly rate goes up. Being in an RVU system really places a premium on charting accurately and not missing anything, which can be a chore and also lead lying on charts

 

[thegenius]

Excellent thought here and something i agree with completely. I've been trying to find the my true value and what hourly rate I could command based on what I actually generate. That's what prompted this whole thought process on RVUs. Now, I would say that at least in my area, there's $260/hr at 2.6pph but the 1.8pph is closer to $180-200/hr. As the numbers diverge more, the $ starts to look more important than pph at times.

I would be quite scared coming out of residency doing 2.6 pph. That is very very hard to do even if you have moderate acuity. Doable with Urgent Care type patients, but all you need are 3 old dizzy /weak patients, 1 trauma, and a guy with poor IV access that requires a non-emergent central line and other crap and you can't do 2.6 /hr or you are staying after 1.5 hours to clean up your mess.

 

[Restart13]

How much does your pay vary in a CMG shop that is 100% RVU? If you're on a slow shift vs a busy shift how much $/hr is it changing? Are we talking like $5-10/hr or $25-50/hr?

 

[Zebra Hunter]

How much does your pay vary in a CMG shop that is 100% RVU? If you're on a slow shift vs a busy shift how much $/hr is it changing? Are we talking like $5-10/hr or $25-50/hr?

It's entirely dependent on how much they are taking off the top as well as where you work. For a typical ER, with a typical patient you are making about 4.5 RVUs per patient. Medicare pays ~$36/RVU which is about average what you'll bring in for all comers if you include self-pay and insured patients. The average physician in an average ED sees 2.2 pph. That means the average ED doc is generating ~$350/hr. However, with many CMGs you might only be getting paid $25/RVU, as they are keeping $10-11/RVU for themselves. So if your job is truly "100% RVU" and there are no ceilings to how much you can earn, then going from 2pph to 3pph might lead to an increase of $100+/hr.

 

[Zebra Hunter]

I would be quite scared coming out of residency doing 2.6 pph. That is very very hard to do even if you have moderate acuity. Doable with Urgent Care type patients, but all you need are 3 old dizzy /weak patients, 1 trauma, and a guy with poor IV access that requires a non-emergent central line and other crap and you can't do 2.6 /hr or you are staying after 1.5 hours to clean up your mess.

Meh, a pace less than 2.5pph and I'm bored, and I work in a very high acuity ED my first year out of residency and I normally am out right on time. I do have scribes, however, which makes it easy to see a ton.

 

[thegenius]

It's simple math:
$25 / RVU
4 RVU / patient
20 pts a shift

$25 * 4 * 20 = $2000

The numbers are fungible...
...maybe you see 25 pts / shift (~$2,500)
...maybe you guys average 4.5 RVU / patient (seems high to me...) (~$2,250)

It's all math.

 

[sum dude]

I've seen a few EM practices that pay different variations of RVU-based pay and somehow end up with similar or extremely different annual salaries. For example:

Base only: 225/hr
RVU only: 200/hr
Base + RVU: 175/hr + RVU "Our guys average around 240/hr"
Base + RVU incentives: 200/hr + RVU "Our guys average around 225"

I'm not sure how RVU can equal $200/hr but can also equal $75/hr, $25/hr, and seemingly everything else.

For the most part, I'm for having RVU-based incentives. Nothing is more painful than having to pick up slack for slow doctors without compensation (also, you should get compensated for getting killed).

Ask how much they make per RVU. Also ask if you get credit for PA RVU charts you co-sign (adds to 1-2 RVU per hour in busy places). Then ask for median (if they have it, if not average) RVU per provider. FWIW, if you are a new grad, expect to be below average RVU's for at least 6 months-1 year (possibly longer), no matter how awesome or quick you are.

Base + RVU is best if you are risk averse, but I can tell you from experience that the "base" is a mirage--it's usually a number so low, when you average out all your patients, virtually everyone in group makes over the "base". Base + RVU incentives usually are a nice little bonus, but not enough to make a significant dent in you pay (eg it will probably add 10-20% at most to your pay over quarter).

Also, ask to see formula, and be aware of RVU "Tricks". Tricks include: not including APP RVU's, weighing higher RVU's based on higher hours (eg benefits those who work most hours at a campus get greater percentage of RVU's), basing RVU's on collections (instead of billed--this is huge red flag that creates cherry picking), and groups that don't pay for several months (eg first paycheck 3 months after starting--suggests group doesn't have enough cash on hand to hit payroll--very concerning for financial health).

 

[turkeyjerky]

So I've hit world straight hourly, as well as hourly with a small RVU bonus (5-10% of pay so not enough to affect my behavior or attitude on shift). But one thing I'm curious about is how you handle slow shifts or days when everything is bogged down (boarders, lab slow etc)

I mean I get irritated enough already when I can't move patients through bc of system delays, I would imagine id be furious if I was also making less money on these days. Also do holidays (typically slower than usual) and overnights especially suck?

 

[bravotwozero]

So I've hit world straight hourly, as well as hourly with a small RVU bonus (5-10% of pay so not enough to affect my behavior or attitude on shift). But one thing I'm curious about is how you handle slow shifts or days when everything is bogged down (boarders, lab slow etc)

I mean I get irritated enough already when I can't move patients through bc of system delays, I would imagine id be furious if I was also making less money on these days. Also do holidays (typically slower than usual) and overnights especially suck?

Trust me on this, even if boarding, you can always see patients. even on those days, there's at least one ED doc who climbs to the top of the RVU pool. Figure out how they're doing it, and copy. At my old shop, we have a room where they do ekg's. when boarding, we just pull patients there and keep seeing them, and putting in labs. lab techs and radiologist techs will take patients even when sitting in the waiting room.

 

[e30ftw]

I worked hourly for the first 3 years and have been 100% RVU for the past two. I prefer an RVU model as a 1099, as long as it's fair. My average hourly went up between $50-70 after switching to RVU compensation. Granted we were underpaid from the prior CMG under the hourly model but still a significant increase in compensation for essentially the same work.

So I've hit world straight hourly, as well as hourly with a small RVU bonus (5-10% of pay so not enough to affect my behavior or attitude on shift). But one thing I'm curious about is how you handle slow shifts or days when everything is bogged down (boarders, lab slow etc)

I mean I get irritated enough already when I can't move patients through bc of system delays, I would imagine id be furious if I was also making less money on these days. Also do holidays (typically slower than usual) and overnights especially suck?

On slow shifts you enjoy the downtime and go home a few hours early. On days that are bogged down, PIT patients, open hallway beds, etc. Essentially the same thing you would do as an hourly doc to move the dept. My $/shift swings from probably $1500 on a slow early day shift where I leave by noon to $3500 on a busy mid-shift with a lot of mid-level patients. I couldn't care less about the difference, on the slow days I just go home and enjoy the time off. My gross is still $20k/mo over expenses. I'm currently on nights: first two nights had 35 charts/night so probably $3k per shift (a few of those are midlevel pts so around 3pt/hr for my patients). Tonight halfway through the shift I have 20 charts, lower acuity and it feels "slow" and I'm loving it..

I'd be totally fine if no one else checked in and I spent the whole time vacation planning, chatting with nurses and online shopping lol.

 

[Groove]

I worked hourly for the first 3 years and have been 100% RVU for the past two. I prefer an RVU model as a 1099, as long as it's fair. My average hourly went up between $50-70 after switching to RVU compensation. Granted we were underpaid from the prior CMG under the hourly model but still a significant increase in compensation for essentially the same work.



On slow shifts you enjoy the downtime and go home a few hours early. On days that are bogged down, PIT patients, open hallway beds, etc. Essentially the same thing you would do as an hourly doc to move the dept. My $/shift swings from probably $1500 on a slow early day shift where I leave by noon to $3500 on a busy mid-shift with a lot of mid-level patients. I couldn't care less about the difference, on the slow days I just go home and enjoy the time off. My gross is still $20k/mo over expenses. I'm currently on nights: first two nights had 35 charts/night so probably $3k per shift (a few of those are midlevel pts so around 3pt/hr for my patients). Tonight halfway through the shift I have 20 charts, lower acuity and it feels "slow" and I'm loving it..

I'd be totally fine if no one else checked in and I spent the whole time vacation planning, chatting with nurses and online shopping lol.

Mind telling us what CMG you work for?

 

[turkeyjerky]

Hmm, I guess if you have such freedom of schedule that you can just leave whenever you want that's not so bad...

However, regarding my comment about dealing with 'bogged down' days was more about psychologically coping, i.e. Keeping from snapping at nurses who haven't sent urine on a patient for 4 hours

 

[e30ftw]

I found those psychological issues just as annoying hourly as RVU. I never worry or even really think about how much money I'm making during the shift anyway.

Another advantage of 100% RVU is staffing flexibility. If you work at a community ED w 40 hrs physician and 20 hrs APP coverage and want to add 10 hrs MD coverage, that will cost a CMG w/ an hourly comp model ~$800k/yr out of their pocket.

However if you're 100% RVU based, it will just result in everyone in the group making a little less hourly and minimally effect the CMGs bottom line. So if everyone's getting killed making $250/hr and you all vote to add coverage at the expense of ~$15/hr, it's easily doable. Effectively this lets individual sites be run almost as a democratic group and the CMG basically manages the hospital contract, which is win-win imo as long as your $/RVU (which is the most important factor in your compensation as an individual doc) is well-negotiated.

 

[EctopicFetus]

I found those psychological issues just as annoying hourly as RVU. I never worry or even really think about how much money I'm making during the shift anyway.

Another advantage of 100% RVU is staffing flexibility. If you work at a community ED w 40 hrs physician and 20 hrs APP coverage and want to add 10 hrs MD coverage, that will cost a CMG w/ an hourly comp model ~$800k/yr out of their pocket.

However if you're 100% RVU based, it will just result in everyone in the group making a little less hourly and minimally effect the CMGs bottom line. So if everyone's getting killed making $250/hr and you all vote to add coverage at the expense of ~$15/hr, it's easily doable. Effectively this lets individual sites be run almost as a democratic group and the CMG basically manages the hospital contract, which is win-win imo as long as your $/RVU (which is the most important factor in your compensation as an individual doc) is well-negotiated.

Most importantly the cmg wins.

 

[e30ftw]

Perhaps but I’d argue the docs win too more often than not.

EM is a great specialty.

 

[TooMuchResearch]

Trust me on this, even if boarding, you can always see patients. even on those days, there's at least one ED doc who climbs to the top of the RVU pool. Figure out how they're doing it, and copy. At my old shop, we have a room where they do ekg's. when boarding, we just pull patients there and keep seeing them, and putting in labs. lab techs and radiologist techs will take patients even when sitting in the waiting room.

Unless your union nurses aren't comfortable with it...

 

[bravotwozero]

I'm in texas. What's a union?

 

[thegenius]

I'm bumping this thread. I wanted to bump an existing RVU thread (of which there are many) instead of making a new one...so I just chose this recent one.

For those of you who work in an RVU only place, or maybe a hybrid RVU...how do you address the following scenario:

Doc A sees a patient and signs it out to Doc B. Doc B finishes the encounter. The encounter generates 5 RVUs. And both doctors created a note in the system. Who gets the RVUs? My guess is it's Doc B. That's the way I've seen it.

For those of you who work in a model like this, does it produce physician behaviors such as
- docs not wanting to pick up complicated patients over the last 1-2 hours of their shift
- docs ordering tests, perhaps numerous ones like CTs, on patients without seeing them
- docs staying late to prevent signing out the patient to the next doc (thus keeping their RVUs)
- docs "stealing" charts and putting in a meaningless 2nd chart on patients already tucked away awaiting either transport to the floor, SS consult, or just waiting for the morning prior to discharge

 

[deleted836128]

My group recently started doing RVUs plus base pay within the last year. I like the way it’s set up because it’s like a normal hourly rate, a rate that would be good as is. And then they have a target RVU per hour they want you to hit. If you don’t hit it, it doesn’t matter in terms of your pay. But for every RVU you make over that baseline target, you collect a certain amount of dollars per RVU.

At first I saw a change in a FEW people’s behavior. Hoarding patients, refusing to let the APPs see patients, calling docs and APPs and telling them “you can come in an hour later today.” That lasted for like... a couple weeks. Now things are back to normal. Everyone that seems to work super hard always used to work super hard. The docs who were always a little slow are still a little slow.

As a PA, I am expected to just help out when available so I pick up patients all over. I do admit that if it’s not that busy I will often ask to pick up patients in a doc’s pod before I pick them up because I don’t want to seem greedy. I’d doc already has eight patients and I have two, I might not ask. But when I do need to ask, 75 percent of the time, they’re like “PLEASE see it!”

I think the RVU thing has created a little anxiety for me because I want to meet my target and once you get that BOMB RVU check you could basically buy a brand new car with, you don’t want to give that up. So I think I am more likely to push myself or stay late as compared to how I was in the past. It has only translated into seeing maybe two extra patients per twelve hour shift because I have always worked my buns off and I can only do so much while still being safe. Along those lines I won’t carry more than seven or eight patients at a time because that’s when I stop being safe... plus I want to be able to spend an appropriate amount of time with patients. When we had doctors hoarding patients in the beginning with this system, I always felt like it was crazy when they had fifteen patients and didn’t want me to take ONE of them when I came in. I mean, RVUs aside, don’t you think the patient deserves to see the fresh provider who could devote 100 percent of their efforts to them versus the doc spread too thin carrying every patient in the ER?

For sign outs - if a PA like me signs out to the doc the doc will automatically get the RVU because they always do if they ever see the PA’s patient. But for docs to doc hand offs - we were basically told that whoever does the majority of the work will actually get the RVUs. But this is vague and everyone knows it. I have not seen how this works in practice... So I would say most the docs really don’t stay late; they do some sign outs. HOWEVER - there aren’t really a lot of sign outs because, yes, given the uncertainty about who “gets” the RVU, you do want to avoid having someone else show up on the chart. Therefore most all of us avoid seeing work ups in the last two hours of the shift. This is generally not a problem given shift overlap. However the night doc often hates her life when she comes in and there are five patients to be seen and some in the lobby...

One thing that COULD happen in our ER that doesn’t is docs stealing RVUs from the PAs. If the doc sees the patient they get all the RVUs. If I am concerned about the patient or the doc is concerned and feels they need to see them then great - please see them! It would just be weird if they went in and said “Hi, bye” just to get the RVUs. That’s luckily only happened maybe five times in the last year. First time it happened - I told one of the docs “Hey, I have a cholecystitis in a healthy 40 year old female I am admitting in room 20, just a heads up” because the patient was in her zone. I had spent four hours working this patient up. Was walking in the room to tell the patient she had cholecystitis and this doc slipped into the room and said “Hi, I am Dr So and So, you have cholecystitis and the PA is admitting you. Feel better” - she walked out and that was IT. No questions, no exam, nothing and of course she billed for those RVUs. Hahaha.

I admit that I am guilty of ordering tests before I see the patient if trying to stake my claim on the patient and know it might be ten minutes before I see them. I might order a chest x-ray if the complaint is a cough, a CT on a 90 year old who hits their head, basic labs on a belly pain, etc.

 

[GonnaBeADoc2222]

My group recently started doing RVUs plus base pay within the last year. I like the way it’s set up because it’s like a normal hourly rate, a rate that would be good as is. And then they have a target RVU per hour they want you to hit. If you don’t hit it, it doesn’t matter in terms of your pay. But for every RVU you make over that baseline target, you collect a certain amount of dollars per RVU.

At first I saw a change in a FEW people’s behavior. Hoarding patients, refusing to let the APPs see patients, calling docs and APPs and telling them “you can come in an hour later today.” That lasted for like... a couple weeks. Now things are back to normal. Everyone that seems to work super hard always used to work super hard. The docs who were always a little slow are still a little slow.

As a PA, I am expected to just help out when available so I pick up patients all over. I do admit that if it’s not that busy I will often ask to pick up patients in a doc’s pod before I pick them up because I don’t want to seem greedy. I’d doc already has eight patients and I have two, I might not ask. But when I do need to ask, 75 percent of the time, they’re like “PLEASE see it!”

I think the RVU thing has created a little anxiety for me because I want to meet my target and once you get that BOMB RVU check you could basically buy a brand new car with, you don’t want to give that up. So I think I am more likely to push myself or stay late as compared to how I was in the past. It has only translated into seeing maybe two extra patients per twelve hour shift because I have always worked my buns off and I can only do so much while still being safe. Along those lines I won’t carry more than seven or eight patients at a time because that’s when I stop being safe... plus I want to be able to spend an appropriate amount of time with patients. When we had doctors hoarding patients in the beginning with this system, I always felt like it was crazy when they had fifteen patients and didn’t want me to take ONE of them when I came in. I mean, RVUs aside, don’t you think the patient deserves to see the fresh provider who could devote 100 percent of their efforts to them versus the doc spread too thin carrying every patient in the ER?

For sign outs - if a PA like me signs out to the doc the doc will automatically get the RVU because they always do if they ever see the PA’s patient. But for docs to doc hand offs - we were basically told that whoever does the majority of the work will actually get the RVUs. But this is vague and everyone knows it. I have not seen how this works in practice... So I would say most the docs really don’t stay late; they do some sign outs. HOWEVER - there aren’t really a lot of sign outs because, yes, given the uncertainty about who “gets” the RVU, you do want to avoid having someone else show up on the chart. Therefore most all of us avoid seeing work ups in the last two hours of the shift. This is generally not a problem given shift overlap. However the night doc often hates her life when she comes in and there are five patients to be seen and some in the lobby...

One thing that COULD happen in our ER that doesn’t is docs stealing RVUs from the PAs. If the doc sees the patient they get all the RVUs. If I am concerned about the patient or the doc is concerned and feels they need to see them then great - please see them! It would just be weird if they went in and said “Hi, bye” just to get the RVUs. That’s luckily only happened maybe five times in the last year. First time it happened - I told one of the docs “Hey, I have a cholecystitis in a healthy 40 year old female I am admitting in room 20, just a heads up” because the patient was in her zone. I had spent four hours working this patient up. Was walking in the room to tell the patient she had cholecystitis and this doc slipped into the room and said “Hi, I am Dr So and So, you have cholecystitis and the PA is admitting you. Feel better” - she walked out and that was IT. No questions, no exam, nothing and of course she billed for those RVUs. Hahaha.

I admit that I am guilty of ordering tests before I see the patient if trying to stake my claim on the patient and know it might be ten minutes before I see them. I might order a chest x-ray if the complaint is a cough, a CT on a 90 year old who hits their head, basic labs on a belly pain, etc.

Yes, if the physician saw the patient, and the chart is ultimately being billed under their name, they should bill the RVUs. It's their liability ultimately, so of course they should get the RVUs. A lot can be gleamed from just a visual exam (probably the most valuable part of any ER encounter is the first 30 seconds of meeting the patient). Physicians should be seeing all patients that midlevels admit. Midlevels are physician extenders.

I've never worked in an RVU system, but I think rewarding RVUs to either the first or last physician to see them incentivises poor behaviors.

I'd rather see a system where group RVUs are divided by individual patients seen per hour (with credit given to all physicians involved in the care) and a bonus weighted by that ratio.

 

[BoardingDoc]

I'm bumping this thread. I wanted to bump an existing RVU thread (of which there are many) instead of making a new one...so I just chose this recent one.

For those of you who work in an RVU only place, or maybe a hybrid RVU...how do you address the following scenario:

Doc A sees a patient and signs it out to Doc B. Doc B finishes the encounter. The encounter generates 5 RVUs. And both doctors created a note in the system. Who gets the RVUs? My guess is it's Doc B. That's the way I've seen it.

For those of you who work in a model like this, does it produce physician behaviors such as
- docs not wanting to pick up complicated patients over the last 1-2 hours of their shift
- docs ordering tests, perhaps numerous ones like CTs, on patients without seeing them
- docs staying late to prevent signing out the patient to the next doc (thus keeping their RVUs)
- docs "stealing" charts and putting in a meaningless 2nd chart on patients already tucked away awaiting either transport to the floor, SS consult, or just waiting for the morning prior to discharge

"Doc A sees a patient and signs it out to Doc B. Doc B finishes the encounter. The encounter generates 5 RVUs. And both doctors created a note in the system. Who gets the RVUs? My guess is it's Doc B. That's the way I've seen it."

- Doc A generally gets the patient, provided that they actually did the work.
If you sign out a patient to me with normal labs, who feels fine and is getting a CT scan, and the signout is basically "dispo per CT. They can go home if it's fine" then you get the bill.
If you sign out a patient getting nebs and the plan is: "home once they feel better" and I need to order another round of nebs on them after I see they aren't better yet and then I either admit/DC them at that point... you still get the bill.
If you sign out a patient who rolled in 10 minutes ago and you've ordered a bunch of tests and imaging and they haven't even drawn labs from the patient yet, I'll write a full chart on the patient and take the bill.
If you've done a bunch of labs/tests, they're mostly done and you've done a lot of work but then the patient actively decompensates and I need to intubate/place a CVL/start on BiPAP/etc I will probably write my own chart (starting BiPAP in of itself doesn't mean I'm taking the chart).


For those of you who work in a model like this, does it produce physician behaviors such as
- docs not wanting to pick up complicated patients over the last 1-2 hours of their shift
Yes. Unless it's super busy in which case we all generally just expect to stay a bit late to help out.

- docs ordering tests, perhaps numerous ones like CTs, on patients without seeing them
If the CC warrants it, sometimes. Triage note says: 89F with hx of SBO sent in by PCP with vomiting and abdominal pain. Yeah, you can order a CT A/P without seeing her first.

- docs staying late to prevent signing out the patient to the next doc (thus keeping their RVUs)
People generally stay late if needed so they aren't signing out crap. That said, we are generally able to leave on time. We also are busy enough that we have shift overlap so the idea that you aren't picking up sick people in the last 1 hr doesn't matter as the other doc who is on will. This is again because of the expectation that you will get paid for the work you did, provided you actually, you know, did work.

- docs "stealing" charts and putting in a meaningless 2nd chart on patients already tucked away awaiting either transport to the floor, SS consult, or just waiting for the morning prior to discharge
No. This would be noticed and isn't good behavior. I'm lucky enough to work in a group where I like all my colleagues. If you're taking someone else's chart, there is a good reason for it.

 

[TooMuchResearch]

H&P gets the RVUs. Generally doc A.

 

[GeneralVeers]

My RVU job has a 5 doc day, and generally it's staggered so there's almost no sign out. Also it's clearly structured so that no one is fighting over patients

Hours 1-3 newest doc sees all Level 1 and 2 patients with some level 3s if not busy
Hours 3-6 mostly level 3s, but can see level 2s and 4s if they have been waiting longer than 15 min to be seen
Hours 3-9 simple level 4 patients

We are usually paired 1:1 with midlevels who will pick up Level 3 charts during the first part of our shift and switch to level 4s when we do.

Any patient can be seen by any doc/midlevel regardless of acuity level if they have been waiting longer than 15 minutes.

Patients who are signed out have their RVU assigned to the doctor who does final disposition. I think it's fair as they are taking the bulk of the liability. Sign-outs are rare, and usually no more than 1 per shift because we have that last 3 hours of the shift where we are picking up super simple stuff and dispositioning all of the more complex ones. I usually use this last 3 hours to pick up some low-hanging fruit to pad my RVUs, and finish my charting. Generally done and go home 30 minutes to an hour early.

 

[Janders]

So when you set up your protocol with your billing company, you can chose as a group to either let (1) the first doc or (2) the last/dispo'ing doc take the $$/rvu. Most groups chose (1), but both are do-able. We do (1), but if the second doc writes a whole new note that is billable at a higher level than the first... they get the $. This would be for the rare case of, say, a guy who tripped and fell and just needed an ankle X-ray (1st doc handled this), and then when leaving had a fainting spell, was found to be in 3rd degree block, required resuscitation, pacer, xfer to cath lab, etc (2nd doc did this).

We just have a largely unspoken understanding on sign-outs-- if you have a bunch of active patients, that means you are making good money and you are going to stay a bit late fixing them up. On the flip side, if you have 3 psych holds, a drunk hold, and 1 "pending CT r/o appy" then sign out right away and get the hell out of dodge! Also, the overnight doc gets to sign out nearly anything ,before they fall asleep on their keyboard...

I heart RVU based pay (technically we are straight P&L, not even using the RVU middle man).

But you need a few things to make it right--
-Strong QI/QA with a professional staff. Somone of light moral character may be tempted to move the meat to the point of providing suboptimal care. They must be reigned in via professional QI. Doesn't happen as much as you think; lawsuits are scary.
-A staff that respects each other. No stealing patients. No stealing mid levels. No picking up 5 patients in the last 5 minutes of your shift, and immediately signing them out. Sometimes you have to huddle up and agree to take turns picking up patients... no biggie.

Basically, you need to work with a bunch of grown-ups who treat each other like professionals-- or family.

Being eat-what-you-kill fixes so many problems vis-a-vis productivity, laziness, staffing, pay for staying late, charting/coding, procedures, critical care billing, etc.

 

[thegenius]

I've never worked in an RVU system, but I think rewarding RVUs to either the first or last physician to see them incentivises poor behaviors.

Depending if it's the first or last doc, it does change the incentives for seeing patients. Generally not favorable. I tend to think awarding the RVU's to the last doc seems to perform better for patient flow through the ED and incentivizing docs to complete their workups, rather than the other way around. but it's a lesser of two evils.

I'd rather see a system where group RVUs are divided by individual patients seen per hour (with credit given to all physicians involved in the care) and a bonus weighted by that ratio.

What do you mean by that?
I personally think that it's better to reward productivity in term of patients seen and not RVU's generated....as you end up ordering all sorts of unnecessary tests when RVU's are the reward. Although it seems like all different payment models have their pros and cons.

 

[GeneralVeers]

I agree with the last doc getting the RVUS. Otherwise it would promote doctors to pick up a bunch of patients then sign them out. I would be annoyed if I was stuck with a bunch of work, taking all the liability so someone else would benefit. I do know a few docs who would do this. Not having sign out is the best from a liability standpoint, and giving the last doc the RVU credit all but eliminates sign out (except end of night shift).

 

[Janders]

Agree with you guy, it can be problematic.

That said we are a small, stable group so we know each other well and tend not to screw each other over 🙂 It would be perhaps more difficult in a massive ED with tons of providers and lots of turnover (a more "corporate" setting versus a "democratic group" feeling).

The other thing is our... ancillary services can be slow. Not the doc's fault sometimes that they did everything for a patient but the CT is pending for 5 hours.

I guess the key is that you can chose first doc or last doc to get the RVU... its basically flipping a switch at the billing company, so easy to do what the group feels is best for your setting.

 

[Hercules]

My group is almost 100% RVU pay. Last doc gets the RVUs as they should. Giving them to the first doc would incentivize bad behavior and sloppy sign outs. Similar to Veers, we schedule overlapping shifts so that you can be wrapping up your complex patients and primarily cherry picking easy patients that you can dispo prior to the end of your shift. Our group pretty much always leaves on time as well so the system works for us.

 

[Hercules]

Depending if it's the first or last doc, it does change the incentives for seeing patients. Generally not favorable. I tend to think awarding the RVU's to the last doc seems to perform better for patient flow through the ED and incentivizing docs to complete their workups, rather than the other way around. but it's a lesser of two evils.


What do you mean by that?
I personally think that it's better to reward productivity in term of patients seen and not RVU's generated....as you end up ordering all sorts of unnecessary tests when RVU's are the reward. Although it seems like all different payment models have their pros and cons.

This is a bad idea. It would disincentivize seeing sicker patients that require procedures. If you strictly do it by patients per hour, then I can go see 6 URIs while you’re working a code and I’ll make way more than you which everyone would agree is unfair.

Propensity for ordering tests (within reason) isn’t usually going to affect RVUs all that much. RVUs are assigned for each E/M code and whether you order 1 lab or 50 labs will usually not be the deciding factor in either your E/M code or correspondingly your RVUs on that patient. Your patients are going to be predominantly 99283s, 99284s, and 99285s with some 99291s thrown in for critical care.