Inpatient RVU target

[psych_0]

Have been fielding some job offers that follow the base salary + RVU bonus model. Wanted to get a better idea of what RVU target I should be aiming for. The job I am currently looking at is offering $240k base salary + RVU target of 5000/year with a bonus of $50/RVU after 5100. Inpatient physicians at the hospital last year varied from 7000 - 10,000 RVUs/year, with the higher end of that spectrum doing more ECT & outpatient work alongside their inpatient work. Patient load varies from 10-15 patients per day. Average length of stay varies 3-7 days. Job is M-F with call 1 weekend every 4 weeks. No telephone call (covered by moonlighters/NPs Monday-Sunday).

Initially, I got the sense that 5000 was a high target. One of my co-residents got a similar offer (in a different state) for $235k base + 4000 RVU target with $55/RVU bonus, but that hospital couldn't offer any RVU estimates because this was the first year they had switched to that model.

Any thoughts or insights would be greatly appreciated.

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[Sushirolls]

4000 is doable. Above that you are working too hard for 'the man' and risk not being able to take vacation because of wRVU handcuffs. That $55 wRVU bonus rate is way too low. For a bonus, it should be higher, and in $59-65 range.

 

[wolfvgang22]

I average about 4,100 RVUs a year, but that's outpatient 40 hour work week. I wouldn't want to do more than that.

 

[Merely]

Have been fielding some job offers that follow the base salary + RVU bonus model. Wanted to get a better idea of what RVU target I should be aiming for. The job I am currently looking at is offering $240k base salary + RVU target of 5000/year with a bonus of $50/RVU after 5100. Inpatient physicians at the hospital last year varied from 7000 - 10,000 RVUs/year, with the higher end of that spectrum doing more ECT & outpatient work alongside their inpatient work. Patient load varies from 10-15 patients per day. Average length of stay varies 3-7 days. Job is M-F with call 1 weekend every 4 weeks. No telephone call (covered by moonlighters/NPs Monday-Sunday).

Initially, I got the sense that 5000 was a high target. One of my co-residents got a similar offer (in a different state) for $235k base + 4000 RVU target with $55/RVU bonus, but that hospital couldn't offer any RVU estimates because this was the first year they had switched to that model.

Any thoughts or insights would be greatly appreciated.

those are bad targets..the base rvu should be around 4K..5k is way too high, also above that it should be ideally around 60+ per RVU..otherwise you are getting ripped off unless this is a highly desirable location. Also 10k RVU is very difficult to achieve so idk how those people are getting that in psych

 

[Sushirolls]

Inpatient wRVUs overall are a little lower, relatively speaking, compared to outpatient encounter productivity. That's part of the reason why 7000-1000/year is eye brow raising. I mean if the weekend rounding per month is covering like 40 patients that still might only generate 800-1200 wRVUs per year extra in addition to base work week. ECT, depending upon how its done, could either be a wRVU loss, or a boon compared to routine inpatient. But I wouldn't count on ECT wRVUs when looking at your projections for this contract.

 

[Sushirolls]

99232 = 1.39wRVU (most common billing code you'll use, follow ups)
Estimate your average encounter wRVU to be 1.8, but could be as high as 2.0 for possible projections give you some estimates.
2019 medicare conversion factor is ~$36. ~$36 x 1.39 wRVUs = $50
A hospital has negotiated with private insurers a far better rate than a medicare $36. Likely $60-70 or even more.
Private insurance will be anywhere from 40-60% of the admissions. Other things can impact this percent.
What is the total dollar value of your benefit package? How many vacations days do you get?

They also have the facility fee they are already getting and profiting off of to pay for many things.

 

[Stagg737]

Estimate your average encounter wRVU to be 1.8,

Could you clarify what you mean by encounter wRVU? Do you mean 1.8 after add-on codes or is this something else?

 

[splik]

10-15 pts is a lot (10 is fine, 15 is stretching it). people want to do a crappy job and see lots of pts but you can actually generate a lot of wRVUs and receive fair compensation by seeing 9 patients a day. I consider 8-10 pts for inpt the ideal number in terms of providing high quality care.You can easily clear over 7000 wRVUs annually with 9 pts, working 40 weeks per yr, not including weekends or overnight coverage by providing quality care, documenting appropriately and billing for those services appropriately.

 

[Merely]

10-15 pts is a lot (10 is fine, 15 is stretching it). people want to do a crappy job and see lots of pts but you can actually generate a lot of wRVUs and receive fair compensation by seeing 9 patients a day. I consider 8-10 pts for inpt the ideal number in terms of providing high quality care.You can easily clear over 7000 wRVUs annually with 9 pts, working 40 weeks per yr, not including weekends or overnight coverage by providing quality care, documenting appropriately and billing for those services appropriately.

so you can clear 14k RVU with 18-20 patients?

 

[downwithDTB]

10-15 pts is a lot (10 is fine, 15 is stretching it). people want to do a crappy job and see lots of pts but you can actually generate a lot of wRVUs and receive fair compensation by seeing 9 patients a day. I consider 8-10 pts for inpt the ideal number in terms of providing high quality care.You can easily clear over 7000 wRVUs annually with 9 pts, working 40 weeks per yr, not including weekends or overnight coverage by providing quality care, documenting appropriately and billing for those services appropriately.

Could you share an example of a set of codes that might be used for a patient or two that allow you to receive more reasonable compensation for high quality care of fewer patients?

 

[NickNaylor]

I'm at an academic center with a gross salary of ~$220k. Our annual RVU target is just under 3800. We can achieve this with inpatient work alone, however we get an incentive at 150% of this target (~5700 RVUs), which is not achievable with inpatient work alone. Keep in mind that our team sizes are quite low, and the average number of patients we have per day is 6-8. We have relatively quick turnover, which means we have a good number of admissions and discharges rather than long-term patients that are mostly being billed as follow-ups. We also have a bustling ECT service that we rotate on which is sufficient to allow us reach our incentive each year; for us, ECT is an RVU boon rather than a drain.

Based on the above model, billing 7000-10000 RVUs each year wouldn't be something I would want to do. I'd either be working all the time or providing substandard care.

 

[Sushirolls]

Could you clarify what you mean by encounter wRVU? Do you mean 1.8 after add-on codes or is this something else?

It's wRVU total divided by total patients/encounters, for instance in one day, if you have 10 patients: 2 new, 2 discharge, 6 fu, and 1 therapy add on code, and 1 smoking cessation add on code totaling 18 wRVU's, your per encounter would be 1.8 wRVUs.

 

[Stagg737]

Could you share an example of a set of codes that might be used for a patient or two that allow you to receive more reasonable compensation for high quality care of fewer patients?

Second this. @splik , would you mind sharing what a typical day of billing codes would look like for this? Ie, #of admits, d/c, f-ups, add-on codes, etc. very interested in this.

 

[Psych19]

10-15 pts is a lot (10 is fine, 15 is stretching it). people want to do a crappy job and see lots of pts but you can actually generate a lot of wRVUs and receive fair compensation by seeing 9 patients a day. I consider 8-10 pts for inpt the ideal number in terms of providing high quality care.You can easily clear over 7000 wRVUs annually with 9 pts, working 40 weeks per yr, not including weekends or overnight coverage by providing quality care, documenting appropriately and billing for those services appropriately.

I too would be curious to see the math on this.
Let's say your avg length of stay is 5 days.
Let's say you for the sake of argument you always bill the highest level for admit, f/u and discharge. You'd be getting 3.86 rvu for admission (99223), 2 rvu for each f/u day (99233), and 1.9 on discharge (99239). Avg rvu per patient encounter = 2.352
x9 patients per day = 21.168 rvu per day
x5 days per week = 105.84 rvu per week
x40 weeks per year = 4233.6 rvu annually

Still 2766.4 short of 7000...

 

[Sushirolls]

Except the usual is not the 99233, but the 99232 which is 1.39 wRVU, and would pull down this estimate you tossed out.

3.86 wRVU for admission (99223), 1.39 wRVU for each f/u day (99232), and 1.9 on discharge (99239). Avg rvu per patient encounter = 1.986
x10 patients per day = 19.86 wRVUs per day
x5 days per week = 99. wRVUs per week
x46 weeks per year = 4567.8 wRVUs annually

Still short. but lets say the unit for weekends is 20 patients? and once per month, =953.28 total for the year additional wRVUs, if truly rounding on 40 patients for two days with same per encounter average of 1.986 - which is generous. More likely to be a 1.8 wRVU.

 

[Psych19]

Except the usual is not the 99233, but the 99232 which is 1.39 wRVU, and would pull down this estimate you tossed out.

Right! So we'd be even further from 7000 RVUs annually, and all the more reason I'd like to see the math.

 

[NickNaylor]

Could you share an example of a set of codes that might be used for a patient or two that allow you to receive more reasonable compensation for high quality care of fewer patients?

Psychotherapy add-ons are an easy one: even a 15-37-minute add-on more than doubles the RVUs for a level 2 follow-up visit. The documentation isn't that onerous, and frankly most patients can likely benefit from some psychotherapeutic work. A level 2 follow-up with 15-37 minutes of psychotherapy would be ~2.9 wRUVs. If you stretch that out to 38-52 minutes, tack on another 0.5 RVUs.

I'm a bit skeptical of 7000 RVUs annually with a 9-patient census...

 

[Merely]

Psychotherapy add-ons are an easy one: even a 15-37-minute add-on more than doubles the RVUs for a level 2 follow-up visit. The documentation isn't that onerous, and frankly most patients can likely benefit from some psychotherapeutic work. A level 2 follow-up with 15-37 minutes of psychotherapy would be ~2.9 wRUVs. If you stretch that out to 38-52 minutes, tack on another 0.5 RVUs.

I'm a bit skeptical of 7000 RVUs annually with a 9-patient census...

yeah that would mean 14k RVU for 19 patients a day lol

 

[Psych19]

I'm perplexed by this idea of billing psychotherapy add-on codes for patients admitted to the hospital. I'd expect that payors would balk at this idea, and refuse to pay for this service. But I guess I've never tried.

 

[SmallBird]

I'm perplexed by this idea of billing psychotherapy add-on codes for patients admitted to the hospital. I'd expect that payors would balk at this idea, and refuse to pay for this service. But I guess I've never tried.

There needs to be some attempt made to understand why the patient was in crisis, how this can be avoided in the future, and what the psychological determinants are of their current distress. This takes time, draws on specific therapy concepts across a range of traditions, and is billable as it should be. Just this week I had a Cigna reviewer encourage us to do MORE family therapy before discharge. I do agree that there isn’t a strong empiric evidence base for ‘6 days of therapy’ but inpatient units that focus only on biological determinants are horrible.

 

[downwithDTB]

[QUOTE="Psych19, post: 21352498, member: 1016558"I I'mperplexed by this idea of billing psychotherapy add-on codes for patients admitted to the hospital. I'd expect that payors would balk at this idea, and refuse to pay for this service. But I guess I've never tried.
[/QUOTE]

I am as well, although I guess I'm just completely complexed by the whole inpatient billing process... are groups and individual non-MD therapy billed seperately in addition to "hospital fees" or is that just included?

While I guess I'm generally pretty skeptical that moving away from fee-for-service models will do anything beyond totally screw over people treating low SES patients even more than the current system... I guess it would be pretty sweet to incentivize hospitals to hire people who can do better not more.

 

[Sushirolls]

... I guess it would be pretty sweet to incentivize hospitals to hire people who can do better not more.

LOL. *Insert jaded comment about hospitals, and especially hospital admin, and department managers here*

 

[NickNaylor]

I'm perplexed by this idea of billing psychotherapy add-on codes for patients admitted to the hospital. I'd expect that payors would balk at this idea, and refuse to pay for this service. But I guess I've never tried.

In general, we do not have trouble getting payers to pay for psychotherapy add-ons. They will typically balk at prolonged service codes, but psychotherapy add-ons generally haven't been a problem.

 

[psych_0]

So if my math estimates are correct:
- 2 New patients: (2*3.86) = 7.72
- 12 Follow-up (12*1.39) = 16.68
- Total ~ 24.4 wRVU/day

= 24.4 * 5 days * 47 weeks = 5734 wRVU

Adding on the weekends (let's say 13 weekends / year, seeing 2 new + 20 f/u per day).
= 4 new + 40 f/u (total for the whole weekend)
= [4*3.86 + 40*1.39] * 13 weekends = 1646 wRVU per year

So for 5 days per week, 47 weeks per year + 13 weekends per year, I'm calculating : 5734+1646 = 7380 wRVU/year

If we add on ECT, let's say 3 cases per day x 3 days per week x 47 weeks per year = [2.5* 3 cases/day * 3 days/week * 47 weeks/year] = 1080 wRVU year

Adding all of this together:
- 5734 wRVU for the 47 weeks
- 1646 wRVU for the 13 weekends
- 1080 wRVU for the ECT

= 8460 wRVU
= This total subtracts by ~122 wRVU (~$6700!!!) per additional week taken off. I calculated 5 weeks off in the estimate, but have up to 6 weeks + 1 week CME available per the contract.

Thoughts? The weekends seem busy as hell, but doable. There is no overnight call. NPs take all overnight call Mon-Sun, even when you are on call during the weekend days.

 

[clausewitz2]

So if my math estimates are correct:
- 2 New patients: (2*3.86) = 7.72
- 12 Follow-up (12*1.39) = 16.68
- Total ~ 24.4 wRVU/day

= 24.4 * 5 days * 47 weeks = 5734 wRVU

Adding on the weekends (let's say 13 weekends / year, seeing 2 new + 20 f/u per day).
= 4 new + 40 f/u (total for the whole weekend)
= [4*3.86 + 40*1.39] * 13 weekends = 1646 wRVU per year

So for 5 days per week, 47 weeks per year + 13 weekends per year, I'm calculating : 5734+1646 = 7380 wRVU/year

If we add on ECT, let's say 3 cases per day x 3 days per week x 47 weeks per year = [2.5* 3 cases/day * 3 days/week * 47 weeks/year] = 1080 wRVU year

Adding all of this together:
- 5734 wRVU for the 47 weeks
- 1646 wRVU for the 13 weekends
- 1080 wRVU for the ECT

= 8460 wRVU
= This total subtracts by ~122 wRVU (~$6700!!!) per additional week taken off. I calculated 5 weeks off in the estimate, but have up to 6 weeks + 1 week CME available per the contract.

Thoughts? The weekends seem busy as hell, but doable. There is no overnight call. NPs take all overnight call Mon-Sun, even when you are on call during the weekend days.

An ECT service that only does three cases a day is going to absolutely hemorrhage money. Is the idea that you are going to be switching out with other attendings? That seems like it would kill the workflow, you'd be rotating out on an hourly basis.

Doing like 10-15 a day is a more typical break-even point. Obviously depends a lot on the details of the fixed costs involved (space, nursing staff, anesthesia, who is paying for the PACU beds) but they are going to be considerable and require waaaay more volume than 3 a day unless you have a sweetheart deal with am insurer or your hospital has decided to take it on the chin just so they can say they have ECT for some reason.

 

[psych_0]

An ECT service that only does three cases a day is going to absolutely hemorrhage money. Is the idea that you are going to be switching out with other attendings? That seems like it would kill the workflow, you'd be rotating out on an hourly basis.

Doing like 10-15 a day is a more typical break-even point. Obviously depends a lot on the details of the fixed costs involved (space, nursing staff, anesthesia, who is paying for the PACU beds) but they are going to be considerable and require waaaay more volume than 3 a day unless you have a sweetheart deal with am insurer or your hospital has decided to take it on the chin just so they can say they have ECT for some reason.

Yea so I just threw in the 3 per day number as an estimate. They are currently doing 3-5 per day, but there is only one person doing it. They have the space for 10 per day. At the interview they were basically saying, "if you want to do ECT you can. We have space for it but with only one doctor doing it currently, we haven't been marketing it that much. If you were to come on and want to do it, we'd make more of an effort to get you the volume via marketing. No other hospitals are doing ECT in the surrounding area."

 

[NickNaylor]

Yea so I just threw in the 3 per day number as an estimate. They are currently doing 3-5 per day, but there is only one person doing it. They have the space for 10 per day. At the interview they were basically saying, "if you want to do ECT you can. We have space for it but with only one doctor doing it currently, we haven't been marketing it that much. If you were to come on and want to do it, we'd make more of an effort to get you the volume via marketing. No other hospitals are doing ECT in the surrounding area."

Famous last words with respect to "just do more marketing." My own experience is that esketamine has been cannibalizing our ECT service to a very large degree. Given a choice (and, IMO, if you're properly doing informed consent, discussion of esketamine as an option - albeit less effective - is part of that), my experience has been that many patients would rather try esketamine first before ECT.

We aren't the only shop doing ECT in our area, but we're the only outpatient program in a large metropolitan area. Despite fairly aggressive marketing our volumes have gradually fallen since esketamine was approved and has been available for use. This also isn't helped by the fact that we offer esketamine in our clinic so it's a readily available treatment for most folks (after jumping through insurance hoops), but just another thing to consider.

 

[clausewitz2]

Famous last words with respect to "just do more marketing." My own experience is that esketamine has been cannibalizing our ECT service to a very large degree. Given a choice (and, IMO, if you're properly doing informed consent, discussion of esketamine as an option - albeit less effective - is part of that), my experience has been that many patients would rather try esketamine first before ECT.

We aren't the only shop doing ECT in our area, but we're the only outpatient program in a large metropolitan area. Despite fairly aggressive marketing our volumes have gradually fallen since esketamine was approved and has been available for use. This also isn't helped by the fact that we offer esketamine in our clinic so it's a readily available treatment for most folks (after jumping through insurance hoops), but just another thing to consider.

I think if our ECT service wasn't doing as many tapers or maintenance on an outpatient basis on folks who got started on ECT inpatient they'd be struggling for sure. We also have a contingent who get brought from the rather distant state hospital on a regular basis which helps bolster the numbers. For whatever reason our system does not do esketamine at the moment and anesthesia has totally shut down any attempt to do IV ketamine at a dosage consistent with what the literature suggests will be effective.

And this is how some people in this town ended up with a psychiatrist who was trying to get someone to put in ports to facilitate getting ketamine regularly. Then he plead guilty to narcotic trafficking charges and all those people came to us. True story.

 

[Sushirolls]

Famous last words with respect to "just do more marketing." My own experience is that esketamine has been cannibalizing our ECT service to a very large degree. Given a choice (and, IMO, if you're properly doing informed consent, discussion of esketamine as an option - albeit less effective - is part of that), my experience has been that many patients would rather try esketamine first before ECT.

We aren't the only shop doing ECT in our area, but we're the only outpatient program in a large metropolitan area. Despite fairly aggressive marketing our volumes have gradually fallen since esketamine was approved and has been available for use. This also isn't helped by the fact that we offer esketamine in our clinic so it's a readily available treatment for most folks (after jumping through insurance hoops), but just another thing to consider.

How much of a drop? ~5%, 15%, 40%?

 

[NickNaylor]

How much of a drop? ~5%, 15%, 40%?

A bit hard to say concretely without looking into it, but I’d say 10-20%. The real challenge is that we’re not getting as many ECT starts from community referrals as patients are preferring to go the esketamine route, so I expect that our volume will continue to fall. We still have a fair number of patients that get started after being admitted to our inpatient unit, but that doesn’t make up for the decrease in the cases coming from community referrals.

 

[Sushirolls]

Do you think this will be a permanent reduction or more of temporary blip, an additional trial, before the eventual need for ECT?

Your guesstimate reduction may be just enough to kill my ECT service line dream in my little area. Naturally we know that there are and will always be a place for ECT for many patients.

 

[psych_0]

Famous last words with respect to "just do more marketing." My own experience is that esketamine has been cannibalizing our ECT service to a very large degree. Given a choice (and, IMO, if you're properly doing informed consent, discussion of esketamine as an option - albeit less effective - is part of that), my experience has been that many patients would rather try esketamine first before ECT.

We aren't the only shop doing ECT in our area, but we're the only outpatient program in a large metropolitan area. Despite fairly aggressive marketing our volumes have gradually fallen since esketamine was approved and has been available for use. This also isn't helped by the fact that we offer esketamine in our clinic so it's a readily available treatment for most folks (after jumping through insurance hoops), but just another thing to consider.

Yea, I asked about ketamine/esketamine while I was there. There are currently no providers doing IV or nasal ketamine in the area. Nearest ketamine clinic is about 50-60 min away. I don't think they were lying because I tried to Google ketamine clinics in the area and could not find any.

Question: which is more expensive to the patient, ECT or esketamine? I thought insurance was not readily paying for esketamine but they were paying for ECT. Is that not what you've experienced? Reason I ask is because this is not a wealthy town at all. Average income is less than $45,000 per household.

 

[downwithDTB]

Questionwhich is more expensive to the patient, ECT or esketamine?

Almost certainly esketamine given the meager effect size... also with the crazy number of people who died in the clinical trials, they may pay with the ultimate price.

If I were running an ECT service, I would be very aggressively pointing out the weak effect size of esketamine and the number of deaths in the relatively small clinical trials (6 or 7 vs 0 in placebo). I doubt anyone doing esketamine and having so many buyers is really doing informed consent and telling every patient the clinical trial death rate.

 

[NickNaylor]

Yea, I asked about ketamine/esketamine while I was there. There are currently no providers doing IV or nasal ketamine in the area. Nearest ketamine clinic is about 50-60 min away. I don't think they were lying because I tried to Google ketamine clinics in the area and could not find any.

Question: which is more expensive to the patient, ECT or esketamine? I thought insurance was not readily paying for esketamine but they were paying for ECT. Is that not what you've experienced? Reason I ask is because this is not a wealthy town at all. Average income is less than $45,000 per household.

Our experience has been that esketamine treatments cost anywhere from $100-300 per treatment with Medicare. Private insurers can be temporarily cheaper since they qualify for a copay assistance program. I don’t know what the cost of an ECT treatment is, but I would guess slightly comparable, maybe less with respect to out-of-pocket costs.