RVU-based ER Psych

[clement]

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Curious if any ER or crisis stabilization unit attendings in an academic setting have an RVU reliant (base) salary?

Admittedly, I’ve never heard of this (and perhaps didn’t realize it when I was in academia doing ER psych). I do know RVU based CL is unpopular, and that academic employers started moving toward a model where it mainly incentivizes bonuses.

Some early career advice I stumbled across the hard way: If it’s a new role in the hospital and the volume isn’t defined (and won’t ever be), only accept it in a very part time capacity.

 

[comp1]

Nope, ER psych (as opposed to combined with CL) jobs are rare as it is and academic jobs are almost always salaried. The fact that a bonus is even involved with RVUs is pretty impressive. Remember, academic jobs primarily pay in "prestige."

 

[clement]

Nope, ER psych (as opposed to combined with CL) jobs are rare as it is and academic jobs are almost always salaried. The fact that a bonus is even involved with RVUs is pretty impressive. Remember, academic jobs primarily pay in "prestige."

I’ve always understood most academic jobs have an underlying base salary rvu formula. In this case both the base and bonus are incentivized by volume. If RVU’s drop, so does base.

 

[Atreides]

I doubt it. My current academic job offered me the option to do ER instead of outpatient psychiatry for a higher salary but the marginal increase in salary (something like 20k) definitely doesn't making up for the higher patient volume, lack of remote work (I'm 50% virtual), and abysmal parking situation at the main campus (easily adds 30-45 minutes a day of uncompensated time).

 

[TexasPhysician]

Curious if any ER or crisis stabilization unit attendings in an academic setting have an RVU reliant (base) salary?

Admittedly, I’ve never heard of this (and perhaps didn’t realize it when I was in academia doing ER psych). I do know RVU based CL is unpopular, and that academic employers started moving toward a model where it mainly incentivizes bonuses.

Some early career advice I stumbled across the hard way: If it’s a new role in the hospital and the volume isn’t defined (and won’t ever be), only accept it in a very part time capacity.

Yes. Some academic centers realized that they had collected psychiatrists that love teaching but don’t want to see many patients. The solution was to implement a RVU minimum for the department with bonus structure. Non-patient activities were given a RVU equivalent so teaching wasn’t necessarily punished. The RVU minimum for base salary wasn’t hard to hit for an average psychiatrist. It was actually more of a bonus structure designed to increase productivity with the fear of a salary reduction.

This resulted in improved productivity and increased desire to take home call supervising residents. It also made supervising resident clinics super desirable as you get their RVU’s.

This wasn’t an ER initiative as it was a department-wide change. Everyone had to fall in line.

 

[Stagg737]

Curious if any ER or crisis stabilization unit attendings in an academic setting have an RVU reliant (base) salary?

Admittedly, I’ve never heard of this (and perhaps didn’t realize it when I was in academia doing ER psych). I do know RVU based CL is unpopular, and that academic employers started moving toward a model where it mainly incentivizes bonuses.

Some early career advice I stumbled across the hard way: If it’s a new role in the hospital and the volume isn’t defined (and won’t ever be), only accept it in a very part time capacity.

This was my first job out of residency and I don’t recommend it for a few reasons. For me, the first year was straight salaried but after 12 months it was RVU-based calculated by looking back at the previous 12 months production which updated quarterly. I switched over to “full-time” CL after 1.5 years and haven’t regretted it one bit (and I don’t mind RVU based CL at all). Reasons for the switch:

1. In the first year I only hit ~2000 RVUs from the ER role (only mornings) and I needed to be hitting closer to 3000-3500 RVUs to maintain the income I wanted. RVUs were often feast or famine and I’d have days where I’d see 6-7 new patients in 6 hours and then go a day or two with no consults at all. I got around 15 RVUs per week from 5ish hours of outpatient/week and made up the remaining RVUs by covering the consult team and ECT when people needed it. I was fortunate that our department subsidized my income quite a bit in the 6 months I was RVU based or else I would have taken a significant pay hit (probably around 30%). Seemed silly to be doing only ER and scrounging for RVUs elsewhere working alone vs just shifting to full CL mostly staffing residents and hitting well over my personal minimum (hitting >4000/yr now).

2. The ER had a RN/SW team I worked with. It was great because they could take care of most of the social stuff, but they also saw the straightforward psych patients (suicide attempt now asking for inpatient admission, etc) so I only saw the more complex or higher liability cases. After a while, it starts to take a mental toll only seeing train wrecks and having to make the hard decisions for everyone else, so was ready to move out of that role. That wouldn’t have been nearly as bad if I saw all the straightforward cases to get easy RVUs and patients that were less mentally/emotionally taxing for me, but towards the end I was definitely starting to hit burnout.

3. The time some of these patients require is often not appropriately reimbursed by RVUs. There are some patients who due to administrative issues surrounding their complexity may take several hours throughout the day to address appropriately and a 90792 or just using 99417/8 add-ons don’t earn the RVUs concordant with the work put in.

Feel free to DM me with specific questions. These positions are out there (we recently filled this position after previous psychiatrist left to become a PD) but they certainly aren’t the standard.

 

[clement]

This was my first job out of residency and I don’t recommend it for a few reasons. For me, the first year was straight salaried but after 12 months it was RVU-based calculated by looking back at the previous 12 months production which updated quarterly. I switched over to “full-time” CL after 1.5 years and haven’t regretted it one bit (and I don’t mind RVU based CL at all). Reasons for the switch:

1. In the first year I only hit ~2000 RVUs from the ER role (only mornings) and I needed to be hitting closer to 3000-3500 RVUs to maintain the income I wanted. RVUs were often feast or famine and I’d have days where I’d see 6-7 new patients in 6 hours and then go a day or two with no consults at all. I got around 15 RVUs per week from 5ish hours of outpatient/week and made up the remaining RVUs by covering the consult team and ECT when people needed it. I was fortunate that our department subsidized my income quite a bit in the 6 months I was RVU based or else I would have taken a significant pay hit (probably around 30%). Seemed silly to be doing only ER and scrounging for RVUs elsewhere working alone vs just shifting to full CL mostly staffing residents and hitting well over my personal minimum (hitting >4000/yr now).

2. The ER had a RN/SW team I worked with. It was great because they could take care of most of the social stuff, but they also saw the straightforward psych patients (suicide attempt now asking for inpatient admission, etc) so I only saw the more complex or higher liability cases. After a while, it starts to take a mental toll only seeing train wrecks and having to make the hard decisions for everyone else, so was ready to move out of that role. That wouldn’t have been nearly as bad if I saw all the straightforward cases to get easy RVUs and patients that were less mentally/emotionally taxing for me, but towards the end I was definitely starting to hit burnout.

3. The time some of these patients require is often not appropriately reimbursed by RVUs. There are some patients who due to administrative issues surrounding their complexity may take several hours throughout the day to address appropriately and a 90792 or just using 99417/8 add-ons don’t earn the RVUs concordant with the work put in.

Feel free to DM me with specific questions. These positions are out there (we recently filled this position after previous psychiatrist left to become a PD) but they certainly aren’t the standard.

When you say, “…aren’t the standard?” in your experience is ER psych (even if just 0.5 FTE’s) in academic settings not RVU reliant?

 

[comp1]

In my experience, no. There may be certain workload expectations, but they aren't going to be tied to your pay.

 

[psych_0]

We have ER psych. They get paid a flat salary without any bonus incentive and it is straight shift work, 8am-4pm. Some days they twiddle their thumbs all day, some days they see 8-10 a shift. It truly is feast or famine. There's also pressure from the CL team to not see them in the ER if they are being admitted medically so that the CL team can collect those wRVUs (CL is RVU bonus based vs. ER is salary).

If you don't care about money (<270k/year here) and chasing the wRVU dreams, ER psych can be the easiest job in psychiatry imo. One of the guys we have now plays video games for hours until the pager goes off. He loves his life. Oh, and we also have residents often so for like 70-80% of shifts he doesn't even have to write a note.

 

[Stagg737]

When you say, “…aren’t the standard?” in your experience is ER psych (even if just 0.5 FTE’s) in academic settings not RVU reliant?

From what I've seen and speaking to a former co-resident who did an emergency psych fellowship, most positions for ER psych are either employed, salaried positions or contractors that are paid either a flat rate per shift/hourly or a flat rate per patient (which I guess you can say is like RVU-based if you always bill the same code and calculate how much per RVU you get).

 

[throw-away-go-away]

We have ER psych. They get paid a flat salary without any bonus incentive and it is straight shift work, 8am-4pm. Some days they twiddle their thumbs all day, some days they see 8-10 a shift. It truly is feast or famine. There's also pressure from the CL team to not see them in the ER if they are being admitted medically so that the CL team can collect those wRVUs (CL is RVU bonus based vs. ER is salary).

If you don't care about money (<270k/year here) and chasing the wRVU dreams, ER psych can be the easiest job in psychiatry imo. One of the guys we have now plays video games for hours until the pager goes off. He loves his life. Oh, and we also have residents often so for like 70-80% of shifts he doesn't even have to write a note.

Is that in the south?

 

[mistafab]

I'm about to do full time ER. I have already done alot of ER in side gig work.

I would not do RVU only based practice in an ER setting. Base + RVU if base is already good maybe, but not poor base with "possible" RVU for me.

The reason being - I have no control over flow of patients. RVU models only make sense if there are limitless patients, or some control over flow.

Edit: A lot of this can be figured out in the "due diligence" stage of interviewing. After the interview, before accepting the offer, insist to speak to someone who has done (or is doing) that job now. Perhaps you found a rare spot with RVU only who gives HUGE salary... who knows. Always do due diligence if you are bothering to do an interview and are considering it.

 

[lobstar]

What do you all typical see more pay in CL, ED, or a combined CL/ED position? I'm seeing stuff ranging from mid/low 200s to about low/mid 300s.

 

[psych_0]

Depends. Our CL guy is the highest paid psych in the department. Between him and the two residents on that service, they see probably 15-20 patients a day. Mostly new with some follow-ups sprinkled in.

Our ER makes the least, but he is only salary only with no wRVU incentive

 

[lobstar]

Depends. Our CL guy is the highest paid psych in the department. Between him and the two residents on that service, they see probably 15-20 patients a day. Mostly new with some follow-ups sprinkled in.

Our ER makes the least, but he is only salary only with no wRVU incentive

Academic or community?

 

[Stagg737]

What do you all typical see more pay in CL, ED, or a combined CL/ED position? I'm seeing stuff ranging from mid/low 200s to about low/mid 300s.

I make much more in my CL role than I did in my ED role but also see a lot more patients. It's also a lot easier to see 7-8 new patients on consults where there often a very specific question to answer and may be quite low-acuity vs the ER where pretty much every consult is high acuity and requires significantly more time to do the job well.

 

[lobstar]

I make much more in my CL role than I did in my ED role but also see a lot more patients. It's also a lot easier to see 7-8 new patients on consults where there often a very specific question to answer and may be quite low-acuity vs the ER where pretty much every consult is high acuity and requires significantly more time to do the job well.

I think I have a geography problem more than anything then. All the places around me have flat salary for ED or CL positions. Can I ask your general region of the country?

 

[mistafab]

I think I have a geography problem more than anything then. All the places around me have flat salary for ED or CL positions. Can I ask your general region of the country?

I think stagg is academic midwest if I recall.

Geography is a huge factor. Most ED/CL positions (to my preference) have been flat salary. I wouldn't be opposed to solid base + RVU on a busy service though.

My CL/ED work is chill, 285 flat daytime only. Large metro texas

 

[Stagg737]

I think I have a geography problem more than anything then. All the places around me have flat salary for ED or CL positions. Can I ask your general region of the country?

Mistafab is correct that I'm midwest academic. I prefer RVU/case based payment for CL where I'm at as there's no shortage of work and I get paid for taking more work. I wish ER had been salaried though, as there simply weren't enough RVUs to reach the income I wanted and found myself covering other services to hit the numbers I wanted. I no longer have to do that with our CL service.

 

[lobstar]

Do you all have a shortlist of places you've heard good things about in the Midwest and south, specifically ED/CL?. I'm thinking about broadening my search options. I can DM too if that's better.

 

[Stagg737]

Do you all have a shortlist of places you've heard good things about in the Midwest and south, specifically ED/CL?. I'm thinking about broadening my search options. I can DM too if that's better.

Honestly not really, I'm happy to try and provide more info for my position in DMs, but I didn't interview at too many places as I interviewed with my current position first and accepted pretty quickly.