RVU only contract

[DOnut]

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Hey everyone,

Looking for some senior advice. Have 2 offers on the plate. One at a community hospital with academic affiliation, the other straight community. I want to teach some, so I am leaning towards the 1st option. They pay pure salary for the 1st 20 months while calculating your productivity. They then switch to an all RVU system after 2 years. What are your thoughts on this. I'm still learning the RVU game, and just want to know if it's worth it to base my salary on RVU's alone. Please let me know what you think!

Thanks!!

 

[Old_Mil]

You might get different points of view on this, but mine is this: I'm unwilling to work on a strict RVU basis. The reason for this is that significant benfits on the upside go to my employer while I bear sole risk on the downside.

In an EM setting especially, the only patients actively seeking out a particular physician are probably drug seekers.

You buy my time, I show up, and admin worries about the rest is how I like to play the game.

 

[GeneralVeers]

Hey everyone,

Looking for some senior advice. Have 2 offers on the plate. One at a community hospital with academic affiliation, the other straight community. I want to teach some, so I am leaning towards the 1st option. They pay pure salary for the 1st 20 months while calculating your productivity. They then switch to an all RVU system after 2 years. What are your thoughts on this. I'm still learning the RVU game, and just want to know if it's worth it to base my salary on RVU's alone. Please let me know what you think!

Thanks!!

My position is similar, during an initial period we are salaried, then once we hit the hourly target the salary chances to mostly RVU with some base salary. From what I'm able to determine the salary goes up once you reach the RVU compensation. The nice thing about having 20 months of salaried work is that it gives you time to learn the system, and work on maximizing your RVUs without taking a penalty.

 

[BADMD]

Personally, I like a blend of the two.

Pure salary is comfortable, but you get lazy and there is no reward for busting you ass. Your employer has no incentive to give you help as they reap rewards for making you work as hard as possible and giving you as little help as they can.

Pure RVU can be great. You bust your butt and you get paid more. Do more procedures, more critical care, bill more efficiently, and you get paid more. However you can get screwed by seeing non-insured patients and complex patients with simple problems. Your co-workers can also screw you over by cherry picking "better" cases for themselves and engineering the system so that they stick you with more, lower paid work. You have to ensure that there is a system for distributing patients. You also have to look carefully at exactly how RVUs are credited: do they go the person that saw the patient or to the person that is there when the patient leaves the ED. Both systems can be used by your co-workers to screw you. And as another pointed out, all the risk is yours: slow night = low pay.

Don't forget to look at how benefits and insurance get paid. Some of the RVU only places will 1099 you. Yeah, the check is huge, but you have to pay both portions of social security, medicare and income tax, then you have to pay your malpractice insurance. That can suck a check dry.

 

[spyderdoc]

Don't forget to look at how benefits and insurance get paid. Some of the RVU only places will 1099 you. Yeah, the check is huge, but you have to pay both portions of social security, medicare and income tax, then you have to pay your malpractice insurance. That can suck a check dry.

Well, you must remember though, in most group settings, you are really "paying" for these things anyhow, you just don't see it. Unless the group is subsidized by the hospital and getting "free money", which is unlikely, you are still paying these fees through receiving lower paychecks.

 

[txterp98]

I work mainly at 2 hospitals which are straight RVU pay. In order for it to be worth your while, you need a good volume of patients. Both of my hospitals see around 40,000/yr and you're busy day and night. Actually, you make a little more at night because of our drop in coverage.

The pros of RVU pay have been well-named above. To sum it up, you basically eat-what-you-kill.

The biggest con of straight RVU pay is that in your quest to see more patients (and thus, increase your take-home pay), you might end up skimping on documentation. You have to be diligent to make sure you don't do this. You only get one chance with that chart.

And BadMD is completely correct that your co-workers can screw you over if they cherry pick (shoulder reduction for them, 7-yr old with a cough for you). Hopefully you'll end up at a place with good colleagues who'll be diligent about not seeing patients out-of-order (assuming triage is done correctly and that it's most critical to most stable) and who will assure that you go back-and-forth on seeing patients for times when it is slow.

For what it's worth, I'm an employee at my place. I get a W2 at the end-of-the-year.

 

[southerndoc]

My group uses a productivity model that is RVU based, but isn't strictly fee-for-service. Meaning we get set reimbursement amounts for levels 1-5, procedures, EKG interpretation, etc. regardless of the patient's ability to pay. This eliminates the cherry picking.

It's a great system if you are efficient. Even if it is reported as a 1099, it can still be good. My earnings are far more as an independent contractor than it would have been by the major employers in my area... even when I take into account me paying my own health/disability/life insurance, self-employment tax, etc.

 

[docB]

This may get a little long but bear with me as the question you’ve asked is actually pretty complicated.

Getting paid based on RVUs alone is fine if you have a reasonable volume, ie. since you need to generate RVUs to get paid you want to make sure you have enough patients to see to generate those RVUs. Generating RVUs also requires good documentation. “If you don’t write it down it didn’t happen.” applies to billing as much as it does to legal. If you’re working with residents that means making sure they document correctly and that you are billing for their workups and procedures which you are supervising.

Note that one possible way that new guys get abused in that system is by being given low volume shifts while the senior guys get all the busy shifts. It’s the opposite of the salaried groups putting the new guys on the really busy shifts while the senior guys get paid to sit around.

The good thing about being on an RVU model is that when you’re getting killed you can at least feel better in that you’re making more money. When it’s slow it cost you but it’s nicer. When your on salary or hourly being really busy just bites and there’s no silver lining.

It’s important to know that getting paid based on RVUs is different than getting paid on a straight fee for service or “eat what you kill” system. Both of those pay you based on what you collect rather than how many RVUs you generate. The problem with that situation is that you get penalized for treating uninsured patients. It can create bad incentives within groups and can lead to cherry picking.

BTW – I started writing this at 0600. It’s now 1552 and I’m still getting killed at work. Here it is. More later.

 

[BADMD]

Well, you must remember though, in most group settings, you are really "paying" for these things anyhow, you just don't see it. Unless the group is subsidized by the hospital and getting "free money", which is unlikely, you are still paying these fees through receiving lower paychecks.

Yes and no. There are certain tax advantages to an employer sponsored retirement. I also believe there are tax advantages to having the employer portion paid by the employer.

 

[DOnut]

Thank you everyone for your replies. As far as the volume goes, I wont know. It's a brand new ED (hospital just reopened), but it is in an urban fairly large city. Beautiful facility now, but literally opened 2 weeks ago. So when I start in July, there will only be 6 months of data to go by. One thing I find positive is that I am considered an employee. The cherry-picking thing was a great point. I'll make sure to ask this specifically to some of the guys next time I'm there. I can seriously see how the new guy can get screwed. Thanks again for your thoughts. Really appreciated.

 

[tkim]

You might get different points of view on this, but mine is this: I'm unwilling to work on a strict RVU basis. The reason for this is that significant benfits on the upside go to my employer while I bear sole risk on the downside.

In an EM setting especially, the only patients actively seeking out a particular physician are probably drug seekers.

You buy my time, I show up, and admin worries about the rest is how I like to play the game.

Just curious how you know enough about the different compensation plans that you already have an opinion, as we haven't had much in the way of advice during residency.