Where do medoncs generate most of their WRVUs?

[thesauce]

Hey guys. I’m wondering what activities generate the most wRVUs for a medonc? Is it mostly just the consults/followups? How about giving/monitoring infusions? Other things?

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[gutonc]

Hey guys. I’m wondering what activities generate the most wRVUs for a medonc? Is it mostly just the consults/followups? How about giving/monitoring infusions? Other things?

Are you asking what generates the most income for whoever owns/operates the clinic? Or what generates the most compensation for physicians? Because the answers are different.

In the first case, the answer is drugs. Plain and simple. And by a massive margin.

The answer to the 2nd question will depend on the structure of the job. For almost all employed models, compensation is driven by moving the meat in the clinic. Whether or not a particular comp plan explicitly or implicitly takes that into account and breaks it down for you is variable. For a true PP/"eat what you kill" model, there will be compensation derived from both E/M and infusion, but the breakdown of the latter will vary, and it's not as simple as "I prescribe $10M worth of drugs a year so I make X% of that".

One thing to keep in mind, regardless of the compensation model, is that there are lots of ways that employers will try to hide money from you. In employed models, the easiest way is to separate the infusion/drug income stream from the clinical income stream. That way the clinic (i.e. you the physician) looks like you're losing money, or just barely breaking even, while the hospital or pharmacy (wherever they're hiding the drug revenue) has an annual income that rivals a small European nation's GDP. But that money "belongs" to the hospital or the pharmacy and occasionally, they'll be so kind as to "supplement" the clinic. The reality of course is that if there's no clinic, there's no infusion and if there's no infusion, there's no drug income, so it really all belongs to the clinic.

Sorry, longwinded and somewhat bitter answer to what I bet you thought was a simple question.

 

[thesauce]

Are you asking what generates the most income for whoever owns/operates the clinic? Or what generates the most compensation for physicians? Because the answers are different….

Thanks, @gutonc. Appreciate your feedback.

I’m actually not asking about money to the clinic/owners or physicians, per se.

What I am trying to find is simply what activities generate the most wRVUs for a medonc? Many medonc contracts are structured as $/wRVU so I’m hoping this would be a quick reflex answer for many.

For instance, in radonc, it’s E&M visits, reviewing films, treatment planning charges, and on-treatment visits. Those make up 75% or more of the wRVUs a radonc generates.

What is it for medoncs? Just E&Ms? Are there wRVUs for monitoring drug administration?

Basically, what are the big contributors to the total wRVUs that a medonc generates? Assuming mid-sized community and practicing general medical oncology if that matters.

 

[Mehena]

One thing to keep in mind, regardless of the compensation model, is that there are lots of ways that employers will try to hide money from you. In employed models, the easiest way is to separate the infusion/drug income stream from the clinical income stream. That way the clinic (i.e. you the physician) looks like you're losing money, or just barely breaking even, while the hospital or pharmacy (wherever they're hiding the drug revenue) has an annual income that rivals a small European nation's GDP. But that money "belongs" to the hospital or the pharmacy and occasionally, they'll be so kind as to "supplement" the clinic. The reality of course is that if there's no clinic, there's no infusion and if there's no infusion, there's no drug income, so it really all belongs to the clinic.

In that case, I wonder, in total, how many of the global south nations' GDP that will amount to.

To the OP, I've tried to look into it. It's similar to radoncs, I would say roughly 80% comes from E/M (85% clinic versus 15% hospital). Probably 10% from monitoring drug administration, and in my opinion, it should be more because it can be a pain. The rest may come from supervising APPs and performing bone marrow biopsies or IT chemo

 

[gutonc]

Thanks, @gutonc. Appreciate your feedback.

I’m actually not asking about money to the clinic/owners or physicians, per se.

What I am trying to find is simply what activities generate the most wRVUs for a medonc? Many medonc contracts are structured as $/wRVU so I’m hoping this would be a quick reflex answer for many.

For instance, in radonc, it’s E&M visits, reviewing films, treatment planning charges, and on-treatment visits. Those make up 75% or more of the wRVUs a radonc generates.

What is it for medoncs? Just E&Ms? Are there wRVUs for monitoring drug administration?

Basically, what are the big contributors to the total wRVUs that a medonc generates? Assuming mid-sized community and practicing general medical oncology if that matters.

For most med oncs in employed positions, it's strictly E/M. The compensation for drug administration is usually rolled into the $/wRVU compensation.

APP "supervision" is either nothing, or, in some groups, the wRVUs generated by the APP go to "their" physician, but the APP salary is then deducted from that physicians gross. So it's not exactly "free" wRVUs.

The short and simple-ish answer to your question is "moving the meat in clinic".

 

[TexasMed22]

Are you asking what generates the most income for whoever owns/operates the clinic? Or what generates the most compensation for physicians? Because the answers are different.

In the first case, the answer is drugs. Plain and simple. And by a massive margin.

The answer to the 2nd question will depend on the structure of the job. For almost all employed models, compensation is driven by moving the meat in the clinic. Whether or not a particular comp plan explicitly or implicitly takes that into account and breaks it down for you is variable. For a true PP/"eat what you kill" model, there will be compensation derived from both E/M and infusion, but the breakdown of the latter will vary, and it's not as simple as "I prescribe $10M worth of drugs a year so I make X% of that".

One thing to keep in mind, regardless of the compensation model, is that there are lots of ways that employers will try to hide money from you. In employed models, the easiest way is to separate the infusion/drug income stream from the clinical income stream. That way the clinic (i.e. you the physician) looks like you're losing money, or just barely breaking even, while the hospital or pharmacy (wherever they're hiding the drug revenue) has an annual income that rivals a small European nation's GDP. But that money "belongs" to the hospital or the pharmacy and occasionally, they'll be so kind as to "supplement" the clinic. The reality of course is that if there's no clinic, there's no infusion and if there's no infusion, there's no drug income, so it really all belongs to the clinic.

Sorry, longwinded and somewhat bitter answer to what I bet you thought was a simple question.

If there were to be a change in billing, and oncologists could no longer get a cut of the infusion drug cost and were only paid based on RVUs generated (like mosts other specialties), what percent reduction would you expect in oncologist salaries? Purely from a RVU perspective, it seems like hem oncs would make the same or less than hospitalists.

 

[gutonc]

If there were to be a change in billing, and oncologists could no longer get a cut of the infusion drug cost and were only paid based on RVUs generated (like mosts other specialties), what percent reduction would you expect in oncologist salaries? Purely from a RVU perspective, it seems like hem oncs would make the same or less than hospitalists.

30-50%.

I mean, I "only" get paid on the wRVUs I produce. But I'm compensated more for each of them than an endocrinologist or PCP would be.

 

[HemeOncHopeful19]

If there were to be a change in billing, and oncologists could no longer get a cut of the infusion drug cost and were only paid based on RVUs generated (like mosts other specialties), what percent reduction would you expect in oncologist salaries? Purely from a RVU perspective, it seems like hem oncs would make the same or less than hospitalists.

We already get paid based on RVUs generated.

Are you asking in a world where every single specialty makes the same $/RVU? Yes I suppose we would come down but I’m not familiar with typical annual RVUs by specialty so I have no idea how that would end up shaking out.

 

[Mehena]

I ain't trying to crack the code here. If I were, I'd totally claim the Nobel Prize for Economics by cracking the Rubik's Cube of market economies in healthcare. Then i bet i'd belong in the corner office up in that ivory tower of the C-suite.
I would be perfectly happy doing hem/onc if I were paid less than hospitalists. But also making the hay now.

 

[HemeOncHopeful19]

I ain't trying to crack the code here. If I were, I'd totally claim the Nobel Prize for Economics by cracking the Rubik's Cube of market economies in healthcare. Then i bet i'd belong in the corner office up in that ivory tower of the C-suite.
I would be perfectly happy doing hem/onc if I were paid less than hospitalists. But also making the hay now.

I would not be totally happy to make what Hospitalists make, but I WOULD be totally happy for Hospitalists, Endocrinologists, Pediatricians etc. to make what Heme/Onc makes.

 

[solidonc2020]

Not to hijack the thread, but I know @gutonc has typically used ~2 wRVUs per oncology clinic visit as the multiplier when calculating out how many wRVUs one can expect to generate. Is there a rough estimate for adding in inpatient consult time as a general Hem/Onc consultant? Is a typical new vs follow-up inpatient consult billed similarly to a new clinic visit or higher?

I assume those are usually calculated in for the physician when trying to meet yearly wRVU thresholds for bonuses. My calculations for the job I'm taking have only been accounting for office visits but I realized I should likely generate some from 4-6 weeks of additional inpatient consults per year.

 

[HemeOncHopeful19]

Not to hijack the thread, but I know @gutonc has typically used ~2 wRVUs per oncology clinic visit as the multiplier when calculating out how many wRVUs one can expect to generate. Is there a rough estimate for adding in inpatient consult time as a general Hem/Onc consultant? Is a typical new vs follow-up inpatient consult billed similarly to a new clinic visit or higher?

I assume those are usually calculated in for the physician when trying to meet yearly wRVU thresholds for bonuses. My calculations for the job I'm taking have only been accounting for office visits but I realized I should likely generate some from 4-6 weeks of additional inpatient consults per year.

Well assuming your inpatient weeks are lighter in clinic (for example if you use half day in clinic to go round) then it may just be a wash

 

[gutonc]

Well assuming your inpatient weeks are lighter in clinic (for example if you use half day in clinic to go round) then it may just be a wash

My experience in a general hem/onc community setting is that it's a wash. But you can kind of figure out what to expect based on the 2023 CMS numbers.

Outpt:
99203 - 1.6
99204 - 2.6
99205 - 3.5

99123 - 1.3
99214 - 1.92
99215 - 2.8

Inpt:
99221 - 1.63
99222 - 2.60
99223 - 3.5

99231 - 1.0
99232 - 1.59
99233 - 2.4

 

[gutonc]

I assume those are usually calculated in for the physician when trying to meet yearly wRVU thresholds for bonuses. My calculations for the job I'm taking have only been accounting for office visits but I realized I should likely generate some from 4-6 weeks of additional inpatient consults per year.

If you're doing both inpatient and outpatient those weeks, it will probably be similar to a full outpatient week. If you're just seeing inpatients, likely lower unless you've got a massively busy service.

 

[bobbyknightranger]

Sorry to hijack a bit as well - but what is the difference between a 9924x and a 9920x? The first is for a "consult" and the second for a new patient. But what is the practical difference in clinic, and should we be billing one or the other? Most of what I see on here is people mentioning 9920x codes. Thanks.

 

[gutonc]

Sorry to hijack a bit as well - but what is the difference between a 9924x and a 9920x? The first is for a "consult" and the second for a new patient. But what is the practical difference in clinic, and should we be billing one or the other? Most of what I see on here is people mentioning 9920x codes. Thanks.

CMS stopped paying consult codes over a decade ago. To my knowledge, private insurers have followed suit at this point.

If you're billing a 9924X, your coders are probably changing it to a 9920X so it will get paid.

 

[whoknows2012]

CMS stopped paying consult codes over a decade ago. To my knowledge, private insurers have followed suit at this point.

If you're billing a 9924X, your coders are probably changing it to a 9920X so it will get paid.

Didn’t realize the specifics but our coders were changing the inpatient consult coding bc of lack of payment as you mention. For inpatient complex consults I bill 99223 as per my billing compliance folks.

The ~2rvu per visit estimate that @gutonc mentioned before applies for inpatient too. As an inpatient leukemia doc I have an average census of 20-25 and over the course of the year (48 weeks of work roughly) it works out to an average of 2.5 per patient visit. Between the higher admission notes (about 1/10 of all visits/notes l) and the slightly lower level 2 for not as complicated patients and discharges that I usually bill at 99239 (2.15 wRVU). I agree that depending on how busy inpatient work is and how busy outpatient work is during the inpatient weeks it may work out as a wash.

The one caveat to the above is in academic practice especially malignant heme where you may decrease your clinic burden in your inpatient week form 60 visits (120 rvu) to 20 pt visits (40 rvu) but then cover a service for 12 days with 15-20 patients and 40-50 rvu/day which works out to a significantly higher 2 week rvu acquisition (240 vs minimum 550)

 

[solidonc2020]

If you're doing both inpatient and outpatient those weeks, it will probably be similar to a full outpatient week. If you're just seeing inpatients, likely lower unless you've got a massively busy service.

Thanks. Our setup will be inpatient consults (mostly handled by APP, then staffed by us) on top of usual clinics, but I think most probably schedule a little lighter those weeks. No primary service responsibility. So probably close to a wash unless you maintain your usual clinic and the added consults.

 

[TexasMed22]

30-50%.

I mean, I "only" get paid on the wRVUs I produce. But I'm compensated more for each of them than an endocrinologist or PCP would be.

Is there any indication that this type of change is likely to occur? For example, if you ask radiologists, they'll basically all tell you that reimbursement cuts are inevitable for radiology in the future, since they happen every year. Is this same true for oncology here? Or is buy-and-bill too central to the current healthcare system (either directly as a private practice getting the 6% drug margin, or through inflated $/RVU paid out in an employed hospital setting)?

 

[gutonc]

Is there any indication that this type of change is likely to occur? For example, if you ask radiologists, they'll basically all tell you that reimbursement cuts are inevitable for radiology in the future, since they happen every year. Is this same true for oncology here? Or is buy-and-bill too central to the current healthcare system (either directly as a private practice getting the 6% drug margin, or through inflated $/RVU paid out in an employed hospital setting)?

Some type of change is bound to happen. What, when and how is TBD.

I can say with certainty that there will be a massive lobbying campaign against this, when it comes around. Hospitals in particular are so dependent on infusion revenue (and not just oncology these days, although much of this income flows through oncology since in many small/medium hospitals, oncology "owns" infusion) that they won't stand idly by when this comes about.

 

[TexasMed22]

Some type of change is bound to happen. What, when and how is TBD.

I can say with certainty that there will be a massive lobbying campaign against this, when it comes around. Hospitals in particular are so dependent on infusion revenue (and not just oncology these days, although much of this income flows through oncology since in many small/medium hospitals, oncology "owns" infusion) that they won't stand idly by when this comes about.

This was my thought as well. I can only speak anecdotally, but in my ~5 hospital health system, 4 of the hospitals run in the red each year, with the 1 cancer hospital making so much that it props the entire system up. I would imagine if infusion revenue were to be removed, the entire system might collapse.

 

[gutonc]

This was my thought as well. I can only speak anecdotally, but in my ~5 hospital health system, 4 of the hospitals run in the red each year, with the 1 cancer hospital making so much that it props the entire system up. I would imagine if infusion revenue were to be removed, the entire system might collapse.

In most hospitals, oncology (through infusion) is the top revenue generating non-procedural specialty and unless there's spine surgery or a very busy hip/knee replacement or cardiac cath lab, can be the top generating specialty overall.

At my prior hospital it was:
1. Spine
2. Ortho (all)
3. Oncology
4. Interventional cards

At my current hospital the only reason ortho beats oncology is that we're the closest hospital to 3 ski resorts and there's an active hiking/MTBing/whitewater rafting/kiteboarding/windsurfing community here. So there's a lot of new knees and shoulders in the summer and ORIFs and ACL repairs in the winter.