The three-member pediatric hospitalist group at Kentucky Children’s Hospital also doesn’t use RVUs, either for compensation or as a productivity proxy. Jeff Bennett, MD, its lead hospitalist, says pediatric outcomes data aren’t robust enough to establish proper RVU benchmarks. He adds that adult RVUs are “denser” than pediatric RVUs because of lower acuity and fewer procedures with children’s illnesses. Additionally, productivity measures don’t affect pediatrics significantly because children’s hospitals “are at the bottom of the funnel,” he says. “We have to take every kid who comes our way. Pediatric hospitals tend not to be competitive. There are four hospitals in town competing for adult patients, while we’re the only tertiary care hospital for 300 miles.”
Compounding the problem is that determining pediatric hospitalist compensation is problematic. With only 2,200 pediatric hospitalists versus 20,000 who work with adults, compensation packages tend to idiosyncratic. “Compensation is important, but RVUs won’t figure into pediatrics for a while,” says Dr. Bennett. “People chose hospital medicine from residency because they’re itching for inpatient work, with its complexity and sharp edges. The shine dims quickly, though, because they are protected during residency and then have full responsibility as hospitalists.”
David Dale, MD, director of the University of Washington’s internal medicine residency program, and American College of Physicians’ president, says hospitalist careers loom large for his annual crop of 35 to 40 residents—but RVUs don’t. “For them it’s an easy transition, a guaranteed salary versus establishing a small business,” he says. “The office practice is where the RVUs really impact generalists. We have a hard job preparing residents for those reimbursement issues.”
Dr. Dale says between two-thirds and three-quarters of his residents become hospitalists, although that’s often not their final career destination. “Some don’t treat hospitalist medicine as a long-term career because the work is hard and the hours are stressful. Many are waiting for a fellowship track to specialization.”
The General Surgeon
A 2007 article by Josef Fischer, MD, in the Journal of the American Medical Association raises questions about the dwindling general surgeon cadre.1 Dr. Fischer posits that RVUs can’t boost surgeons’ incomes because surgeons can’t increase utilization when reimbursement decreases.
For example, since patients have only one gallbladder and indications for removal are constant, there’s no way to increase surgical RVUs. He says this unattractive RVU scheme dissuades residents from general surgery careers.
Dr. Fischer’s concerns don’t faze David Joyce, CEO of Morrisville, N.C.-based Delphi Healthcare Partners, which has three surgicalist programs nationally. Each employs two general surgeons working two weeks on, two weeks off, covering indigent and unassigned patients.
On average, each sees eight patients daily, two requiring surgery. The surgicalists all are either age 50 to 55 or under 35 and reject the hassles of office-based practices at both ends of the career ladder. They earn fixed salaries; Delphi uses RVUs for reimbursement but not for productivity bonuses.
“RVUs aren’t very important in our surgicalist equation, which is a winning situation for everyone involved,” Joyce says. “Private-practice surgeons are thrilled because they don’t cover call and can build their practices. The hospitals do well and don’t mind kicking in several hundred thousand dollars to cover surgicalist compensation.
“In our Charleston, W. Va., program the hospital derived $1.6 million above our program’s cost because the private docs did more surgeries, our surgicalists do what they were trained to do and are well compensated. It’s great,” he says.
Delphi surgicalist Richard Fogle, MD, works at Thomas Memorial Hospital in South Charleston, W. Va., and doesn’t think about RVUs. “The problem with surgeons is lifestyle,” he asserts. “If you have 10 surgeons, you cover call once every 10 days. With three surgeons it’s once every three days.”