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2/18/2019 Radiologist Productivity Benchmarks: Slacker or Slave?

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PRODUCTS & PRACTICE MANAGEMENT

Radiologist Productivity Benchmarks: Slacker or Slave?


Productivity is an important management tool in any business, including that of the
radiology practice. Relative value units (RVUs) are frequently pressed into service to
measure radiologist productivity, but there are some inherent shortcomings in the
RVU system in that some examinations are undervalued. The goal of this article is to
suggest how examination information can be compiled and shared nationally to
provide credible benchmarking information for all radiologists. Because the
information portrayed in the tables of this article is derived from a small private
practice, all practices cannot necessarily assume that their numbers should be
similar.
James A. Kieffer, MBA
The simulation model at the end of the article is based on an incorrect assumption,
but the mechanics of the model could be a valid tool for recompiling work RVUs. The assumption is that work
RVUs are based strictly on the relative average time to perform the procedure in relation to others. Time certainly is
a direct by-product of the complexity of an examination, but it appears that a “clinical signi cance factor” is also
included. The model would help test the time/clinical signi cance component in each RVU and also identify
procedures that are undervalued.

The radiology practice pro led uses a scheduling program that


provided useful coverage information that facilitates compilation of
work RVU per hour, something not commonly available. This article
will explore the linkage of coverage hours and a simulation of
caseload hours using work RVUs. It is an experiment that will
Table 1.(Click the image for a larger version.)
hopefully trigger constructive feedback from the readership.

This practice, out of economic necessity, is a busy one. This does not eliminate the administrative duties not
re ected in work RVU. Whenever possible, the administrative duties are limited to “off-hours” when the department
caseload is lightest. The scheduling program does codify these time commitments and, hopefully, they were
accurately factored in the time simulations.

There is another factor that is di cult to quantify when comparing productivity statistics for this practice versus
others. The major coverage location is still lm-based in many areas, but is moving forward with the installation of
a full PACS. It is likely that the work RVU per FTE could be higher in a fully digital environment. There is little or no
information published on this issue because it is di cult to quantify, plus there is a behavioral component. If a
digital environment does make a radiologist more productive, then practices will either restructure themselves to
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handle caseload with fewer members, thus enhancing income, or choose to take more time off because
productivity per hour/day/week is higher.

PAYOR MIX

The group portrayed in this case study services a health care delivery system with a payor mix that likely impacts
its ability to generate a competitive salary/bene t package. Table 1 puts this in context.

Column A represents a generalized payor mix; column B shows the


distribution of practice charges. Column C might be considered the
payor mix of the Average Practice, although the percentage ranges
within each payor group can be broad, regionally and nationally. The
group’s payor con guration has signi cant amounts of low to medium
payors and self-pay population. The self-pay/indigent populations of Table 2.(Click the image for a larger version.)
all practices account for most of bad debt, where the collection ratio ranges between 5% and 15%.

Column D is a relative measure of income per payor group, using Medicare as a baseline. Many commercial and
managed care payors establish fees that are multiples of the Medicare rates since HCFA (now CMS) established
its relative value system in the late 80s. The multiplication of the two payor mixes by these income factors
establishes a weighted difference in overall income, all other factors being constant (more on this point later). This
implies that the average practice in the sample practice’s region could produce almost 20% more income from its
cases.

If two practices covered different hospital/health care delivery systems with approximately equal caseload
demands, and one generated 20% more income from its caseload, the number of radiologists in that group might
be greater, choosing to reduce coverage hours per member rather than receive higher income.

Recommendation: When national organizations seek out work RVU statistics from their membership, they should
ask for a payor breakdown as a data subset, to establish a correlation between payor mix and productivity.

COVERAGE SCHEDULES

The practice’s scheduling program had extensive coding detail to


de ne coverage responsibility. Table 2 is an abbreviated distribution of
all calendar days per member, distinguishing call, weekday and
weekend coverage, and time off.

There were seven full-time and one part-time members in 2004, the
compilation year for the examination statistics. Three of the full-time Table 3.(Click the image for a larger version.)
members handled the interventional caseload and are assigned more backup call. As a practical matter, they were
potentially on backup call one third of the time to handle any off-hour interventional demands that, fortunately, are
infrequent. The trade-off was fewer weekend call days. The “CALL-NOON” and “CALL-10AM” designations imply
that the individual assigned that responsibility arrived at either noon or 10 AM, remaining in the department until 10
PM. Any diagnostic cases after 10 PM were handled as a wet reading by a nighthawk service, with the formal
dictation performed by one of the eight radiologists the following day. The four columns at far right start the
simulation of coverage hours by assignment of assumed physical time in the departments. The backup call time is
a non-scienti c attempt to simulate annual hours actually in the department while on backup call. Table 3 portrays
the on-site hours.
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The physical hours on-site are an important component of the differences in productivity between groups. It is not
likely that any surveys have asked respondents to provide both work RVUs and coverage hours. If, as suggested,
material differences in the income systems affect decisions about coverage hours, we would likely see the more
lucrative practices showing fewer hours per full-time-equivalent (FTE).

PRODUCTIVITY SUMMARY

Column A in Table 4 reproduces the simulated coverage hours from


Table 3. Column B is an organization of examinations by physician for
calendar 2004 derived from the practice receivable system. The data
was provided by CPT code, facilitating compilation of work RVU.
Subsequent tables will offer more detail to illustrate the extent in
which work RVUs can be organized. Column D averages the work RVU
per procedure. Those with the higher average are the three members Table 4.(Click the image for a larger version.)
who handle the interventional caseloads. The practice average of .58 is consistent with a complex caseload
universe. This is an important point given the size of this group. The case mix will be illustrated shortly.

Columns E and F represent caseload handled by the practice, not billed through the receivable system. It consists
primarily of plain lms with no CPT code detail and was arbitrarily distributed equally among the full-time
diagnostic members, using the average RVU/procedure for plain lms. Columns G and H are the combined totals,
and column I represents the average work RVU per coverage hour.

The full-time member statistics are segmented at bottom as to totals, mean, and standard deviation. The standard
deviation, as a percent of the mean, suggests the value of using the work RVU as a productivity measure.
Procedure volume has a predictably large variance because of case mix differences, yet the work RVU and
resulting RVU/hour are tightly bunched.

CASE MIX DISTRIBUTION

This practice has a complex case mix that demands, because of the
volume in relation to group size, that each full-time member handle all
modalities. Concessions are made to the three members who handle
the interventional workload, yet they all do cover other areas to some
degree. This explains why the total work RVUs per member are tightly Table 5.(Click the image for a larger version.)
bunched.

There is a theory that specialists who concentrate on only a few modalities can produce a great number of work
RVUs because of disproportionate weighting of the values. Compiling the work RVU distribution this way might
help answer questions about wider disparity among members of other practices that are larger and more
subspecialized. The nal model of this article also is a useful tool to test if some examination groupings are
over/under weighted.

The section above on payor mix discussed the theory that practices with more lucrative income systems would
likely favor quality of life over enhanced income. Table 5 also hints at another reason why the work RVUs for this
practice might be higher than average, again in uenced by income-related issues. This group has a
disproportionate amount of surgical cases for its size. The payor fees for surgical codes are less favorable than for
diagnostic ones. This implies that other groups with a procedure volume of 127,000 might have not only a better
payor mix but also fewer surgical codes.
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SIMULATION: CASELOAD USING RVUS

Table 6a and Table 6b represents a hypothetical simulation of


annual caseload time using work RVUs. The statistics for FTD
#4 were chosen because the examination mix was the most
broadly based, including interventional procedures, and this
individual was not asked to interpret the outside plain lms.

Column A contains an abbreviated description of the sections


in the CPT manual where the imaging and surgical procedures
are grouped. The number of codes in each group may range
from as few as three to as many as 25. Column B is the
imaging modality. The best way to describe the
interrelationship between columns A and B is to reference
“Head & Neck.” There are groups of codes covering CT, MRI,
and Plain Films within the “Head & Neck” section of the Table 6a.(Click the image for a larger version – PDF.)
manual (Ultrasound has its own “Head & Neck” section).

Column C is the 2004 examination volume for the grouping and modality con gurations, and column D is work
RVU resulting from the examinations. Column E shows average work RVU/procedure for the grouping/modality
con guration. Column F is the normalization of the column E values, using the Chest/Plain Film as “1.00”; all other
groupings are restructured in relation to this benchmark.

Column G is the simulation of average procedure times for each grouping based on the assumption made about
the average reading time for Chest cases. Column H is the multiplication of the time per procedure by the annual
volume. The total is then divided by 60 to estimate annual hours handling caseload. Now we need to critique this
model:

1. The 1,241 hour simulation was based on an assumption that caseload time has to be less than coverage
time. It is not reasonable to expect any physician to handle clinical workload 100% of the hours worked.
No data exists that suggests maximum workloads before stress interferes with clinical e ciency. An
arbitrary assumption was made that 6 reading hours out of 8 coverage hours is a maximum limit.

2. FTD#4 simulated average of 6.04 work RVU per coverage hour would translate to a different gure per
reading hour. If 6 hours per day is a limit (75%), then the work RVU per reading hour is 6.04/.75 = 8.05.
The chest lm(s) average RVU is .21, implying: 8.05/.21 = 38+ Chest examinations per hour. That
translates to 1.58 minutes per examination (top of column G).

3. The surgical codes likely have a work RVU that does not t well with the diagnostic examinations; this is
just a theory based on the history of how the original RVU values were assigned. Each specialty had direct
input about its own coding mix, and the performance of cases involving the surgical codes in the 1980s
was impacted by turf battles. Also, interventional cases involve multiple surgical codes, implying that
simulation of the time for an interventional case requires addition of two or more surgical and S&I codes.

4. The challenge to the reader is to determine if the column G averages per procedure are realistic. Changing
the baseline time to a higher number will result in simulated hours at or greater than the coverage hours.
This model could just as easily be expanded to include each CPT code in this radiologist’s 2004 universe
where we used the single view Chest as the baseline.

5. If the work RVU includes both a time and “clinical signi cance” component, would there be a value in
splitting them up? Is it reasonable to assume that large groups that might subspecialize should use the

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work RVU to distribute part of their income pool because some specialists might be handling more
“clinically signi cant” cases?

CONCLUSIONS

This article suggests that the work RVU per member for this
practice is higher than average out of economic necessity. If
the reader is a member of a practice with a more favorable
payor mix, and the proportion of surgical codes is lower, then
the theory put forth by this article is that the reader’s annual
work RVU will be lower.

An important caveat in using this data is to consider how


e cient the radiologists are because of department
infrastructure. Could the work RVU per FTE for this group be Table 6b.(Click the image for a larger version – PDF.)
higher (thus fewer members) if their major coverage sites
were more digital? This suggests that practices with more favorable payor and case mix might produce greater
work RVU per FTE because they are more e ciently organized. This gives them the double bene t of greater
income in fewer reading hours.

It would not be di cult for the American College of Radiology, if their members wanted it, to produce a work RVU
based strictly on time commitments per CPT code. It would be more straightforward than the subjective “clinical
signi cance” component.

The practice pro led democratically distributes the caseload out of logistical necessity. It is too small to
subspecialize. This eliminates any inappropriate weighting of CPT code groups where an hour spent on a single
modality or organ system arti cially generates more work RVU than is appropriate. The only way to test if the
assigned work RVU is wrong is to speculate on how many cases can be done in an hour for a procedure grouping
and then decide if the resulting total work RVU difference is justi ed because one type of caseload is more
clinically important than the other.

James A. Kieffer, MBA, is president, Proforma Financial Group Inc, Nashua, NH; www.Proformafg.com .

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