Leveraging RVU Data to Improve Productivity
Friendly competition has developed among the five radiologists of Capital Imaging Associates, Albany, New York, to the benefit of referrers (and, potentially, to patient care). Six months ago, the group implemented an RVU-based system for productivity tracking, which has allowed the physicians to gain awareness of their individual caseloads and how they stack up against those of their colleagues. The ultimate goal is to improve efficiency and maintain the group’s current position as the radiology practice with the fastest turnaround time in its county.
Michael Gabor, MD, MBA
Michael Gabor, MD, MBA, managing partner of the group and chair of the medical imaging department at Albany Memorial Hospital, explains, “At the margin, I’ve been pushing myself. Instead of any animosity, it’s been more that if I have someone breathing on my heels, I’m going to push myself more. It’s a friendly competition, and I think that’s a healthy thing.” In the late 1980s, the ACR®, together with the DHHS, created the ACR RVS. The mission was to use a value scale to show the relative amount of work input for the various types of imaging exams, and to scale reimbursement appropriately under the Medicare program. Values were assigned to the professional and technical components of exams. In 1992, HCFA implemented the more comprehensive RBRVS, an adaptation of the earlier ACR RVS. According to the RBMA, the RBRVS differed in one major respect: For each code, the RVUs assigned to the professional component were subdivided into expenses for work, practice overhead, and malpractice risk. Gabor has been interested in RVUs for about a decade, ever since reading about the management tool in medical journals. From 2002 to 2006, he intermittently received a monthly RVU report, which he says “was essentially useless because it was just a small snapshot in time.” Due to skepticism from the group, as well as an antiquated RIS, however, fully implementing the system was never more than a pipe dream for him. That all changed two years ago, when the group hired Medical Imaging Specialists (MIS), a consulting company based in Hammond, Louisiana. By this time, Gabor had become managing partner. When he began talking with MIS about RVUs, he discovered that the company would be able to help mine the relevant data. Gabor started discussing RVUs during meetings, and eventually, the radiologists became more comfortable with the concept. With the company’s help, the practice’s billing partners were able to cull the necessary data from its RIS, and the data can now be manipulated in a way that allows RVU calculation. Since earlier this year, the group has been able to look at monthly RVU reports broken down by individual radiologist; in addition, it can see the group‘s total RVUs compared with national-average benchmarks by site and by modality. Getting Started The productivity-tracking tool was initially greeted with skepticism by some of Gabor’s colleagues, but he attributes this to a fear of the unknown. “You can’t manage what you can’t measure,” Gabor says. “Every person thought he or she was doing more work than everybody else, so people were sometimes disgruntled.” Gabor says that some of the group’s radiologists were not happy with their existing compensation scheme, which divided the pie equally among the partners. “On the surface, that sounds very fair, but in practice, it incentivizes mediocrity, in my opinion,” Gabor says. “There is no incentive to go the extra mile or push the gas pedal to the floor. If you lag, there is no penalty. If you surpass others, there is no reward.” Gabor admits there might have also been a subconscious fear among the radiologists that salaries would decrease for certain people with lower RVU totals, or that RVU tracking could fuel in-house fighting. Keeping in mind the group’s concerns, Gabor argued his case, pointing out that the system would be used for informational purposes at first, not to shake up salaries. In time, the group started to warm up to the idea, and the radiologists have become increasingly comfortable with the concept. “Thanks to the help of our consultants, RVU analyses as part of the monthly practice meetings have been very clinical, matter-of-fact presentations,” Gabor says. “There have been some good discussions, and nobody has been singled out; I think some behaviors have changed just because we’ve been showing the numbers.” Although Gabor praises the use of RVUs, he does concede the method’s limitations. In particular, he cautions his colleagues not to turn into RVU chasers. Productivity is not the only measure of value at the practice, he notes. A key disadvantage with an RVU alone is it does not account for business duties, administrative work, marketing, and communication. “It is also of value to the practice to spend a half hour with the surgeon who comes by and wants to discuss a complicated case, but if we’re just focusing on RVUs, that radiologist is penalized,” Gabor says, adding that under the RVU scheme, he would also be penalized for attending important meetings. “We don’t want to become an RVU mill and just juice up RVUs at the expense of doing a case properly,” he says. “We don’t want to shortchange the patients, but we do want to maximize our efficiency and productivity." While the RVU method might be imperfect, Gabor feels that it is better than other measures. The next step is to add another measurement for quality, in addition to quantity. Layering scores from customer-satisfaction surveys on top of the RVU formula might be a solution. “We don’t have all the answers yet, but I think we are heading in the right direction incrementally,” Gabor says. “We are undergoing the journey, taking baby steps.” A Look Ahead Because the group only began tracking RVUs six months ago, no relevant data analysis is currently available. Based on Gabor’s anecdotal evidence, however, the practice has become more aware of individual performance and personal efficiency through the monthly reports. Gabor says that he was surprised by the disparity in work, especially the wide spread between the top and bottom performers. “What I’m hoping to see is that the spread narrows—not that the top goes down, but that the bottom guys kick it up a little bit,” Gabor says. Being able to shine a critical light on workflow processes has been the RVU method’s great success, according to Gabor. “It really didn’t cost us anything,” he adds. Once the group figures out how to quantify the more qualitative elements, Gabor hopes to tie some portion of compensation to RVU figures, possibly by offering productivity bonuses. After all, the practice is no stranger to incentive-based compensation schemes. Its current one has been “a capitalistic success,” according to Gabor: After 5 PM, radiologists are paid per click to read cases, and as a result, cases do not stay on the unread list. Gabor says that part of the group would rather work more to get more financial compensation, while the other members would prefer not to be bothered after going home. “I think the RVU method enables us to have some flexibility and allows us to be responsive to the different needs and concerns of our radiologists,” Gabor says. “Someone who wants to work extra will get rewarded for it. If someone wants to work more, then why not? If someone else wants to work a little less hard, that’s fine, too, if the rest of the practice can absorb it. Just by any sense of equity, that individual should make less than the guys working more.” While Gabor expects to implement an RVU-based compensation scheme within the next year, he does not think “that pill should be swallowed whole. I think we should start with a small productivity bonus and have people get used to that,” he says. “I think what will happen is that people will want more of it, so then we’ll change it.” Aside from compensation, future applications of RVU data might address staffing issues, Gabor says. Imaging volume is up every year at the practice, he reports, and the group is currently at the 90th percentile of practice productivity, according to the MIS benchmark. By encouraging increased productivity among those on the lower end of the RVU scale, Gabor says that the group can avoid having to hire someone new, at least for some period of time, and can therefore minimize a salary hit. From the standpoint of day-to-day staffing, Gabor can try to rearrange radiologists’ site assignments to play to their strengths (the group operates in three locations in the Albany area). “I can put the big producers at the places that are the busiest,” he says. “I think, as far as managing the workflow goes, the RVU data are already helping me.” Elaine Sanchez is a contributing writer for ImagingBiz.com.