Published in the January 2017 issue of Today’s Hospitalist
LAST MONTH, I looked at the relationship between compensation and productivity. If the two don’t line up, you’re going to have problems with your operational efficiency.
So how many patients should you be seeing? That all depends on your salary. In last month’s column, I pegged the number of hospitalist encounters at 12.8 per day for someone salaried at $254,000, which is the median compensation for internal medicine hospitalists. This breaks down to 1.9 H&Ps, 1.6 discharge exams and 9.3 follow-up visits. (Please refer to my December 2016 column to see how I got there.)
In this issue, I’d like to take it a step further. How much time do you need to be able to care for those patients? I’ll start with the answer—10 hours and 44 minutes—and then show you the underlying math.
The AMA is the keeper of the Current Procedural Terminology (CPT), the massive code set that you use to bill for your services. Everything ranging from an H&P to a heart transplant is in there. The value of each CPT code is determined by the AMA’s Resource-Based Relative Value Scale (RBRVS) Update Committee, or RUC.
Do your current shifts make sense both in terms of hours and encounters?
The committee is populated by representatives from major specialty societies—for example, the American College of Physicians—who hash out the value of each CPT code. The document that came out of its last meeting in January 2016 runs a staggering 2,521 pages.
This should ring a bell. Think relative value units (RVUs), the productivity measure. The RUC is the source of those units.
RVUs are a mash-up of three components:
- physician work (wRVU);
- practice expense; and
- professional liability insurance (malpractice expense).
Physician work, according to the AMA, is dictated by “the time it takes to perform the service, the technical skill and physical effort, the required mental effort and judgment and stress due to the potential risk to the patient.”
Take your garden variety 99233 (level 3 subsequent hospital care). The whole shebang is worth 2.93 RVUs: 2.00 for the provider’s work, 0.79 for practice expenses and 0.14 for professional liability insurance.
You eventually need to transmute RVUs into money. Enter the conversion factor. In 2016, Medicare paid us $35.8043 per RVU. (Only Congress, which sets the rate, would complicate our lives with three ten-thousandths of a penny.) Boom! Your 99233 becomes $104.91. (Small qualification: This is the national payment amount. Although there is some regional variability, your payment will generally be within a few dollars of this.)
Time x 3
The RUC also parses CPT codes into three distinct periods: pre-service, intra-service and post-service. Intra-service is basically rounding on the patient or, per the AMA, “services provided while you are present on the patient’s hospital unit or floor, including: reviewing the patient’s chart; seeing the patient, writing notes, and communicating with other professionals and the patient’s family.” The pre-service and post-service periods involve off-unit work for the patient before and after the visit.
The RUC takes it a step further and provides time estimates for each period. For example, the pre-service, intra-service and post-service times for a 99233 are 10 minutes, 30 minutes and 15 minutes, respectively. This tallies up to 55 minutes of total time for that type of encounter. (For times for other CPT codes that hospitalists commonly use, see “Time per encounter.”)
(A brief digression. Don’t confuse all of this with billing based on time, which is something completely different. For a 99233, you need to spend at least 35 minutes face-to-face with the patient, which—as you can see—doesn’t exactly jibe with the numbers above.)
This brings me back to the 12.8 encounters per day described above. When you load in all the RUC numbers for those encounters, they add up to 644 minutes, of which 296 minutes (46%) occurs on a combined pre-service and post-service basis.
Now the big question is whether this corresponds to reality. After all, the RUC has taken flak from various quarters. The U.S. Government Accountability Office, for instance, issued a report in May 2015 that concluded the RUC’s recommendations “may not be accurate due to process and data-related weaknesses.” That report cited problems including conflicts of interest, RVU inflation by specialty societies and iffy field survey data to establish service times.
Nevertheless, a time-motion study in the July/ August 2010 issue of the Journal of Hospital Medicine suggests that the RUC’s numbers aren’t all bad. Researchers shadowed 24 hospitalists for about 500 hours and found that they saw an average of 13.2 ± 0.6 patients per day. Moreover, the doctors’ average shift was 10 hours and 19 minutes ± 52 minutes. This agrees remarkably well with the RUC’s 10 hours and 44 minutes based on my calculation of 12.8 encounters.
So what’s the point? It’s the schedule, stupid! Do your current shifts make sense both in terms of hours and encounters?
Or are you trying to see too many patients each day? Do you need longer shifts, more providers per shift, or swing shifts to better match personnel and volume? And do your pre-, intra- and post-service times basically line up with the RUC’s estimates, or are process problems in any of those phases of care bogging you down?
David A. Frenz, MD, is vice president and executive medical director for North Memorial Health Care in Robbinsdale, Minn. You can learn more about him and his work at www.davidfrenz.com or LinkedIn.