Published in the March 2012 issue of Today’s Hospitalist
JUST A FEW YEARS AGO, Aaron Gottesman, MD, had to beg or cajole (or even threaten) the hospitalists in his group to make sure that key nonclinical activities “like leading multidisciplinary rounds “got done. Often, out of sheer frustration, Dr. Gottesman, director of hospitalist services at Staten Island University Hospital in New York, just did the work himself.
“I was essentially the vacuum cleaner for everyone else,” recalls Dr. Gottesman, longtime leader of the 26-physician group.
Finally, he decided there had to be a better way to deal with a problem that crops up in all hospitalist programs and employment models: getting physicians to not only participate in nonclinical work, but to do so without feeling put upon by colleagues who aren’t so eager.
“Because there’s no clear-cut way to measure or incentivize individuals to do this,” says Dr. Gottesman, “we tend to fall back on concepts such as professionalism, citizenship and honor “most of which, unfortunately, don’t mean the same thing they did in the past. But the reality is that there’s no reason why nonclinical work should not be valued the way the clinical work is.”
The solution was to find a way to quantify and compensate hospitalists for their nonclinical work. With some assistance from consultants, Dr. Gottesman and Theodore Strange, MD, the associate chair of medicine, developed a system to measure nonclinical relative value units (RVUs), assigning eligible activities both a time and dollar value.
The now two-year-old innovation is similar to the clinical RVU system that governs physician reimbursement, with each activity given a relative worth and total value.
Leading multidisciplinary rounds, for example, is worth one hour, as is delivering a lecture to medical students. For budgetary purposes, one hour of nonclinical time is worth six nonclinical RVUs “and six nonclinical RVUs are valued at $90.
The group also crunched the numbers, figuring out its historical workload and number of nonclinical hours spent every year. Based on those estimates, the group calculated the project’s anticipated costs, then approached the department of hospital medicine and the administration for buy-in and a budget increase.
What counts and what doesn’t
The nonclinical RVU system is predicated on paying for work above and beyond the call of duty. All hospitalists are expected to participate in a broad range of nonclinical activities before they begin generating “payable” nonclinical RVUs.
Hospitalists are expected to produce a minimum of 500 nonclinical RVUs annually for “core requirements.” Doctors who don’t meet those numbers can’t earn additional money for other nonclinical activities, Dr. Gottesman says, and may face sanctions, just as they would for lapses in clinical performance.
Group members decided which nonclinical activities are core and which are eligible for additional, payable RVUs. Core responsibilities include participating on committees, attending grand rounds, reviewing morbidity and mortality data, and meeting quality standards. Other core requirements include attending monthly department meetings and doing basic work tied to clinical activities such as billing, medical record completion, and dealing with insurance or billing inquiries.
So what qualifies for payable nonclinical RVUs? That list includes leading multidisciplinary rounds, mentoring medical students, giving lectures, and planning and directing performance-improvement projects. Directing rounds on some floors come weighted with more RVUs because those floors have more or higher-acuity patients.
“We didn’t want every little activity to generate payable RVUs,” Dr. Gottesman says. “We wanted to be fair, but we also didn’t want our budget to balloon and have to keep going to the administration for extra funds.”
Because the nonclinical values are strictly defined, they don’t offer an opportunity for “gaming the system.” Hospitalists receive only the assigned number of RVUs for eligible activities, even if they take more than the assigned amount of time to do the job. “If hospitalists take more than one hour to lead multidisciplinary rounds or to review a medical student’s write-up, that’s their prerogative “and their problem,” Dr. Gottesman says.
At the same time, there’s no ceiling on the extra compensation hospitalists can earn, provided they first meet their core requirements.
We don’t tell a hospitalist, ‘The most you can make above your base salary is X.’ Putting in a cap, though appealing from a budgetary standpoint, could lead to hospitalists asking, ‘Why should I do anything more? Because I’m a good guy?’ ” Dr. Gottesman says. “At the same time, we allow all to participate in the nonclinical RVU payment program; nothing is slanted in anyone’s favor because he or she has more experience.”
As things have worked out, “over-performance” hasn’t been an issue. While some hospitalists have increased their earnings by 10% or more, others who neither can nor want to go beyond their core requirements are relieved knowing that their colleagues are filling the slots.
Nor has the group’s budget gone haywire, Dr. Gottesman notes. Incremental increases occurred in the project’s first 18 months but have leveled off since July 2011. In Dr. Gottesman’s view, that means that the group accurately predicted its nonclinical needs.
“We have data “and justification “now to support funding requests and to predict future needs,” he says.
According to Dr. Gottesman, the program has achieved “100%” of its objective. “Based on my experience in the past, it was somewhere between difficult and nightmarish to get people to agree to do this kind of work,” he reports. “Now individuals jump at the opportunity. It’s a non-issue.”
Every once in a while, a hospitalist may call in sick and the group scrambles to fill a scheduled, nonclinical work slot. But Dr. Gottesman says that’s rare.
Paying for nonclinical RVUs has brought other benefits. Hospitalists can pursue individual areas of interest, with a few assuming most of the responsibility for multidisciplinary rounds. Others do much more teaching than they once did or launch quality improvement projects.
Group members also enjoy better morale and a sense of professionalism, and much of the rivalry and bad feelings that may have erupted in the past have been effectively “defused,” Dr. Gottesman says.
It’s led to a much more cohesive, integrated hospitalist working group “and the environment is much less competitive than it used to be.”
As for the effect on Dr. Gottesman’s own workload, the new program has delivered peace of mind. “Even if the record-keeping and monitoring have increased, the flip side is that the group is easier to manage now,” he says.
“The main thing is that the work is getting done “and I’m not doing the hospitalists’ job any more.”
Bonnie Darves is a freelance health care writer based in Seattle.