Generalist

The Hospitalist. 2008 May;2008(05):

May 1, 2008|The Hospitalist

Medical generalists tell a sad story. Their steadily declining numbers reflect a compensation system that still rewards specialists handsomely at generalists’ expense.

Even though the venerable relative value unit (RVU)-based reimbursement system was intended to equalize pay between primary care’s cognitive work and specialists’ procedure-driven high pay, it hasn’t. Since 1992, when Medicare started paying physicians using RVUs based on the resources used, the specialist-generalist gap remains. RVUs comprise three factors:

Work (55%);
Practice expense (42%); and
Malpractice insurance (3%).

Arguably, generalist RVUs have risen and proceduralist RVUs have decreased. However, generalists argue this skewed pay scale still causes residents to shun internal medicine, hospital medicine, family practice, general pediatrics, and general surgery. Is that true?

Hospitalists and RVUs

Although RVUs don’t always figure into hospitalist compensation, they can have an effect. Vibhu Sharma, MD, of SUNY Downstate Medical Center’s section director, hospital medicine program, heads a 13-hospitalist group employed by the medical center and carries extensive teaching responsibilities.

RVUs don’t currently factor into his hospitalists’ pay but that’s becoming troublesome to Dr. Sharma. “We’d make a lot more money if RVUs were factored in, but they aren’t because we’re a teaching hospital,” he says. “Our group is only four years old, and we aren’t ready to push for it.”

Without the RVU productivity component, Dr. Sharma says he’s at a disadvantage when recruiting. Internal medicine, family practice, and other generalists “stuck with the perception that specialization is a better career option,” he says. “If payers paid us the same as non-invasive cardiologists there’d be a lot more hospitalists.”

Boosts in compensation will be slow in coming, says Dr. Sharma, because hospitalists have demonstrated only modest cost savings and LOS decreases. He adds: “Today nobody wants to be a hospitalist for the rest of their career. We perceive that the patient care we deliver isn’t well compensated, and that the RVU gap between generalists and sub-specialists can never be closed.” As for RVUs, he sees the hospital eventually adding an RVU bonus component. For now, it bumps up hospitalist salaries when the group complains.

VIRGINIA HMG downplays RVUs

Randy Ferrance, DC, MD, hospitalist medical director at Riverside Tappahannock Hospital in rural Virginia, heads a team of four pediatric hospitalists.

Two are board certified in med/peds, and two in internal medicine. Their compensation includes base salary, quality metrics, and “citizenship” points for volunteering for hospital committees, among other things.

“We don’t emphasize RVUs, although the billing department maximizes them for reimbursement,” he says. Although their quarterly productivity reports reflect RVUs, Dr. Ferrance downplays their importance because “we handle all admissions, have had a stable team, take pride in our work and are autonomous. We have no pressure to increase RVUs.”

Recruiting hospitalists to the 50-bed rural hospital wasn’t easy, and Dr. Ferrance waited to fill his team with the right hospitalists. He found four like-minded individuals who enjoyed the bucolic setting but felt close enough to Richmond and Washington, D.C., to have big-city amenities.

“Our incentive is high quality, which we accomplish via consensus on pathways,” he says. “We don’t have a lot of people to convince about our work. The hospital is very pleased because [length of stay] and utilization are both down.”

Despite not including RVUs currently as part of their salary packages, the doctors have discussed adding an RVU component. “We are hesitant to put an RVU-based system in place because we don’t believe it would boost our productivity,” says Dr. Ferrance. Variability in daily admissions is one factor that may make them change their minds. “Sometimes we have five or six admits, some days 11 or 12. We’re thinking of an RVU productivity bonus for those extra busy days.”

Overall, Dr. Ferrance admits to a disconnect about why RVUs matter: “It’s of passing interest to the business end of things, but it’s not important to us as hospitalists. I understand that RVUs for hospitalists have been upgraded but that has nothing to do with my work. I enjoy the acuity of hospital medicine. As for the RVUs, they’re fine for the accountants.”—MP