Am I crazy for thinking that hospital medicine is one of the best lifestyle specialties?

[collegestud2013]

I don't understand the RVU system that well since I have been a salaried employee.

I have already mentioned my salary here before. For those who did not read the whole thread, my salary is ~330k/year. 7 days on/off

My job just started a new system. We were straight salaried employee with ZERO incentive. However, now for every encounter above 18 patients, we get $150 per patient. For instance, let's say I start the day with 18 patients. If I admit 1 patient, I get an extra $150 for the day on top of my daily salary. If I admit 2 patients, I got $300...and so forth.

The same way, if start with 20 patients, I get paid $300 on top of my daily salary. However, that has never happened, I can remember only once or twice I started the day with 19 patients during the whole year since I have been at this place.

Is that better or worse than typical RVU?

Depends on if the extra patients are rounding patients (that are already admitted), discharges, or new admissions. In a RVU system the number of RVUs is supposed be roughly proportion to the amount of work/effort needed. Seeing a follow up on an already admitted patient is usually a lot less work than admitting a new patient, so it's also worth less RVUs based on CMS standards. A level 3 follow-up/progress note (99233) is worth 2.0 wRVUs and a level 2 is worth 1.39 wRVUs (99232). In contrast an inpatient H&P which most people will bill at a level 3 is worth 3.86 wRUVs (99223). A discharge >30 minutes is worth 1.9 wRVUs (99239) (which IMO is a bit low given the amount of work that goes into a typical discharge). So getting $150 for seeing an additional follow-up is a pretty good deal but getting the same for an admission isn't as good, but still much better than being 100% salaried.

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[gutonc]

Depends on if the extra patients are rounding patients (that are already admitted), discharges, or new admissions. In a RVU system the number of RVUs is supposed be roughly proportion to the amount of work/effort needed. Seeing a follow up on an already admitted patient is usually a lot less work than admitting a new patient, so it's also worth less RVUs based on CMS standards. A level 3 follow-up/progress note (99233) is worth 2.0 wRVUs and a level 2 is worth 1.39 wRVUs (99232). In contrast an inpatient H&P which most people will bill at a level 3 is worth 3.86 wRUVs (99223). A discharge >30 minutes is worth 1.9 wRVUs (99239) (which IMO is a bit low given the amount of work that goes into a typical discharge). So getting $150 for seeing an additional follow-up is a pretty good deal but getting the same for an admission isn't as good, but still much better than being 100% salaried.

Pretty much this. You're getting paid somewhere between $40-75/wRVU on these patients. $75 is reasonable. I think we can all agree than $40 is bulls***.

 

[Nocturnist]

Pretty much this. You're getting paid somewhere between $40-75/wRVU on these patients. $75 is reasonable. I think we can all agree than $40 is bulls***.

I think that's only half the story. The other half is what his shop's target hourly RVUs are. If he's being asked to round on 18 patients a day without incentive, and a level 3 follow up is 2.0 RVUs- assuming mostly high level followups and a 10 hour workday...his target RVU is around 36 a day or 3.6 an hour.

I can't tell you how reasonable a daily census of 18 is since i only admit but i can tell you that's equivalent to nearly 10 high level admits a night which to me is an outrageously high target.

At my shop our targets are 1.0-1.9 RVUs an hour depending on whether we have responsibilities other admitting (triage, rapid response etc), and our incentive is a little less than $40 per RVU...but I hit my bonus FAR sooner so I'll take it any day over $75 after seeing 18 pts or admitting 10.

 

[Nocturnist]

I don't understand the RVU system that well since I have been a salaried employee.

I have already mentioned my salary here before. For those who did not read the whole thread, my salary is ~330k/year. 7 days on/off

My job just started a new system. We were straight salaried employee with ZERO incentive. However, now for every encounter above 18 patients, we get $150 per patient. For instance, let's say I start the day with 18 patients. If I admit 1 patient, I get an extra $150 for the day on top of my daily salary. If I admit 2 patients, I got $300...and so forth.

The same way, if start with 20 patients, I get paid $300 on top of my daily salary. However, that has never happened, I can remember only once or twice I started the day with 19 patients during the whole year since I have been at this place.

Is that better or worse than typical RVU?

Sounds like they're getting busier and realized its cheaper to grind you to the bone with a 20 day and a small incentive rather than hire more staff?
I dont do days but is it common or sustainable to round on 18-20 on a regular/long term basis?
At my hospital the target census is 12-14.

$300 a day x 180 shifts a year is 54k a year.
Maybe they're all super low acuity but the last time I rounded on 20 was on my weekend call day in residency- it was with one of the interns and an attending and was still the most miserable day of my life each and every week.

Is 384k a year worth it for you to round on 20 pts a day 182 times a year? Id burn out after a week.

 

[Splenda88]

Sounds like they're getting busier and realized its cheaper to grind you to the bone with a 20 day and a small incentive rather than hire more staff?
I dont do days but is it common or sustainable to round on 18-20 on a regular/long term basis?
At my hospital the target census is 12-14.

$300 a day x 180 shifts a year is 54k a year.
Maybe they're all super low acuity but the last time I rounded on 20 was on my weekend call day in residency- it was with one of the interns and an attending and was still the most miserable day of my life each and every week.

Is 384k a year worth it for you to round on 20 pts a day 182 times a year? Id burn out after a week.

That is super low. Our census most of the time is 16-17.

You are correct that it's getting busier. Corporations always find a way to screw their workers.

 

[end stage fibro]

Some figures, based on 330k/yr @ 182 shifts (7 shifts * 26 weeks) and avg census of 16.5 (from you saying average census is 16-17)

16.5 pts * 182 shifts = 3003 encounters a year. $330k/3003 = $109.89 per encounter. Based on this alone, i agree with what others have said...great deal for a rounding patient. Fair deal for an admission. More insight can be gained by chopping up your 16-17 into rounding vs. admission. I also agree some discharges should be worth well more than critical care time due to the tremendous time suck.

Across years of practice, my average RVU across all comers is about 1.85 RVU
At old CMS rate of $36.50, you're looking at 1.85*36.5=$67.5 a pt ( 140.89 for a high level admit)
with the new conversion factor of $33.59, it is $62.14 a pt ( 129.65 for an admit)
Gutonc mentions $40-75 an rvu...I think $75 is a pipe dream for a hospitalist. Low 50s is probably what your health system is getting for you (at least according to Sullivan Cotter and MGMA blend). By the time everyone extracts their pound of flesh, you probably are getting around $40 a pt.
Anyways, at $75: $138.75 a pt( $289.5 for an admit)
At $40: $74 a pt ($154.4 for an admit)

I think given the above info, 150 is fair. Is the patient bonus calculated on a daily census, monthly, or quarterly?

I am amazed at some of the censuses and pay on here. i was a full time hospitalist (very recently) in a top 20 population city and still pick up shifts very frequently. As an employee, the average census has risen from 16-18 to 18-20 WITHOUT a pay increase AND ever-rising RVU requirements over the last 6 years. The job market is also tightening, such that it looks like there are only 1-2 extra shifts availble per hospitalist, which is barely enough to get any production bonus. At a smaller private group, everyone is starting with 20 to get roughly 1300 bucks. You are already sitting at $1800 just walking in the door. Are you guys hiring?

 

[Splenda88]

@end stage fibro

We start with 16-17 patients and average 1 admission per day.

The patient bonus is calculated on a daily census (not monthly or quarterly)


I guess you probably right that it might not be a bad deal. I interviewed at a place 35 mins outside of Orlando in 2021 and the offer was 225k/yr for 22 patients. If I see 22 patients on average at my place now, I will be making ~450k/yr. If I pick an extra shift per pay period, it will be 500k/yr.

 

[collegestud2013]

Sounds like they're getting busier and realized its cheaper to grind you to the bone with a 20 day and a small incentive rather than hire more staff?
I dont do days but is it common or sustainable to round on 18-20 on a regular/long term basis?
At my hospital the target census is 12-14.

$300 a day x 180 shifts a year is 54k a year.
Maybe they're all super low acuity but the last time I rounded on 20 was on my weekend call day in residency- it was with one of the interns and an attending and was still the most miserable day of my life each and every week.

Is 384k a year worth it for you to round on 20 pts a day 182 times a year? Id burn out after a week.

How doable a given amount of volume can largely depend on availably of other services/specialties and ancillary staffing at your specific facility. 20 rounding patients per 12 hr shift is becoming not uncommon if you want to make slightly above average. pay. It' also pretty doable if your hospital has full subspecialty support and ancillary services (eg good case manager for all the discharge planning, pharmacist to help with med recs and dosing, palliative care to have the lengthy GOC discussions with families). A lot of times a few of the patients your list are just pending placement and pretty stable, and quite a few more are mainly being managed by one or more of the specialists. If you're in more of a smaller or critical access hospital without much support and a lot more work falls on the hospitalist, than 20 patients is probably too busy for a 12 hr shift.

Also with rounding only your workflow is much more predictable than admitting. With rounding you start with a fixed number of patients and your census can't go higher than that for the day; and if your hospital allows it you can leave a bit early and just take call from home. On admitting the workflow can be pretty unpredictable and largely depends on when and how many patients the ED decides to admit, and so you end up having to stay your whole shift; I would say it's quite a bit easier to make the same amount of RVUs just rounding on admitted patients than doing admitting. And of course it's even harder when admitting at night if you have to cross cover the floor patients (and the vast majority cross coverage work at night doesn't generate any RVUs).

 

[collegestud2013]

Some figures, based on 330k/yr @ 182 shifts (7 shifts * 26 weeks) and avg census of 16.5 (from you saying average census is 16-17)

16.5 pts * 182 shifts = 3003 encounters a year. $330k/3003 = $109.89 per encounter. Based on this alone, i agree with what others have said...great deal for a rounding patient. Fair deal for an admission. More insight can be gained by chopping up your 16-17 into rounding vs. admission. I also agree some discharges should be worth well more than critical care time due to the tremendous time suck.

Across years of practice, my average RVU across all comers is about 1.85 RVU
At old CMS rate of $36.50, you're looking at 1.85*36.5=$67.5 a pt ( 140.89 for a high level admit)
with the new conversion factor of $33.59, it is $62.14 a pt ( 129.65 for an admit)
Gutonc mentions $40-75 an rvu...I think $75 is a pipe dream for a hospitalist. Low 50s is probably what your health system is getting for you (at least according to Sullivan Cotter and MGMA blend). By the time everyone extracts their pound of flesh, you probably are getting around $40 a pt.
Anyways, at $75: $138.75 a pt( $289.5 for an admit)
At $40: $74 a pt ($154.4 for an admit)

I think given the above info, 150 is fair. Is the patient bonus calculated on a daily census, monthly, or quarterly?

I am amazed at some of the censuses and pay on here. i was a full time hospitalist (very recently) in a top 20 population city and still pick up shifts very frequently. As an employee, the average census has risen from 16-18 to 18-20 WITHOUT a pay increase AND ever-rising RVU requirements over the last 6 years. The job market is also tightening, such that it looks like there are only 1-2 extra shifts availble per hospitalist, which is barely enough to get any production bonus. At a smaller private group, everyone is starting with 20 to get roughly 1300 bucks. You are already sitting at $1800 just walking in the door. Are you guys hiring?

Physician salaries, including that of hospitalists, tends to be largely geography/location specific and it comes down to local supply and demand. The jobs on here with good pay for the census probably have a catch to it, the most common being that it's in a less desirable location that's difficult to recruit. A lot of bigger cities already have just about all the physicians they need and are a saturated already, so they have little incentive to pay more if someone is willing to do it for cheaper. But definitely agree that 20 patients for just $1300 a day (assuming no RVU bonus on top of the base) is a bit unsatisfying even if it's in a desirable location. The best you can do is just not work for them.

 

[CCM-MD]

Sounds like they're getting busier and realized its cheaper to grind you to the bone with a 20 day and a small incentive rather than hire more staff?
I dont do days but is it common or sustainable to round on 18-20 on a regular/long term basis?
At my hospital the target census is 12-14.

$300 a day x 180 shifts a year is 54k a year.
Maybe they're all super low acuity but the last time I rounded on 20 was on my weekend call day in residency- it was with one of the interns and an attending and was still the most miserable day of my life each and every week.

Is 384k a year worth it for you to round on 20 pts a day 182 times a year? Id burn out after a week.

12-14 census as a hospitalist is one of the most unicorn things I have heard. It’s more like 18-22… or more.

 

[Nocturnist]

12-14 census as a hospitalist is one of the most unicorn things I have heard. It’s more like 18-22… or more.

Could be, just sharing my N=1.
make that N=2, it's actually 11-13 at the place I moonlight at (needless to say, virtually no turnover there).
Granted, that doesn't include an admission (or rarely, two) on top.
we used to have censuses of 18-22. Some folks were bonusing 20-30k a quarter, but so many others were burning out and leaving that the dept massively overhauled the program with the goal of getting the census down to 12-14. It took a couple years, and it doesn't happen 100% of the time with sick calls, but since committing to that number turnover is a nonissue.
No idea how folks round on 22 pts a day 182 shifts a year and last more than a couple months 🤷🏻‍♂️

 

[collegestud2013]

12-14 census as a hospitalist is one of the most unicorn things I have heard. It’s more like 18-22… or more.

This. The only places I've heard of a census that low for hospitalist is if they do 8 or 10 hour shifts (and would require working more than 182 days to make the same base pay), at a critical access hospital (where you have minimal subspecialty support and have to manage pretty much the whole patient by yourself), or if if's open ICU and some of those patients are requiring ICU level of care. Otherwise there would probably be a pay cut.

 

[wamcp]

12-14 census as a hospitalist is one of the most unicorn things I have heard. It’s more like 18-22… or more.

Not as uncommon as you think. There were two gigs like that which I worked through from past moonlighting and you will never burn out working there fulltime
But the pay is typically very low vs the median

Also have seen a job that nearly always has a morning census start at 10-12 and it increases by a few from drip admits in the day. Pay is not bad at that place

 

[wamcp]

Could be, just sharing my N=1.
make that N=2, it's actually 11-13 at the place I moonlight at (needless to say, virtually no turnover there).
Granted, that doesn't include an admission (or rarely, two) on top.
we used to have censuses of 18-22. Some folks were bonusing 20-30k a quarter, but so many others were burning out and leaving that the dept massively overhauled the program with the goal of getting the census down to 12-14. It took a couple years, and it doesn't happen 100% of the time with sick calls, but since committing to that number turnover is a nonissue.
No idea how folks round on 22 pts a day 182 shifts a year and last more than a couple months 🤷🏻‍♂️

My n=7
Of all the 7 hospitals i have ever worked as a hospitalist, only one of them had a census of 22 on some days, but not usually. Everywhere else was never ever that high.

 

[CCM-MD]

Never seen or heard of a 10 patient census for a hospitalist. I'll believe it when I see or hear of it anywhere other than this website of unicorns.

 

[Nocturnist]

Never seen or heard of a 10 patient census for a hospitalist. I'll believe it when I see or hear of it anywhere other than this website of unicorns.

I will never understand this attitude.
Obviously this is an anonymous forum.
Obviously there's a selection bias.
But what's the point of participating in this community if you're going to regard any information you haven't personally verified as lies til proven otherwise?
Either we're all out to troll each other, or we're just human beings sharing our own individual experiences in hopes to inform and help each other out. I recognize that in any platform where humans gather to share experience, there's always going to be some degree of exaggeration (like you calling it 10 when literally nobody ever mentioned 10, though I get the spirit of it), bragging, and self selection- but never have I approached this community with the mindset of everything is false til I see it for myself.

 

[Raryn]

Never seen or heard of a 10 patient census for a hospitalist. I'll believe it when I see or hear of it anywhere other than this website of unicorns.

Last I saw surveys, the nationwide average census was c. 15. I doubt it's normally distributed, but some proportion of hospitalists have to be below that given the amount above it. 10 is probably abnormally low outside of some truly small hospitals, but it's not outside the realm of possibilities.

 

[CCM-MD]

I will never understand this attitude.
Obviously this is an anonymous forum.
Obviously there's a selection bias.
But what's the point of participating in this community if you're going to regard any information you haven't personally verified as lies til proven otherwise?
Either we're all out to troll each other, or we're just human beings sharing our own individual experiences in hopes to inform and help each other out. I recognize that in any platform where humans gather to share experience, there's always going to be some degree of exaggeration (like you calling it 10 when literally nobody ever mentioned 10, though I get the spirit of it), bragging, and self selection- but never have I approached this community with the mindset of everything is false til I see it for myself.

Not as uncommon as you think. There were two gigs like that which I worked through from past moonlighting and you will never burn out working there fulltime
But the pay is typically very low vs the median

Also have seen a job that nearly always has a morning census start at 10-12 and it increases by a few from drip admits in the day. Pay is not bad at that place

Quoted and bolded the census of 10 for you. I didn’t make it up.

 

[Splenda88]

Quoted and bolded the census of 10 for you. I didn’t make it up.

I have seen 8-10 at the VA affiliated to the residency program I graduated from. 12-14 at main hospital of my residency program. I have heard of many 14-16.

I have read some of the @Nocturnist posts in other thread and he has made a lot of $$$ to the point he can basically retire after practicing for 6-7 yrs. He has had some great gigs.

 

[DrMetal]

Problem with the whole census thing is, it's not in any of our contracts that we necessarily cap at certain numbers. Yes, our groups have policies (cap at 20, no more than 6 new admissions per day, etc etc), but that's not strictly in out individual contracts. So they ask us to see how ever many is necessary to get through the lists. At the height of covid and with people calling out, I was seeing 30-40 per day sometimes. Paid very handsomely for it (sometimes up to $4-5K per shift). Was it safe medicine? Hell no, I'm still waiting for the lawyers to come depo me on something (thankfully it hasn't happened yet). But what can you do?

 

[CCM-MD]

Problem with the whole census thing is, it's not in any of our contracts that we necessarily cap at certain numbers. Yes, our groups have policies (cap at 20, no more than 6 new admissions per day, etc etc), but that's not strictly in out individual contracts. So they ask us to see how ever many is necessary to get through the lists. At the height of covid and with people calling out, I was seeing 30-40 per day sometimes. Paid very handsomely for it (sometimes up to $4-5K per shift). Was it safe medicine? Hell no, I'm still waiting for the lawyers to come depo me on something (thankfully it hasn't happened yet). But what can you do?

I was rounding on 30 ICU during COVID. I don't think about it much, probably PTSD.

 

[DrMetal]

I was rounding on 30 ICU during COVID. I don't think about it much, probably PTSD.

Luckily nurses usually have a strict cap, thanks to their unions (imagine that!). No more than 2 patients for an ICu nurse, 3-4 for the floor. I'm ok with that, they were my eyes and ears.

 

[Osteoth]

Luckily nurses usually have a strict cap, thanks to their unions (imagine that!). No more than 2 patients for an ICu nurse, 3-4 for the floor. I'm ok with that, they were my eyes and ears.

Lol at nurses having a strict cap. Where I’m at they’re constantly out of ratio

 

[findinghappiness]

They give you that 182-200 days off a year for a reason...

 

[PikminOC]

This makes me unreasonably happy

Many times this is not a choice