wRVU-based Compensation

[dogjam]

I'm in a hospital-employed group with a straight salary, no production bonus. We are thinking about switching to a pure wRVU-based compensation model for a variety of reasons. I know there are MGMA/AMGA stats out there for $ per wRVU, but I think much of that data is probably secondarily derived from people who are getting straight salary, a base salary plus bonus, etc. In other words, they are negotiating some other number and the $ per wRVU is just what shakes out.

Has anyone negotiated an actual $ per wRVU? What sort of range did you end up in? Any downsides (apart from the clinic volume just nosediving)? Thanks in advance for any info.

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[medgator]

Any downsides (apart from the clinic volume just nosediving)? Thanks in advance for any info.

Why would it nosedive?

 

[RickyScott]

I'm in a hospital-employed group with a straight salary, no production bonus. We are thinking about switching to a pure wRVU-based compensation model for a variety of reasons. I know there are MGMA/AMGA stats out there for $ per wRVU, but I think much of that data is probably secondarily derived from people who are getting straight salary, a base salary plus bonus, etc. In other words, they are negotiating some other number and the $ per wRVU is just what shakes out.

Has anyone negotiated an actual $ per wRVU? What sort of range did you end up in? Any downsides (apart from the clinic volume just nosediving)? Thanks in advance for any info.

In similar situation. Hospital trying to get me to accept in low 40s per RVU, but I have been delaying this for several years. Typical range is 45-65 from what I understand, with a lot in the high 50s, low 60s when I asked around

 

[KHE88]

Why would the wRVU numbers be derived from the salary guarantee? They are an independent data point worthy of their own negotiation, likely more important that the "salary" number.

The biggest downside is that the hospital will try to lowball you and find sneaky ways to adjust the conversion factors down year to year. Be careful -- they may flat out lie to you. I was given a very low wRVU conversion factor and told that I would make up for this because I would be producing extremely high wRVU numbers (so I would be working extra hard for less money? Right...).

If you're going to go straight production based, you need to negotiate multiple conversion factor levels such that as you work more wRVUs the conversion factor goes up. If you're working 90th percentile wRVUs (13k+), you should be getting paid 90th percentile conversion factor on those wRVUs ($80+). Obviously this is going to be harder to do in a competitive area.

You can calculate your current average conversion factor by dividing your salary by last year's wRVU numbers. I would bump this up by a little bit and start negotiations from there as giving up the security of a salary guarantee is worth something.

Bottom line, make sure you are incentivized properly for increasing production and make sure they don't cap your total compensation or total number of wRVUs you can be compensated for (i.e., steal from you).

 

[dogjam]

Low 40s seems crazy low! I know the mean/medians are in the ballpark of $60-$65. I am curious if people who are negotiating just a straight money-per-RVU get higher than the median numbers since there's no safety-net base salary. All very dependent on hospital, geography, etc. of course.

 

[RickyScott]

Low 40s seems crazy low! I know the mean/medians are in the ballpark of $60-$65. I am curious if people who are negotiating just a straight money-per-RVU get higher than the median numbers since there's no safety-net base salary. All very dependent on hospital, geography, etc. of course.

it is. part of the hospital rational is that I treat a decent amount of indigent patients and I have a ton of RVUs,

 

[Neuronix]

Low 40s seems crazy low!

Low 40s here. If you include benefits that gets me to high 40s. I've seen high 30s out there as well. No safety nets.

I've never seen a job offering in the 60s and would be interested in such a position personally. I hear of people making that, but I've never seen it advertised or personally been offered that even after a partnership track.

Downsides of straight RVU model:
Lack of salary security (particularly problematic for mortgage or car loan applications)

People within group subtly or not subtly fight for patients.

Nobody in group wants to do things that don't generate much or any professional wRVUs.

Inequalities in salary between disease sites--some sites/procedures generate lots of wRVUs, others do not.

Other benchmarks worked into the wRVU formulas that are used to lower your salary (base or bonus). Also, wRVUs end up paying as well for things like bonuses or benefits (vacation, clinic support, medical insurance, etc) that were previously included. While that may not be made explicit at the start that your RVUs will have to pay for things previously included, it ends up being in the fine print or renegotiated that way in the future.

 

[KHE88]

Low 40s here. I mean if you include benefits that gets me into the high 40s. I've seen high 30s out there as well.

I've never seen a job offering in the 60s and would be interested in such a position personally. I hear of people making that, but I've never seen it advertised or personally been offered that even after a partnership track.

Downsides of straight RVU model:
Lack of salary security (particularly problematic for mortgage or car loan applications)

People within group subtly or not subtly fight for patients.

Nobody in group wants to do things that don't generate much or any professional wRVUs.

Inequalities in salary between disease sites--some sites/procedures generate lots of wRVUs, others do not.

Other benchmarks worked into the wRVU formulas that are used to lower your salary (base or bonus). Also, wRVUs end up paying as well for things like bonuses/vacations that were previously included.

It's going to depend on the location and the payor mix in that location.

California, yeah high 30s-low 40s. Terrible payor mix. Some parts of the midwest will pay in the 60s and even 70s. But even in the midwest it's going to be highly variable. If you want a job in the 60s, they exist in undesirable locations. I saw multiple ones that topped out in the high 70s, but you needed to be 10k+ wRVU to reach that level.

 

[KHE88]

it is- part of the hospital rational is that I treat a decent amount of indigent patients and I have a ton of RVUs,

You also bring the hospital in a ton of other money indirectly through imaging, studies, and referrals you order. Not to mention the technical fees you allow them to bill by providing incident to coverage as a linac babysitter. They like to ignore that part. You are worth far more to them than the professional fees they collect on your behalf.

 

[RickyScott]

You also bring the hospital in a ton of other money indirectly through imaging, studies, and referrals you order. Not to mention the technical fees you allow them to bill by providing incident to coverage as a linac babysitter. They like to ignore that part.

All of that is very true. But, if I walk away, there would be a ton of radoncs lining up to take my job, so have very limited leverage and they certainly know that. Like with all negotiations, if push comes to shove, what I am going to do: they will be fine, I probably wont. All of this comes down to supply and demand, everything else is just artficial rationalization. I know of medoncs who get 80 per RVU and hospital responds to every whim i.e. the center needs a bathroom navigator, we will get you a bathroom navigator.

 

[Neuronix]

Not to mention the technical fees you allow them to bill by providing incident to coverage as a linac babysitter. They like to ignore that part.

This is huge problem. Need Linac coverage at multiple sites but no wRVUs are provided for Linac coverage (this is all technical).

Also some other duties like inpatients for example. You often don't treat them, and when you do they're often short palliative courses that don't generate many wRVUs. So who does it? People just kind of get forced into it, which creates inequities when some people have to worker harder and make fewer RVUs.

 

[RickyScott]

I have never scrutinized RVUs, but I heard that daily imaging is a big contributor to RVUs?

 

[medgator]

I have never scrutinized RVUs, but I heard that daily imaging is a big contributor to RVUs?

I don't believe igrt is a separate billable service in the hospital only freestanding... But maybe that has no bearing on rvu /wrvu

 

[Neuronix]

I don't believe igrt is a separate billable service in the hospital only freestanding... But maybe that has no bearing on rvu /wrvu

Rad onc billing is very complicated. This makes it easy to screw up wRVU calculations (accidentally or otherwise) and get away with it...

Even this relatively simple question has a complicated answer.

 

[seper]

I can confirm that adding daily conebeam to a 3D-CRT treatment ups wRVU take dramatically (3-4 wRVUs per cone beam I think).

I don't believe igrt is a separate billable service in the hospital only freestanding... But maybe that has no bearing on rvu /wrvu

 

[lhl]

Just to clear up some misinformation:

there is a professional fee for CBCT review (even if the igrt is bundled into IMRT from a technical fee perspective).
the cpt code is 77014.
it is worth 0.85 wRVU
it most modern practices it makes up for a fairly large portion of wRVU's though typically not as much as OTV does (77427)

Don't believe everything you read on the internet, especially conjecture and anecdote.

 

[RickyScott]

Just to clear up some misinformation:

there is a professional fee for CBCT review (even if the igrt is bundled into IMRT from a technical fee perspective).
the cpt code is 77014.
it is worth 0.85 wRVU
it most modern practices it makes up for a fairly large portion of wRVU's though typically not as much as OTV does (77427)

Don't believe everything you read on the internet, especially conjecture and anecdote.

Are RVUs standardized for the same procedure between instituitions? If you are doing 15-20 cone beams a day, prostate/lung etc thats a lot of rvu from imaging.

 

[OTN]

This is huge problem. Need Linac coverage at multiple sites but no wRVUs are provided for Linac coverage (this is all technical).

Also some other duties like inpatients for example. You often don't treat them, and when you do they're often short palliative courses that don't generate many wRVUs. So who does it? People just kind of get forced into it, which creates inequities when some people have to worker harder and make fewer RVUs.

The AAAs are still important, though. If you accept that inpatient consult for a palliative course of XRT, the next one from the hospitalist might be a Stage III NSCLC.

 

[Neuronix]

The AAAs are still important, though. If you accept that inpatient consult for a palliative course of XRT, the next one from the hospitalist might be a Stage III NSCLC.

I know this is conventional wisdom and is true many places.

That's just not how it works in our practice. Most definitive referrals don't come through the hospital, and even when they do the lung case will go to the lung attending.

 

[Mandelin Rain]

So because their hospital has a poor payor mix (not your fault), they want to pay you less to see those patients (who often have many more needs and require more time)?

Seems about right.

I'd figure out about where you're at wRVU wise currently and what your pay is currently. Then divide it through. If you're happy with where you're at, ask for a little more and compromise to keep your salary consistent. If you want more (who doesn't?), you'll really need to justify it. 10k wRVU is a decently busy radonc. So at $50/wRVU, that puts you at 500k, which may be right for your area. Who knows?

FWIW, when I looked a wRVU based jobs several years ago, I was offered $45-63, mainly based on desirability of market I'd say. But most of those included a base salary. If you're taking the downside risk of earning $0, I'd ask for more. Low 40's sounds bad. Also, never agree to a cap.

 

[Neuronix]

If you're taking the downside risk of earning $0, I'd ask for more. Low 40's sounds bad. Also, never agree to a cap.

Have I mentioned that the job market is really bad? PS: I also have a cap and essentially no floor. This was given to me as take it or find a new job.

 

[RickyScott]

once you are mid career, have kids in school, a wife with her own career, and limited by a large noncompete by your hospital, you have very poor leverage in a bad job market. 10 years ago, I was more than willing to tell someone to go f himself.

 

[medgator]

I know this is conventional wisdom and is true many places.

That's just not how it works in our practice. Most definitive referrals don't come through the hospital, and even when they do the lung case will go to the lung attending.

Very location and practice dependent.

Some of the same folks that send me outpatient will consult me in the hospital if the pt is newly diagnosed related to their presenting sx. And the hospitalists do appreciate timely service to get patients going for brain mets, bone mets, scc etc

But yes agree, most definitive cases will usually show up outpatient.

 

[lhl]

Are RVUs standardized for the same procedure between instituitions? If you are doing 15-20 cone beams a day, prostate/lung etc thats a lot of rvu from imaging.

yes. you can look up the values: Work RVU Calculator - Relative Value Unit - AAPC

The number of rvu's you get per cpt code remains fixed. How efficiently your facility captures charges will vary and the dollar per rvu collected by the facility varies based on payer source/mix/contract/setting etc. If collections aren't good and/or administration is greedy then you get a low dollar per RVU number. If collections are good and/or administration is generous then dollar per RVU is higher. Then there is the obvious component of how much leverage you have in the negotiating process.

The only other thing that comes into the equation is how your benefits are calculated and treated. In this case benefits include everything from health insurance and retirement contributions to office space, mid-level support etc. Sometimes you will have to pay for your own benefits, other times those benefits may be covered by the institution. For example, if you want "the perk" of a PA or NP helping you with documentation/patient care/care coordination, well then the facility may deduct that cost from your global wRVU collections when calculating your $/RVU (if you want a higher $/RVU, do all your own patient care and charting).