New Landscape: Physician Compensation.

The work relative value units (wRVUs) for a physician service can be conceptualized as the amount of time spent by the physician multiplied by a compensation rate (wRVUs/min). Disproportionately high compensation rates assigned to procedures have been blamed for pay differences across specialties, but to our knowledge, a comprehensive assessment is lacking. To assess how compensation rates built into work RVUs contribute to differences in physician compensation across specialties. This cross-sectional analysis examined 2017 Part B fee-for-service Medicare data. The data were analyzed from May 1 to May 30, 2019. A specialty-wide compensation rate (wRVUs/min) was generated for 42 medical and surgical specialties defined as the sum of wRVUs for all billed current procedural terminology codes divided by the presumed time to perform those services. This measure accounted for the volume and diversity of services each specialty provides. Sensitivity analyses were performed to assess the association of errors in wRVU time estimates with average compensation rates. The final sample included 42 specialties and 6587 distinct Current Procedual Terminology (CPT) codes. The number of CPT codes attributed to a specialty ranged from 575 (medical oncology) to 4346 (general surgery). Compensation rates ranged from 0.029 wRVUs/min (pathology) to 0.057 wRVUs/min (emergency medicine). Most specialties (34/42 [81.0%]) had compensation rates between 0.035 and 0.045 wRVUs/min. The mean compensation rate for surgical specialties was 7.2% higher than for medical specialties, a difference that was not statistically significant. This narrow range reflects the fact that most specialties had more than 60% of time allocated to activities outside the intraservice period. Assuming that time values for surgical procedures are significantly overestimated increased the difference in average compensation between surgical and medical specialties to 23.4%. Compensation rates assumed in wRVU valuations are small contributors to differences in physician compensation. Factors outside of the wRVU system, such as payer mix and work hours, could be targeted if narrowing the difference in compensation across specialties is desired.

By implementation of the Health Transformation Plan (HTP), a revised tariff system for healthcare services was executed in Iran. This study explores the changes in physicians' behaviour in facing informal payment (IP) based on HTP implementation in Iran. We conducted in-depth semi-structured interviews with 15 purposefully selected physicians and policy makers to explore the changes (positive, negative and no) in physicians' behaviours with and without the implementation of HTP. The interviews were conducted individually and face to face. The conventional content analysis for data analysis by MAXQDA ver.10 was used. Based on the results, regardless of the HTP implemented, market competitiveness could control physicians' demand for IP. However, unreal tariffs, irregular payments, inflation, expensive healthcare and comparing income with other occupations increase physicians' demand for IP as negative behaviour. This study explored three patterns of physicians' behavioural change because of HTP implementation: 1-positive behavioural change with four factors; 2-negative behavioural changes with two factors; and 3-no behavioural change with four factors. Various factors influenced physicians' behaviour towards IP with and without the HTP. To combat IP more efficiently, we recommend strengthening the HTP's positive interventions, compensation of physicians' target income, enhancing supervision, reducing the gap among various medical specialities and taking a systematic approach with law offenders.

Value-based surgery physician compensation model: Review of the literature

Negotiating physician compensation can be complicated because many factors now influence the ways in which physicians can be compensated. Infectious diseases (ID) specialists typically provide a wide array of services, ranging from patient care to administrative leadership. Compensation surveys from national organizations have produced results based on small samples and often are not congruent with ID physicians' perceptions. In July of 2015, the Infectious Diseases Society of America (IDSA) conducted a compensation survey to assess current compensation earned by the diverse ID specialists within its membership. Members of IDSA's Clinical Affairs Committee report the results from the 2015 IDSA Physician Compensation survey, with a particular focus on the findings from respondents who indicate "patient care" as their primary responsibility and present a discussion that compares and contrasts results against other survey data.

Physician compensation rates and gender disparities in interventional spine and pain practices: Insights from a Spine Intervention society survey study.

Physician Compensation: Approach and Models in Neurological Practice

CKD Express © - A New IT-Software Proposed for a Paradigm Change in CKD Care

Medical groups are challenged to adopt a systematic, evidence-based approach to selecting a physician compensation method that supports the group's overall financial and organizational strategies, including managed care contracting strategies; is consistent with the philosophies, beliefs, and attitudes of the group's membership as they pertain to individual productivity; and can be supported by the organization's information technology, decision support, and management infrastructures. This article explains how research in physician profiling, benchmarking, general compensation theory, and physician productivity provides evidence that can serve as the foundation for a pragmatic approach to evaluating physician compensation method alternatives. It also presents a unique production-based compensation model for illustrative purposes.

This article examines the sentiments of a Phoenix-area hospitalist who feels underpaid despite earning an objectively high salary. While physician compensation in the UnitedStates, including that of hospitalists (around $365,000 in Phoenix), ranks among the highest globally and places them in the top income percentiles domestically, the perception of being "underpaid" persists. The piece argues this feeling is a complex value judgment, influenced by the immense effort, sacrifice, and societal contribution inherent in the profession, often perceived as inadequately reflected by market-driven compensation. Cognitive biases, such as the Intrinsic Worth Fallacy and Social Comparison Bias, further shape this perception. Systemic healthcare issues, including administrative burdens and professional disempowerment, also contribute, leading to dissatisfaction where salary becomes a primary, yet seemingly insufficient, metric of worth. The article concludes that true professional value transcends monetary figures, calling for systemic changes to better acknowledge and support physicians, ensuring their profound contributions are recognized beyond financial metrics.

MP47-05 PHYSICIAN AND HOSPITAL MISALIGNMENT IN THE ERA OF WRVU: CAN THIS MODEL HURT THE CORE OF ACADEMIC MEDICINE?

A new metric was developed and implemented at the University of Kansas School of Medicine Department of Internal Medicine, the financial value unit (FVU). This metric analyzes faculty clinical compensation compared with clinical work productivity as a transparent means to decrease the physician compensation variability and compensate faculty equitably for clinical work.The FVU is the ratio of individual faculty clinical compensation compared with their total work relative value units (wRVUs) generated divided by Medical Group Management Association (MGMA) salary to wRVUs of a similar MGMA physician.The closer the FVU ratio is to 1.0, the closer clinical compensation is to that of an MGMA physician with similar clinical productivity. Using FVU metrics to calculate a faculty salary gap compared with MGMA median salary and wRVU productivity, a divisional production payment was established annually.From FY 2006 to FY 2011, both total faculty numbers and overall clinical activity increased. With the implementation of the FVU, both clinical productivity and compensation increased while, at the same time, physician retention rates remained high. Variability in physician compensation decreased. Dramatic clinical growth was associated with the alignment of clinical work and clinical compensation in a transparent and equable process.

Background: There has been much recent discussion about the reimbursement of telehealth virtual visits. Advocates argue strongly for payment parity with in-person encounters, whereas payers insist that telehealth visits should be reimbursed at a lower value. Methods: Using the Resource-Based Relative Value Scale structure as a guideline (where physician compensation is divided into categories: time/medical decision making/malpractice expense and practice expense), we developed a framework to examine the difference in practice expense of an in-person practice compared with a scaled virtual practice. Results: We found that for current procedural terminology (CPT) code 99213, the total relative value unit (RVU) for a virtual visit would be 1.62. The in-office RVU for CPT code 99213 is 2.09. This difference could serve as the basis for a rational discussion on differential reimbursement for virtual visits.

The National Surgical Adjuvant Breast and Bowel Project (NSABP) –B06 trial published over 25 years ago and subsequent trials conclusively showed no difference in survival outcomes between radical mastectomy and breast-conserving surgery (BCS) with radiation. This provided women with breast cancer the option of the less disfiguring, less morbid partial mastectomy. However, over the past 10 years, the proportion of women treated with mastectomy may be increasing despite no scientific data demonstrating its superiority over BCS. Reasons for this trend are unclear but may be related to including increased use of breast MRI, awareness and use of genetic testing, increased patient voice in shared decision and use of mastectomy by high-profile celebrities. In addition there has been an increased-rate prophylactic mastectomy of the unaffected breast. One factor making mastectomy a more palatable option to women and a possible additional driver of increased rates of mastectomy is access to breast reconstruction at the time of or subsequent to mastectomy. In the article accompanying this editorial, Jagsi et al evaluate the rate of reconstruction in women with breast cancer undergoing mastectomy in a modern cohort of privately insured, working-age women. Using MarketScan (Truven Health Analytics, Ann Arbor, MI) a commercial claims-based database, 20,560 women were identified who underwent mastectomy with a breast cancer diagnosis between 1998 and 2007. Among these younger, well-insured women treated with mastectomy, reconstruction increased from 46% in 1998% to 63% in 2007. Reconstruction also correlated with plastic surgeon availability defined by population density of specialists, as well as with geographic region, patient age, and use of bilateral mastectomy. Jagsi et al are to be commended for the highly methodical approach to analyzing these data and for both recognizing and avoiding some of the most dangerous potential biases. However, differences in the cohort over time independent of wider trends in the greater population could have affected the magnitude of the observed change. In 2002, the data set was expanded to include additional health plans, significantly enlarging the cohort available for analysis. The time point of expansion correlates with the increasing reconstruction rates noted in the results. Another factor affecting using these data as indicative of the general population is that this cohort consists mostly of women in noncapitated PPO insurance plans (80%) with over two thirds of patients are within the two highest quartiles in income. Age certainly affects the use of breast reconstruction. Among women over age 65 years (Medicare recipients) reconstruction rates are reported as low as 6% to 16% nationally. In addition, there are personal issues that affect a woman’s choice, and these issues are different for older women. However, there is no evidence demonstrating an increased complication rate in older woman undergoing breast reconstructions, including older women who undergo autologous reconstructions. Older woman should be offered breast reconstruction based on their overall health status and perioperative risk assessment. Treatment also varies by provider. The SEER data cited examining rates of reconstruction in women over 65 reported an average rate of reconstruction for women with Stage 0 to 2 disease of 6%. However, there was significant variability across institutions with reconstruction rates ranging from 0% to 44%, with a few institutions performing a large proportion of the reconstructions. Similarly, patients treated at different National Comprehensive Cancer Network centers nationally were found to have different rates of breast conservation, mastectomy, and mastectomy with reconstruction. This highlights that patient care may be driven by regional culture and provider biases reflected by an institution’s practice, or resource. The type of reconstruction also varies, potentially related to provider bias and interests in the use autologous tissue reconstruction. This occurs most frequently at large or academic centers. While in many cases autologous tissue reconstruction provides superior cosmetic and longer lasting results, autologous reconstructions rates are declining compared with implant reconstruction. Staffing limitations in private practice settings are constrained, often with no trainees or other readily available assistants for the labor-intensive tissue techniques. This trend may also be driven by the low reimbursements rendered for these lengthy and complex procedures. On one survey, many plastic surgeons reported limiting the breast reconstructions performed, citing decrease reimbursement as the reason. Those who continue to perform breast reconstruction are incentivized to perform implant-based reconstruction, with reimbursement as much as six times greater based on intraoperative hourly rates. While physician compensation may be lower, system-wide, autologous tissue reconstruction with either pedicle flaps or free flaps may be more cost effective in the long run than implant-based reconstruction Another key trend is the increased use of contralateral prophylactic mastectomy (CPM) and associated higher rates of implant reconstruction as shown by Jagsi et al. Other studies have duplicated these results with increasing CPM rates and increasing use of implant JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 32 NUMBER 9 MARCH 2

To determine utilization and reimbursement trends of coronary revascularization procedures in the US Medicare population from 2000 to 2018. US Medicare population is increasing, and coronary revascularization decreased in the 2000s. This is a population-based, cross sectional study of US Medicare beneficiaries from 2010 to 2018. The Centers for Medicare and Medicaid Services' database was queried for revascularization procedures using the coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) current procedural terminology (CPT) codes. Trends in Medicare enrollees, PCIs, CABGs, and physician reimbursements were analyzed. Total utilization and reimbursement decreased for both revascularization procedures. The national CABG and PCI utilization per enrollee has decreased by 40.7% (best fit line: b coefficient, 95% CI; -0.297, -0.358 to -0.235) and 26.4% (best fit line: -0.229, -0.373 to -0.0858), respectively. For CABG, annual Medicare payout per enrollee and physician compensation per procedure has decreased by 49.3% (best fit line: -0.250, -0.315 to -0.185) and 14.5% (best fit line: -11.54, -15.62 to -7.452), respectively, and for PCI, decreased by 53.3% (best fit line: -0.373, -0.560 to -0.186) and 36.6% (best fit line: -34.15, -49.35 to -18.95), respectively. Amongst the states, there was significant variability in procedure utilization, and CABG reimbursement rates but minimal variability in PCI reimbursement rates. Even though the US population has aged, revascularization utilization and reimbursement continue to decline. Advancement in medical intervention strategies, particularly non-surgical management, may account for these trends. Further understanding of these trends will allow health systems to tailor resources to the aging population.

In the 1940s Canada and the United States had similar lack of structure and reimbursement for diagnostic, hospital, and physician services. In Canada over the next 40 years there evolved a complex system mandated and partially funded by the federal government, but administered and delivered through 10 provincial and 2 territorial jurisdictions. Each must negotiate with federal government on cost sharing and deal with hospital budgets and physician compensation at the provincial or territorial level. The Medical Care Act of 1966 enshrined in law the five principles of public administration, universality, comprehensiveness, portability, and accessibility, converting all medical services in Canada from a privilege to a right. Any patient participation in hospital or physician charges came under increasing political attack. In 1984 the Canada Health Act specified financial penalties in federal transfer payments to provinces that permitted any direct patient charges. While Canada has “contained” health expenditures at 8.7% of gross national product, universal access to quality care is increasingly subject to rationing. The relationship between the profession and governments hard pressed to fund escalating costs in a deteriorating economy has been one of increasingly bitter confrontations. There have been four acrimonious doctors' strikes. More optimistically, there is now an emerging recognition of society's need to have physicians actively participating with other providers and governments to create a balance between access to quality health services and both public and private funding.