Today’s Musing
Accounting for non-clinical activities in your practice
Nobody likes to work without compensation or recognition. In traditional and concierge medical practices, there’s a clear need to have all hands on deck to make a lighter load of non-clinical work. And professionalism, citizenship and honor only go so far when you are trying to balance work/life activities.
In recent months, we’ve been engaged by a few practices and integrated health systems to end the infighting and cajoling that was happening among the medical staff and the executives. As part of our deliverable, we developed systems to measure nonclinical efforts by some and not others using relative value units (RVUs), assigning eligible activities both a time and dollar value.
Nonclinical RVUs were measured in 10-minute increments, and six nonclinical RVUs were valued at $120.00.
We also crunched the numbers, figuring out each group’s current and historical workload (technology made this necessary because much of what was done before is now alleviated by technology apps, rubrics, and macros, which changed the number and type of nonclinical hours spent every year. Based on those estimates, we then calculated the anticipated costs, and negotiated physician shareholder and practice administration buy-in and a budget allocation. In a hospital-owned practice, the only thing that’s different is who has to approve the new compensation method and budget.
The nonclinical RVU system is predicated on paying for work above and beyond the call of duty. All clinicians are expected to participate in a broad range of nonclinical activities before they begin generating “payable” nonclinical RVUs. One way we mediated this among group members was to develop a “fee schedule” with specific codes (similar to CPT codes but with slightly different taxonomy.
Clinicians were then expected to produce a minimum of nonclinical RVUs annually for “core requirements.” Those who fail to meet those numbers can’t earn additional money for other nonclinical activities, and may face sanctions, just as they would for lapses in clinical performance.
Group members decided which nonclinical activities were designated as core and which were eligible for additional, payable RVUs. Core responsibilities included participating on committees, attending grand rounds, reviewing M&M data, and meeting quality reporting requirements. Other core requirements included attending monthly staff meetings and doing basic work tied to clinical activities such as billing, medical record completion, and dealing with insurance appeals, contract negotiations, or billing inquiries.
Activities that accrued nonclinical RVUs for additional pay included leading multidisciplinary rounds, mentoring medical students, giving lectures, participating in blogging and public relations activities, and planning and directing performance-improvement projects. Activities that required additional training or skills (contract analysis and negotiation, for example) were weighted with more RVUs because those activities required additional skills training and travel time or community involvement.
Lessons Learned
Our clients wanted the system to be fair but not blow the budget to an out of control accounting monster. One thing we did on later projects that came from lessons learned was to strictly define the nonclinical values and expectations so that the potential for “gaming the system” was mitigated. Similar to an auto mechanic’s job book, clinicians 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 they take additional time, that’s their prerogative—and their problem. Another lesson we learned was to remove any ceiling on extra compensation that each clinician can earn, provided they first met their core requirements. This also allowed for flexibility between team members in case one had administrative work that they wanted to hand off to another team member on occasion.
Looking back over the engagements we concluded, “over-performance” hasn’t been an issue. While some team members in each practice 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 getting the job done without feeling “dumped on”.
The budget saw reasonable incremental increases during the first 18 months, but it has since leveled off, an indication that we had accurately predicted the clients’ nonclinical activities and the time allocations for each.
Paying for nonclinical RVUs has enabled the clients to realize other benefits. Clinicians can pursue individual areas of interest (social media, negotiating, quality improvement, fine tuning for increased efficiency and leadership duties). Team members also enjoy better morale and a sense of professionalism, and much of the rivalry and negativity of the past has been effectively eliminated, leading to a much more cohesive, productive and integrated working group.
We’d be pleased to analyze your practice and set up a similar system for you. It’s not an expensive project and the results are worth the effort. Please call me to learn more.
