Busy Hospitalist Night Shift Experience: Review of the Economics.

I had a really busy hospitalist night shift.  13 admissions, one consult and one central line in a 12 hour shift.

7 : 99223 high level complexity admissions

4 : 99220 high level observation admissions

2 : 99291 critical care admissions

1 : 99233 ortho follow up consult

1 : 36556 central line

with 1/2 hour left to write this post.

If every one of those patients were Medicare, how much did I bill for the night? Let's see

7 (99223) About 5 Total RVUs worth about $170 each for a total of 35 RVUs/$1190

4 (99220) About 4 Total RVUs worth about $140 each for a total of 16 RVUs/$560

2 (99291) About 6 Total RVUs worth about $200 each for a total of 12 RVUs/$400

1 (99233) About 2.5 Total RVUs worth about $90

1 (36556) About 3.5 Total RVUs worth about $110

Remember, it's all relative. Tonight, a record night, I produced a total RVU (work RVU+practice expense+malpractice) of about 69 RVUs. If every one of those encounters was a Medicare patient, I would have collected close to $2,400. What is RVU?  You need to understand the process to continue reading.  

If you look at just the work RVU's, that RVU amount that is attributed only to physician expertise, education and effort (strip out the practice expense and malpractice expense from the total RVUs) , the workRVUs amounts to about 52 RVUs for 14 complicated admissions/critical care/consults/ and a central line.

Lets compare this to the Medicare payment to the orthopaedic surgeon for doing the total knee arthroplasty (CPT 27447) that I was consulted on. It is worth about 23 work RVUs. Add in the 4 work RVUs for the consult before surgery and you're looking at 27 work RVUs to do a total knee arthroplasty. Now granted, this surgery carries with it a global 90 day period for which the surgeon is required to care for the patient as part of their agreement.

To produce 52 work RVUs an orthopaedic surgeon would have to perform just under two total knee arthroplasties (about 1.9). So lets assume they do that in the 11 hours. Let's say the consult takes 1/2 an hour ( that's pushing it). Two consults would take an hour. That leaves 10 hours of time for 1.9 surgeries and all post operative follow up.

It would take an orthopaedic surgeon a time commitment of 5 hours over a 90 day period for their total knee to produce the volume equivalent to the time and effort put in by a hospitalist on a record busy day.  Let's even assume that it takes 5 hours of OR/post OR cares to do a total knee (which is perhaps double or triple the actual time commitment), if you are a medical student would you rather spend 11 hours admitting 14 people or would you rather spend 11 hours doing surgery on two of them.

The answer is simple. And that's why medical students know exactly what they are doing when they shun E/M only medicine in favor of the lucrative procedural/surgical based subspecialties. When you can earn the same amount seeing two patients with a five hour commitment that in actuality may take less than 1/2 that much, deciding what medical career to pursue is not rocket science. And it's all courtesy of the RUC.

Before some subspecialists spam me as saying I knew what I was getting into, let me say I love my job. Hospitalist medicine has left the irrational constraints the RVU pot. This discussion is not personally about me, but rather about the reality of the model for which we choose to pay doctors to perform.

I forgot to add, the central line, from start to finish took me 20 minutes.  The observation admissions, which paid slightly more than the central line took at least 45 minutes.  It's not effort that is being paid.  The central lines are easy compared to admissions.  But they pay so much better on a time based axis.  And that has nothing to do with skill and everything to do with the RVU as determined by the RUC.  It takes far more skill for me to think my way through a differential diagnosis than it does for me to swab some cleanser on the skin and stick a needle in a vein.

Make sure to visit my lectures on coding for hospitalists and my  hospitalist resource center for a wealth of practice management information

LINK TO E/M POCKET CODING CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital:  (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic:  (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high definition view