The impact of emergency medicine residents on clinical productivity

CONTEXT

Faculty productivity is of interest for hospital and university administrators as pressure is placed on them by government and private payors. Further, the effect of trainees on clinical productivity is of personal interest to physicians because their performance evaluations and earning potential are often tied to their productivity. Several groups have utilized creative methodology to study the effect of learners on emergency department (ED) productivity, but they were faced with multiple confounding variables for which it was difficult to adjust. In this study, we utilize relative value unit (RVU)/h to study the effect of resident physicians and medical students on the productivity of academic emergency physicians (EPs) during the implementation of a new residency program. Each physician's productivity on shifts with distinct types of learners present is compared to their shifts worked without any learners during the same time frame. Each attending physician serves as their own control while the confounding variables introduced by comparing over multiple years are minimized.

OBJECTIVES

The objective of this study is to measure the influence of emergency medicine (EM) residents on the clinical productivity of attending EPs.

METHODS

We conducted an observational study of a single ED during implementation of a new residency program. The productivity of each EP was measured by RVU/h billed. Trainees' schedules and end-of-shift evaluations were utilized to determine what learners (if any) were working with the EP on each shift. RVU/h calculations were performed for each EP (overall, when working without learners, and when working with each of the four learner categories). The primary outcome (determined a priori) was the difference in RVU/h for the attending EPs when they worked without learners compared to when they worked a majority of their shift with at least one learner. The secondary outcome (also determined a priori) was determining the influence of the learners of each type on EP RVU/h for the subgrouped shifts in which a learner was present for the majority of the shift.

RESULTS

There was no significant difference in mean EP RVU/h when attendings worked with a medical student or non-EM R1 in comparison to working without learners in the 1761 ED encounters analyzed (12.95 RVU/h vs. 12.52 RVU/h; p=0.125). Although there was variability among individual physicians, EP RVU/h increased significantly for the overall group when one or more EM R1s were present (15.19 RVU/h with one EM R1 present, 15.25 RVU/h with two, 24.75 RVU/h with three; p<0.001). Similarly, mean EP productivity increased significantly with the addition of an EM R2 (17.96 RVU/h vs. 16.84 RVU/h; p=0.001).

CONCLUSIONS

The presence of EM residents was positively associated with the clinical productivity of EM faculty as measured by RVU/h. There was also a positive association between productivity and the number of EM residents present as well as their training level. Non-EM residents and medical students had no effect on EP productivity.

Optimal Use of Advanced Practice Providers at an Academic Medical Center: A First-Year Retrospective Review

Background Physician assistants/associates (PAs) and nurse practitioners (NPs), together known as advanced practice providers (APPs), practice with a high degree of clinical autonomy and professional respect, and play a critical role in team-based care. Aligning APP care delivery models to promote top-of-license practice is essential to improving ambulatory capacity and bottom-line expectations at academic medical centers (AMCs) in the 21^st century and beyond. This administrative quality improvement study assesses the downstream impact of restructuring our APP care models to promote independent practice sessions. Methods Our AMC formed an APP oversight committee in April 2021 to optimize the ambulatory care model, realign APP funds flow, and set performance standards to which PAs and NPs are being held accountable. We conducted a one-year retrospective review of internal data from July 2021 to June 30, 2022. Certified registered nurse anesthetists (CRNAs) were excluded from this analysis. Results  APP productivity year-over-year (YOY) aggregate data across all School of Medicine (SOM) departments, demonstrated a 53% increase in work relative value units (wRVUs), 84% increase in payments, and 79% increase in charges from the prior fiscal year (July to June). Regarding APP ambulatory clinical effort (YOY), there was a 45% increase in the number of APP completed visits (92% return patient visits, 8% new visits). An increase in APP productivity did not adversely impact patient satisfaction, physician-generated wRVUs, or delay programmatic expansion efforts. Lastly, in a recent engagement survey, the majority of PA and NP respondents (78%) reported working either "most of the time" or "always" at the top-of-license. Conclusion This quality improvement study demonstrates that enhancement of PA and NP utilization through top-of-license initiatives can be achieved without jeopardizing physician wRVUs or performance. While we acknowledge, there are differences between healthcare institutions in terms of care delivery and compensation models, organizational culture, and distribution of clinical resources, there remains an opportunity among hospitals and health systems to optimize this critical and essential APP workforce.

Are Orthopedic Hand Surgeons Undercompensated for Time Spent in the Operating Room? A Study of Relative Value Units

BACKGROUND

This study aims to investigate whether compensation is equitable among the most commonly performed orthopedic hand surgeries and when compared with general orthopedic procedures.

METHODS

The National Surgical Quality Improvement Program database was queried for all orthopedic procedures, from 2016 to 2018, performed more than 150 times using Current Procedural Terminology (CPT) codes. Physician work relative value unit (wRVU) data were obtained from the 2020 US Centers for Medicare and Medicaid Services fee schedule. Linear regressions were used to determine whether there was an association among wRVU, operative time, and wRVU per hour (wRVU/h). Reimbursement for hand surgery CPT codes was compared with that of nonhand orthopedic CPT codes. The CPT codes were stratified into quartile cohorts based on mean operative time, major complication rate, mortality rate, American Society of Anesthesiologists class, reoperation rate, and readmission rate. Student t tests were used to compare wRVU/h between cohorts.

RESULTS

Forty-two hand CPT codes were identified from 214 orthopedic CPT codes, accounting for 32 333 hand procedures. The median wRVU/h was significantly lower for procedures in the longest operative time quartile compared with the shortest operative time quartile (P < .001). Compared with hand procedures, nonhand procedures were found to have significantly higher mean operative time (P < .001), mean complication rate (P < .001), mean wRVU (P = .001), and mean wRVU/h (P = .007).

CONCLUSIONS

The 2020 Physician wRVU scale does not allocate proportional wRVUs to orthopedic hand procedures with longer mean operative times. There is a decrease in mean reimbursement rate for hand procedures with longer mean operative time. When compared with general orthopedic procedures, hand procedures have a lower mean wRVU/h and complication rate.

Impact of a scribe program on patient throughput, physician productivity, and patient satisfaction in a community-based emergency department

Previous literature on the impact of scribe programs varies and has mostly been reported from academic institutions or other clinics. We report the implementation of the scribe program in the emergency room of a community hospital and its impact on patient throughput, physician productivity, and patient satisfaction. We performed a quasi-experimental, before-and-after study measuring patient throughput metrics, physician productivity, and patient satisfaction. The intervention measuring the scribe implementation was divided into pre- and post-implementation periods. Patient throughput metrics were (1) door-to-room time, (2) room-to-doc time, (3) door-to-doc time, (4) doc-to-disposition time, and (5) length of stay for discharged/admitted patients. Our secondary outcome was physician productivity, which was calculated by measuring total patients seen per hour and work relative value units per hour. Additionally, we calculated the time-motion analysis in minutes to measure the emergency department physician's efficiency by recording the following: (1) chart preparation, (2) chart review, (3) doctor-patient interaction, (4) physical examination, and (5) post-visit documentation. Finally, we measured patient satisfaction as provided by Press Ganey surveys. Data analysis was conducted in 12,721 patient encounters in the pre-scribe cohort, and 13,598 patient encounters in the post-scribe cohort. All the patient throughput metrics were statistically significant (p < 0.0001). The patients per hour increased from 2.3 ± 0.3 pre-scribe to 3.2 ± 0.6 post-scribe cohorts (p < 0.001). Total work relative value units per hour increased from 241(3.1 ± 1.5 per hour) pre-scribe cohort to 336 (5.2 ± 1.4 per hour) post-scribe cohort (p < 0.001). The pre-scribe patient satisfaction was high and remained high in the post-scribe cohort. There was a significant increase in the clinician providing satisfactory feedback from the pre-scribe (3.9 ± 0.3) to the post-scribe (4.7 ± 0.1) cohorts (p < 0.01). We describe a prospective trial of medical scribe use in the emergency department setting to improve patient throughput, physician productivity, and patient satisfaction. We illustrate that scribe use in community emergency department is feasible and results in improvement in all three metrics.

Annual impact of scribes on physician productivity and revenue in a cardiology clinic

Objective

Scribes are increasingly being used in clinics to assist physicians with documentation during patient care. The annual effect of scribes in a real-world clinic on physician productivity and revenue has not been evaluated.

Methods

We performed a retrospective study comparing the productivity during routine clinic visits of ten cardiologists using scribes vs 15 cardiologists without scribes. We tracked patients per hour and patients per year seen per physician. Average direct revenue (clinic visit) and downstream revenue (cardiovascular revenue in the 2 months following a clinic visit) were measured in 486 patients and used to calculate annual revenue generated as a result of increased productivity.

Results

Physicians with scribes saw 955 new and 4,830 follow-up patients vs 1,318 new and 7,150 follow-up patients seen by physicians without scribes. Physicians with scribes saw 9.6% more patients per hour (2.50±0.27 vs 2.28±0.15, P<0.001). This improved productivity resulted in 84 additional new and 423 additional follow-up patients seen, 3,029 additional work relative value units (wRVUs) generated, and an increased cardiovascular revenue of $1,348,437. Physicians with scribes also generated an additional revenue of $24,257 by producing clinic notes that were coded at a higher level. Total additional revenue generated was $1,372,694 at a cost of $98,588 for the scribes.

Conclusion

Physician productivity in a cardiology clinic was ∼10% higher for physicians using scribes. This improved productivity resulted in 84 additional new and 423 additional follow-up patients seen in 1 year. The use of scribes resulted in the generation of 3,029 additional wRVUs and an additional annual revenue of $1,372,694 at a cost of $98,588.

Of mice and men: escaping the relative value unit trap

Although radiologists have kept pace with the dramatic growth of medical imaging during the past two decades through the use of PACS, digital dictation, and 3-dimensional reconstruction, radiology is approaching the point of diminishing returns. As reimbursements further decline, attempts to increase radiologists' productivity risk commoditization of the specialty. The continued evolution of US health care policy, however, presents an opportunity for radiologists, using their core competencies, to shape the future direction of medicine.

The impact of financial incentives on physician productivity in medical groups

OBJECTIVE

To estimate the effect of financial incentives in medical groups--both at the level of individual physician and collectively--on individual physician productivity.

DATA SOURCES/STUDY SETTING

Secondary data from 1997 on individual physician and group characteristics from two surveys: Medical Group Management Association (MGMA) Physician Compensation and Production Survey and the Cost Survey Area Resource File data on market characteristics, and various sources of state regulatory data.

STUDY DESIGN

Cross-sectional estimation of individual physician production function models, using ordinary least squares and two-stage least squares regression.

DATA COLLECTION

Data from respondents completing all items required for the two stages of production function estimation on both MGMA surveys (with RBRVS units as production measure: 102 groups, 2,237 physicians; and with charges as the production measure: 383 groups, 6,129 physicians). The 102 groups with complete data represent 1.8 percent of the 5,725 MGMA member groups.

PRINCIPAL FINDINGS

Individual production-based physician compensation leads to increased productivity, as expected (elasticity = .07, p < .05). The productivity effects of compensation methods based on equal shares of group net income and incentive bonuses are significantly positive (p < .05) and smaller in magnitude. The group-level financial incentive does not appear to be significantly related to physician productivity.

CONCLUSIONS

Individual physician incentives based on own production do increase physician productivity.