Radiology Reimbursement Advice: Ignore the RVUs If You Can

Radiology social media ran a post from someone experiencing a productivity-based compensation model for the first time. He was disappointed with his first quarterly tally of RVUs and looking for ways to improve. Specifically, he asked whether it was better to read lots of quick, low-value studies or slower but higher-ticket stuff.

There was a decent amount of feedback. Some of it was simple and direct: CT A/P, ER cases unlikely to have lots of findings, etc. Other folks focused on the evils of cherry picking “good” studies to the point where fellow rads get stuck with the less desirable stuff. That included higher order debate over whether RVU-based comp is an evil in and of itself since it can incentivize such unneighborly behavior.

My contribution was that I preferred maintaining as broad a swath of study variety as possible. I find that keeps things interesting and avoids any of my skills growing rusty from disuse. I concluded with “The RVU numbers sort themselves out.”

That might sound like a strange thing to say from a rad who has gone back and forth between salaried, hourly, and per-click employment models, and chose most recently to stick with the RVUs. Heck, if I went back in time and gave this advice to my 2011 self, who was just about to enter the per-click world for the first time, younger me would not have been impressed.

I wouldn’t blame him. I can recall the frame of mind I was in, hoping I was making the right career move and trying to figure out the impact it would have on my bank account. A salary is a pretty simple thing to compare against given that it is more of a fixed number. You can complicate things as much as you like of course by figuring out values of whatever benefits you are getting, divide by the number of hours you are working, etc. However, there aren’t many variables.

Meanwhile, if you move into productivity world, almost everything becomes a variable. Even the per-RVU dollar amount assigned by my first telerad company shifted a few times, once being in the months between my signing a contract and reading my first case. Especially if you have never had reason to track your productivity before, you might wonder how your per-click comp will stack up against your previously reliable salary.

You might therefore spend a lot of time trying to figure out where your RVUs will “land” in advance. Even months into your per-click work, you might still be trying to get a feel for what you can count on. Will my numbers improve as I get accustomed to this new-to-me system? How can I improve my efficiency? Case mix inevitably enters the picture, whether you are able to choose studies like the social media poster above, or if you are assigned cases and want to ask your employer to adjust what comes your way.

So how did I come to believe “the RVUs will sort themselves out?”

Part of it is that I have been in the field for a while. The longer you do something without catastrophe, the more you take things in stride. I have seen my RVUs fluctuate from one job to the next as result of their hardware/software rigs, infrastructure, etc., but my personal capabilities haven’t gone through such ups and downs. In the fullness of time, maybe I have gotten more productive or more laid back. Any changes, outside of the first few months of my per-click life in 2011, have been minor.

That in mind, nothing gimmicky like grabbing a couple more ER A/Ps in favor of thyroid nodule ultrasounds per day is going to make big waves. Such machinations might gain (or lose if I judge things wrongly) a few bucks in a given session but nothing life changing. It won’t be worth hassling myself, let alone potentially annoying teammates or employers.

Meanwhile, I haven’t tried to track RVU values over the long haul, so this is purely subjective, but the “valuable” cases seem to have shifted over the years. Around the time of my residency, neuro was considered the pot of gold (angio also appeared to have value but I was no good for that). Not long after, word was that your fellowship should be in MSK if you wanted big bucks. I wound up feeling lackluster with my body imaging credentials.

Then imagine my surprise to hear people on the social media thread saying that CT A/P is the desirable moneymaker now. I know RVUs change as the government yanks us around, but could it be that neuro, MSK, etc. got devalued and/or body imaging propped up, or was all the scuttlebutt I had heard over the years wrong?

If the latter, and so many rads trying to keep tabs on what’s profitable can be wrong, is any individual likely to buck that trend? Successfully identify what fraction of a worklist makes a fatter paycheck? Or is one just as likely to get it wrong and earn less? Perhaps waste a bunch of energy flailing about to wind up in the same position as if one had just read the list from top to bottom.

Otherwise, if there has been a cycling of subspecialty favorability, and body imaging is currently enjoying a moment in the sun, there is no reason to believe it will last forever. The financial “sweet spot” will move on, and future year social media will advise rads to aim for some other thing.

Now, you could constantly keep an ear to the ground and shift focus to preferentially read whatever is “hot,” but your skills in other, excluded areas are liable to atrophy. How long will it be before the new hotness is something you really shouldn’t (or can’t) be reading? Suppose you got a few extra thousand bucks per year along the way. Would that payoff be worth it?

My approach — keeping as much variety in the worklist as I can — avoids that, and averages out my exposure to fluctuating RVUs in this subspecialty or that one. My bets are hedged. Further, if I ever have to change jobs (perish the thought! I like mine), I will be all the more marketable without having to say things like “I don’t read neuro.”

There is also the other part of the advice I gave, about keeping a strongly mixed worklist. This keeps things interesting. Your mileage may vary, but there have been times when I had nothing but abdominal/pelvic CTs to read all day long and I found it mind-numbing. There’s a palate-cleansing effect from shifting over to read some brains and spines, or just gobbling a stack of US and XR.