Clicks and Curves

Not everything shows up on curves.

Last time around, I dwelled on the so-called “pay per click” model of radiology-compensation. As then mentioned, I’ve seen some love it, some loathe it, and a lot of folks scattered across the spectrum in-between.

Most of the non-polar sentiments include a recognition of tradeoffs: Yes, it can be a bean-counting, headache-making, quarrel-inducing mess, but what else are you going to do? Just pay people a set amount and hope they’ll do a reasonable amount of work? Not noticing/caring if they seem to be pulling harder than others on the team who earn just as much, if not more?

A “happy medium” system would be one in which rads knew they could go about their work without fretting over the daily vagaries of their RVU tally…but nevertheless assured that their productivity would be on the record. And that slackers on the team wouldn’t go undetected.

Leadership would, similarly, have an idea who was shouldering how much of the group’s burden…without having to constantly tinker with complex schemes of differing exam-values, deterrence-mechanisms for “cherrypicking” of easier or higher-value cases, etc.

Tracking RVUs, or even RVU-related “work units,” doesn’t really get at this. You certainly wind up with a bunch of numbers to apply to your rads, numbers which can be put on tables and charts for periodic review. You can make sophisticated-looking curves to show a rad’s productivity over time, and stack them up against other rads, throw in standard-deviation ranges, etc.

Most rads who’ve been working more than a little while have seen their performance tracked. Even if you’re not in a pay-per-click situation, the folks in charge need to know if you’ve been generating enough revenue to warrant whatever salary or hourly rate you receive. Also how to fairly apportion bonuses and consider requests for raises.

But as long as all of that is based on curves, bar-charts, etc. derived from your RVU total, the per-click issues are a big part of the picture. Somewhat paradoxically, I think adding a second curve would simplify things, for groups preferring to operate via salaries or hourly rates:

By all means, keep tracking RVUs. After all, if that’s how your group is receiving its revenue, it doesn’t make sense to pretend otherwise. Rads who are doing the heavy lifting to make that revenue happen should definitely be recognized, if not rewarded.

But alongside the RVU curve, have another measurement, truer to the simplicity that “per click” implies: A curve of the raw number of exams a rad has read.

This way, the rad(s) who are dealing with the neverending onslaught of low-paying studies like XR…work that has to get done one way or another…can be tracked for the service they are providing. One important facet of which is running interference so the RVU-sluggers can focus on their MR.

Maybe the rads who would look better on the second curve don’t have the skills to read many of the higher-ticket scans. Maybe they prefer lower-tech modalities. Or maybe their other responsibilities (fluoro, diagnostic mammos, fielding phone calls, etc.) interrupt them so much, it’s just easier to squeeze “bite-sized” studies like XR in between.

If such rads know that they will be valued for taking care of the mountain of XR—despite that mountain’s reimbursement-worth being unimpressive next to a reasonable daily haul of MR and CT—they can go about their work without constantly being tempted to sift through the list for brainscans to shore up their RVU-numbers.

When it’s time for performance reviews, each rad’s two curves can then be seen as equally-important parts of the big picture. Total exams in bottom quartile, but you’re tops RVU-wise? You did your part. RVUs low, but study-volume high? You get praise, not browbeating.

Sort of like being on a track-n-field team: A sprinter is used/valued for what he can do in the 100-meter dash. A distance-runner is regarded for his performance in the 5k. You wouldn’t put either guy in the other’s event and expect good results.

Of course, rads aren’t quite as pigeonholed as all that. Some might do well if told, each day they came into work, whether they should be going for case-volume or RVUs. Or self-select which suits them at any given moment, depending on their mood or circumstances around them.

Obviously, not everybody can be focused on the same curve; the work all needs to be done. Some coordination of efforts via assignment of roles might be needed to avoid all the XR getting gobbled up early in the day, lest there be dozens of RVU-heavy scans that only a fraction of the group can take care of. Or the opposite: Nothing but XR left on the lists at 4pm, and while some of the volume-centric rads industriously plug away, the “I wish I had some MR” rads reluctantly poke through a few cases at a snail’s pace.

For such reasons, both of a rad’s curves are relevant, rather than just choosing one to be his personal yardstick. A top-quartile RVU-rad with bottom-quartile volume, for instance, might be considered as being on the same level as a top-volume/bottom-RVU member of the team…as well as a rad who’s dead-center for both RVU and case-number.

Meanwhile, a rad in the 75th percentile on both of his curves might be considered something of a hero, and bonused appropriately. And a rad whose two curves were in the bottom 10% might be approached for remediation…unless, of course, that rad had other roles of value such as in administration.

Because not everything shows up on curves, no matter how many you’re willing to draw.