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“Generally [compensation systems] worked
best if the group had met as a whole, discussed
the activities under consideration, sometimes
with a facilitator, and arrived at values. The
general formula for compensating nonclinical work
thus seems to be whatever the group agrees upon.”
— Robert E. Johnstone, M.D.,
chair, summarizing the Committee on Practice Management’s
recent listserve discussion on compensating nonclinical
time.
“There is no one plan that will work
for all groups. Each group has its unique coverage
issues and needs. With appropriate thought, planning,
goal setting, research and consensus-building,
however, changing your plan can be successful
and create extremely positive outcomes.”
— Lynda F. Venters, FACMPE,
writing in the July
1998 ASA NEWSLETTER “Practice Management”
column.
nesthesiologists spend considerable time on group
administration, payer negotiations, institutional
committees, practice promotion, citizenship activities
and other nonclinical duties. Some group members
teach classes such as advanced cardiac life support.
These nonclinical duties demand more time than
they have in past years, and groups are increasingly
compensating members for performing them.
Some groups have tried to divide nonclinical work
equally, often rotating these burdens among members.
Many leadership tasks, though, are best performed
by members with special expertise, and within
a group everyone benefits if the tasks are done
well. Quite a few anesthesiologists have acquired
special skills in business management, financial
negotiation and strategic development either through
experience or special education such as completion
of the ASA Certificate in Business Administration
Program. Others have developed useful networking
contacts. Thus groups face the philosophical question
of how to distribute nonclinical opportunities
– and often end up asking a few members
to perform these tasks on behalf of the group.
There is no single or preferred method for compensating
nonclinical work [Table 1] or even for deciding
which work deserves compensation [Table 2]. The
Committee on Practice Management has received
several inquiries related to this issue. Committee
members, including Jeffrey L. Apfelbaum, M.D.,
Donald E. Arnold, M.D., Linda B. Hertzberg, M.D.,
Asa C. Lockhart, M.D., Eric W. Mason, M.D., and
Paul Rein, D.O., contributed to the discussion
below.
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One member wrote: “For years we gave no
compensation, just awarding extra vacation for
those most involved. This worked well, but several
partners felt it was not fair. We now pay partners
by the hour for required meetings beyond normal
clinical hours. Also partners who have to provide
extra coverage for meetings are paid. We approve
all meetings in advance. Members perceive this
system as fair, and we have had no problems since
implementing it three years ago. Overall the cost
to the practice is small.”
A second group provides less compensation for
nonclinical work. “We struggle with this
issue. Our group (20 anesthesiologists and six
nurse anesthetists) pays for billing unit production
based on a blended unit. We do pay extra for first
call, and the group president and suite chief
are compensated extra for meetings, negotiating
and other duties. As for compensating anything
else, we believe that there is more to being an
anesthesiologist than just clinical anesthesia.
Attending hospital committee meetings, performing
quality assurance analysis, and scheduling are
all considered part of our job. It is part of
being an anesthesiologist.”
Other practices work differently. “My group
has a time-based productivity compensation system.
This allows for compensation of nonclinical duties
that require a significant amount of time. We
compensate our president, the medical director,
a representative to our local independent practice
association, or IPA, the strategic planning committee,
and representatives to state and national committees.
The group provides partial compensation for AMA
delegation attendance and for participation in
our Blue Cross advisory council. We do not compensate
for executive and hospital committee participation
since we expect all members to sit on these committees
sometime. With the exception of 50 percent reimbursement
for the AMA days, we compensate either actual
minutes for meetings in town or group average
minutes per day for out-of-town meetings. One
of our guiding principles is to encourage participation
in activities that enhance our group.”
Members addressed the varying value of different
activities. “I guess you have to define
what it means to benefit the group. In the recent
past, I served as president of the hospital medical
staff, and one of my partners served as the president
of the state society of anesthesiologists. The
group excused both of us from call during that
time and covered all our meetings. In addition
we received some minor financial support. The
group did not necessarily receive a tangible benefit
from this sort of service, but everyone thought
that the group should support these sorts of endeavors
by its members for the benefit of the medical
community.”
Groups that salary everyone equally allocate time
for partners to perform nonclinical duties. One
member of such a group with more than 50 anesthesiologists
describes their method: “On days when we
have a demand-supply mismatch and extra staff,
we create nonclinical time for an individual to
tackle deferrable administrative tasks. Several
of us maintain project files and time lines and
use time as it becomes available. We define a
7 a.m. to 5 p.m. day and measure and report time
accrued before 7 a.m. or after 5 p.m. We credit
equally time after 5 p.m. for clinical and administrative
activities…. Our seven-member managing board
meets 13 times per year. Based on meeting length
and time for duties that flow from this commitment,
these seven physicians receive compensatory time
based roughly on our 50-hour work week ….
We have ‘practice’ administrative
work and ‘hospital’ administrative
work and treat both types equally. When the hospital
is paying for a duty, the money goes to the group.”
Still other committee members described formulas
involving point systems, stipends or work and
vacation days. Their formulas had changed over
time and were still evolving. Generally they worked
best if the group had met as a whole, discussed
the activities under consideration, sometimes
with a facilitator, and arrived at values. The
general formula for compensating nonclinical work
thus seems to be whatever the group agrees upon.
Several professional anesthesiology practice administrators
held a similar listserve discussion last spring,
leading to similar conclusions: First, many physicians
devote great efforts to important nonclinical
activities. Asked how his group pays its president,
one administrator responded, “grief, aggravation,
sleepless nights and torment.” Second, every
group must determine its own customized system
by consensus. One group had gone from paying equal
amounts for both administrative and clinical duties
to paying a specific stipend for each of more
than 60 administrative functions identified and
valued by an ad hoc committee. This also illustrates
the third general conclusion: The system will
inevitably change over time. Finally, some level
of service to one’s colleagues and to the
profession should be its own reward.
Staying
Off the Medicare Inspector General’s Watch
List
he Office of the Inspector General (OIG) has posted
its Work Plan for 2007 at <www.oig.hhs.gov/publications/docs/workplan/2007/Work%20Plan%202007.pdf>.
The annual Work Plan tells the public which Medicare
billing issues the OIG will be examining for potential
fraud in the next fiscal year. The target areas
span hundreds of “vulnerabilities”
in hospital, home health, prescription drugs and
others in addition to the realm of “physicians’
and other health professionals’” services.
Among the limited number of items in the 2007
Work Plan that may be of interest to anesthesiologists
are the following: