In this episode of RadCentral, a radiology podcast, we are joined by Attorney and Emergency Medicine Physician William Sullivan, DO of Illinois to discuss the compensation model of RVUs.

In the ever-evolving landscape of healthcare, understanding the nuances of compensation models is crucial for both providers and administrators. One model that has gained significant traction over the years is the Relative Value Unit (RVU) system. While RVUs are widely used to determine physician compensation and reimbursement rates, their complexity can often lead to confusion. In this episode of RadCentral, we’ll delve into RVUs, how they function, and the ongoing debates surrounding their effectiveness.

Attorney Sullivan is a practicing Emergency Medicine Physician and experienced Attorney who provides legal services related to the field of medicine including contract review, state medical board representation, medical record review and education services in the state of Illinois.

Listen, Like, and Follow RadCentral a radiology podcast on Apple Podcasts Spotify and Amazon Music.

Audio Only Version:

Key excerpts:

“With compensation from RVUs, there’s two things you have to consider. One is you have to consider the conversion factor. But the other one is you have to consider the RVUs themselves. And CMS is constantly modifying how many RVUs they pay. So there’s two moving targets [and] you have to keep track of both of those.”

“If you get paid by procedure or by the patient… and they decrease the amount of money that you’re receiving for each visit. The only way to maintain your income is to see more patients. So I don’t know if that’s beneficial for patients that instead of seeing a patient every 20 minutes, you make it every 15 minutes or every ten minutes just so you can maintain that same RVU stream.”

“One of the other things in the Medscape survey that I saw was it discourages physicians from entering certain fields because they don’t get paid as much like primary care or mental health, chronic disease management. So when the  value of those services is undervalued by CMS, then naturally the market’s going to select against providing those services because doctors want to be paid for what they’re doing.”

It’s easy to game the system, but that’s the way the system set up. And you you can’t blame people for gaming the system. So in terms of getting more doctors involved, that’s one of the ways I think we can create a better system is create some type of RVU consortium where you get representatives from all the major specialties. They all come to a meeting somewhere and they say, okay, how much is how much are we going to pay for radiology versus, oncology versus emergency medicine versus primary care versus like psychiatry and they all get together and kind of decide between them what’s going to be fair and what’s going to incentivize care, what’s going to disincentivize care.”

---

Transcript Episode 6: Discussing The Compensation Model of RVUs

The transcript has been edited from the video content: Repetitions and vocal disfluencies have been removed for reading clarity.

00;00;00;00 – 00;00;14;04
Dr. Sullivan
And that’s why I think RVU compensation is kind of growing in popularity with employers, because I still don’t have a grasp on exactly what goes on with RVUs.

00;00;14;07 – 00;00;19;18
Laura
Welcome to RedCentral, a radiology podcast hosted by Excalibur Healthcare. I’m Laura.

00;00;19;19 – 00;00;20;08
Betsy
I’m Betsy.

00;00;20;14 – 00;00;48;29
Laura
So recently in August, Medscape released a survey which revealed data collected by a bunch of physicians in a whole lot of specialties, which kind of went through the reimbursement system of RVUs and whether they’re fair or not. So we’re really asking, do RVUs incentivize physicians to prioritize the quantity of patients seen over the quality of patient care?

00;00;49;01 – 00;01;08;15
Laura
We’re sitting down with Doctor Sullivan, who is the senior editor at Emergency Physicians Monthly magazine, a practicing emergency and medicine physician and an experienced attorney based in Illinois providing legal services related to the practice of medicine. So welcome, Doctor Sullivan.

00;01;08;17 – 00;01;10;23
Dr. Sullivan
Thanks for the great introduction. I appreciate it.

00;01;10;23 – 00;01;30;15
Laura
Of course, and thank you so much for taking the time to sit down with us and talk this over. We really appreciate it. So, Doctor Sullivan, let’s start off by learning a little bit about you. How did you become involved in both emergency medicine and law? Which came first? What drew you to both of these fields and how did they complement each other in your practice?

00;01;30;18 – 00;01;55;13
Dr. Sullivan
I started out my training as, I did a dual residency in emergency medicine, internal medicine. And towards the end of my residency, I kind of did a, I applied the law school almost on a dare. It was back when HMOs were really big, and I was. My intent was, I’m going to put HMOs out of business.

00;01;55;15 – 00;02;15;06
Dr. Sullivan
couldn’t stand them, I thought that they were horrible for patient care. And by the time I graduated law school, they kind of did it to themselves. They weren’t really as as prevalent as much. So then I started, just doing things to help doctors are helpful to you, their contracts, and I’d give people advice on medical malpractice cases. And I just kind of kept going from there.

00;02;15;06 – 00;02;32;19
Dr. Sullivan
So I still practice emergency medicine about 120 hours a month. And then in my spare time, I practice law, RVU contracts, or represent doctors. And for the medical boards, I still give advice on medical malpractice cases, and I do fun lectures.

00;02;32;22 – 00;02;53;29
Laura
That’s great. It’s kind of a philanthropic start, right? You’re helping your colleagues with, you know, relevant information. That’s great. Defining RVUs. RVUs are it’s such a complicated system of reimbursement. Can you provide a clear definition of what RVUs are for our audience?

00;02;54;02 – 00;03;13;26
Dr. Sullivan
Absolutely. So and I’ll just getting back to the RVU thing. The reason I got into this was because I was trying to help a client who was a surgeon who is, not getting compensated properly for RVUs. So I did a deep dive into what are RVUs, how do they how are they used to pay doctors?

00;03;13;26 – 00;03;33;16
Dr. Sullivan
How can doctors make sure that they are paid properly for RVUs? So, I didn’t start out as a, an RVU specialist, but I kind of tweaked it once I found out that doctors weren’t really getting paid appropriately for it. So our RVUs as a part. Sorry. Go ahead.

00;03;33;19 – 00;03;45;28
Betsy
Oh, I was just, historically, when did RVUs begin to kind of creep into contracts and compensation for physicians? Can you give us a timeline?

00;03;45;29 – 00;04;04;12
Dr. Sullivan
Sure. So I can’t tell you exactly when they a CMS came up with the idea of RVUs. I can say in the contracts that I’ve RVUed, probably in the past 6 to 8 years, is when I first started seeing mention of RVUs and, it’s kind of snowballed from there. And I think that’s where a lot of reasons.

00;04;04;16 – 00;04;12;20
Betsy
That seems recent, I, I, I didn’t know it was something that was within the past decade. I would have assumed you’d say something like 20 or 30 years.

00;04;12;27 – 00;04;38;07
Dr. Sullivan
No. And my I mean, I’ve, I’ve probably gone through about 800, medical employment contracts in my career, and I’ve been doing it for about more than 20 years. So, I mean, I think I’ve got a decent, cross-section of what you’d see, but I obviously my, my experience is maybe different than others, but that just from basic recollection that it’s I’m going to say it’s about 6 or 8 years.

00;04;38;09 – 00;05;13;23
Dr. Sullivan
Okay. So RVUs stand for relative value units. And it’s the one of the it’s a basic component of how CMS decides to pay both physicians and medical providers for treatment. They were initially developed to standardize charges for every services, all the services that patients receive. And the idea behind them was certain procedures require more, direct patient care, or they require more physician services or equipment or supplies or technical knowledge.

00;05;13;25 – 00;05;40;24
Dr. Sullivan
So the CMS said, we’re going to try and normalize that and say something that is worth two RVUs. It requires twice as much work or knowledge or supplies as something that involves one RVU. So I’ll give you an example for, interpreting a non contrast CT of the head, which is a CPT code 70450. You get paid 0.85 RVUs.

00;05;40;27 – 00;06;13;28
Dr. Sullivan
If you interpret a CT scan of the abdomen and pelvis with contrast, which is CPT codes 74177, you get 1.82 RVUs. So a little more than twice as much time and experience goes into, RVUing a, or interpreting a CT scan of the abdomen and pelvis than it does a CT scan of the head. And just for a comparison, if I’m in the emergency department and I interpret a cardiac rhythm stroke by looking at modern and say, what’s the rhythm that gets 0.15 RVUs?

00;06;14;01 – 00;06;30;23
Dr. Sullivan
So and I’m going to I’m going to go off on a tangent for a second and not know if you guys knew, but I’m a billionaire. I don’t like to brag about too much. I keep a lot of my money in my house, so, but I just wanted to show you, this is my. This is my billionaire status.

00;06;30;25 – 00;06;32;00
Laura
And the 50.

00;06;32;04 – 00;06;56;10
Dr. Sullivan
$50 billion bill. And I use that as an example to kind of illustrate how RVUs are. It’s a two step process. You may say, I’m getting paid 1.82 RVUs for interpreting in the abdomen, CT and pelvis. A CT scan of the abdomen and pelvis. But what’s the RVU worth? Just the same way as what’s $50 billion worth?

00;06;56;13 – 00;07;15;10
Dr. Sullivan
I bought this off eBay for, I think, a dollar and a half, just to show my kids the the effects of inflation. But if you don’t know what the RVUs are worth, you can’t really determine whether you’re getting paid fairly. So once you determine the RVU of the value of a service that’s provided, then you have to multiply it by some conversion rate.

00;07;15;12 – 00;07;27;10
Dr. Sullivan
And that conversion rate varies. So there’s two variables that really go into determining whether you’re being paid fairly with RVUs.

00;07;27;13 – 00;07;52;27
Dr. Sullivan
Or the conversion rates. There’s a general conversion rate that’s put up by CMS. And I think it’s $34 per RVU. It changes a little bit every year, but it’s around 33 or $34. Parties can agree in a contract to a different RVU or, sorry, a different conversion factor. I’ve seen surgeons that get paid $80 per RVU, and I’ve seen, psychiatrists that get paid $12 per RVU.

00;07;52;27 – 00;08;13;09
Dr. Sullivan
So it varies a lot. And that variable can determine maybe in a market where there’s a high saturation of physicians or providers, they’re going to pay less RVUs because they can get away with it. But maybe in a market where they really need medical providers and they want to attract the providers, then they may pay more RVUs. So it’s it’s quite variable.

00;08;13;17 – 00;08;41;22
Laura
Sure, sure. Part of this Medscape survey, they seven and ten doctors think that RVUs are not an accurate measure of cases seen. And they’re not an indicator of a timely diagnosis or treatment. So are RVUs accurately reflecting productivity? Or are they accurately reflecting how well a doctor can care for their patients?

00;08;41;24 – 00;09;12;17
Dr. Sullivan
RVUs. I think that they’re a decent measure of productivity. But then you come across good hearts law and good hearts law says. When you start to measure a target, it’s easy to be a good measure anymore. So people quickly learn how to game the system to get this, to get to that desired target. RVUs will compensate doctors for some things, but they won’t compensate doctors for other things, and my experience so far is that a lot of physicians just haven’t caught on to this yet.

00;09;12;19 – 00;09;38;03
Dr. Sullivan
And that’s why I think RVU compensation is kind of growing in popularity with employers, because physicians still don’t have a grasp on exactly what goes on with RVUs. Now, some employers may say they may generate more confusion. They may say, okay, if an employer goes to you and says, I’m going to cut, you pay by $30,000, you’re going to be upset and you’re going to say, I might not even work here anymore.

00;09;38;05 – 00;10;01;01
Dr. Sullivan
But if the employer comes up to you and says, we’re going to pay you $30 per RVU instead of $35 per RVU, but here’s some calculations, and we’re based on our calculations. We think you’re gonna earn more money next year. And physicians agree with that. And I if you start looking into. The calculations themselves, you see you’re getting paid less.

00;10;01;01 – 00;10;08;27
Dr. Sullivan
But they all physicians look at is the end calculations and the numbers. So I think it’s the employers are gaming the systems a little bit too.

00;10;09;02 – 00;10;33;22
Betsy
I read your essay and I read about Good hearts Law and I didn’t know about it. So I do a little further and found out a little bit more about it. And I thought it was I thought it was very interesting. Tell me a little bit more, a good hearts law and a little bit more about how it leads to the increase of RVU production goals that might be set by CEOs that aren’t physicians themselves.

00;10;33;25 – 00;10;59;12
Dr. Sullivan
I think I understand what you’re getting at. And and there are two things. Remember, with compensation from RVUs. There’s two things you have to consider. One is you have to consider the conversion factor. But the other one is you have to consider the RVUs themselves. And CMS is constantly modifying how many RVUs they pay. So there’s two moving targets that you have to keep track of both of those I will employers take advantage of that?

00;10;59;12 – 00;11;24;21
Dr. Sullivan
I think they will. I mean, I don’t think any employer wants to pay physicians more money. And if there’s a way that they can decrease the personnel costs, which is generally the most the highest cost in any type of a hospital or medical system, they’re going to do it. Physicians, when we talk about Good Hearts Law too, it may encourage physicians to either avoid procedures where they don’t get paid for it.

00;11;24;21 – 00;11;50;28
Dr. Sullivan
If there’s not a CPT code for it, you’re not going to get paid for it. Like patient education. So you may avoid that, or you may game the system a little bit. Physicians can do it too. I’ll give you an example for emergency medicine. If you drain an abscess, there’s, you get paid 1.22 RVUs If the abscess is considered complex, you get 2.45 RVUs for draining the same abscess.

00;11;51;04 – 00;12;14;01
Dr. Sullivan
Now, how do you change a abscess from being simple to complex? Either you probe it to break up locations or you put a drain in. So if a physician is understands that they can make twice as many RVUs just by putting a probe in there and probing for localizations or by packing it, I think the incentive is to do more, even if maybe the abscess doesn’t need it.

00;12;14;03 – 00;12;23;18
Dr. Sullivan
So again, that just goes back to good hearts law once you start measuring something, it ceases become to become a good measure. When you start tying incentives to that.

00;12;23;24 – 00;12;49;17
Laura
Many, it’s says many doctors have felt pressure to up patient count for RVUs. So this is kind of what you’re discussing. Rate up billing in order to make more money. You’re doing the same procedure. Basically, there’s a little bit of an extra step and you’re making twice as much money. It says 43% of doctors say they frequently have felt pressure to up patient counts for RVUs, and 30% have said they’ve occasionally felt pressured.

00;12;49;18 – 00;13;11;00
Laura
A patient counts, only 14% have said they’ve never felt pressured to up patient counts. That’s that’s shocking. That makes me think, you know, I’m going to my doctor and they’re giving me some kind of procedure. They may do something that’s not necessary just to make more money. I mean, it’s not I understand that they’re still going to help me, of course, but it’s also unnecessary possibly.

00;13;12;02 – 00;13;42;22
Dr. Sullivan
And when you have we didn’t get paid by our RVUs. If you get paid by, a procedure or by the patient, you see, for the visits, you see, and they decrease the amount of money that you’re receiving for each visit. The only way, the only way to maintain your income is to see more patients. So I don’t know if that’s beneficial for patients that instead of seeing a patient every 20 minutes, you make it every 15 minutes or every ten minutes just so you can maintain that same RVU stream.

00;13;42;24 – 00;13;50;01
Laura
Sure. And then patients feel rushed. Their quality of care declines. It’s not it’s not a great I great place to be.

00;13;50;03 – 00;14;29;26
Betsy
I read something that can relate to radiology that I read that RVUs can play a part in over testing that rather than spending time with the patient to discuss more and find out more about what could possibly be, the bothering them, they are inclined to over order tests because they’re quick and easy, but for radiologists that that exacerbates the the problem with, overall ordering of imaging, which is which is a very big issue these days with the shortage of radiologists.

00;14;29;29 – 00;14;36;19
Betsy
And, studies are showing that there’s a whole lot of unnecessary image ordering happening.

00;14;36;22 – 00;14;58;14
Dr. Sullivan
And that may be the case. I mean, that can be for more than one reason to that can be because you don’t want to. You want to make sure you have every test available so you can make the diagnosis and you don’t miss anything. So some of that may be medical legally related. So I don’t know that it’s exclusively due to RVUs, but I know and with radiologists I mean if you’re doing procedures that’s one thing.

00;14;58;14 – 00;15;36;07
Dr. Sullivan
But if you’re reading films, there’s not really that, patient counseling component that you, that you would see with the primary care provider or a specialist and I think that that goes back to good hearts. Like you, if you’re not getting paid, once you start measuring these things, if you’re not getting paid to provide counseling or to for all the cognitive skills that go in that are involved in making a differential diagnosis, then I think physicians are going to spend less time doing those things, and they may take the easy route out that just says, okay, I’m going to order another test rather than sit down and think about it and think about a

00;15;36;07 – 00;15;40;18
Dr. Sullivan
differential diagnosis, because I’m not getting paid to do that.

00;15;40;21 – 00;15;47;06
Betsy
Yeah. Yeah. The testing has a RVU attached to it. But the discussing with the patient does not.

00;15;47;09 – 00;16;00;14
Dr. Sullivan
In a lot of care. And I can’t say in every case, but in a lot of cases the cognitive value of the physician services is either not paid or it’s discounted.

00;16;00;16 – 00;16;01;12
Laura
Sure.

00;16;01;15 – 00;16;30;24
Dr. Sullivan
So they said an unnecessary procedures. And then one of the other things in the Medscape survey that I saw was it discourages physicians from entering certain fields because they don’t get paid as much like primary care or mental health. Chronic disease management. So when the the the value of those services is undervalued by CMS, then you naturally the market’s going to select against providing those services because doctors want to be paid for what they’re doing.

00;16;30;27 – 00;16;56;11
Laura
Right, right. So we’re sort of discussing, you know are RVUs impeding the quality of patient care. Another result from the survey is that RVUs should include qualitative aspects of treatments. 73% of doctors said they should absolutely include qualitative aspects of treatment. That’s a lot. So that brings us to discussing sort of like a hybrid model.

00;16;56;14 – 00;17;17;04
Laura
Is there any way that you could do you have any suggestions for a hybrid model of RVU compensation in order to fairly compensate doctors for all of this cognitive work and paper work? You know, all of that time that goes into a patient care, not just the procedure that happens.

00;17;17;06 – 00;17;35;03
Dr. Sullivan
Right. So to think about a hybrid model, I think first you’ve got to think about what are the models out there and what are the pros and cons of each model. So we’ve got a, a salary like a salaried model, an hourly model where doctors get paid either a certain amount per year or a certain amount per hour.

00;17;35;06 – 00;17;56;21
Dr. Sullivan
And the pros are that it’s payment security for physicians. You know, if you see one patient per hour, you see ten patients per hour. You’re getting the same amount of money. Now, what’s one of the cons? The employers are still paying the same amount of money, even if there’s are low volume. So you don’t have any patients or if there’s a low producing physician.

00;17;56;23 – 00;18;18;22
Dr. Sullivan
So it may not be fair to the employers. If there’s a low producing physician and it may not be fair to their physicians colleagues if they’re seeing half as many patients or interpreting half as many studies as someone else who’s getting paid the payment, the same rate. And that may eventually turn into frustration, which causes the higher producers to leave.

00;18;18;24 – 00;18;34;01
Dr. Sullivan
And you think about it, if everybody if you go to school and everybody in the class gets a B, no matter how much work they do, what incentive is there to do more work? Right. So that’s kind of the salary model. Then you have a fee for service model, which is kind of what the RVU system is now.

00;18;34;03 – 00;18;55;21
Dr. Sullivan
And the pros are is that it incentivizes more services, but it also drives up costs. And if you’re a higher producer, you’re going to see more patients. You get to earn more money. But the cons are is obviously it’s going to need to maybe it’s going to lead to over testing or overtreatment, or it encourages provision of services to generate more money.

00;18;55;23 – 00;19;18;14
Dr. Sullivan
There’s also a capitation type of a model where you get a set amount, doctors get a set amount per patient. I know it doesn’t really apply as much, although I guess it could apply for, for radiology. But regardless of the number of services that are provided, you get the same amount of money. And the pros are that encourages preventative care because you don’t want to keep patients.

00;19;18;14 – 00;19;40;07
Dr. Sullivan
You want to keep patients healthy and not allow them to get sick. The cons are is that what’s going to happen if you only you get paid a certain amount of money, regardless of how much care you provide, is if there’s a patient that’s very ill, or patients who are likely due to have a lot of chronic illnesses, doctors are probably going to avoid them because it’s going to cost them more money to treat them.

00;19;40;10 – 00;20;01;25
Dr. Sullivan
And then you get into this whole value. There’s another system of value based care where providers are rewarded for meeting certain outcomes or, performance metrics or however you want to look at it. And ideally, that’s supposed to improve quality. But the big question I have is how do we define quality? How do you define quality care? How do you define a quality radiology reading?

00;20;01;27 – 00;20;25;19
Dr. Sullivan
It’s tough to do. And so if if there’s a focus on providing these quality measures, whatever they are, then the providers, it’s that good hearts law. You’re going to start focusing on just doing those things because you know, that’s what you get paid for. And you may neglect other important aspects of patient care. So get it making a hybrid, I think, is a good idea where you have to incorporate a lot of those things.

00;20;25;19 – 00;20;45;24
Dr. Sullivan
Maybe you get a a base rate. You say, say, the market value for a doctor in a given area is $300,000 per year. You say, okay, we’re going to pay you $250,000 per year, but we’re going to give you incentives. So that way there’s a base that the doctor knows I’m not going to earn. You know, a third of what everybody else should, should earn in this area.

00;20;46;01 – 00;21;04;16
Dr. Sullivan
But I also have the ability, if I work hard to make more than that $300,000 base, if I see a lot of patients, if I if I meet the quality metrics. So I think there’s it would have to be a blend of both an hourly of a RVU or a fee for service and quality, adding all three of those.

00;21;04;18 – 00;21;15;21
Dr. Sullivan
How are you going to make it just to, to create both a, a fair system for compensation, but also a system that rewards high producers and it rewards quality?

00;21;15;24 – 00;21;45;18
Laura
Sure. And I mean, that’s the way that it seems like it should be going, just getting doctors involved in the conversation with how they should be compensated, I think is the first step. I think a lot of doctors feel, unappreciated or unfairly compensated. So we went to Reddit and we asked a bunch of, I said, you know, what are your thoughts on this system of RVUs and how you’re compensated for the work that you do?

00;21;45;20 – 00;22;04;13
Laura
And a lot of radiologists came back and they said, you know, you’re going to see a lot of low value cases left on the work list because it’s not worth their time to put that, but put the time in on it when they can make just as much money reading a quick one. So it’s this cherry picking of cases that another radiologist said.

00;22;04;16 – 00;22;28;04
Laura
They said it’s easy to game the system. It makes you less likely to answer the phone or be friendly to colleagues, to do conferences. And they said, I’m against the metric of RVUs. Somebody else said, this is what happens when MBAs and PE groups run medicine. So again, just getting physicians involved in the conversation is, I think, the first step to fix what we’re thinking is kind of the problem, right?

00;22;28;07 – 00;22;51;29
Dr. Sullivan
I could give you a good example from emergency medicine. There are when we have, somebody who there’s a if there’s a long list of, studies that are waiting to be read. Are you as a radiologist that’s getting paid by RVUs? Are they going to pick up a, quick plane brain where somebody’s got, you know, hit in the head and you’re worried about, you know, what to look for.

00;22;51;29 – 00;23;19;06
Dr. Sullivan
Maybe that takes you five minutes to read versus picking up a CT, abdomen, pelvis on somebody with metastatic cancer where you’ve got to compare and CTS measure all these different, things. And it’s going to take you five times as much time, which is what you’re, you’re going to be more likely to pick up, even though, a CT scan of the abdomen and pelvis with contrast may pay you more RVUs if you can bang out three head CTs in that same amount of time or less, you’re more likely to pick up the easier cases.

00;23;19;06 – 00;23;44;09
Dr. Sullivan
Get paid more, and just run them through the, run the mill. So I completely agree. It’s easy to game the system, but that’s the way the system set up. And you you can’t blame people for gaming the system. So in terms of getting more doctors involved, that’s one of the ways I think we can create a better system is create some type of RVU consortium where you get representatives from all the major specialties.

00;23;44;12 – 00;24;04;21
Dr. Sullivan
They all come to a meeting somewhere and they say, okay, how much is how much are we going to pay for radiology versus, oncology versus emergency medicine versus primary care versus like psychiatry and they all get together and kind of decide between them what’s going to be fair and what’s going to incentivize care, what’s going to disincentivize care.

00;24;04;21 – 00;24;28;17
Dr. Sullivan
And maybe there’s a lot of arguments of break out, but hopefully at the end of that meeting and maybe hold that meeting every year so you can address any technological advances or changes in medical practices or things like that. At the end of that meeting, you come to an agreement about how many RVUs or how much a given process, in a given specialty is going to pay for heavy use.

00;24;28;20 – 00;24;33;13
Laura
And maybe the solution, just getting everybody together to discuss the issues.

00;24;33;16 – 00;25;02;26
Betsy
I have something to say about the cherry picking, part of it. I mean, you, I’m not sticking up for RVUs, but to some degree. To some degree, the cherry picking based on the idea that, they can, increase their, their own personal productivity score by reading things that, that are very high value, but don’t take a lot of time to read cases of radiology.

00;25;02;29 – 00;25;32;24
Betsy
To me, it also makes me wonder if that isn’t a management issue because a well-run practice would have radiologists reading everything, from oldest to newest, regardless of whether or not the RVUs had different values. So it’s a complaint, but you can’t really blame the RVUs. If the physicians are allowed to cherry pick and make decisions without being overseen by a good manager.

00;25;32;27 – 00;25;52;26
Dr. Sullivan
Right. And it can and I would, I would say that that’s one way of doing it is saying you’re you get the studies, you have to read the studies in the order that they come. But if a physician feels like they’re providing services and they’re not getting a fair shake, and what studies are next up in the queue, then that may be cause for them to say, I’m not, I’m done with this.

00;25;52;26 – 00;26;01;09
Dr. Sullivan
I’m going to go somewhere else where I can cherry pick my patients again. So it’s a lot of times market forces play a big role in this.

00;26;01;11 – 00;26;25;23
Laura
It’s definitely a complicated issue and so difficult to find a hybrid model that suits everybody. Let’s shift the conversation to AI, which it often seems to do in medicine. Do you have any input and how might increasing the use of technology and AI impact our use?

00;26;25;26 – 00;26;26;09
Dr. Sullivan
Yes.

00;26;26;10 – 00;26;29;11
Laura
Yeah, that’s a tough one. I know, I know.

00;26;29;14 – 00;26;50;06
Dr. Sullivan
I think, I still has a long way to go, but I also think it’s improving quickly, and I happen to like it. I’ve got to AI programs on my, my phone that I use to help me with differential diagnosis when I’m an emergency department. And it’s now it’s getting to the point where I can upload images to.

00;26;50;06 – 00;27;09;15
Dr. Sullivan
I actually wrote an article about this on my, my blog about will I be able to replace physicians? And I took a couple of derm pictures that I have in a teaching file that I use when I teach students and residents that I have never been on the internet before. And I uploaded to the AI and said, what’s your differential diagnosis?

00;27;09;15 – 00;27;36;15
Dr. Sullivan
And both times the two that I picked out got them right away. And they weren’t even one was disseminated herpes, which you really don’t see very often. And another one was erythema, no dose. Which again, isn’t that common. I picked them both out right away. So in some senses, I think we have to be careful what we ask for because as they eye matures, I don’t think it’s going to result in physicians getting paid more.

00;27;36;18 – 00;27;40;18
Dr. Sullivan
I think it’s going to be it’s going to result in physicians paying, getting paid less.

00;27;40;20 – 00;28;08;22
Betsy
I read something interesting. It was on your website. It was pointing out that as far as RVUs, and conversion factors, physicians, or providers are getting paid less in 2023 than they got paid in 2022 and even less than in 2021. So is, is the conversion factor going to keep going down? For sure.

00;28;08;25 – 00;28;33;28
Dr. Sullivan
There’s there’s really no way to tell. And I know that in 2024, CMS increased the RVU values of some. For example, they increased the RVUs for outpatients, medical visits somewhat. So even if the conversion factor is going down, and that’s why I said it’s kind of tough because there’s two different variables you have to look into.

00;28;34;01 – 00;28;51;27
Dr. Sullivan
Part of it is where the RVU is going, but part of it is where the conversion factors are going. So you have to be able to measure both of those and then estimate based on your prior work, what you’re going to be able to do with, with both RVUs and conversion factors and visits and films you read and everything else to determine how much you’re going to get paid.

00;28;51;27 – 00;29;15;08
Dr. Sullivan
So you have to make all these calculations and determine, am I going to be paid the more or less with the same as I was last year? And that’s that kind of ties back into the I as well. Because if you think about it from a radiology standpoint, suppose that I enables physicians to read more films in less time or to generate reports more quickly.

00;29;15;11 – 00;29;26;09
Dr. Sullivan
How do you think that’s going to affect the payers in the hospitals? Are they going to keep paying you the same amount of money to read the read the reports or read the films and generate the reports if they know you can do it in half the time?

00;29;26;12 – 00;29;28;09
Betsy
That’s a very interesting point.

00;29;28;11 – 00;29;53;15
Dr. Sullivan
So they’ll just reduce the compensation for those procedures and they’ll pay less per RVU. And another I think another thing that we have to think about with AI is it’s could conceivably be used to track your productivity. So if they have AI that’s on your computer and they have a little camera looking at you like, my camera’s looking at me right now, I could say, okay, how much time is he looking at the films?

00;29;53;15 – 00;30;12;27
Dr. Sullivan
How much time as he scrolling his phone, how much times he’s surfing the internet and how product. How, productive is the doctor? Based on all that, they can calculate all these things. So is that something we want to do? Like some little, computer snitch? Watching everything we do. Everything at the time we’re at work because I wrote this report.

00;30;13;00 – 00;30;15;05
Laura
Yeah.

00;30;15;07 – 00;30;33;18
Dr. Sullivan
And on the other hand, maybe I could also help us to say this film is a complex film, real time, and say the doctor should get paid more for reading this film because it’s complex where as opposed to someone who just takes a five second look at a brain plane brain and a kid and said, yep, there’s no bleed.

00;30;33;18 – 00;30;44;12
Dr. Sullivan
Next. The AI may be able to differentiate between what’s the levels of complexity and interpretation. So,

00;30;44;15 – 00;30;53;20
Betsy
And then thanks for thinking about this for us. I think you’re bringing up points that seem obvious now, but I hadn’t considered them.

00;30;53;23 – 00;31;14;28
Dr. Sullivan
Since you’re talking to a lawyer, there’s a lot of legal issues too. What if you use AI to help you? Or if I comes up with a diagnosis and you adopt that diagnosis and it’s wrong, or AI hallucinates because AI hallucinates. And so what happens if I gives you the wrong diagnosis or lead you down the wrong path for some reason?

00;31;15;03 – 00;31;47;24
Dr. Sullivan
Who’s liable for that? If I get a better question, what happens is, I mean, right now epic is incorporating AI into its electronic medical records, both to generate diagnoses and to refine your notes. So what if the AI refines your reports, and when it does so, it changes the meaning or changes the, the report that what you’ve actually seen and it changes it to something that you didn’t dictate, then it was liable.

00;31;47;27 – 00;32;07;26
Dr. Sullivan
Or what happens if I says, hey, we’re going to use AI to generate billing? Based on what you read and what you say and what the X-rays look like. But what if it what if it’s over emphasizes certain factors, and you submit bills to CMS and CMS or the payers come back and say, yeah, there is there is false billing there.

00;32;07;26 – 00;32;30;26
Dr. Sullivan
You billed too much for this procedure. Then what? So I think there’s a lot I is a a useful tool, but in some cases I think we may put too much emphasis on it. And I also think that there are a lot of people that are really considering the adverse or the potential adverse consequences of using AI.

00;32;30;29 – 00;32;43;24
Laura
Sure. And the bias in the in the data that’s there. Right? I know there’s a lot of biases, right? Age groups, demographics, stuff like that. So yeah, it’s just not there yet. Possibly. But it’s very interesting to talk about.

00;32;43;26 – 00;32;48;23
Betsy
That’s a whole other topic for a whole other podcast. Yeah. So we’ll bring you back in.

00;32;48;25 – 00;32;54;15
Dr. Sullivan
I’m happy. I always love talking about stuff like this and have fun doing it.

00;32;54;17 – 00;33;44;25
Betsy
Well, this is a radiology podcast, but this could apply to any physician’s contract. So when, when a radiologist or another physician is being offered a job, perhaps their first job out of, training, what advice? As someone who RVUs contracts, what advice can you give them for? I guess being on the alert for clauses about RVUs and whether or not they should suspect that there’s some, there’s some thing being, masked or something, they’re not understanding because they haven’t done enough research or they just.

00;33;44;27 – 00;34;06;17
Betsy
They just don’t even care. They got into medicine to care for patients, and suddenly they’re forced to think of things in terms of RVUs. And it’s just something that that they are they in over their heads with their very first employment contract. What can they what advice can you give them.

00;34;06;19 – 00;34;38;13
Dr. Sullivan
So I’ve got a contract lecture in itself that lasts an hour and a half. So, I mean, and so I could sit here and talk for hours about that literally. But if we’re going to focus on RVUs, there’s a few things that I would, I’d suggest I don’t I don’t think there’s ever going to be like a national standard for having RVUs and contracts and stuff like that, just because, like I said, the amount of money that or the amount, the conversion factor, the amount of money that some places pay for RVUs and the value that they put on RVUs.

00;34;38;18 – 00;35;04;27
Dr. Sullivan
And the total compensation is going to change from, hospital to hospital to group to group. So some of the things that maybe you should consider asking for in the contract is, I always try to include auditing rights because I think that’s important, that the whole reason I wrote that article on my website was because the surgeon that was involved, they really underpaid her substantially.

00;35;04;29 – 00;35;32;01
Dr. Sullivan
And she went to try to audit the, RVUs and they wouldn’t give it to her. And so we had to make a whole big stink about it. But that’s what got the ball rolling with this. So I really think that auditing rights ought to be part of the contract where the, the physician is allowed to audit, the RVUs are getting paid for and maybe even say, you know, if there’s less, if there’s more of the 15% discrepancy, then there’s some penalty.

00;35;32;04 – 00;35;48;05
Dr. Sullivan
I think I don’t know if the will agree to that, but that’s, that’s something I would do just to keep the, the hospitals on the up and up. Another thing is you really have to keep track of how many RVUs are made. If you’re getting paid by RVUs, you have to track RVUs. You have to know what patients you’re treating, how many patients you’re treating.

00;35;48;05 – 00;36;12;03
Dr. Sullivan
If from a radiology standpoint, understand what tests that you’re performing or what you’re interpreting, and keep a list of them, and then you’ll be able to compare them with the RVUs later when you get paid. Maybe requesting monthly reporting of the RVUs. So, you know, instead of demanding it, that should be part of the contract where they do it automatically the monthly or quarterly, if you want to make it quarterly.

00;36;12;06 – 00;36;34;16
Dr. Sullivan
But I think one of the biggest things is becoming educated about it. It’s you’re going to be getting paid based on this $50 billion bill, but you don’t even know what the $50 billion bill is worth. And you’re going to use that to pay back your student loans and to live on. You really need to be educated about what our RVUs are.

00;36;34;16 – 00;36;57;01
Dr. Sullivan
What are the values for services that you’re providing. And you need to be able to figure out how many services am I going to provide during a day? How much am I going to get paid for over you? And then how many, how much money I’m going to get paid, per conversion factor for that RVU. So you can determine at the end of the day, am I making a decent salary.

00;36;57;04 – 00;37;06;10
Dr. Sullivan
So there’s a lot that goes into it. But education probably the biggest thing the better you understand it, the better you’ll be able to deal with it on the back end.

00;37;06;12 – 00;37;54;29
Betsy
I have a question about, this is about something that I hear often. I’m often told by radiologists looking for work I want, and I’m just going to make up a number. I’m hoping to make $50 per RVU. From what you’ve been telling me, it sounds like that. Is that is is that a I guess, is there a reason to stating the amount you want to make per RVU if you’re saying that the RVUs can differ from practice to practice and, environment to environment, is are they or is that a good way for a, a, a physician to talk about what their, what they’re hoping to earn.

00;37;55;02 – 00;38;24;13
Dr. Sullivan
It’s I think that if you, if you just focus on, I want this much power over you a it’s difficult to say because ideally you want you’re going to turn those RVUs into cash at some point, but that’s what you hope to do because you don’t pay your mortgage with RVUs. So in saying how many RVUs I want to earn, you know, or how much money I would earn per RVU, I think you still have to translate it into what’s my yearly salary going to be?

00;38;24;13 – 00;38;48;00
Dr. Sullivan
Because if you say, all right, great, I’m going to earn $50 per RVU, but it’s in a low volume hospital, or you’re only read five scans for a 12 hour period, you’re going to pay nothing. So you really need to know. You have to have more information about the system and about the patients and everything else before you can just say, I want $50 per hour for you.

00;38;48;02 – 00;39;15;08
Dr. Sullivan
If you, you estimate, say, maybe a, a radiologist is going to earn $7 seven or generate 7000 RVUs per year. If you multiply that times 50, that’s $250,000, which is on the low side for for a radiologist. So you really need to know more about it before you just say, I want $50 per RVU. I want, you know, 40 hours per RVU.

00;39;15;10 – 00;39;22;24
Dr. Sullivan
You have to learn more about the system and what you’re getting paid before you just come up with a random number like that.

00;39;22;26 – 00;39;53;10
Betsy
Okay. That that makes sense. That makes sense. Because I’ve always questioned whether or not I can take that information and, and work with it, it seems, and yet they say it so emphatically so it must be right. They can make $50 per RVU. And I just sometimes I just don’t know, how to take that information and turn it into, how they can envision, their income potential.

00;39;53;14 – 00;40;21;29
Dr. Sullivan
And that’s, that’s what I would, I would relay back to them is to remember that getting paid by RVUs, there are two variables that, constantly go up and down, even if you fix the fix it to say, I’m getting paid $50 per hour, you. So you control one of the variables, one of the other variables can still go up and down in terms of how many patients you see or what the, the, severity of, illness of the patients are or those types of things.

00;40;21;29 – 00;40;33;19
Dr. Sullivan
So even if you’re making that magic $50, you may not be making as much money if you’re not seeing as many patients or if the patients that you’re seeing are less intensive. So it’s you need to know both.

00;40;33;21 – 00;41;08;12
Betsy
Okay. And this is all the reason why I find this very interesting for other reasons, is we don’t use RVUs as a, as a value, as a compensation, as a compensation value unit. We pay the dollar amount per study. So it’s pretty easy for radiologists to do the math and figure out if they read this, they get paid that, and then and that’s why I was surprised that you were saying that RVUs have kind of seeped into, into our vocabulary in the past 6 to 8 year

00;41;08;12 – 00;41;10;18
Betsy
You said it’s only been about okay.

00;41;10;19 – 00;41;11;24
Dr. Sullivan
My guess. Yeah.

00;41;11;27 – 00;41;41;25
Betsy
Because, speaking with new radiologists, fresh out of training, it’s as if they have been taught to speak in RVUs, starting with, you know, starting with their residencies and their fellowships. They they’re already developing this, work by the RVU, model. And it blows their minds that they can be offered a dollar amount for a study.

00;41;41;28 – 00;42;08;22
Betsy
They it’s not it doesn’t compute. I have a difficult time talking about it with some of them because they’re they just want to turn it into RVUs or they want to talk about the, the, the RVUs that they’ve already, experienced and, and what they, how they see that going forward into their careers. So they’re very they’re very RVU.

00;42;08;24 – 00;42;21;01
Betsy
They speak a lot about RVUs, but I suspect they don’t know as much about them as, as they should.

00;42;21;04 – 00;42;54;00
Dr. Sullivan
It’s interesting that it’s interesting that they’re kind of being becoming more RVU savvy, but maybe, maybe they need to learn more about the nuts and bolts once they get, once they get a real job and they I shouldn’t say real bad, but once they start, they’re attending jobs that they’re going to want to learn more about the nuts and bolts of how you convert those RVUs into money, where they’re going to be left behind, or they’re going to get a, they’re not going to get the best compensation package that they could earn.

00;42;54;02 – 00;43;09;13
Laura
So, Doctor Sullivan, I know that you do contract RVU. What else can you help, physicians out with in your legal practice? Can you give us a quick, let’s for your business, give us a thumbs.

00;43;09;15 – 00;43;31;01
Dr. Sullivan
Up for my business? What do I do? So I represent in Illinois. I represent people in front of the state medical boards. I sometimes I’ll represent doctors when they’re getting kicked off a staff at a hospital just to try. Yeah, sometimes things don’t work out, and I’ll try to help them get the best separation agreement that we can.

00;43;31;03 – 00;43;55;15
Dr. Sullivan
Under the circumstances, they’ll try to mitigate just what’s what happens to them or try to keep from getting reported the state to the national practitioner data bank type of thing. So, mitigating stuff like that, I, I try to focus on helping docs understand all the different legal aspects of medicine, because that’s something I really don’t think is taught in medical school or in residency.

00;43;55;17 – 00;44;03;27
Dr. Sullivan
So, a lot of, a lot of legal stuff. I try to do a lot of lectures on. I do lectures on contracts and documentation, those, those types of things.

00;44;03;27 – 00;44;31;19
Betsy
So you obviously enjoy it. You obviously invited me because you’re smiling the whole time you’re telling us about it. And, and the other thing too is it could easily take up all of your time, and yet you are still an emergency physician and an inactive one. What? Just a quick question about the, the physician side of you.

00;44;31;22 – 00;44;42;19
Betsy
Why do you love that? You. I can tell you love all of the legal speak in the RV. You talk. But what do you love about, working in the emergency department?

00;44;42;22 – 00;44;57;20
Dr. Sullivan
Just helping patients. I mean, my gosh, I actually have a collection for it. I just I just got a card to the thank you card. I’ve got it somewhere. But I got a thank you note from a patient that just said your care was exemplary. And thank you for all you do. I mean, that’s not that type of stuff.

00;44;57;22 – 00;45;02;22
Dr. Sullivan
I mean, that’s worth at least 50 or 60 RVUs right there. Yeah. Just there.

00;45;02;23 – 00;45;03;05
Laura
You know.

00;45;03;05 – 00;45;24;13
Dr. Sullivan
I you helping people or helping people, especially in the emergency department. A lot of times we’ll come to the emergency department because nobody wants to be there, but they’ll come there because they’ve got a problem that no one else can solve it. It’s just come to a head. And they really need the help and to sit there and be able to talk with them and, and help them figure out their problem, even if I can’t figure it out.

00;45;24;13 – 00;45;46;23
Dr. Sullivan
But if I can point them in the right direction and, and help them get better or help them, whatever their problem is, go away. I mean, that’s pretty awesome. I mean, that’s a I think that’s a gift. That’s, you know, we’ve been given by God and, and to, to pass that on to somebody else is I would I never do it I mean if I was independently wealthy, if this was 50 billion.

00;45;46;24 – 00;45;48;17
Betsy
You’re a billionaire.

00;45;48;20 – 00;45;51;27
Dr. Sullivan
I’d still I’d still do medicine just because I love it.

00;45;52;00 – 00;45;57;29
Laura
That’s great. Doctor Sullivan, how can people find you online if they’d like to use your services?

00;45;58;02 – 00;46;19;25
Dr. Sullivan
My website is www.sullivanlegal.us, and I’ve got a lot of articles up there. I when I, when I have free time, I, I try to write articles about things that people questions and people that ask me and the RVU actually the RVU articles, one of the most popular articles on my site. And that came from an issue that one of my clients was having.

00;46;19;25 – 00;46;40;16
Dr. Sullivan
So, it’s helped a lot of other people, which I think is great. So if you’ve got other questions that you want to ask, just shoot me a, there’s a contact form on there. I don’t put my email address on there just because, I guess the last time I did that, I got spammed it relentlessly. So that was a contact form.

00;46;40;16 – 00;46;48;00
Dr. Sullivan
But I usually write back within 24 hours of, of when somebody sends me a contact. So be happy to try to help.

00;46;48;02 – 00;47;05;12
Laura
Now. The blog is great. We both have enjoyed reading a lot of your articles. So Doctor Sullivan, thank you so much for taking the time to sit down with us and discuss all of this very complex and complicated RPG stuff. Your experience, your knowledge has been really educational. I’ve learned a lot just speaking to you. Thank you.

00;47;05;12 – 00;47;08;05
Dr. Sullivan
I’m glad. Thanks for inviting me. It’s been a pleasure.

00;47;08;07 – 00;47;29;27
Laura
If you have anything you would like to add or share about our conversation today, or if you would like to be a guest on RadCentral, please get in touch on www.radcentralpodcast.com. Thank you for listening. RadCentral, a radiology podcast, is hosted by Excalibur Healthcare. Be sure to like and subscribe wherever you get your podcasts.

00;47;30;05 – 00;47;37;22
Laura
From all of us here at Excalibur Healthcare. Have a great week!

---

** The views, opinions, and statements expressed by guests on this RadCentral are solely their own and do not necessarily reflect the views, opinions, or positions of the RadCentral podcast, Excalibur Healthcare, or its hosts. Excalibur Healthcare does not endorse or guarantee the accuracy, completeness, or reliability of any information shared by guests during the episodes. *

---

Featured Articles

• Discussing The Compensation Model of RVUs with Attorney and Emergency Physician William Sullivan, DO: RadCentral Episode 6
• Breast Cancer Awareness, The Find it Early Act & The Brem Foundation: RadCentral Episode 5
• Physician Wellness & Burnout with Dr. Gregory Charlop of The Physician Wellness Project: RadCentral Episode 4
• Political Advocacy for Radiology Discussion with Ted Burnes, Senior Director of Political Affairs for The ACR: RadCentral Episode 3
• Press Release: Ted Burnes, Senior Political Advisor for ACR and RADPAC, talks lobbying strategy and radiology advocacy