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Productivity of Radiologist
Productivity of Radiologist
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Productivity
of Radiologists:
Estimates
Based
Value Units
Patrick M. Conoley1
Sally W. Vernon2
on Analysis
of Relative
Analysis of relative value units (RVUs) was used to quantify patient-care productivity
of radiologists in 19 multispecialty
group practices
and to determine
how productivity
is
affected
by certain characteristics
of the practices.
The RVUs used in this study are the
professional
component
RVUs developed
by the American
College of Radiology and the
Health Care Financing
Administration
and published
as the Radiology
Relative
Value
Scale. An RVU workload
was calculated
by multiplying
the number
of times each
procedure
was performed
by the procedures
corresponding
RVU; the sum of these
products gave the overall professional
RVU workload.
Five productivity
Indexes
were
calculated.
The physician
index denotes the ratio of the total number of physicians
in
the clinics to the total number of radiologists.
The availability
index denotes the fraction
of radiologists
who are available
to perform
clinical work after deductions
are made for
time away from clinical work. The difficulty index measures, in RVUs per examination,
the level of complexity
of the overall examination
mix. The examination
index measures
examinations
per available
radiologist,
and the RVU index measures
RVUs per available
radiologist.
Altogether, the 19 clinics reported 3,234,451 examinations
performed
by 299
radiologists.
The computed
overall indexes
were as follows:
physician
index = 20
physicians
per radiologist; availability index = 0.77; difficulty
index = 2.27 RVUs per
examination;
examination
index = 14,098
examinations
per year per available
radiologist; RVU index = 32,065
RVUs per year per available
radiologist.
When the clinics were
grouped
according
to characteristics
of the practices,
the RVU index was higher for
single-site
practices,
high-prepaid
practices,
outpatient-only
practices,
and practices
without radiology
training
programs.
Fifty-two
percent
of the RVUs were in general
radiology,
37% in sectional
The concept
workloads
is timely because
by third-party
AJR
imaging,
of RVU workload
payers
procedures.
it undoubtedly
to compensation.
December
157:1337-1340,
1991
The American
College of Radiology
(ACR) and Health Care Financing
Administration have quantified
radiology
services for purposes
of reimbursement
by using
relative value units (RVUs) [1]. The service of interpreting
a posteroanterior
chest
radiograph
was assigned
the value of 1 .00 RVU. All other procedures
in the
after
revi-
1 Kelsey-Seybold
Clinic, P. A., 6624 Fannin St.,
Ste. 1800, Houston, TX 77030. Address reprint
requests to P. M. Conoley.
Houston,School
77225.
0361-803X/91/1576-1337
0 American Roentgen Ray Society
graph,
is the Relative
components
consideration
.
Value
was assigned
Scale.
The scale
of each procedure.
rates
In the assignment
a value
in RVUs.
both
technical
of the professional
as the training,
values
and professional
knowledge,
component,
skill, stress,
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RVUs assigned
education,
research,
didactic
teaching,
clinical instruction
of residents,
and administrative
duties.
In this paper, the radiologist
resources allocated to these non-RVU efforts are removed from
the staffing analysis through
the concept
of available
radiologists, defined in the Methods
section.
The study of total professional
RVU workload
of radiologists is timely and relevant
because
the RVU workload
undoubtedly
will be compared
with the total Resource-Based
Relative
Value Scale workload
of other
specialists,
and
these workloads
will be related
by third-party
payers
to
compensation.
Twenty-two
United
States,
large, multispecialty
clinics,
scattered
across
the
that are members
of the American
Society of Clinic
Radiologists
were
asked
to
provide
a comprehensive
list
of
the
volume of procedures
performed
during
a recent
1 2-month
period for
each of the CPT codes in the Diagnostic
Radiology
section of the
Relative Value Scale [1 , 2]. Nuclear imaging and radiotherapy
proCPT
in the study.
codes
using
these
codes,
to the procedures
New diagnostic
because
radiology
were
even though
RVUs
have not yet been assigned
by ACA and the Health Care Financing Administra-
system
accurately
were underreported
or
ences between
clinics
introduced
only random
Of the 22 clinics, 21
provided a comprehensive
included
of
duties.
radiology
Residents
staffing.
were
not included
Practices
also
were
in the quantifica-
asked
to
index
physicians
was
calculated
(headcount)
number
in
of radiologists
was calculated
as
the
the
ratio
of the
multispecialty
(headcount)
in the
the
in Table
total
clinics
clinics.
report
1. A
number
to
of
the
An availability
total
index
the total
number
radiologists
were
of radiologists,
available
indicating
to do
clinical
the fraction
work.
to
of time
A difficulty
the
index
was
calculated
by dividing the total AVU workload
by the total number of
examinations
to express in AVUs per examination
the weighted
level
of
difficulty
of
the
procedures
performed.
Finally,
two
workload
according
to
selected
variables
The criteria
and resultant
clinic
Productivity
indexes
calculated
by all the
clinics
were
and
by clinic
that
groupings
might
affect
are presented
on the combined
categories
on the
workload.
in Table
data
combined
2.
submitted
data
of all
of the
indexes
among
the
clinics.
Each CPT-code
was also categorized
to permit analysis
of the
workload
distribution
among examination
techniques.
The categories
were (1) general radiography
and fluoroscopy
(head and neck, chest,
extremity,
and spinal plain film radiography;
genitourinary,
gastroin-
Methods
cedures
administrative
tion
in the
RVU
or to ascertain
whether
examinations
Nine
of the
clinics
were
located
in the
Midwest,
four in the South, three in the Northeast,
and three in the
West/Southwest.
Data were submitted
for 12-month
periods with
ending dates from as early as December
31 , 1 989, to as recent as
September
30,
1 990.
Two practices
estimated
gave the entire professional RVU workload. The total AVU workload
and the total number of examinations
provided numerators for the
productivity
calculations.
to adjust
radiologists
for these
in the
differences
practice
by reducing
by a self-reported
not available
for clinical
work.
Not available
for continuing
medical
education,
vacations,
the total
amount
of
of radiologists
deductions
academic
number
were made
activities,
musculoskeletal,
and
intrathecal
contrast
studies;
and
mam-
mography),
(2) sectional
imaging (sonography,
MA, and CT of the
head and body), (3) specials (angiography,
neuroangiography,
and
interventional),
and (4) other (unlisted procedures,
review of outside
films).
In a previous
breakdown
procedures
data.
report,
Nuclear
procedures
index
category
was
been
the
attributed
1 980
Johnson
and
Abernathy
[4]
provided
by imaging technique
of projected
national
radiologic
in the United States for 1 980 that we compared
with our
AVU
reported
calculated
from
used to estimate
to that
workload
in their
study
were
excluded
in
that technique
was not included in our survey.
Value Scale did not exist in 1 980, a weighted
technique
among
the
current
data
Thus,
could
for
each
technique
that would
the
have
distribution
of
be estimated.
Results
overreported.
This study assumes that differin the use of the CPT-coding
system have
error into the data.
responded
to the questionnaire,
but only 19
list of CPT-code
volumes. These 1 9 were
analysis.
testinal,
and
Altogether,
these 1 9 practices
reported
3,234,451
examinations, corresponding
to 7,356,462
RVUs. These were performed
by 299 radiologists
among the total of 6055 physicians
in the clinics. The productivity
indexes are presented
in Table
outpatient-only
practices.
The availability
index
was higher
for
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indexes accentuates
the drop in general radiology from 74%
of the national RVU workload in 1980 to 52% of the clinics
RVU workload in 1989. By percentage of examinations
and
RVUS, special
procedures
remained
stable. The overall
weighted
difficulty
index for all national procedures
in 1980
was 1 .82, whereas the overall weighted difficulty index in the
and RVU indexes were higher for single-site practices, highprepaid practices, outpatient-only
practices, the large as opposed to very large practices,
and the practices without
clinic procedures
radiology
Discussion
training
programs.
Table 3 presents the breakdown of the reported examinations and the distribution
of RVUs by technique category.
Also, the 1980 data from Johnson and Abernathy
[4] are
included in the table for comparison.
Their examination categones have been grouped
to correspond
with our current
groups.
Sectional
imaging
represented
1 4% of all examinations in the clinics in 1 989 compared
with 6% of all national
examinations
in 1980, and general radiology represented
83%
of all examinations
in 1989 compared with 93% in 1980. The
weighted difficulty index of sectional imaging of 5.86 RVUs
per examination
was higher than the difficulty index for general
radiology
TABLE
of 1 .44.
1: Definitions
This
fourfold
of Productivity
difference
in difficulty
Indexes
Index
Definition
Physician
Total
Availability
Available
value
Number
Examination
Available
RVUS
Available
TABLE
2: Productivity
Indexes
(RVUs)
of examinations
Examinations
RVU
units
year
radiologist
for Individual
Clinics,
All Clinics,
and by Characteristics
of Clinics
Productivity
Type
of Clinic or Characteristic
Indexes
No.
P1
Individual
was consulted
to provide
with our data. According
to
year
radiologist
per
per
department
to compare
increase.
radiologists
Total radiologists
Relative
a 25%
nationally
weighted
difficulty
index of 2.31 RVU per examination for diagnostic
radiology procedures
performed
on Medicare patients.
By using the 1 989 ACR examination
index, the
physicians
Total radiologists
Difficulty
Al
DI
El
Rl
clinics
Mean
Standard
deviation
Standard
error
All clinics
Number
of sites
Single
Multiple
Prepaid fraction
19
23
0.77
2.25
15,231
33,705
19
7
1 .6
20
0.07
0.02
0.77
0.24
0.06
2.27
4,577
1 ,050
14,098
7,855
1,802
32,065
24
0.77
2.15
16,410
35,268
13
19
0.77
2.31
13,551
31,306
7
12
17
24
0.76
0.77
2.31
2.24
13,440
14,750
31,017
33,104
0%
30
0.80
2.01
18,666
37,464
>0%
16
19
0.76
2.30
13,737
31,639
11
23
0.79
2.22
15,374
34,114
19
0.76
2.31
13,347
30,858
10
9
22
19
0.75
0.77
2.19
2.31
14,843
1 3,762
32,564
31,841
5%
>5%
Inpatient
fraction
residenc?
Resident
Radiology
>5 Residents
Size
300,000
RVU
>300,000
RVU
Note.-Pl
No practice
large)
= physician
a Theoretically,
b
(large)
(very
TABLE
3: Percentage
Distribution
of Examinations
and of Professional
Relative
Value
Units Among
Examination
1989
1980
(%)
(%)
Technique
Examinations
RVUS
Examinations
RVUS
83
52
93
74
Sectional
14
37
16
10
10
Specials
MA)
interventional)
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Techniques
Note.-RVUs
= relative
value
units.
and Abemathy
of radiologists
in the United States. Because as a group,
practices with training programs have a lower RVU index than
practices without training programs, the mean RVU index for
our study
is probably
an underestimate
of the national
RVU
index. When these two points are kept in mind and when the
standard
error of 23% is considered, this figure extrapolated
from ACR and Medicare data is fairly close to the RVU index
that we report.
In the analysis by clinic characteristics,
the high examination
and RVU indexes in the single-site clinics may indicate that
these practices are more efficient, possibly because of the
ease of scheduling work assignments,
immediate availability
of cross coverage, or less time spent in commuting. Likewise,
the high physician, examination,
and RVU indexes of highprepaid
practices
corroborate
the managed-care
philosophy
of high-volume,
low-cost care. Of interest, the difficulty index
is lower in the prepaid practices, possibly because utilizationreview processes control access to the more advanced imaging procedures.
The higher difficulty index of practices with an inpatient
component
is due to the admixture of high RVU procedures
such as interventional
and angiographic
work in the inpatient
setting. However, the higher availability, physician, and examination indexes in the outpatient-only
practices compensated for low difficulty, so that the workload as measured by
RVU index was 18% greater in the outpatient-only
setting
compared with the inpatient setting.
The practices with radiology training programs had a higher
difficulty index but lower examination
and RVU indexes than
practices without training programs. The lower productivity
may be due to an intrinsic inefficiency in teaching residents
during film interpretation;
however, this teaching is a valid
activity
within
the mission
of the sponsoring
organizations.
It
category,
with
difficulty
indexes
higher
along
with
supervision
and
interpretation
proce-
for reference.
Finally,
Johnson
and Abernathys
study
[4] was
designed
of our data
to give
an estimate
of the 1 989
national
distribution
is beyond the scope of this study, it is plausible
to suggest that the dramatic shift of RVU workload
from
general radiology to advanced imaging techniques (Table 3)
reflects trends in the national data.
Conclusions
This study
attempted
to quantify
work
devoted
to the care
accurate
and complete
coding will be essenall the billable RVUs; injection
codes, in partic-
which
can be used
to study
trends
in utilization.
ACKNOWLEDGMENTS
We express appreciation
to Michael Lenker
for helpful editorial suggestions,
Virginia
of Kelsey-Seybold
Heckel of Kelsey-
Clinic
Seybold
Foundation
Mike Nelson
Crump
of Park Nicollet
Cancer
Center
Medical
for
Center,
statistical
Center
for
and
suggestions
all respondents
regarding
assistance,
Merritt
of
Parker of Love-
Christopher
the
survey
question-
to the questionnaire.
REFERENCES
1 . Medicare programs:
fee schedules
for radiologists services. Federal Register. March 2, 1989;54:8994-9023
2. American
Medical Association.
CPT: Physicians
Current Procedural
Terminology.
Chicago: American
Medical Association,
1990
3. Hsiao WC, Braun P, Becker ER, et al. A national study of resource-based
relative value scales for physician
services:
final report to the Health Care
Financing
Administration
(Publication
17-C-98795/1-03).
Cambridge,
MA:
Harvard School of Public Health. September
1988.
4. Johnson
JL, Abernathy DL. Diagnostic imaging procedure volume in the
lhiited States. Radiology
1983;146:851-853