Physician Compensation Research Articles

Association of a Heart Failure Management Incentive in Primary Care With Clinical Outcomes: A Retrospective Cohort Study.

We aim to examine the association between primary care physicians' billing of Q050A, a pay-for-performance heart failure (HF) management incentive fee code, and the composite outcome of mortality, hospitalization, and emergency department visits. This population-based cohort study linked administrative health databases in Ontario, Canada, for patients with HF aged >66 years between January 1, 2008, and March 31, 2020. Cases were patients with HF who had a Q050A fee code billed. Cases and controls were matched 1:1 on age, sex, patient status on being rostered to a primary care physician, cardiologist, or internist visit in the 6 months before study enrollment, Johns Hopkins Adjusted Clinical Group resource use bands, days between HF diagnosis and study enrollment (±2 years), and the logit of the propensity score. A Cox proportional hazards model assessed the association of Q050A with the outcome. A total of 59 664 cases had a Q050A billed, whereas 244 883 patients did not. Before matching, patients who had a Q050A billed were more likely to be men (52% versus 49%), were rostered to a primary care physician (100% versus 96%), had a higher Charlson Comorbidity Index, and had higher health care costs. The mean follow-up was 481 days for cases and 530 days for controls. The composite outcome (hazard ratio, 1.11 [95% CI, 1.09-1.12]) was significantly higher for cases than controls. The Q050A incentive improved financial compensation for primary care physicians managing patients with HF but was not associated with improvements in the outcome. Research on promoting evidence-based HF management is warranted.

Development and evaluation of the Rural and Northern Community Focused Model of COPD Care (RaNCoM)

BackgroundThe prevalence of COPD continues to rise. To address the challenges to provide high quality COPD care in rural and northern communities, leaders in one rural and northern community in Western Canada sought to change the culture of COPD screening and care. Recognizing effective assessment, diagnosis, and treatment for patients with COPD are crucial to improve outcomes, a program was developed between 2012 and 2021 to enhance primary care for COPD patients.MethodsA process evaluation was undertaken to assess program development, implementation, mechanisms of impact, and context of COPD program. Qualitative thematic analysis of stakeholder interviews (n = 11) and a document review (n = 60; ~ 500 pages) of key clinic documents was conducted.ResultsWe describe five phases of the COPD program’s development (Survive; Reorganize and Stabilize; Assess and Respond; Build and Refine; and Sustain and Share), highlighting areas of innovation. Outreach and localizing resources improved access to the program. Acquiring secured physician compensation, capturing quality data, and improving patient and provider self-efficacy built the capacity of the system and stakeholders within it. Finally, relationships were forged through building an integrated facility, collaborative networking, and patient engagement. Key elements of program implementation included the resources (infrastructure, software, operational) required to ensure operation.ConclusionTeam-based care and service integration enhanced care capacity and the health network. Focused use of infrastructure and resources supported the people in the care system. Upholding a shared value of relationship is critical to deliver robust and sustainable rural healthcare. Quality improvement requires investment in rural community healthcare resources.

Quantifying EHR and Policy Factors Associated with the Gender Productivity Gap in Ambulatory, General Internal Medicine

BackgroundThe gender gap in physician compensation has persisted for decades. Little is known about how differences in use of the electronic health record (EHR) may contribute.ObjectiveTo characterize how time on clinical activities, time on the EHR, and clinical productivity vary by physician gender and to identify factors associated with physician productivity.Design, Setting, and ParticipantsThis longitudinal study included general internal medicine physicians employed by a large ambulatory practice network in the Northeastern United States from August 2018 to June 2021.Main MeasuresMonthly data on physician work relative value units (wRVUs), physician and practice characteristics, metrics of EHR use and note content, and temporal trend variables.Key ResultsThe analysis included 3227 physician-months of data for 108 physicians (44% women). Compared with men physicians, women physicians generated 23.8% fewer wRVUs per month, completed 22.1% fewer visits per month, spent 4.0 more minutes/visit and 8.72 more minutes on the EHR per hour worked (all p < 0.001), and typed or dictated 36.4% more note characters per note (p = 0.006). With multivariable adjustment for physician age, practice characteristics, EHR use, and temporal trends, physician gender was no longer associated with productivity (men 4.20 vs. women 3.88 wRVUs/hour, p = 0.31). Typing/dictating fewer characters per note, relying on greater teamwork to manage orders, and spending less time on documentation were associated with higher wRVUs/hour. The 2021 E/M code change was associated with higher wRVUs/hour for all physicians: 10% higher for men physicians and 18% higher for women physicians (p < 0.001 and p = 0.009, respectively).ConclusionsIncreased team support, briefer documentation, and the 2021 E/M code change were associated with higher physician productivity. The E/M code change may have preferentially benefited women physicians by incentivizing time-intensive activities such as medical decision-making, preventive care discussion, and patient counseling that women physicians have historically spent more time performing.

Patterns in Physician Burnout in a Stable-Linked Cohort

Physician burnout is widely reported to be an increasing problem in the US. Although prior analyses suggest physician burnout is rising nationally, these analyses have substantial limitations, including different physicians joining and leaving clinical practice. To examine the prevalence of burnout among physicians in a large multispecialty group over a 5-year period. This survey study was conducted in 2017, 2019, and 2021 and involved physician faculty members of the Massachusetts General Physicians Organization. Participants represented different clinical specialties and a full range of career stages. The online survey instrument had 4 domains: physician career and compensation satisfaction, physician well-being, administrative workload on physicians, and leadership and diversity. Time. Physician burnout, which was assessed with the Maslach Burnout Inventory. A binary burnout measure was used, which defined burnout as a high score in 2 of the 3 burnout subscales: Exhaustion, Cynicism, and Reduced Personal Efficacy. A total of 1373 physicians (72.9% of the original 2017 cohort) participated in all 3 surveys. The cohort included 690 (50.3%) male, 921 (67.1%) White, and 1189 (86.6%) non-Hispanic individuals. The response rates were 93.0% in 2017, 93.0% in 2019, and 92.0% in 2021. Concerning years of experience, the cohort was relatively well distributed, with the highest number and proportion of physicians (478 [34.8%]) reporting between 11 and 20 years of experience. Within this group, burnout declined from 44.4% (610 physicians) in 2017 to 41.9% (575) in 2019 (P = .18) before increasing to 50.4% (692) in 2021 (P < .001). Findings of this survey study suggest that the physician burnout rate in the US is increasing. This pattern represents a potential threat to the ability of the US health care system to care for patients and needs urgent solutions.

Complexity of Infectious Diseases Compared With Other Medical Subspecialties.

We aimed to highlight the complexity of the field of clinical infectious diseases compared with other medical specialties. Using available metrics, the body of knowledge within clinical infectious diseases is comparatively large and complex. This increasing complexity is underappreciated by current physician compensation schemes, needs to be carefully managed to educate future physicians, and may serve as a barrier to recruitment into the field.

Preserving the Future of Infectious Diseases: Why We Must Address the Decline in Compensation for Clinicians and Researchers.

Infectious diseases (ID) physicians play a pivotal role in patient care and public health, yet concerns are mounting about their under-compensation compared with other medical specialties. This trend sees ID physicians, including new graduates, receiving lower remuneration than their general and hospital medicine peers, despite their significant contributions. The persistent disparity in compensation has been identified as a key factor behind the declining interest in the ID specialty among medical students and residents, potentially threatening patient care quality, research advancement, and diversity within the ID workforce. This viewpoint underscores the urgent need for the ID community to rally behind the Infectious Diseases Society of America in advocating for fair compensation for ID physicians and researchers. While focusing on wellness and work-life balance is vital, it is critical to address compensation, a significant source of distress for physicians. Failure to confront the issue of under-compensation promptly may jeopardize the future growth and sustainability of the ID specialty.

Burnout in US hematologists and oncologists: impact of compensation models and advanced practice provider support.

Burnout is prevalent throughout medicine. Few large-scale studies have examined the impact of physician compensation or clinical support staff on burnout among hematologists and oncologists. In 2019, the American Society of Hematology conducted a practice survey of hematologists and oncologists in the AMA (American Medical Association) Masterfile; burnout was measured using a validated, single-item burnout instrument from the Physician Work-Life Study, while satisfaction was assessed in several domains using a 5-point Likert scale. The overall survey response rate was 25.2% (n= 631). Of 411 respondents with complete responses in the final analysis, 36.7% (n= 151) were from academic practices and 63.3% (n= 260) from community practices; 29.0% (n= 119) were female. Over one-third (36.5%; n= 150) reported burnout, while 12.0% (n= 50) had a high level of burnout. In weighted multivariate logistic regression models incorporating numerous variables, compensation plans based entirely on relative value unit (RVU) generation were significantly associated with high burnout among academic and community physicians, while the combination of RVU+ salary compensation showed no significant association. Female gender was associated with high burnout among academic physicians. High advanced practice provider utilization was inversely associated with high burnout among community physicians. Distinct patterns of career dissatisfaction were observed between academic and community physicians. We propose that the implementation of compensation models not based entirely on clinical productivity increased support for women in academic medicine, and expansion of advanced practice provider support in community practices may address burnout among hematologists and oncologists.

“The debt is suffocating to be honest”: Student loan debt, prospective sensemaking, and the social psychology of precarity in an allopathic medical school

Confronted with soaring medical school costs and intensifying disparities in physician compensation by specialty, medical students are forced to make sense of medical education debt during the nascent stages of their careers in medicine. Few studies, however, have examined exactly how medical students make sense of these constraints or how this process might influence decisions about which specialty to pursue or affect doctors’ wellbeing. Leveraging qualitative data collected from current students across all four years of medical education at a Midwestern allopathic medical school, we document how medical students collectively engage in prospective sensemaking about their debt and how it may affect their futures. We find that debt creates a palpable sense of financial precarity for people entering a high-status profession. We frame our analysis within a burgeoning new literature in organizational sociology and the professions known as inhabited institutionalism, which draws attention to the reciprocal relationships between local interaction and sensemaking with wider institutional pressures. We conclude with discussion of the implications our findings have for the supply of physicians across specialties as well as for the wellbeing of physicians across their careers.

The Perceived Impact of the New Medicare Rules for Split/Shared Visits: A Survey of Advanced Practice Administrators.

Background The Centers for Medicare and Medicaid Services (CMS) recently updated its split/shared policy but delayed enforcing sole time-based billing methodology in 2023 after industry pushback. However, the newtime-basedrequirement is set for 2024. Yet, there is no published literature addressing perceived organizational impacts associated with new split/shared rules. Methods A cross-sectional survey study was administered via electronic email Listserv (n= 108) over a two-and-a-half-week period in 2023. The survey was conducted to examine the potential organizational impact of complying with the new Medicare split/shared visit policy. The collected survey data were analyzed using descriptive statistics. Results Despite the small sample size,this novel research study seems tosuggestthat there is a range ofperceived issuesassociated with the new split/shared rules, including a perceived decrease in physician compensation due to changes in work relative value unit(wRVU) attribution and potential conflict between physicians and advanced practice providers (APPs) as they compete for wRVU credit for inpatient services. Additionally, respondents felt that the new regulatory change would lead to layoffs and/or hiring freezes of inpatient APP positions, thereby impacting team-based care dynamics. Further work is needed to better understand the impact of the new split/shared rules on coding practices, revenue, efficiency, provider, and patient satisfaction. Conclusion Thefindingsreported in this study shednewlight onthe perceived impacts of the new split/shared visit rules on healthcare institutions. Although the updated rules are designed to provide greater transparency and better align reimbursement with services performed, concerns persist around the potentialimpact on day-to-day workflows, physician compensation, net revenue, and potential economic impact on the traditional team-based care model.

Finding the Financial Margin Expansion Leverage in the Medical Practice

All U.S. medical groups, especially the independents, are under financial pressure from third-party payers, both commercial and governmental. These pressures come in the form of unit price controls, services utilization constraints, and total costs of care oversight, especially for the management of chronic conditions. The only solution to the deterioration of practice operating economics and related financial performance is operating margin expansion strategies—the expansion of the margin that funds the provider compensation pool. Such strategies are available. The principal challenges to margin expansion often are products of entrenched, and frequently intractable, clinical models and related business models, together with facility constraints, and access to investment capital that doesn’t excessively draw down physician compensation.

Academic productivity metrics correlate positively with industry funding amongst orthopedic shoulder and elbow surgeons

Research efforts can produce practice-changing results with widespread implications for patient care. While critical to the advancement of the field, such efforts do not often provide direct compensation. However, a researcher's academic productivity may facilitate industry relationships, either as the impetus for the affiliation or a result of collaboration. Queries of the Centers for Medicaid and Medicare Services publicly available Open Payments System allowed for extraction of industry compensation data for orthopedic surgeons in 7 categories, including royalties and licensing fees, consulting fees, gifts, honoria, and 3 unique speaking fees delineations. This system identifies physicians by taxonomy identifications; however, Centers for Medicaid and Medicare Services does not have a unique code for shoulder and elbow surgeons. Therefore, identification of shoulder and elbow surgeons proceeded utilizing the American Shoulder and Elbow Surgeons (ASES) society 2019 membership directory. Cross-referencing this membership list with extracted Open Payments data provided industry funding information for all ASES members. Physicians then underwent an academic productivity assessment. Queries of Web of Science, Scopus, and Google Scholar User Profile databases provided the Hirsch index (h-index) and m-index for each surgeon. Bivariate and multivariate analyses produced statistical results. From 2016 to 2020, 631,130, 158, and 72 ASES members earned mean annual industry compensation <$1000, between $1001 and $10,000, between $10,001 and $100,000, and >$100,000, respectively. Royalties (91.5%) predominated in the top earning group, compared with consulting fees (58.0%, 55.0%) in the 2 middle-tier groups. H-index and m-index correlated positively with total compensation (h-index: r=0.18, P<.001; m-index: r=0.10, P<.001). The highest income group (>$100,000) had higher h-index and m-index scores than either intermediate ($1001-$10,000, $10,001-$100,000) or lowest (<$1000) compensation groups (From lowest to highest income bracket-h-index: 14.8 vs. 16.4 vs. 19.4 vs. 32, P<.001; m-index: 0.79 vs. 0.85 vs. 0.91 vs. 1.18, P=.003). Multivariable analysis of factors associated with increased industry compensation identified only h-index (B=8046, P<.001) as having a significant association with physician compensation, with each single unit increase in h-index associated with an 18% increase in industry funding. Among a group of academic shoulder and elbow surgeons, industry compensation correlates positively with academic productivity metrics, with an associated $8046/yr increase in industry funding for each single-unit increase in h-index over 9. Future studies may focus on more clearly defining the causal directionality of these results.

Gender Disparities in Physician Assistant Educator Promotion and Compensation: A Mixed Methods Approach.

The gender wage gap is well documented in many industries. A disparity in salary between female and male physician assistant (PA) educators has been demonstrated, but disparities in academic rank have not been shown. The purpose of this study was to re-examine gender disparities in compensation to PA educators and to explore whether gender-based disparities exist in promotion to higher academic rank in this field. An explanatory sequential mixed-methods design was used to determine differences in salary and rank by gender. PA Education Association Faculty and Directors Survey data from 2014, 2017, and 2019 were analyzed. A focus group was conducted to explain the findings and understand the barriers to promotion for female faculty. Female PA faculty members earn $7573 less than their male colleagues when controlling for all other variables. Female faculty members have an increased likelihood (RR 1.150) for being in early career stage versus late career stage. Obtaining a doctoral degree decreased the risk for being in an early career stage (RR 0.567) with men twice as likely to have a doctoral degree as women. Rank and salary disparities exist in PA faculty by gender. Female faculty are less likely to hold doctoral degrees or to be promoted to higher academic ranks, and they earn less than men. Degree level and career track are themes unique to the PA education profession, and further research is needed to understand their impact. With more women entering PA education, pay equity and promotion need to be addressed.

Comparative Ethics of Modern Payment Models

Comparative Ethics of Modern Payment Models

Analysis of Industry-Related Payments Among Physician Editors of Pathology Journals.

Gender inequities in editorial board representation and physician compensation are well documented, but few studies have focused on how editors of journals are compensated. In this cross-sectional study, we examined industry-related compensation (from 2014 to 2020) among physician editors of 35 pathology journals using publicly available data from the Centers for Medicare & Medicaid Services Open Payments Database. Of the physician editors included, 135 (69.9%) were men and 58 (30.1%) were women. Similar percentages of men and women physicians who were eligible received payments (112/135 [83.0%] men and 51/58 [87.9%] women; P = .38, χ2 test). Of the total transfer of value ($211,192,532), 112 men received $192,727,555 (91.3%), and 51 women received $18,464,978 (8.7%). Mean total payment per person was $1,720,782 for men and $362,058 for women (P = .05). The payment range for men was $18-$47,568,400 and the range of payments for women was $31-$2,375,637. The findings highlight significant gender inequities in industry-related payments to physician editors of pathology journals. The financial relationships of journal editors and industry deserve further study, particularly as they relate to advancing science and closing both workforce and patient care inequities.

Study of goal programming approach in resource allocation in acute care hospitals

In this study, the goal programming approach is discussed which is used in hospitals to allocate resources. Two linear goal-programming models are included in the process. One model fixes the ratio of different types of cases that doctors see each year, while the other translates case mix decisions into a set of practice changes for doctors. Decision-makers may use the models to find the optimal case mix that maximizes profitability for the institution while minimizing negative impacts on physician compensation and clinical workflow.

AN INNOVATIVE APPROACH TO ENHANCING COPD CARE AND MANAGEMENT IN A RURAL NORTHERN COMMUNITY

Abstract Background COPD is the third leading cause of death worldwide. Rural communities often face challenges to provide high quality chronic disease care for aging populations. Despite these longstanding challenges, there was an intention to improve the care setting by developing and fostering a shared vision for quality care, as evidenced by enhancing COPD screening and care. To ensure consistent and longitudinal patient access to high quality of care as well and ongoing physician recruitment and retention a new rural program was developed. Objective-In this presentation we will describe a new rural community based COPD program from conceptualization and development through to current functioning highlighting areas of innovation. Methods-A process evaluation guided by Moore et al.’s framework to assess program implementation, mechanisms of impact, and context was conducted. Qualitative thematic analysis was undertaken of stakeholder interviews conducted in 2021 (n=11) and document review (n=60;~500 pages) of key clinic documents dated back to pre-program development. Results We describe five phases of program development: Survive; Reorganize and Stabilize; Assess and Respond; Build and Refine; and Sustain and Share. Outreach and localizing resources improved access to the program. Acquiring secured physician compensation, capturing quality data, and improving patient and provider self-efficacy built the capacity of the system and stakeholders within it. Finally, relationships were forged through building an integrated facility, collaborative networking, and patient engagement. The key elements of program implementation were the resources required to ensure its operation, categorized as hardware, software, organizational, and human.

What Every Colorectal Surgeon Needs to Know About Compensation for Physicians Employed by Hospitals and Health Care Systems.

Poggio, Juan Lucas M.D.1; Williams, J. Ryan M.D.2; Colvin, Donald B. M.D.3; Tyler, Kelly M. M.D.4; On behalf of the Healthcare Economics Committee of the American Society of Colon and Rectal Surgeons Author Information

National Undervaluation of Cleft Surgical Services: Evidence from a Comparative Analysis of 50,450 Cases.

Relative value units (RVUs) are broadly used for billing and physician compensation; however, the accuracy of RVU assignments has not been scientifically evaluated for craniofacial surgery. The authors hypothesize that unbalanced RVU allocation creates inappropriate disparities in value among procedures performed by cleft and craniofacial surgeons. The National Surgical Quality Improvement Program Pediatric database was queried to identify all cleft and craniofacial surgery cases performed by plastic surgeons from 2012 to 2019 based on CPT code. Microsurgical cases and CPT codes with a case count of fewer than 10 were excluded. Efficiency was defined as total RVUs divided by total operative time (ie, RVUs/hour). Mean efficiency per CPT code was ranked and compared by quartile using t tests. The sample consisted of 69 CPT codes with 50,450 cases. In the top quartile, most CPT codes were craniofacial procedures including frontofacial procedures (23.53%) and craniectomies for craniosynostosis or bony lesions (35.29%) (mean, 15.65 ± 4.22 RVUs/hour). The lowest quartile was composed mainly of CPT codes for cleft procedures including operations for velopharyngeal insufficiency (17.65%), cleft palate repair (23.53%), and cleft septoplasty (5.88%) (mean, 7.39 ± 0.98 RVUs/hour; P < 0.001). It was 2.5 times more efficient for a cleft and craniofacial surgeon to perform a local skin flap (15.18 RVUs/hour) than a secondary palatal lengthening for cleft palate (6.09 RVUs/hour). The current RVU allocation to cleft and craniofacial procedures creates arbitrary disparities in physician efficiency, with cleft procedures disproportionately negatively affected. RVU assignments should be reevaluated to avoid disincentivizing cleft surgical care.

Financing Models for Virtual Care.

Principles for determining physician compensation in the provision of virtual care are discussed along with analysis of the virtual care components included in the 2022 Ontario Physician Services Agreement (SEAMO 2022). Ministries and medical associations should continue to discuss appropriate payment for virtual advice for patients who do not have a primary care provider. They should also determine methods for payment for physician engagement in apps designed to optimize treatment of chronic diseases.

The Association Between Orthopaedic Surgeon Academic Productivity Metrics and Compensation from Medical Industry.

Academic research has value well beyond personal financial gain. However, these endeavors do require a notable amount of time and opportunity cost. Academic productivity may raise a researcher's profile within the field, increasing the likelihood for interactions with the medical industry and possibly cultivating relationships with future monetary significance. Queries of the Centers for Medicaid and Medicare Services publicly available Open Payments System allowed for extraction of industry compensation data for orthopaedic surgeons. Aggregate data produce three compensation groups (mean annual income) for individual physicians: none; 1 to $100,000; and >$100,000. Physicians in the highest income category were matched 1:1 with physicians in each of the other two compensation groups. Selected physicians then underwent an academic productivity assessment. Queries of Web of Science, Scopus, and Google Scholar User Profile databases provided the h-index and m-index for each surgeon. Bivariate and multivariate analyses produced statistical results. In addition to the analysis of the tiered income groups, analysis of compensation as a continuous variable also occurred. From 2016 to 2020, 636, 7,617, and 22,091 US orthopaedic surgeons earned mean annual industry compensation >$100,000; between $1 and $100,000; and $0, respectively. Royalties (80.8%) predominated in the top earning group, compared with Consulting Fees (46.5%) in the second-tier group. The highest income group had higher h-index ($0 versus $1 to 100,000 versus >$100,000 = 3.6 versus 7.5 versus 20.0, P < 0.001) and m-index ($0 versus $1 to 100,000 versus >$100,000 = 0.26 versus 0.44 versus 0.80, P < 0.001) scores than either the intermediate or no compensation groups. In addition, h-index and m-index correlated positively with total compensation (h-index: r = 0.32, P < 0.001; m-index: r = 0.20, P < 0.001). Multivariable analysis of factors associated with increased industry compensation identified h-index (B = 0.034, P < 0.001) and years active (B = 0.042, P < 0.001) as having significant associations with physician compensation. Physician subspecialty also correlated with industry compensation. Academic research can provide invaluable contributions to the improvement of patient care. These efforts often require notable personal sacrifice with minimal direct remuneration. However, academic productivity metrics correlate positively with industry compensation, highlighting a possible supplementary benefit to scholarly efforts. Level III.