Salary Survey Results Questioned

An annual salary study shows a continued trend in modest rises in compensation for most medical specialties, with concurrent losses for medical practices, and has drawn calls for changes to the ways physicians are compensated.

John A. Patti, M.D. North Shore Medical Center, Salem, Mass.

Brad Vaudrey, M.B.A., C.P.A. RSM McGladrey, Inc

The American Medical Group Association recently issued the 2008 Medical Group Compensation and Financial Survey, a 2008 report based on 2007 data. The survey, in its 21st year, is conducted by RSM McGladrey, Inc.'s Health Care Consulting Group.

For radiologists, the AMGA Survey does not represent an applicable sample, said John A. Patti, M.D., a radiologist at North Shore Medical Center in Salem, Mass., and the group's chief financial officer for the past 23 years. Dr. Patti also serves as vice-chair of the American College of Radiology (ACR) Board of Chancellors.

AMGA mailed the survey questionnaire to more than 2,700 medical groups. Survey administrator RSM McGladrey received valid responses from 224 medical groups representing more than 44,000 providers in 146 specialties, including radiology.

"When drawing conclusions about the survey, keep in mind that AMGA is a small and atypical piece of the workforce," said Dr. Patti. "AMGA has 67,000 member physicians—less than 10 percent of the total U.S. physician population. Large, multispecialty groups are its primary members." He noted the survey, answered by just eight percent of the groups to whom it was sent, is not enough to draw the nationwide conclusions it makes.

Dr. Patti is a speaker at two RSNA 2008 refresher courses, "Radiology Reimbursement 2008–2009: How We Influence Our Economic Future" and "Important Health Policy Issues Affecting Radiology: An ACR Leadership Perspective." Both courses are being offered in conjunction with ACR.

AMGA Survey Recognized for Benchmarking

The survey is indeed geared toward multispecialty groups, said Brad Vaudrey, a director with RSM McGladrey's Health Care Consulting Group, who defended the legitimacy of the survey results. "It is one of the top surveys recognized for benchmarking," he said. The review is important, he added, because "providing a fair market value is essential" when it comes to recruitment and retention.

Vaudrey indicated that radiology was a "hot" specialty for many years, especially in terms of compensation. The AMGA survey shows salaries for radiologists started leveling off in recent years. In 2007, the median compensation for a diagnostic radiologist was $420,858, up 1.44 percent from 2006. For interventional radiologists, the median compensation was $463,219, up 5.28 percent from the previous year.

While the increase for interventional radiologists is above the inflationary levels, "it is a bit of a slow down from previous years," said Vaudrey.

The AMGA assessment shows the highest compensation increases for dermatology, cardiac and thoracic surgery, hematology, pathology and hospitalists. Dermatology compensation rose 8.9 percent and that of hospitalists increased 7.3 percent. Vaudrey noted that while compensation for cardiac and thoracic surgery fell 2.13 percent in 2006, it rose 8.1 percent in 2007.

Overall, there was a 3.5 percent compensation increase in all specialties, a level just under inflationary indexing, said Vaudrey.

The 2008 survey also yielded interesting results with regard to work relative value units (RVUs). The study notes, "For the majority of participating medical groups, work RVUs are the primary measure of a physician's productivity. These figures include work effort changes as well as CMS value changes that occurred in the 2007 CMS CPT (Centers for Medicare and Medicaid Services Current Procedural Terminology) register. The overall average increase was around 14 percent. The RVU measure is normally a very steady benchmark; however, the changes in RVU values are creating a period of fluctuation."

For diagnostic radiologists, the AMGA analysis shows a 5.83 percent decrease in median work RVUs, from 9,208 in 2006 to 8,671 in 2007. For interventional radiologists, there was a 2.62 percent drop, from 7,815 in 2006 to 7,610 last year. There was a $55.39 benchmarking per work RVU for diagnostic radiologists, with a $60.89 benchmarking per work RVU for interventional radiologists.

"A lot of groups pay on a per RVU rate, which held steady to 2006 rates due to the CMS changes this year. I expect a 4.2 percent increase once the groups get used to the conversion factors," Vaudrey said. "There is a lot of uncertainty this year about how this will all shake out in the future."

Dr. Patti questioned this portion of the study as well. "I talk to radiologists every day who say, 'I'm working harder than I ever did in my life.' How can it be that the work RVUs for radiologists fell more than five percent? Today, there is a shift to higher work RVU procedures, such as MR imaging."

ACR has performed similar surveys focusing on workload and productivity, but not compensation, said Dr. Patti. An ACR survey on 2002–2003 workload levels, published in the September 2005 issue of Radiology, showed that, over the prior decade, procedures per full-time equivalent (FTE) increased about 2 percent annually while RVUs per procedure also rose at the same rate, resulting in a 4 percent annual increase in RVUs per FTE radiologist.

A new survey conducted by ACR in 2007 showed that work RVU procedures per FTE grew considerably from 2002–2003 to 2006–2007. "This contradicts the AMGA survey in terms of growth and productivity," said Dr. Patti.

Vaudrey noted, however, that AMGA figures also show an increase between 2002 and 2007, from 6,156 to 8,671.

"There are various reasons for this increase in both AMGA and ACR studies—harder work, an increase in CMS values, improved efficiencies," said Vaudrey. "The one-year decrease in 2007 did occur, but this is coming off more than five years of increase. One year does not make a trend and we will continue to watch the market. However, if I were to speculate, I would say the decrease may indicate that the physicians are not all working less, but have recognized the impact of performing higher RVU valued procedures and could be starting to plateau in their work capacity."

Limited information on the ACR survey can be released at this time because the study has not yet been published, said Dr. Patti; however, the ACR report will show radiology is not stagnating, he said.

Current Compensation System Must Change, Some Say

Donald W. Fisher, Ph.D., AMGA president and chief executive officer, said the survey shows the current payment system to providers is unsustainable due to declining reimbursements, competition for specialists and the cost of new technology. "Groups are spending huge amounts of time and money to improve quality and efficiency of care," said Dr. Fisher, noting that when a patient is or gets healthy, no extra services are needed and that reduces revenues.

The system should be changed to pay for outcomes or results, Dr. Fisher said. "Instead of paying for the number of services, you pay for the results," he said. He offered an example: "A patient with diabetes suffers congestive heart failure. You figure out how much money it will cost for one year of treatment. Then, you treat the patient with that money. Your incentive to improve the patient is money. Your group will lose money if the patient doesn't improve."

Modifications to the payment system must be made, Dr. Patti agreed, noting that it is important to make those changes realistic and practical. He said he too supports the concept of working together for the health of patients but questions how, in an outcomes-based system, costs would be covered when patients wind up needing more care than expected.

A 3-year pilot to test the concept described by Dr. Fisher is being developed by Blue Cross and Blue Shield and will be launched in North Dakota next year.