Dr. McGahan
is a Professor of Radiology, the Vice Chair of Radiology, and the
Director of Ultrasound, Department of Diagnostic Radiology,
University of California, Davis Medical Center, Sacramento, CA.
He is also a member of the editorial board of this journal.
The work relative value units (RVUs) earned by different
subspecialties in academic radiology may differ by a large
magnitude, according to data supplied by the Association of
Administrators in Academic Radiology. This discrepancy in earnings
potential may be a source of conflict in large
subspecialty group practices. Certain radiology subspecialties are
more heavily reimbursed because of their higher RVUs.
Interpretations of computed tomography and magnetic resonance are
heavily reimbursed while, alternatively, those radiologists who
interpret examinations such as plain films are not as well
reimbursed because of the lower RVUs per study. Even within a
single subspecialty such as abdominal imaging, those performing
fluoroscopic procedures (eg, upper gastrointestinal
contrast studies) earn fewer RVUs than those interpreting abdominal
CT examinations. Should these different earning potentials relate
to salary among various specialties? If so, how?
When I entered radiology and ultimately chose a specialty, I had
no idea that earning potential could or would relate to RVU
generation. I chose a subspecialty based on clinical and academic
interest.
At the request of the Dean of our Medical School, we have in
place a faculty incentive earning plan. We have often revised the
plan since it was originally developed. The incentive portion of
our salary is primarily based on RVUs (clinical productivity), and,
to a lesser degree, on one's academic and teaching
responsibilities.
Conversations with members of our department regarding this plan
reveal 3 different camps of opinion. There are those who strongly
favor the incentive pay plan and wish to have it include a greater
percentage of total salary, and there are those who clearly prefer
an even salary distribution, other factors being equal. The
majority of our faculty is generally silent on the issue; I assume,
therefore, that they fall somewhere between the two extremes. As
might be expected, those who wish to have a higher incentive pay
are those achieving high RVUs, while others with low RVU
productivity wish for an even income distribution. The latter group
feels that if they did not perform these less-well-reimbursed
examinations, then everyone would have to share equally in
interpreting them and so would be "penalized."
The issue of incentive pay versus equal salary distribution is
also debated among private practice radiologists. There are
multiple combinations and permutations among income plans. In my
brief casual survey, it seems that quarterly or yearly bonuses are
often given to group partners, in equal amounts, especially in
small group practices. Other radiologists believe an
incentive-based plan is more appropriate because, as one
radiologist quoted, "You eat what you kill." Simply put, this
statement means that your salary should be based upon your
productivity. Other groups with an incentive-based salary plan have
expressed resentment, arguing that if all members work equal hours
they should receive equivalent salaries. Some groups take a more
pragmatic approach, using more limited incentive-earning potential.
However, there is often a differential salary based on call
responsibility. In talking to radiologists, whether in academics or
in a private practice, this approach seems fairly well accepted, as
it reimburses those who routinely perform or interpret studies at 2
AM more highly as compared with group members without this
responsibility. Some practices require that certain select criteria
be met to obtain full bonuses. These criteria could include prompt
signing of reports, attending meetings, and other methods of
showing "good citizenship."
In speaking to a variety of radiologists, my sense is that it is
difficult to move from one payment plan to another. A radiology
colleague of mine in private practice is in a group that switched
from an incentive pay plan, in which a portion of his salary was
based upon his collections, to a plan in which there was equal
salary distribution. Thus, from a year where there was a financial
incentive for collection to the next year of equal distribution, he
saw a large salary decline while the majority of his partners had a
salary increase. Thus, one's opinion stems from which side of the
street one is standing on. From his side of the street, he felt he
was working longer hours and had higher collections, but because of
equal distribution of salaries, had little incentive to continue
his very demanding schedule.
Which plan works best? There is no doubt that "one size won't
fit all." What I have learned is that when there is a discussion
that involves money, there will never be a complete consensus. Some
will always perceive themselves as losers.