Incentive System for Clinical Work: A Focus on Academic Anesthesiology Programs

Amr Abouleish, MD, MBA The University of Texas Medical Branch Galveston, Texas

Incentives for Clinical Work

 Survey of Academic Anesthesiology Programs  Components and Issues of Incentive Plans

Introduction

  Therefore, the right system is the system that allows your department to succeed   Unlike when comparing group performance with other groups (i.e., benchmarking), measuring individual work is done within a single department Everyone’s different “Devil’s in the Details”

Incentive Plans (Productivity Measures) Private Practice  In private-practice, this is the revenue distribution plan 1  Equal Share 56%  “Everyone works the same amount, same calls, same time off”    “If the groups makes more, then everyone makes more.” NOT straight salary SHIFT WORKED  Charges 23%  What about academic groups?

1 Blough GG, Scott SJ. AAA Survey, 2003 ASA Practice Management Conference

Survey of Clinical Incentive Systems Among Academic Anesthesiology Departments

Amr Abouleish, MD, MBA, Jeffrey Apfelbaum, MD, Donald Prough, MD, Charles Whitten, MD, John Williams, MD, Jay Roskoph, MD, MBA William Johnston, MD

Purpose

 To determine the prevalence and characteristics of different categories of clinical incentive plans among academic anesthesiology departments in the Spring of 2003

Methods

 Survey of the members of the Society of Academic Anesthesiology Chairs and Association of Anesthesiology Program Directors (SAAC/AAPD)   Via email from April to May 2003 Incentive plan existed if  Measure clinical work  Vary compensation dependent on work done

Categories – Primary Measurement

None No Incentive Plan (Straight Salary Compensation) Charges Billed Charges Time Shift Mini Billed Time Shift worked – all time Shift worked – calls or late rooms only Other Revenue-collected or other plans that do not fit in the above categories

Data Collected

  Departmental Demographics, such as   Number of providers Number of hospitals Overall Plan Characteristics, such as       If no plan  is there pressure How long has the dept. had a plan % of compensation Pay how often Any quality measurement When is plan evaluated and how

Category Details

  Tailored for each category Examples  Do you give extra credit for  Personally performed cases    Schedule runner Day Surgery Remote  How are late rooms and different calls handled?

 How are differences in concurrency handled?

Results

 88 of 138 (64%) members of SAAC/AAPD responded from 37 different states   83 included 5 excluded – incomplete information

Prevalence of Clinical Incentive Plans None Mini Shift Charges Time Other* N 24 25 17 9 5 3 % of Total 29% 30% 20% 11% 6% 4% * Revenue (2), Other (1) 59% No or only calls/late rooms 41% Clinical Incentive Program

Prevalence of Clinical Incentive Plans None Mini Shift Charges Time Other* N 24 25 17 9 5 3 % of Total 29% 59% 30% 20% 11% 41% 6% 3% % by Number of Clinical Faculty 1-20 (n=20) 21-40 (n=32) >40 (n=31) * Revenue (2), Other (1)

Prevalence of Clinical Incentive Plans None Mini Shift Charges Time Other* N 24 25 17 9 5 3 % of Total 29% 59% 30% 20% 11% 41% 6% 3% % by Number of Clinical Faculty 1-20 (n=20) 21-40 (n=32) >40 (n=31) 45% 75% 30% 22% 63% 41% 26% 45% 19% 10% 15% 25% 0% 0% 22% 3% 37% 6% 6% 26% 16% 55% 10% 3% * Revenue (2), Other (1)

Prevalence of Clinical Incentive Plans Years in existence N None Mini Shift Charges Time Other* 24 25 17 9 5 3 % of Total 29% 30% 20% 11% 6% 3% % 1-2 years - 17% 22% 33% 60% 0% Median - 4 3.5

6.0

2.5

11.0

Min - 1 1 1 1 7 Max - 12 20 21 20 15 * Revenue (2), Other (1)

Are you considering an incentive plan?

   5 of 24 with no plan considering 8 of 25 with mini plan considering Reason: Pressure from Dean, University

% of Total Compensation

 59 groups with incentive plan (includes Mini)  90% have incentive <25% of total compensation 0-5% 6-10% 11-25% 26-50% >50% N 12 14 27 3 3 3 of 9 groups using charges estimate that incentive is more than 25% of compensation

Payments

   Pays incentive   Monthly – 53% Quarterly – 32% For groups that cover multiple hospitals and have incentive (n = 46), 30% pay differently by location  Most common reason is other hospital is either private or VA Quality Measurements  12 (20%) include quality in incentive plan – most common is peer evaluation

Details: Mini

  N = 25 Late rooms paid by hourly rate Late Rooms Call Weekend Call Extra Call N* 19 14 5 4 % 76% 56% 20% 16% *15 groups cover late rooms and call in some combination

Details: Shift

   N = 17 14 define shift as clinical days worked   1 – shift worked (and varied value for each shift) 2 – hours on duty How many plans accounted for … N Personally Performed Cases Schedule Runner Mentoring new residents Different shifts Charges/Collections for Pain 3 8 2 1 3

Details: Shift: Calls

  N = 17 In comparison to regular hours shift, did you give extra credit to … N Late Rooms In House – OR In House – OB Out of House OR (includes Specialty Call) Pain ICU 8 4 5 4 3 2

Details: Charges

   N = 9 6 used gross charges only  1 used AA gross charges, 80% for medical direction charges  2 used units (ASA or RVU)   1 converted RVUs to ASA units (esp. Pain) 1 converted ASA units to RVUs How many plans accounted for … N Concurrency Schedule Runner DSU Preop Clinic Labor and Delivery 1 3 2 0

Details: Charges: Calls

  N = 9 In comparison to regular hours shift, did you give extra credit to … N Late Rooms In House – OR In House – OB Out of House OR (includes Specialty Call) Pain ICU 3 2 1 1 2 1

Details: Time

   N = 5 All 5 used billed time   3 included pain and ICU in plan Converted charges or patients seen to time How many plans accounted for … N Concurrency Turnover time Schedule Runner DSU Preop Clinic Base Units > 6 Labor and Delivery 2 1 1 2 0 1

Details: Time: Calls

  N = 5 In comparison to regular hours shift, did you give extra credit to (billed time + Extra)… N N/A Late Rooms In House – OR In House – OB Out of House OR (includes Specialty Call) Pain ICU 2 1 1 0 0 1 2 3 2 4 4 4

Non-Clinical Incentive Plans

 60% of groups with Shift, Time, Charges had an Academic incentive plan   36% of groups with Mini 0% of groups with None

Summary of Survey

 30% of groups have no incentive plan (straight salary)  30% pay extra only for late rooms and/or calls  Of 40% that have incentive plan that includes regular hours, half are based on shift worked  “Devil is in the Details”

Incentives for Clinical Work

 Survey of Academic Anesthesiology Programs  Components and Issues of Incentive Plans  Devil is in the Details

Disclaimers

  No studies done – Anecdotal Evidence No right way, but things to consider

Issues of Clinical Incentive Plans

   Do they really work?

One Measurement for all?

Academic departments are different than private-practice groups   An Hour ≠ An Hour Quality Component

Do Incentive Systems Work in Anesthesiology?    Why create an incentive for clinical work?

Dean’s or Hospital’s perspective  So we can do more cases Chair’s or Faculty’s perspective  To be paid for work done  NOTE: Focus on surgical anesthesia care, not pain management services and critical care services

Dean’s Perspective

   Can clinical incentives significantly change the overall workload (surgical anesthesia) of an anesthesiology department? Example: In-house call  Department required to have one in-house faculty per night   Therefore 365 call nights Incentive plan can’t increase this number or decrease this number Can incentives change number cases done during the day?

Chair’s Perspective

   Instead of overall department workload  Can clinical incentives change the amount work done by each person?  Can incentive plan allow the department to do the SAME work with fewer people?

Example: In-house call  Department required to have one in-house faculty per night   Therefore 365 call nights Incentive plan can pay each person more if 10 people take call rather than 12.

Anecdotal Evidence

Possible Measurements

      Several possible primary measurements Use one or combination Similar to private-practice revenue distribution plan measurements Each values and devalues differently 1 You have to choose what works best for your group Behavior modification Possible Measurements Shift Time billed Charges Revenue 1 Anesthesiology 93:1506, 2000

One Measurement?

OR Anesthesia Pain Management ICU Hospital A Hospital B Possible Measurements Shift Time billed Charges Revenue   Different functions and hospital, is it necessary to measure work the same exact way everywhere?

Or value the same?

Academic vs. Private-Practice

  Revenue distribution plans in private-practice = incentive plans for clinical work CAUTION: Don’t forget Academic groups are not the same as private-practice  Why different? Reasons include (but not limited to)   Cyclic nature of staffing levels Need to do non-clinical activities   Simultaneous with clinical work Non-clinical days

Academic vs. Private-Practice

 If incentive of clinical work is too good (e.g., high % of total, or high $ value), then two situations may occur:  Staff says no need to recruit  Cyclic nature of staffing academic departments – OK in fall, but in trouble in spring  Staff will give up academic time to do clinical work OR Staff will view academic work as punishment (because less valued)

An Hour ≠ An Hour

Regular Hours Late Rooms Call OR Anesthesia Pain Management ICU Hospital A Hospital B  What time should be valued the most?

Possible Measurements Shift Time billed Charges Revenue

An Hour ≠ An Hour

Regular Hours

Late Rooms Call OR Anesthesia Pain Management ICU Hospital A Hospital B Possible Measurements Shift Time billed Charges Revenue   For academic departments, undervalue regular clinic hours because… If too high, may tempt faculty away from academic work or penalize time spent in academics

An Hour ≠ An Hour

Regular Hours

Late Rooms

Call OR Anesthesia Pain Management ICU Hospital A Hospital B    Highest “per Hour” cost Non-call Most programs recognize and pay this Possible Measurements Shift Time billed Charges Revenue

An Hour ≠ An Hour

Regular Hours Late Rooms

Call

OR Anesthesia Pain Management ICU Hospital A Hospital B Possible Measurements Shift Time billed Charges Revenue    Call valued highly Most variable when staffing goes up and down Time away from home

What about Quality?

   Difficult to measure quality of care Difficult to measure OR efficiency    Turnover times, Anesthesia controlled time Faculty there when patient arrives to OR and there at emergence Unintended consequences – on teaching and regional anesthesia Peer Evaluations     Specifically schedule runners evaluation $200/month = one time possible bonus of $2400 Availability, willingness to do add-ons, helps others Behavior modification

Incentives for Clinical Work

 Survey of Academic Anesthesiology Programs  Components and Issues of Incentive Plans  Devil is in the Details Healing is an art, Medicine is a science, and Healthcare is a business