The salaried PM&R physician

Abstract

The breadth of medical practice for a physical medicine and rehabilitation (PM&R) physician is quite extensive. Not only are practice areas quite different among PM&R physicians, but practice settings, procedures, and salary models also vary significantly. For PM&R residents and fellows who are making career decisions regarding specialization versus general practice and/or in the process of negotiating contracts, salary is a significant influence in their decision of clinical practice. Physician payment models may create inadvertent bias against women, those seeking less than full time clinical employment, and those interested in an academic career. In this review and commentary, we will discuss the more common payment models encountered, with a focus on a fixed salary payment model. We will also discuss our experiences as pediatric and adult PM&R providers in a salaried payment model at a not-for-profit academic institution.

Introduction

As a medical specialty, the breadth of medical practice for a physical medicine and rehabilitation (PM&R) physician is quite extensive. Historically, one was a generalist, seeing a variety of musculoskeletal, neurologic, and neuromuscular conditions across the lifespan. However, the specialty seems to be moving away from general PM&R as residents in PM&R opt to pursue subspecialty fellowship training. ¹ This shift is evident by PM&R fellowship training programs growing at a relatively faster rate than PM&R residency programs. ² Prominent areas of subspecialization in PM&R include pain medicine, pediatric rehabilitation, sports medicine, spinal cord injury medicine, neuromuscular medicine, and brain injury medicine. These subspecialties create a variety of opportunities for PM&R physician practice. Not only are practice areas quite different among PM&R physicians, but practice settings, procedures, and salary models also vary significantly. For PM&R residents and fellows who are making career decisions regarding specialization versus general practice and/or in the process of negotiating contracts, salary is a significant influence in their decision of clinical practice. ³

Physician payment models

Identifying and understanding the different salary or payment models for physicians can be difficult to nearly impossible, especially when attempting to secure an ideal clinical and/or procedural practice. Physician payment model preference is influenced by multiple factors including age, sex/gender, risk level acceptance, flexibility, and interest in academic and administrative pursuits.^4–7 Some payment models discourage part-time employment, which may inadvertently discourage women who seek less than full time position offerings more often than men.^4,7–9 While this unintended bias may seem minor, the percentage of women physicians in PM&R is rapidly growing, with the subspecialty of pediatric PM&R having more women than men.^8,9 Below is a brief overview of some more common payment models that physicians encounter, including those in PM&R.

Fixed Salary Model: The “salaried” physician. A predetermined and set salary based on negotiated full time equivalent (FTE) for patient care. ¹⁰ This is a more typical model for academic practices and may permit flexibility for publication, teaching, and leadership pursuits. It may reduce worry about relative value unit (RVU) generation as there is typically no incentive for exceeding patient care targets.

RVU-Based Salary Model: RVU is a metric, initially created by the American Medical Association through the Relative Value Scale Update Committee (RUC) in 1991. This committee identifies the relative value of work done by physicians for Medicare and Medicaid beneficiaries based on Current Procedural Terminology (CPT) coding system codes. ¹¹ The physician work is half the relative value of the service. The RUC periodically re-evaluates RVUs; thus the RVUs for each CPT code can change over time, as practice evolves. While the intent of the RVU was to assess the relative value of a medical service and not a physician's performance, it has become more common for institutions/practices using this model to conflate RVU with physician performance. ¹² In the productivity-driven RVU-based salary model, a physician is paid a fixed amount per RVU generated. ¹⁰

Collections-Based Salary Model: Unlike the RVU-based salary model, in the collections-based salary model the physician is paid a percentage of the physician fee collected from insurance/payor. Thus, unlike RVUs, which are fixed based on CPT code, collection is determined by the amount the insurance company or other payors actually reimburse for the service. ¹⁰ Thus, the same CPT code billed to differing insurers may result in differing payments, despite the same level of work being performed. This could disincentivize providers seeing patients insured by lower paying companies or government payors.

Fixed Salary Plus Incentive Model: This model of salary has a base salary that can be boosted, based on surpassing minimum RVU or collection targets. ¹⁰ This salary augmentation may occur in a graded manner, with more salary received for incrementally greater RVUs and collections above the minimum target.

Capitation Salary Model: In this salary model a physician or group of physicians are paid a set amount of prepaid healthcare premiums to manage a group of patients. Essentially, the physician salary is the money that is not used to provide care for the patients.

Locum Tenens Salary Model: As a salary model, locum tenens may provide flexibility in job choice, hours worked, and location, or may be a supplemental salary.^10,13 Typically paying an hourly rate, the amount paid varies depending on many factors including medical specialty, location, and patient care load. There may be other incentives, such as housing and travel costs covered.

This list is not fully inclusive as there are hybrids of the salary models noted above and other payment models, such a value-based reimbursement. ¹⁴ In pediatric PM&R in the United States, about half of the physicians are in a salaried position with incentives based on RVU generation and a greater proportion of women than men working part-time.^8,15 Regardless of salary model, it is important to note that salary is just one component of the compensation package a physician receives and needs to be evaluated in totality of the compensation package.

Salaried physician

In PM&R, about 13% of physicians identify as practicing in an academic setting; for pediatric PM&R, around 70% practice in an academic setting.^9,15 In many academic settings, a fixed salary model is used. ¹⁶ As PM&R physicians at a not-for-profit academic setting who have worked for years in salaried positions, we will dive further into the salaried physician payment model. As with any payment model, there are pros and cons. The payment model must be evaluated within the totality of the whole compensation package.

With a salaried position, the income is guaranteed, permitting a physician to do personal financial budgeting in a predictable manner. This is important as academic positions may include responsibilities other than patient care such as administrative, teaching, and/or research. While improved career satisfaction can come from the intellectual and leadership growth with these responsibilities, they reduce clinical revenue and clinical care time. In an RVU-based salary model, these more academic-based pursuits are disincentives as they contribute either to reduced clinical care time (and thus lower RVU generation and lower salary) or doing these activities on evenings and weekends. For many, this would negatively impact work-life balance as well as contribute to dissatisfaction and burn-out. ¹⁷ Interestingly, some institutions are using not only clinical RVUs to determine salary and productivity in an RVU reimbursement model, but have also added metrics of research RVUs, education RVUs, and academic RVUs. ¹⁸ While there may be some expectations for clinical productivity in a salaried position, in general, there may be more flexibility with patient care time and number of patients in a clinic day. This too can improve career satisfaction, reduce burn out, and limit moral injury. ¹⁷ Longer patient care slots facilitate time for resident teaching in the clinic setting. Residents have time for thorough patient evaluation and staffing by their proctors with educational discussions and feedback. This environment fosters a healthy and robust learning environment that feeds forward to the next generation of residents.

Collaborative relationships with colleagues can also be fostered in a salaried environment. As opposed to an “eat what you kill” mantra in productivity-based salary models, sharing of patients and even procedures can be done without loss of income to the provider. In an institution with a fixed salary care model, surgeons are not incentivized for surgical productivity. Thus, when referring a patient to a salaried surgeon, one may have greater confidence in getting an opinion on whether an operation should be done as opposed to whether the operation could be done.

While there are many positives to a salaried position, there are also drawbacks. For instance, there is no monetary incentive to add on extra patients or see more patients than directed by the clinical calendar. Yet, one aspect of a collegial practice is finding time to add on patients of colleagues for second opinions or specialty care. Thus, in a salaried physician practice, collaboration in academic pursuits may be fostered while collaboration in clinical care could be hampered. Also, as one's salary is fixed, those who have larger caseloads, add on extra patients, or operate on more complex patients garner no payment bonus or financial incentive for this “extra” clinical or specialized work, thus disincentivizing these activities. From a resident teaching/resident clinical care standpoint, the potentially lower patient volumes of salaried physicians could result in fewer patients for residents to see, thus reducing clinical care experience. Lastly, and perhaps most obvious, the salary in a salaried position is fixed. For instance, a provider in PM&R who has a salaried position or is considering a salaried position may not be able to negotiate a higher salary, even if their practice has or is expected to have a larger procedural practice component than other PM&R colleagues at the institution.

A pediatric PM&R provider prospective – Dr. Joline Brandenburg

The ideal payment model for physicians may vary by specialty or even subspecialty. Within PM&R, approximately 5% of physicians identify as having a primarily pediatric practice. ⁹ As one of this 5%, I would like to speak a bit about my experience as a pediatric PM&R physician employed at one of the largest not-for-profit academic health systems and embedded within a PM&R department. I am a salaried physician. When coming on staff, just out of training, I appreciated the predictability of a fixed salary without negotiation. As a pediatric PM&R physician, I have some procedural component to my practice, but it is not an expectation nor is it the largest part of my practice. In fact, within my pediatric PM&R division, we share the procedural practice. For patients, this keeps procedural times consistent even when providers are on vacation, at conferences, on medical leave, or on hospital service. Thus, patients for whom I recommend a procedure, such as botulinum toxin injections, may have that procedure done by one of my pediatric PM&R colleagues. Sharing patients in this manner not only permits patients to be scheduled in a timely fashion for their procedure, but it also keeps me and my pediatric PM&R colleagues communicating and collaborating regarding the procedure practice. I have found that having differing providers encourages discussion on management if the injecting provider has some additional thoughts on the procedure or care management. This has been helpful for complicated patients and patients I have been seeing for some time with whom I may have stalled in my clinical approach due to the familiarity. This does not exclude patients from electing to have the same provider they see in clinic do their injections but gives them flexibility in choosing when and/or with whom to have their injections. Furthermore, coordinating sedated procedures for a medically fragile pediatric patient across differing surgical and procedural practices is incredibly difficult but critical, and having a shared procedural practice provides more flexibility for coordinating these procedures.

This collaboration also helps when colleagues ask to add patients on to our calendars for a clinic visit or procedures. If I cannot add the patient or am unavailable for a coordinated procedure, frequently my colleagues are able to see the patient. This is in part due to our collaborative environment, and as such, I may need to add on a patient for them in the future. Furthermore, my clinical calendar and administrative time offers me time to reach out to colleagues to have a conversation about a patient, perform my administration responsibilities, and participate in resident education, which facilitates even more collaboration and a much more satisfying work environment. Thus, this collaborative approach does not end with clinical care but is enmeshed with sharing resident teaching and resident clinical experiences, and administration and leadership responsibilities.

Having administrative time, without pressures of adding on more patients to support my salary, has provided opportunity for shaping and growing my clinical practice. With protected administrative time, I can support and represent our pediatric rehabilitation practice on numerous institutional and departmental committees along with serving on committees for national and international organizations. In this way, I can build my leadership skills, grow clinical practice, and foster relationships with colleagues across the world. All of this adds meaning to my clinical practice, supports my intellectual curiosity, and keeps me balanced in my work.

Lastly, an academic position cannot be discussed without some mention of research, which involves building relationships to create a network of individuals for generating ideas, writing grants, conducting studies, and publishing manuscripts. As a salaried physician, I have some time to build and grow these relationships that are critical to research productivity. I am fortunate that I had the time to build relationships in a way that allows me to participate in both basic science and clinical research while also maintaining a healthy clinical practice.

My entire academic career has been at the same institution. A significant component of staying at the same institution has been the environment in which I work, the colleagues by whom I am surrounded, the opportunities I have for intellectual exploration and growth, and the balance I have with clinical care, research, and education. I believe a component of this positive work environment is that we are all salaried. Do I still complain when I have a challenging day or a tough patient, cases added on, a poor score on a grant, or negative comments on a manuscript submission? Absolutely. However, I have support from my colleagues and financial stability of a salaried position to keep those challenging aspects of academic medicine in perspective.

An adult PM&R provider perspective – Dr. Jeffrey Brault

As a salaried adult PM&R physician, I find stability in practice with a set income distributed at fixed intervals of payment. There is no financial fluctuation due to patient volumes, procedures performed, payor mix, no-show rate, or economic downturns. However, as a salaried physician, there is slower income growth, incremental raises are usually fixed to the market, and overall slower income growth over the course of a career.

As a primarily musculoskeletal PM&R physician with a high proportion of my time dedicated to procedural practice, my income is likely lower than it would be under a different payment model. However, without the pressure of seeing high volumes of patients to generate income, I can focus on quality of care. Academic institutions work as a hub of interdisciplinary collaboration, which offers us the ability to interact with various medical and surgical specialties. This allows us to provide comprehensive patient care, particularly in complex cases managed through the team approach. Collaboration fosters discussion and opportunity for diverse perspectives in treatment modalities and enhanced problem-solving abilities. We spend time with each patient, perform a comprehensive assessment, provide direct patient education, and outline a well-defined treatment program. As patients seen at an academic medical center are typically medically complex or unresponsive to standard treatments, the usual treatment paradigms may not be applicable, thus requiring creativity brought about by collaboration to develop or tailor a treatment approach. This takes time, which in an RVU or fee-for-service based salary model, may not be feasible.

At an academic facility, teaching and mentorship are an integral part of my role. As an educator of medical students, residents, and fellows, having time to allow them to learn how to exam the patient, develop a treatment plan, and even carry out that plan or perform the procedure is extremely rewarding. I get to help shape the next generation of physiatrists and have time to help them learn from my experience. It is critical that teaching also includes fostering communication and leadership skills, along with the knowledge of how to distill complex medical information into understandable concepts for the patient and colleagues. As a salaried physician, I can be a part of the teaching faculty, which also is intellectually stimulating for me. I do this without concern that teaching is impacting my clinical productivity. I feel fortunate to be in a dynamic and engaging work environment because of the learners. This has prevented intellectual stagnation, contributed to my professional satisfaction, and brings joy instead of burnout to my practice.

My salaried academic position also fosters a healthier work life. This is because of relatively consistent working hours and environment. I have time to pursue other educational endeavors, personal interest, and hobbies. As a salaried physician, I do not have to boost patient flow or work longer clinical hours in order to cover income lost during these vocational, avocational, and educational activities. However, this comes at the price of less autonomy in a large group practice with less flexibility than one may have in an individual practice. I do not set my schedule. I am limited in making practice changes to facilitate my personal preferences.

I greatly appreciate having time to interact with other intellectually curious clinicians and researchers. I can grow in my academic and research pursuits as I have collaborators to ask difficult clinical/research questions. My institution offers physicians some research, statistical, and often manuscript review and editing support. I know I have colleagues who are also willing to sit down to review a research grant with me, discuss a research idea, or provide constructive feedback and edits on a manuscript draft. Furthermore, my institution supports me in presenting and attending academic conferences. The networking, education, and research collaborations built from attending these meetings is incredibly valuable to my academic and clinical growth while fostering the development of lifelong acquaintances across the world. So while my income may be relatively lower in a salaried position as compared to an incentive-based salary, the other opportunities I have had for growth beyond patient care has helped in my longevity as a physician, ongoing desire to grow and evolve my practice, and ability to practice at the cutting edge of my specialty.

Working in an academic institution has offered me a wealth of benefits including opportunities for personal growth, interdisciplinary collaboration, and active involvement in medical education and research. This has been an intellectually stimulating environment with opportunities to advance rehabilitation science that make this position incredibly rewarding. This is not easy work, but it is satisfying. Do I have bad days, long days, or unexpected issues arise in clinical, education, and research? Yes. However, the resilience I have built through the collegial work environment with my colleagues, fostering the growth of the next generation of physiatrists, and advancing clinical research in areas of interest to my practice has nurtured my well-being and career longevity at a single institution.

Summary

The medical specialty of PM&R is broad. Payment models vary and are only one component of a physician selecting a location for starting or continuing their career. In a more academic setting, a salaried position may not result in the greatest potential income to be earned, but rather foster a career that is rich in collaboration, educating the next generation, and flexibility in clinical and academic pursuits. In our experience in salaried positions in two differing PM&R practices at the same institution, collaboration within and across specialties, well-being, and intellectual growth have been powerful in sustaining satisfaction in our careers within a single institution. This has been possible, in part, because of the payment model in which we are working.