It's great to be with you today. I've been charged with teaching you everything you need to know about endocrine practice, the finances of endocrine practice in the next 30 minutes, so I've got my work cut out for me. I'm going to start by giving you an overview of the endocrinology marketplace. We'll spend some time talking about how endocrinologists are compensated, and then the rest of the time, reviewing practice management strategies that can help you to optimize your compensation in your practice. I guess there's universal consensus that there is a very high demand for endocrinologists in the current marketplace. In 2017, the American Medical Association estimated that there were about 7,500 endocrinologists in practice nationwide. You can see the demographic breakdown here on this slide. Newer data from June of this year from the Kaiser Family Foundation suggests maybe that number is a little higher, perhaps 8,200 endocrinologists. But it's pretty clear there's high demand for endocrinologists and it's, I guess, a great time for you to be finishing your fellowship and entering in the marketplace. One of the questions, I guess, to consider is why is there such a high demand for endocrinologists? Unfortunately, part of that answer relates to lower rates of reimbursement. Endocrinology is one of the lowest reimbursed of any internal medicine subspecialty. Those extra years of training don't really yield much additional increase in your revenue. Because of this, there are higher rates of unfilled endocrinology fellowships nationwide. And there is a tendency for US-trained physicians to choose endocrinology as a subspecialty less frequently as a result. Now, every year, you probably see the Medscape estimates of endocrinology compensation. I think these tend to be a little low. Based on these data, which I'm showing you here, the median base salary for endocrinologists is just over $255,000 a year. You can expect additional compensation in the range of $15,000 to $16,000 over and above that for bonuses or other activities as well. And then also consider the compensation packages that are part of your employment contract, time off, 401k, healthcare benefits, and so forth. Endocrinology is a cognitive medical specialty. And as such, there are some inherent disadvantages to specialties without a lot of procedures. Fortunately, the CMS fee schedule is beginning to redress some of these deficiencies for cognitive medical specialties. Starting next year, that will begin to happen and there may be about a 16% increase in endocrine reimbursements starting at 21. The bottom line though is that compensation is largely driven by RVU productivity for endocrinology and for any medical specialty for that point. So you need to understand how RVUs work in order to understand how you're going to be compensated in the future. So I'd like to start with a few definitions. The first is RBRVS which stands for Resource-Based Relative Value Scale. This is a system for describing, quantifying and reimbursing physician services relative to one another. And it makes use of the Relative Value Unit or RVU which is a national standard that's been set by Medicare to determine how much to pay doctors for their services. RVUs are based on the volume of work or effort that physicians expend in treating patients for services or procedures that are on the physician fee schedule. The last term that you need to know is the conversion factor. And this is really what monetizes the RVU. So the conversion factor for Medicare is assigned every year by Congress. If you're on a contract that's by a non-CMS payer that's using RVRVS, then they will negotiate that CVS or CF rather with each contract that you sign. So the total RVU is actually the sum of three individual RVU components. The physician's work RVU, which is the amount of time training and intensity needed to perform a procedure. This typically is about 53% of total RVU. Also is the practice expense RVU which is covering the overhead costs of doing a procedure. And then finally the malpractice expense RVU which is the liability expenses related to performing that procedure. Now RVUs can be further modified and adjusted. And the most important of these modifiers is known as the geographic practice cost index or GPCI. So this accounts for geographic cost of living and business expense variations across the nation. You take the GPCI and multiply it by, the regional GPCI and multiply it by the RVU to get your regional reimbursement. And as an example here, I've illustrated that it costs less to practice endocrinology in Nevada than it does in Manhattan. And the GPCI is what evens the playing field for providers. So you can determine your rates of reimbursement simply by multiplying the CF by the total RVUs. And this is the formula for total RVUs. The question I'm often asked next is then how many RVUs is an encounter worth? And I've tabulated some RVU data here and for inpatient services and also for outpatient services. So if you're doing a moderate complexity follow-up patient visit, it's worth 1.5 work RVUs. This should hopefully help you to begin to understand why gastroenterologists make a lot more money on average than do endocrinologists. By nature of our work, we have a limited ability to generate work RVUs in a year compared to a full-time gastroenterologist even though we're reimbursed at the same rate per RVU as the other specialties are. So this explains the difference in compensation in the different specialties. Ultimately, you have to remember that your revenue is based on your work RVU output. That's definitely the case if your compensation package is based on production-based contracts or if you're getting bonus pay based upon your work RVUs. But also indirectly, even if you're on a salary, the amount of work you do determines how much revenue is entering into the practice that you're working for. And so either directly or indirectly your work RVUs determine your revenue. And having an idea of what your RVU capacity is helps you to assess your worth in the free market and your ability to generate income, I guess, as a free agent. Now, if there's any component of RVU compensation on your current contract, I would encourage you to ask a few specific questions related to RVUs. The first question might be, are your work RVUs credited based upon codes submitted or on codes paid? Usually it's codes submitted, but you can imagine that if you were being compensated based on codes paid and you have an inefficient billing office, that that would negatively impact your bottom line. A second question to ask is whether your RVUs are credited based on the date of service or the date of submission. This helps you to keep track of your productivity and make comparisons to what your employer's got you logged as producing. Another question to ask is questions related to when you use a modifier code. So a modifier code 25 is used when two services are provided on the same day. You should understand how those additional codes for modifiers are being credited to your productivity log. You should ask if you're being compensated for the work RVUs of a physician assistant or nurse practitioner that's operating under your supervision. You should know who is able to change the codes and the modifiers related to your work. And perhaps most importantly of all, you really need to know what reports you'll be provided on your work RVUs and how often you'll be receiving those reports. You should begin now to understand why work RVUs and auditing these is so important for you. If your compensation is any way based upon work RVUs, you really need to know how you're gonna track production. And I would say never assume that your employer is keeping track of it properly. You have to mind the sore. So I strongly recommend that you get in the habit of logging your work RVUs. You can simply print your schedule every day and just make a note of what codes you charged for each patient and who didn't show up. And then at the end of the month, you can compare the log that you've made with your work RVU transaction reports that you're being provided by your employer. At some point, you're gonna ask yourself, how do I increase my work RVUs and thereby increase my compensation? One way, and maybe not the best way, one way to increase your work RVUs is to work more hours. And so instead of working 50 hours a week, you could work 80 hours a week. I think there are better ways to increase your revenue. I think the one thing that you should resolve to do right now, put your hand on your heart and swear an oath that you won't do is discount your work by undercoding. I've already shown you how endocrinologists are relatively underpaid versus other specialties. So you shouldn't undermine it further by downcoding your claims. I think you should also resolve to bill for all of the procedures that you do perform. So if you do an ultrasound, you should code for it. If you do a CGM analysis or spend extra time or complexity on a patient, then you should bill for those charges as well. What we'll try to do for the remaining time that we have is focus on other strategies that allow you to see patients more efficiently and potentially to generate RVUs through your collaboration with an advanced practice professional, such as a nurse practitioner or physician assistant. So what follows then are some practice management strategies that you can adopt that will help you to increase your productivity and increase your work RVUs. One of the first things that you will have to learn is the art of delegation. And you spent a long time learning how to be an endocrinologist. You really need to spend your time doing those things that only an endocrinologist can do and not spend time doing things that your support staff can do. So for example, you have a medical assistant, use that medical assistant to make phone calls or patient contact or call in prescriptions or whatever. That's not something that you should be using your time to do. The same is true with educating patients. Use the education staff that are on your team to do that training rather than use your time as the endocrinologist to do that. Now, that's not to say you'll never make a call or never do training, but you should focus your time and your efforts on doing endocrinologist types of tasks. You're going to see in our discussion today that we come back to the electronic health record over and over again, and it is a very important determinant of your work productivity, and it's also a major source of physician stress in the real world. I guess just remember that time is RVUs, and if you can find a way to be more efficient and able to see one additional follow-up patient per day, that's going to translate into between 300 and 350 RVUs in a year, and that's not an insignificant amount of revenue to your practice. So focusing on that EHR and helping it to be efficient is part of making you efficient. When you attend a medical risk management seminar, you'll hear them say that if it's not documented, it didn't happen, and that's true. You do have to document your work explicitly, but don't fall into the trap where you over-document your notes. Again, the RVUs that are earned by doing a moderate complexity follow-up visit, they're fixed, and having an elaborate note that goes into far too much detail does not get you compensated anymore. So your notes need to be explicit and adequate, but don't over-document because it's a waste of time and resources. Thankfully, in 21, CMS is changing the focus from documentation onto other more important things like medical complexity and medical decision-making, and that's fortunate, but you do have to make sure that you do appropriate documentation. The electronic health record certainly represents a tool that will enable you to increase your efficiency. It can make your visit with patients, the current patient visit, more efficient and certainly helps to improve the efficiency of the patient's follow-up visits, as the information that you've documented on one encounter can be captured for subsequent encounters as well. I would advise you to, on the front end of your practice, invest enough time to really understand your electronic health record, understand how to import old notes, what the default settings are and how to modify them, and where data are stored in the system so that you can access that, and you should really invest in making some personalized templates that help you to make your interactions with your electronic health record more efficient and suitable to your individual needs. Ultimately, we can't get paid for our work that we do unless we appropriately bill and code for that work, and that's not something that's ever been emphasized for you in your training, so I would encourage you to take a course on billing and coding to help ensure that you're doing it appropriately and optimally. You should, again, resolve to code and bill for all of the work that you do. A word on professional courtesy. In the past, there was the notion that if you see a physician, you don't charge them for the work that you do. I've made a case already that endocrinologists are relatively undercompensated as it is, and I would argue that if you're taking care of patients, whether it's a physician or somebody else, that you simply charge for the work that you do, and when you see your doctor, you should expect to pay your co-pays as well, and so professional courtesy is more of a historical anecdote than it is something that's part of current optimal endocrine practice. Remember that your electronic health record can also be a great resource for billing and coding, analytic tools, billing shortcuts, diagnostic codes, and laboratory shortcuts that will also help to improve your efficiency. I want to take a minute and talk about the schedule and how important that is in keeping you efficient in practice. You should definitely have templates set up, certainly by appointment type, to help you structure your workday, certain time spots that are dedicated for new patient consultations versus follow-up visits versus procedures or ultrasound. It really helps you to utilize the resources in your office optimally. You don't want two people trying to use the ultrasound machine at the same time. You don't want four new patients all clustered together so it puts you behind for the rest of the day, so having that appointment schedule structured appropriately will keep you more efficient in practice. You might even go so far as to structure your schedule based upon disease state so that there are time spots for diabetic patients versus thyroid patients versus procedures or whatever. I think it's a good idea to have protected times on your schedule for emergency consultation so that you can get a patient that's very sick or a new patient assessment in in a timely fashion to help keep your referring doctors happy. I think you should also periodically review your schedule at least with two different questions. One is a question that reviews your patient no-shows. You can analyze these by insurance, by provider, even by disease state. You'll find that patients that need testosterone refills, they show up for their appointments. It's a controlled substance and they can't get it unless they come to the office, whereas other disease states might not be as punctual with their visits. You need to have a policy in place to decide what you do with a habitual no-show patient or if you're charging them a fee. We also analyze the schedule looking at appointment wait times and how long it takes for a new patient to get in to be seen or a follow-up or an ultrasound or a procedure. Remember that long wait times often equate to high no-show rates and that's the single most unproductive part of your practice since you can't be reimbursed for or for a patient that does not come in. I think sometimes there's a false sense of security when there are long wait times in a practice. In fact, long wait times should be a red flag that you need to restructure things in the practice. I want to take a couple of minutes and talk about working with advanced practice professionals. Almost every endocrinology practice has APPs that they're making use of at this point. I think it's safe to say that they're here to stay in endocrine practice. There's simply way too many patients and not enough physicians to do all of this work. The key in using them well is to choose them wisely and train them appropriately. Think about it. Not every physician has the aptitude to do endocrinology. And that's true of a nurse practitioner or a physician assistant. So you have to select those that have the intellect and the aptitude to be able to do this specialty. If you do it properly, there are financial opportunities in doing so, especially if you set them up in independent practice with the appropriate supervision and collaboration from you. And this will increase your ability to generate RVUs for the practice. I strongly recommend incident two billing, which I'll talk about in the next slide. Just remember that you're going to have to prepare your practice. It's a bit of a paradigm shift from all of the care being provided by you or another endocrinology physician endocrinologist to a practice that is using a team of providers to do that work. And the staff need to be trained to accept that model as do the patients. Remember that small things like the words you use or the terms you use, influence the perception of the care that's provided by the APPs. For example, if you refer to them as your PA, it creates a different sort of subliminal message to the patient than referring to them as your colleague or your associate. And I would encourage you to think about those kinds of things to help make this model of practice work. Really, it's up to you to ensure that you provide them with the hands-on supervision and training to allow them to take good care of your patients. After all, it's really your reputation that's on the line. And from a medical legal perspective, it's your neck on the line too, if you're supervising that person. You cannot expect to have a full schedule and have a physician assistant or nurse practitioner working alongside of you and not dedicate some time to their supervision and training. I mentioned incident two billing. And so this is a mechanism that CMS has given us that allow an APPs to be reimbursed at 100% of the physician fee schedule. There are some stipulations though. The initial work has to be provided by a physician and that physician will set up a problem list and a course of care for that patient. And then the APP will provide subsequent care and expand on it or modify it as necessary. But this work has to be done under this direct supervision of a physician, usually within the office suite or within the building. It cannot be done for visits where more than 50% of the visitor is for counseling or care coordination, nor may it be used for diagnostic testing. I have just a couple of minutes left and I want to spend that time talking about reputation management, which definitely influences your ability to earn a living. If you're going into a small group practice, then there is certainly more opportunity for you to stand out in that practice, but there's also less opportunity to hide behind a giant practice where you're just another name on a list. So I would recommend that as you enter practice, that your first priority will be to focus on your in-house reputation with physician colleagues or APPs in the practice. Don't forget your interactions with management administration will influence your reputation in the practice as a whole. And also don't underestimate how important it is to work well with front and back office staff in the office as well. You can also then focus your attention to the external reputation in the community with referring physicians. And remember that in many cases, you'll have physicians that never meet you, that their only access to you is through the notes that you send to their practice. So focus on the quality of those notes and how they appear. Ultimately, the most important thing for you in your reputation is how your patients perceive you. And that reputation in the community is the one that will ultimately sustain you in the long term. So my time is up. I've tried to give you an overview of some important considerations for practice management that will help you to optimize your compensation. I'm excited for you to enter this wonderful specialty of endocrinology. It's been a blast for me over the last 30 years. I would do it again in a heartbeat. I hopefully I've addressed some of those questions that you have and look forward to answering your questions in the next few minutes. Thank you.

endocrine practice

endocrinology marketplace

demand for endocrinologists

endocrinology fellowships

endocrinologist compensation

RVU productivity