In an academic neurosurgery department, maximizing clinical income and productivity is an important, if not primary, goal. This goal must be balanced with the concurrent academic missions of education and research, and be attained working within the structure of an academic medical center.
Using examples from the Department of Neurosurgery at the Medical College of Georgia, this article identifies some obstacles to clinical productivity and suggests methodologies that can be instituted to overcome the perceived obstacles, or in some cases to utilize them.
Barriers to Clinical Productivity
Our department faces several obstacles to clinical income and productivity maximization. First, a significant portion of our patient base emanates from admissions to our emergency department, which is a level I trauma center. This results in a payer mix that is high in uninsured patients requiring neurosurgical intervention.
Second, the faculty members in our department work with residents and students; teaching these young doctors the nuances of the art of neurosurgery requires dedicating more time to each procedure. Moreover, the neurosurgeons participate in clinical and basic research and assume administrative duties that are commensurate with the academic medical center framework, siphoning time away from billable procedures.
Third, a centralized group practice manages all the billing and collecting activity for all the clinical science departments in the medical school. This results in flat “taxes” that disproportionately shift many of the billing office costs onto the higher income producers.
Finally, we have a very active functional neurosurgery program. However, compared to spine cases with instrumentation, functional neurosurgery generates very low relative value units (RVU) per case, and thus, comparatively less revenue.
Strategies That Have Shown Success
While the above factors constantly push against maximal clinical productivity, the following strategies have shown success in counterbalancing the trend.
The main advantage of an academic practice is the clear identification and recognition of a true physician leader, which is the chair of the department. The chair has the authority to set salaries, establish work responsibilities, evaluate performance, and set expected clinical productivity goals with each faculty member.
Maximizing the neurosurgeon’s time out of the operating room is accomplished by employing physician assistants and nurse clinicians as well as other physicians. Currently, we employ a physical medicine and rehabilitation physician and are in the process of hiring a neurointensivist. These physicians additionally work with residents and students, helping to fulfill our teaching mission.
Affiliation with a large academic medical center generates referrals from outside physicians to experts not found in the community, and “built in” referrals due to school loyalty. Additionally, the specialty practices within the academic medical center initiate many referrals. Further, our department benefits from high levels of investment in technology and capitalization, giving us access to the advanced equipment and technology that additionally attracts referrals.
Salary incentive plans encourage productivity. Our typical salary incentive plan guarantees a base salary and an incentive payment contingent on a percentage of the faculty’s individual contribution to the department.
We utilize a centralized billing and collection system. At first blush, this would appear to be contrary to maximizing billing and collecting on claims. However, if managed appropriately, it can result in very competitive billing practices. Some of our specific strategies include:
- Regularly measuring the billing plan’s performance based on accounts receivable days, bad debt percentages, net collection rates, and accounts receivable over 90 days.
- Faculty members taking an active role in the billing process to ensure optimal reimbursement. This includes personally appealing denials, reviewing final billed procedures to ensure correct Current Procedural Terminology (CPT) coding, and completing annual coursework in CPT coding updates in their subspecialty.
- Physically locating as many of the front-end billing personnel as possible in the department’s faculty offices. This has resulted in a positive synergy between the billing personnel and the physicians.
- Negotiating either a cap on or reductions in business office expenses. The expense charge per transaction for a neurosurgical practice is far greater than for other specialties, and the final business office expenses should be prorated to reflect this disparity.
In conclusion, there are strategies that can be implemented to overcome the clinical productivity obstacles facing neurosurgeons in an academic medical center. It takes strong management, perseverance, and a focus on the entire department to realize these goals.
Bill Hamilton, MBA, MHA, is administrative director of the Neuroscience Center at the Medical College of Georgia in Augusta, Ga. Mark Lee, MD, PhD, is chair of the Department of Neurosurgery at the Medical College of Georgia.