1337

Downloaded from www.ajronline.org by 202.62.17.27 on 10/12/15 from IP address 202.62.17.27. Copyright ARRS. For personal use only; all rights reserved

Productivity

of Radiologists:

Estimates
Based
Value Units

Patrick M. Conoley1
Sally W. Vernon2

on Analysis

of Relative

Analysis of relative value units (RVUs) was used to quantify patient-care productivity
of radiologists in 19 multispecialty
group practices
and to determine
how productivity
is
affected

by certain characteristics
of the practices.
The RVUs used in this study are the
professional
component
RVUs developed
by the American
College of Radiology and the
Health Care Financing
Administration
and published
as the Radiology
Relative
Value
Scale. An RVU workload
was calculated
by multiplying
the number
of times each
procedure
was performed
by the procedures
corresponding
RVU; the sum of these
products gave the overall professional
RVU workload.
Five productivity
Indexes
were
calculated.
The physician
index denotes the ratio of the total number of physicians
in
the clinics to the total number of radiologists.
The availability
index denotes the fraction
of radiologists
who are available
to perform
clinical work after deductions
are made for
time away from clinical work. The difficulty index measures, in RVUs per examination,
the level of complexity
of the overall examination
mix. The examination
index measures
examinations
per available
radiologist,
and the RVU index measures
RVUs per available
radiologist.
Altogether, the 19 clinics reported 3,234,451 examinations
performed
by 299
radiologists.
The computed
overall indexes
were as follows:
physician
index = 20
physicians
per radiologist; availability index = 0.77; difficulty
index = 2.27 RVUs per
examination;
examination
index = 14,098
examinations
per year per available
radiologist; RVU index = 32,065
RVUs per year per available
radiologist.
When the clinics were
grouped
according
to characteristics
of the practices,
the RVU index was higher for
single-site
practices,
high-prepaid
practices,
outpatient-only
practices,
and practices
without radiology
training
programs.
Fifty-two
percent
of the RVUs were in general

radiology,

37% in sectional

The concept

workloads

and 10% in special

is timely because

across medical subspecialties,

by third-party
AJR

imaging,

of RVU workload
payers

procedures.

it undoubtedly

and these workloads

will be used to compare

are likely to be related

to compensation.

December

157:1337-1340,

1991

The American
College of Radiology
(ACR) and Health Care Financing
Administration have quantified
radiology
services for purposes
of reimbursement
by using
relative value units (RVUs) [1]. The service of interpreting
a posteroanterior
chest
radiograph
was assigned
the value of 1 .00 RVU. All other procedures
in the

radiology section of the Current Procedural Terminology

(CPT) coding system [2]
were assessed in relation to the service of reading a posteroanterior
chest radioReceived
March 21 , 1991 ; accepted
sion July 24, 1991 .

after

revi-

1 Kelsey-Seybold
Clinic, P. A., 6624 Fannin St.,
Ste. 1800, Houston, TX 77030. Address reprint
requests to P. M. Conoley.

Houston,School

77225.
0361-803X/91/1576-1337
0 American Roentgen Ray Society

graph,

and each procedure

is the Relative

components

consideration
.

Value

was assigned

Scale.

The scale

of each procedure.

rates

In the assignment

was given to such factors

.

a value

in RVUs.

both

The list of these

technical

of the professional

as the training,

values

and professional

knowledge,

component,

skill, stress,

and time required

of the radiologist
to perform
the procedure.
Thus, the scale
measures
the overall reimbursable
service provided
by the radiologist
during the
procedure.
The Relative Value Scale is analogous
to the Resource-Based
Relative
Value Scale, which will be applied by Medicare to nonradiology
physician
reimbursement in 1992 [3].

Downloaded from www.ajronline.org by 202.62.17.27 on 10/12/15 from IP address 202.62.17.27. Copyright ARRS. For personal use only; all rights reserved

In this study, we used the RVU concept

to quantify
the
productivity
of radiologists
in multispecialty
group practices,
to determine
how productivity
is affected
by certain characteristics
of the practices,
and to provide a basis for analyzing
secular trends in the distribution
of radiologists
productivity
among the various
imaging
techniques.
The study accepts
the Relative
Value Scale as the measure
of productivity.
It
should be noted, however,
that only work devoted to the care
of patients
is included
in the CPI and Relative
Value Scale
systems.
Many other activities
of radiologists
do not have

RVUs assigned

to them; these include continuing

education,

research,
didactic
teaching,
clinical instruction
of residents,
and administrative
duties.
In this paper, the radiologist
resources allocated to these non-RVU efforts are removed from
the staffing analysis through
the concept
of available
radiologists, defined in the Methods
section.
The study of total professional
RVU workload
of radiologists is timely and relevant
because
the RVU workload
undoubtedly
will be compared
with the total Resource-Based
Relative
Value Scale workload
of other
specialists,
and
these workloads
will be related
by third-party
payers
to
compensation.

Twenty-two
United
States,

large, multispecialty
clinics,
scattered
across
the
that are members
of the American
Society of Clinic

Radiologists

were

asked

to

provide

a comprehensive

list

of

the

volume of procedures
performed
during
a recent
1 2-month
period for
each of the CPT codes in the Diagnostic
Radiology
section of the
Relative Value Scale [1 , 2]. Nuclear imaging and radiotherapy
proCPT

were not included

in the study.

for 1 990 were included

codes

using

these

codes,

to the procedures

New diagnostic

because

radiology

some of the clinics

were

even though
RVUs
have not yet been assigned
by ACA and the Health Care Financing Administra-

tion. We assigned the new codes AVUs equivalent

to AVUs of similar
techniques
so that all reported examinations
would be included in the
AVU analysis.
These new codes accounted
for approximately
0.7%
of the examinations
and approximately
2% of the total RVUs in the
study. No audit was performed
to determine
if the clinics used the
CPT-coding

system

accurately

were underreported
or
ences between
clinics
introduced
only random
Of the 22 clinics, 21
provided a comprehensive
included

of

duties.

radiology

Residents

staffing.

were

not included

Practices

also

were

in the quantifica-

asked

to

total number of physicians

in the multispecialty
practice.
Five productivity
indexes were calculated,
as defined
physician

index

physicians

was

calculated

(headcount)

number

in

of radiologists

was calculated

as
the

the

ratio

of the

multispecialty

(headcount)

in the

the

in Table

total

clinics

clinics.

report

1. A

number
to

of

the

An availability

total
index

as the ratio of the number of available radiologists

the total

number

radiologists

were

of radiologists,
available

indicating

to do

clinical

the fraction

work.

to

of time

A difficulty

the

index

was

calculated
by dividing the total AVU workload
by the total number of
examinations
to express in AVUs per examination
the weighted
level
of

difficulty

of

the

procedures

performed.

Finally,

two

workload

indexes were calculated:

an examination
index (the total number of
examinations
per year per available radiologist)
and an RVU index
(the total number of RVUs per year per available radiologist).
Other data were collected in the survey in order to categorize
the
clinics

according

to

selected

variables

The criteria

and resultant

clinic

Productivity

indexes

calculated

by all the

clinics

were

and

by clinic

that

groupings

might

affect

are presented

on the combined

categories

on the

workload.

in Table

data

combined

2.

submitted
data

of all

the clinics within each category.

The indexes also were calculated
for
each clinic to obtain mean values, standard deviations,
and standard
errors

of the

indexes

among

the

clinics.

Each CPT-code
was also categorized
to permit analysis
of the
workload
distribution
among examination
techniques.
The categories
were (1) general radiography
and fluoroscopy
(head and neck, chest,
extremity,
and spinal plain film radiography;
genitourinary,
gastroin-

Methods

cedures

administrative
tion

in the

RVU

or to ascertain

whether

examinations

Nine

of the

clinics

were

located

in the

Midwest,
four in the South, three in the Northeast,
and three in the
West/Southwest.
Data were submitted
for 12-month
periods with
ending dates from as early as December
31 , 1 989, to as recent as
September

30,

1 990.

Two practices

estimated

volumes for calendar-

year 1 990 on the basis of two thirds of the years work.

An AVU workload
was calculated
by multiplying
the number of
times each procedure
was performed
by its corresponding
professional-component
RVU. The sum of these individual CPT workloads

gave the entire professional RVU workload. The total AVU workload
and the total number of examinations
provided numerators for the
productivity

calculations.

Practice styles have considerable

variation
both in the amount of
time off and in types of work that cannot be expressed
in RVUs. In
determining
denominators
for the calculations,
an attempt was made

to adjust
radiologists

for these
in the

differences

practice

by reducing

by a self-reported

not available

for clinical

work.

Not available

for continuing

medical

education,

vacations,

the total
amount

of

of radiologists

deductions
academic

number

were made
activities,

musculoskeletal,

and

intrathecal

contrast

studies;

and

mam-

mography),
(2) sectional
imaging (sonography,
MA, and CT of the
head and body), (3) specials (angiography,
neuroangiography,
and
interventional),
and (4) other (unlisted procedures,
review of outside
films).

In a previous

breakdown
procedures
data.

report,

Nuclear

procedures

our analysis because

Although
the Relative
difficulty

index

category

was

been
the

attributed
1 980

Johnson

and

Abernathy

[4]

provided

by imaging technique
of projected
national
radiologic
in the United States for 1 980 that we compared
with our

AVU

reported

calculated

from

used to estimate
to that
workload

in their

study

were

excluded

in

that technique
was not included in our survey.
Value Scale did not exist in 1 980, a weighted

technique
among

the

current

data

the RVU workload

in 1 980.
techniques

Thus,
could

for

each

technique

that would
the

have

distribution

of

be estimated.

Results

overreported.
This study assumes that differin the use of the CPT-coding
system have
error into the data.
responded
to the questionnaire,
but only 19
list of CPT-code
volumes. These 1 9 were

analysis.

testinal,

and

Altogether,
these 1 9 practices
reported
3,234,451
examinations, corresponding
to 7,356,462
RVUs. These were performed
by 299 radiologists
among the total of 6055 physicians
in the clinics. The productivity
indexes are presented
in Table

2. Based on the combined

data of all clinics, the examination

index is 14,098 examinations

per year per available
radiologist, and the RVU index is 32,065 RVUs per year per available
radiologist.
If the availability
correction
is omitted,
there were
1 0,81 8 examinations
and 24,604 RVUs per year per radiologist by headcount.
The questionnaire
did not ask for volumes
of injection
codes, which should accompany
procedures
billed with supervision
and interpretation
CPT codes. Overall, 1 4,1 80 supervision
and interpretation
procedures
were reported.
Although RVUs have not yet been approved
for injection codes,
it is possible
to estimate
that approximately
90,000
RVUs
have not been counted.
Thus, in order to obtain a more
accurate
total RVU workload,
the RVU index should be increased to 32,344 to correct for these lost RVUs.
As shown in Table 2, the physician
index was high in the
single-site
practices,
in the high-prepaid
practices,
and in the

outpatient-only

practices.

The availability

index

was higher

for

outpatient practices and practices without training programs.

The difficulty index was quite low in the outpatient practices

Downloaded from www.ajronline.org by 202.62.17.27 on 10/12/15 from IP address 202.62.17.27. Copyright ARRS. For personal use only; all rights reserved

and slightly high in multiple-site

practices,
low-prepaid
practices, inpatient
practices,
and very large practices,
as well as
in those with radiology
training
programs.
The examination

indexes accentuates
the drop in general radiology from 74%
of the national RVU workload in 1980 to 52% of the clinics
RVU workload in 1989. By percentage of examinations
and
RVUS, special
procedures
remained
stable. The overall
weighted
difficulty
index for all national procedures
in 1980
was 1 .82, whereas the overall weighted difficulty index in the

and RVU indexes were higher for single-site practices, highprepaid practices, outpatient-only
practices, the large as opposed to very large practices,
and the practices without

clinic procedures

radiology

Discussion

training

programs.

Table 3 presents the breakdown of the reported examinations and the distribution
of RVUs by technique category.
Also, the 1980 data from Johnson and Abernathy
[4] are
included in the table for comparison.
Their examination categones have been grouped
to correspond
with our current
groups.
Sectional
imaging
represented
1 4% of all examinations in the clinics in 1 989 compared
with 6% of all national
examinations
in 1980, and general radiology represented
83%

of all examinations
in 1989 compared with 93% in 1980. The
weighted difficulty index of sectional imaging of 5.86 RVUs
per examination
was higher than the difficulty index for general

radiology

TABLE

of 1 .44.

1: Definitions

This

fourfold

of Productivity

difference

in difficulty

Indexes

Index

Definition

Physician

Total

Availability

Available

value

Number

Examination

Available
RVUS

Available

TABLE

2: Productivity

Indexes

(RVUs)

of examinations

Examinations

RVU

units

ACR data (Sunshine J, Mabry M, personal communication),

the examinations
in this study represent approximately
1% of
the total number of examinations
performed by radiologists
in the United States in 1 989, and the radiologists
in the study
constitute
approximately
1 % of the radiologists
estimated
by
the ACR to have been working in the United States in that

year. The ACR reported a national mean of approximately

1 1 ,700 examinations
per radiologist per year, but this estimate does not take availability into account. From the 1987
Medicare Part B Reimbursement
data (Sunshine J, Mabry M,
personal communication)
consisting of 1 1 0,000,000
examinations, mostly diagnostic
radiology, the ACR calculated a

for the Medicare population undoubtedly

is higher than the
index for the general population,
because of greater use of
sectional
imaging and special procedures
in older patients. In

year

radiologist

for Individual

Clinics,

All Clinics,

and by Characteristics

of Clinics

Productivity
Type

of Clinic or Characteristic

Indexes

No.
P1

Individual

was consulted
to provide
with our data. According
to

per year per available

radiologist.
This calculated
national
figure is probably an overestimate
because the difficulty index

year
radiologist
per

per

department
to compare

increase.

1987 Medicare difficulty index as an estimate of the national

difficulty index, and the 1989-1 990 overall availability index
from this survey as an estimate of national availability, a rough
estimate of a national RVU index can be made: 35,1 00 RVUS

radiologists

Total radiologists
Relative

The ACR research

an external reference

a 25%

nationally
weighted
difficulty
index of 2.31 RVU per examination for diagnostic
radiology procedures
performed
on Medicare patients.
By using the 1 989 ACR examination
index, the

physicians

Total radiologists

Difficulty

in 1 989 was 2.28,

Al

DI

El

Rl

clinics

Mean

Standard
deviation
Standard
error
All clinics
Number
of sites

Single
Multiple
Prepaid fraction

19

23

0.77

2.25

15,231

33,705

19

7
1 .6
20

0.07
0.02
0.77

0.24
0.06
2.27

4,577
1 ,050
14,098

7,855
1,802
32,065

24

0.77

2.15

16,410

35,268

13

19

0.77

2.31

13,551

31,306

7
12

17
24

0.76
0.77

2.31
2.24

13,440
14,750

31,017
33,104

0%

30

0.80

2.01

18,666

37,464

>0%

16

19

0.76

2.30

13,737

31,639

11

23

0.79

2.22

15,374

34,114

19

0.76

2.31

13,347

30,858

10
9

22
19

0.75
0.77

2.19
2.31

14,843
1 3,762

32,564
31,841

5%
>5%

Inpatient

fraction

residenc?
Resident

Radiology

>5 Residents
Size
300,000
RVU
>300,000
RVU

Note.-Pl
No practice

large)

index, Al = availability index, Dl = difficulty index, El = examination

index, RI = RVU index.
Dl x El = RI. Discrepancies in the products
and in the standard errors are due to rounding error.
had a radiology
training program with two to four residents.

= physician

a Theoretically,
b

(large)
(very

TABLE

3: Percentage

Distribution

of Examinations

and of Professional

Relative

Value

Units Among

Examination

1989

1980
(%)

(%)

Technique
Examinations

RVUS

Examinations

RVUS

General (radiography and fluoroscopy)

83

52

93

74

Sectional

14

37

16

10

10

Specials

imaging (CT, sonography,

(vascular,

MA)

interventional)

Other (outside films, miscellaneous)

Downloaded from www.ajronline.org by 202.62.17.27 on 10/12/15 from IP address 202.62.17.27. Copyright ARRS. For personal use only; all rights reserved

Techniques

Note.-RVUs

= relative

value

units.

1980 data from Johnson

and Abemathy

addition, almost two thirds of the radiologists

in this study are
involved
in practices with radiology training programs, which
is probably a higher proportion than in the general population

of radiologists
in the United States. Because as a group,
practices with training programs have a lower RVU index than
practices without training programs, the mean RVU index for
our study

is probably

an underestimate
of the national
RVU
index. When these two points are kept in mind and when the
standard
error of 23% is considered, this figure extrapolated
from ACR and Medicare data is fairly close to the RVU index

that we report.
In the analysis by clinic characteristics,
the high examination
and RVU indexes in the single-site clinics may indicate that
these practices are more efficient, possibly because of the
ease of scheduling work assignments,
immediate availability
of cross coverage, or less time spent in commuting. Likewise,
the high physician, examination,
and RVU indexes of highprepaid
practices
corroborate
the managed-care
philosophy
of high-volume,
low-cost care. Of interest, the difficulty index
is lower in the prepaid practices, possibly because utilizationreview processes control access to the more advanced imaging procedures.
The higher difficulty index of practices with an inpatient
component
is due to the admixture of high RVU procedures
such as interventional
and angiographic
work in the inpatient
setting. However, the higher availability, physician, and examination indexes in the outpatient-only
practices compensated for low difficulty, so that the workload as measured by
RVU index was 18% greater in the outpatient-only
setting
compared with the inpatient setting.
The practices with radiology training programs had a higher
difficulty index but lower examination
and RVU indexes than
practices without training programs. The lower productivity
may be due to an intrinsic inefficiency in teaching residents
during film interpretation;
however, this teaching is a valid
activity

within

the mission

of the sponsoring

organizations.

It

simply is not measured by RVUs.

Seven of the nine very large practices (>300,000
RVUS/
year) have training programs, whereas only one among the
10 large practices (s300,000
RVU5/year)
does. Thus, the
categorization
by size largely duplicates
the trends in the
training/nontraining

category,

with

difficulty

indexes

higher

and workload indexes lower in the very large (training) clinics

than in the large (nontraining) clinics.
The 1 % of injection code RVUS not included in the survey
data were spread fairly evenly among the practices (0.014.05%) and probably do not represent a systematic
error.
These lost RVUs, however, may also represent lost revenues to the practices if corresponding
injection codes were
not billed
dures.

along

with

supervision

and

interpretation

proce-

[4] are included

for reference.

Finally,

Johnson

and Abernathys

study

[4] was

designed

to project overall national volumes of examinations

for 1980
and the distribution
of examinations
among techniques. Our
data show actual examinations
performed
by a subset of
practitioners in multispecialty
clinics in 1989. Although extrapolation

of our data

to give

an estimate

of the 1 989

national

distribution
is beyond the scope of this study, it is plausible
to suggest that the dramatic shift of RVU workload
from
general radiology to advanced imaging techniques (Table 3)
reflects trends in the national data.

Conclusions
This study

attempted

to quantify

work

devoted

to the care

of patients that is included in the CPI and Relative Value

Scale systems. The results of this RVU analysis are similar to
the results of extrapolations
based on ACR and Medicare
data. Many other non-RVU activities of radiologists
do not
have assigned RVUS but must be recognized as productive
work. As third-party
payers shift to RVU-based methods of
reimbursement,
tial to include

accurate
and complete
coding will be essenall the billable RVUs; injection
codes, in partic-

ular, must not be neglected. The RVU method allows analysis

of the distribution
of workload among the various imaging
techniques,

which

can be used

to study

trends

in utilization.

Although this method was developed for comparing radiology

practices within multispecialty
groups, it can be used to
evaluate other radiology practice settings, and it can serve as
a model for making workload comparisons
among specialties.

ACKNOWLEDGMENTS
We express appreciation
to Michael Lenker
for helpful editorial suggestions,
Virginia

of Kelsey-Seybold
Heckel of Kelsey-

Clinic

Seybold

Foundation

Mike Nelson

Crump

of Park Nicollet

Cancer

Center

Medical

for

Center,

statistical

Ochsner Clinic, Reilly Kidd of Mason Clinic, Timothy

lace Medical

Center

for

naire and methods,

and

suggestions

all respondents

regarding

assistance,

Merritt
of
Parker of Love-

Christopher
the

survey

question-

to the questionnaire.

REFERENCES
1 . Medicare programs:
fee schedules
for radiologists services. Federal Register. March 2, 1989;54:8994-9023
2. American
Medical Association.
CPT: Physicians
Current Procedural
Terminology.
Chicago: American
Medical Association,
1990
3. Hsiao WC, Braun P, Becker ER, et al. A national study of resource-based
relative value scales for physician
services:
final report to the Health Care
Financing
Administration
(Publication
17-C-98795/1-03).
Cambridge,
MA:
Harvard School of Public Health. September
1988.
4. Johnson
JL, Abernathy DL. Diagnostic imaging procedure volume in the
lhiited States. Radiology
1983;146:851-853