Original Contribution

Economics of Medical Toxicology Practice Based on Patient Scenarios

 

Paul Wax, MD
Department of Emergency Medicine
University of Rochester School Of Medicine
Rochester, New York

Int J Med Toxicol 2002; 5(1): 3


 

Abstract

We conducted a professional fee study to assess whether medical toxicologists generate revenue with their clinical practice or provide care gratis. In 1997-1998 a written survey was mailed to all current ACMT members regarding work force issues pertaining to medical toxicology. Questions about time involved in bedside patient care and professional fee practices were asked about two patient scenarios: 1) inpatient evaluation of hypotensive verapamil SR overdose, 2) outpatient toxicology evaluation of a steel worker presenting with multisystem complaints. Sixty eight percent (160/236) of current ACMT members completed the survey. Responders reported that 70% perform inpatient bedside evaluations and 56% perform outpatient evaluations. Mean time spent on inpatient evaluations was 2.6 hours. Fifty percent charged for this service but the other 50% did not generate a professional fee or did not know if a professional fee was generated, or how much was charged. Median projected professional fee and collection were $280 and $150 respectively. For outpatient evaluations mean evaluation time was 3.5 hours and the median professional fee and collection rate were $300 and $200 respectively. While many toxicologists are able to generate revenue for their clinical services, a large minority practices clinical toxicology without reimbursement, especially for inpatient evaluations.

Background

Medical toxicology is one of the newest recognized medical specialties. Its recognition by the American Board of Medical Specialties during the 1990s came during a time of rapidly changing medical reimbursement and significant fiscal tightening. Compared to other medical specialties, the number of board certified medical toxicologists is very small. Little is known about the professional fees of those few who practice medical toxicology. We conducted a study to assess whether medical toxicologists generate revenue with their clinical practice or provide care gratis.

Methods

In 1997-1998, a written questionnaire was mailed to all current American College of Medical Toxicology (ACMT) members regarding work force issues pertaining to medical toxicology. Questions were asked about the amount of time spent providing bedside patient care and billing practices in regard to two patient scenarios. The first scenario involved an inpatient evaluation of a 70-year-old who ingests 50 verapamil SR and presented to the hospital with a blood pressure of 60 mm Hg systolic and a pulse of 45 beats/min. The second patient scenario involved an outpatient evaluation of a 50-year-old steelworker complaining of 4 weeks of SOB, abdominal pain, headaches, and fatigue. Job duties of this steelworker included torch cutting painted steel and spray painting. Respondents were asked about how much they would charge for each scenario and how much they would expect to collect. Demographic data and information about whether inpatient medical toxicology services are provided by the medical toxicologist as the attending physician or consultant were also asked. Data was also analyzed by geographic location, primary specialty and percentage time devoted to medical toxicology. Per hour charge and collection projections were calculated by dividing billing and collection data for each evaluation by the mean total number of hours for each evaluation.

Results

Of 236 surveyed ACMT members, 160 (68%) responded. 147/160 (92%) are currently practicing medical toxicology. Of the 147 currently practicing, 70% (103/147) perform inpatient bedside evaluations and 56% (83/147) perform outpatient evaluations. Completed information was available on 94 who perform inpatient consultations and 74 who perform outpatient consultations. Regarding inpatient evaluations, 22% (21/94) of the respondents perform medical toxicology evaluations as the attending physician and 78% (73/94) provide consultations but do not serve as the attending physician.

The mean estimated time spent performing the hypothetical inpatient evaluation was 2.6 h of which 2 h was spent at the bedside and 0.6 h was report preparation time (Table 1). Attending evaluations were projected to require 28% more time than consultant evaluations.

Fifty percent (47/94) of respondents would have billed for this inpatient evaluation scenario and know how much they charged (Table 2). Only 37% of respondents would also have collection information. Of the remaining 47 respondents (50%), 32% would have incomplete professional fee information (either did not know if they charged or did not know how much they charged) and 18% would not charge for this evaluation. Inpatient attendings are more likely to have specific charge and collection information than consultants.

Based on the information provided by the 37% (n=35) who knew how much they would have charged and collected, the median professional fee would have been $280 (mean $371, range $35 to $2500) and median collection was estimated to be $150 (mean $210, range $18 to $720), a collection rate of 54%. Charge and collection projections were considerably higher for attendings than for consultants (Table 3). Per hour charges and collection projections are shown in Table 4.

For the outpatient evaluations, estimated mean time spent at the bedside was 1.5 h and mean time preparing the report was 2 h. Thirty-eight of the 74 (54%) would have charged a professional fee for the patient services and would track the revenue collected. Fifteen percent charged but did not know how much they collected. Twenty-three percent would have incomplete charge information and 8% would not charge for these services.

Based on the information provided by the 54% who knew how much they charged and collected, the median outpatient professional fee was projected to be $300 (mean $454, range $30 to $1500) and median collection rate was projected to be $200 (mean $388, range $30 to $2500), a collection rate of 67%. Per hour billing and collection projections are shown in Table 4.

Geographic and specialty variation was considerable. Billing and collections were highest in the western states and lowest in the southern states (Table 5). Regarding primary specialty, occupational medicine physicians charged and collected the most while pediatricians charged and collected the least (Table 6). Those who practiced toxicology 100% of the time generated larger bills and collections than part-time toxicologists (Table 7). Billing variation among geographic region, primary specialty, and percentage of time devoted to toxicology was similar for outpatients and inpatients.

Discussion

This study suggests that a large proportion of medical toxicologists do not appear to keep a close accounting of clinical revenues generated by their bedside patient encounters. When presented with two patient scenarios, only 37% responded that they would have professional fee and collection information on the inpatient encounter; 54% would have this information on the outpatient encounter. Regarding the inpatient scenario, almost 1 in 3 did not know if they charged or did not know how much they charged and almost 1 in 5 clearly stated they did not charge. Although medical toxicologists acting as the inpatient attending were more likely to have professional fee information than their medical toxicologists serving in a consultant role, over 1/3 of the attendings did not have complete professional fee information despite the fact they were the attending with the primary responsibility for the patient.

From the data that we have collected on projected professional fees and collection for the two patient encounters, the responding medical toxicologists with occupational medicine credentials would charge and collect more clinical revenue than other medical toxicologists. This is particularly true regarding the outpatient scenario. The reason behind this pattern may be due to the fact the occupational medicine physicians are more familiar with the outpatient clinic setting and may be more accustomed to performing workmenís compensation evaluations. Furthermore, occupational medicine physicians may be more likely to generate revenue on a fee for service basis, versus the salary arrangements of most emergency physicians. The typical emergency physician cares for whoever presents to the Emergency Department, and is often considerably removed from the departmental professional fee process.

Responding medical toxicologists who practice medical toxicology full-time report that they would charge and collect considerably more on those patient encounters than those who are not full time medical toxicologists. This suggests that part-time toxicologists, who are financially supported outside of their toxicology activities, may be less motivated to maximize their toxicology clinical revenues since they are less dependent on them to generate a salary.

Projected hourly professional fee and collection data suggests that the median hourly collection rate is $58 for inpatient evaluations and $57 for outpatient evaluations. This collection rate is somewhat higher for inpatient attendings, $86, and was only $40 for inpatient consultants. Compared to the typical Emergency Department attending reimbursement that is often in excess of $80 to $100 per hour, toxicology billing reimbursement for clinical activities appears to be considerably less. Independently practicing medical toxicologists would have to first pay office expenses (including malpractice) out of the $57 or $58 per hour collection rate. Furthermore, if patients were only being seen sporadically, those hours not seeing toxicology patients would not generate toxicology clinical revenues. In contrast, emergency physicians are often paid per hour after expenses and work with a guarantee of the same per hour salary for every hour of a work shift (usually 8-12 hours per day). The substantial differences between emergency medicine clinical revenue generation and toxicology revenue generation may act as a disincentive to those hoping to make a living comparable to emergency physicians by caring for medical toxicology patients.

This survey has a number of methodological limitations. Limitations of the study include the fact that the respondents were asked information on hypothetical patient encounters. Professional fee information responses were not actual data on real patients. While it is important to report that the majority of medical toxicologists donít charge or have little information on their charges, the actual number of medical toxicologists who had complete information on professional fees and collections was relatively small. Despite two mailings, only 68% completed the survey raising the possibility of some selection bias in the responses. The non-respondent may have been less likely to be practicing medical toxicology or generating professional fees for these services.

Another conclusion of this study is that there are relatively few practicing medical toxicologists in the United States. This finding of 103 respondents who provide inpatient care is similar to a report in 1992 of 195 who provided direct patient care.1 That report included some who were not board-certified and others who practiced outside the US. If it is assumed that our responders represented the great majority of practicing toxicologists in the US, it appears that the number did not markedly change in the intervening 6 years.

In summary, only 37% of medical toxicologists who care for inpatients know how much they charge and collect for their professional services. In many of the remaining 63%, medical toxicology, as a means of making a living, appears to be more of an unreimbursed academic activity. Attendings bill 2.2 times as much and collect 2.75 times as much as consultants when caring for inpatients. Complex outpatient evaluations often require considerable time to see the patient and write the report (mean 3.5 hours for outpatient vs 2.6 hours for inpatient evaluations). Median per hour reimbursement for toxicology evaluations ranges from $40 for inpatient consultants to $57 for outpatient consultants to $86 for inpatient attendings.

Despite the finding that a large number of toxicologists do not charge for services, toxicologic practice has been shown to be financially feasible. In a study of a single toxicology consulting practice in 1994, there were mean billings of $248.17 per patient for 132 patients.2 This is greater than the means in our study for consultants, and reflects the disparate professional fee practices between groups. Receipts were $86.86 per patients, for a collection rate of 35%. This was greater than their emergency department professional collection rate of 26%. In our study, the hourly billing collection of $86 compares favorably to many other specialties nationwide. Collections were much greater for toxicologist in the Western US and for occupational toxicologists, who collected $354 and $463 respectively per patient. Therefore, it appears that those practiced and knowledgeable in professional fee practices can develop a financially feasible medical toxicology practice. For the others, further education and assistance in medical economics may be warranted.

References

  1. Donovan JW, Goldfrank L. survey of medical toxicologist practice characteristics specialty certification and manpower needs. Vet Hum Toxicol 1992;34:336.
  2. Walter F, Alam G, Fernandez M. Bedside toxicology consulting: a feasibility assessment. J Tox Clin Tox 1995;33:506

Table 1. Estimated Inpatient Evaluation Hours for Hypotensive Verapamil SR Overdose Case

 

Bedside Hours

Report Hours

Total hours

Attendings (n=21)

2.8

0.4

3.2

Consultants (n=73)

1.9

0.6

2.5

All (n=94)

2

0.6

2.6

Table 2. Professional Fee Practices for Inpatient Scenario

 

Charge Info. Known Collection Info. Known

Charge Info. Known Collection Info. Not Known

Charge Info. Not Known

Did not Charge

Attendings (n=21)

57%

5%

38%

0%

Consultants (n=73)

32%

15%

30%

23%

All (n=94)

37%

13%

32%

18%

Table 3. Projected Professional Fees and Collections for Inpatient and Outpatient Scenarios among Medical Toxicologists

   

20th Percentile

50th Percentile

80th Percentile

Inpatient (all) (n=94)

Charge

$150

$280

$500

 

Collect

$65

$150

$300

         

Inpatient (attending) (n=21)

Charge

$240

$550

$1200

 

Collect

$161

$275

$600

         

Inpatient (consultant) (n=73)

Charge

$118

$250

$300

 

Collect

$46

$100

$200

         

Outpatient (n=74)

Charge

$150

$300

$580

 

Collect

$75

$200

$560

Table 4. Projected Hourly Professional Fee and Collections for Inpatient and Outpatient Scenarios Among Medical Toxicologists

   

20th Percentile

50th Percentile

80th Percentile

Inpatient (all) (n=94)

Charge

$58

$108

$192

 

Collect

$25

$58

$115

         

Inpatient (attending) (n=21)

Charge

$75

$172

$375

 

Collect

$50

$86

$188

         

Inpatient (consultant) (n=73)

Charge

$47

$100

$120

 

Collect

$18

$40

$80

         

Outpatient (n=74)

Charge

$43

$86

$166

 

Collect

$21

$57

$160

Table 5. Professional Fee Practices by Region

 

Inpatient

Outpatient

 

Charged

Collected

Charged

Collected

Northeast

$270

$127

$243

$179

Midwest

$309

$190

$281

$181

South

$188

$138

$125

$75

West

$628

$354

$768

$697

Table 6. Professional Fee practices by primary specialty

 

Inpatient

Outpatient

 

Charged

Collected

Charged

Collected

Emergency Medicine

$427

$235

$421

$355

Pediatrics

$157

$85

$149

$96

Occupational Medicine

$650

$463

$908

$875

Table 7. Professional Fee practices by %FTE as a toxicologist

 

Inpatient

Outpatient

 

Charged

Collected

Charged

Collected

100% FTE

$1160

$600

$847

$847

50-99% FTE

$354

$190

$276

$206

< 50% FTE

$272

$180

$267

$203



Journals Home  | Past Issues | Search | Send Comments to ACMTNet

Copyright 1999-2003, American College of Medical Toxicology.