The Math of Private Practice Radiology

There’s a lot of mystique behind radiology and the numbers- the salary, the workload and vacation. A lot of misunderstandings of what is possible and the norm- now that I’m a few years in and involved in the finances of my group, I thought I’d give a breakdown.

Disclaimer: This only works for private groups that are paid on productivity (most are in some way, mostly at the group level). Academic, employed and VA jobs don’t follow this exactly, as there are intangibles.

So for an equation:

Compensation= Avg RVU/day x Avg $ per RVU x Total Days Worked

Total Days Worked= 260 weekdays in a year + weekend calls - vacation days

Pretty straight forward, but wanted to break down the components a bit.

First- the RVU (or wRVU for our discussion)

For every, there is an RVU numeric value assigned that is decided by CMS (center of medicaid and medicare services). In reality, there is a number for actually scanning the patient (technical fee) and then a separate value for generating the report (professional fee). Vast majority of radiologists will only ever see the professional fee- unless you’re in the small niche that own their own scanners. There is a small adjustment to the RVU value for where you practice, but just going to ignore that for now.

Some examples of RVU:

CT Abdomen & Pelvis with contrast - 1.8

Screening Mammogram with Tomo- ~2.0

This goes to the first component of the equation- Avg RVU/day. This is decided by 1. How busy you work which is obvious, but more nuanced is 2. Case mix . With those RVU examples above you’d imagine they take similar time to dictate but they don’t- reading an average CT Abd & Pelvis with contrast takes 5-10 minutes, however a Screening Mammo with Tomo is 3 minutes. So in an hour, a rad reading only CT APs would maybe generate 12- 20 RVU (usually on the lower end of that), but a dedicated breast radiologists could theoretically hit 40. Luckily for us non-breast rads, most groups just pool all their RVUs and pay everyone the same. We’ve figured out a long time ago that RVUs =/= how hard you work. However, a group that has a higher percentage of breast radiologists will have a higher avg rvu/day. From my experience, for non breast rads, 50-60 rvu/day is the norm and a decent/busy pace for an 8 hour day, where mammo can hit 100 easily. More RVUs will require longer days, or reading at an uncomfortable pace/requiring more time off to recover.

On to the next component, and arguably the most important, the average $ per RVU. Most groups bill their patients themselves, and I’ll assume that model (some just get paid a set amount by their employer/hospital). A lot think this is a fixed amount, as CMS comes out with a number ($33/rvu for 2023), and most insurances go near that number. But there is a lot of variability here, based on what type of insurance your patients have and how much $ you actually collect. Imagine a scenario of an uninsured patient coming through the ED for a CT Chest Abdomen Pelvis vs an outpatient, well insured, preauthorized outpatient CT CAP- you may collect $0 on the first one and the full amount on the second, but both require similar work and have the same RVUs. For some guidelines- $30 per RVU is pretty bottom of the barrel, saved for pure teleradiology. $40 is not bad, $50 is great and $60 is amazing and requires an amazing payer mix, and even you getting some extra payment from your hospital/employer (likely coming from the technical component).

Next up, the working days. This is where you hear a lot of variability, from 6 weeks/30 days vacation (think VA) up to 20 weeks/100 days. This is really up to the group and also dependent on their call responsibilities. If you cover a lot of hospitals, you may have call every 3rd week, driving up the days worked. Some take all their vacation in week blocks, some want 4 day work weeks. The average total days worked is around 210, which is 260 working days in a year, minus 12 weeks vacation, plus 10 yearly calls. But going back to the equation, you can’t have it all…

Imagine you want to make 500k and have 15 weeks of vacation. Ignoring call, this breaks down to:

500k/185 days worked = $2700/day. If you work is a less than ideal environment, with less mammo and lower $ per RVU, say $35, you’ll need to do ~77 RVU per day. You either have to do a real busy ~10 RVU per hour for 8 hours, or a still busy 8.5 RVU/hour for 9 hours.

On the other hand, if you work in a high reimbursement practice, with high mammo, you could work 185 days worked x 60 RVU a day (nice pace) x $55/rvu= $610k. Less work per day, same vacation, higher pay.

Both types of practices exist, and you just have to decide what you want (or what’s available). I prefer a reasonable pace, less vacation but several want to work hard and play hard. There are practices where partners make 7 figures, but are literally working 12 hour days, with a ton of call (to allow for vacation). I don’t think that is sustainable or enjoyable, but to each their own. Then you have the VA, with its 5k RVUs but 300k compensation and low vacation. You can’t have it all.

**These salary numbers end up being “total compensation”, you may have to subtract a bunch of stuff including but not limited to malpractice insurance, healthcare, etc etc.

**Also, these are the numbers when you're a partner in the practice and splitting the profits. Associates or new comers on the partner track will just make a set $ amount, usually 50-70% of a partners salary. Those numbers are not that important imo, as long as the practice is sound and makes everyone partner (most do).

Some notes:

Mammo reimbursement will come down- it’s not an if, just a when. Neuro used to be the money maker (more so than mammo), and that changes. Most groups that have more mammo are usually because the population needs it, it’s unlikely to just expand that for the sake of more RVUs (not really possible to say come here for mammo but none of your other imaging needs). That said, targeting a practice with higher outpatient:inpatient ratio on average will lead to higher pay for the same amount of work and overall less call.