Actual and potential effects of medical resident coverage on reimbursement for inpatient visits by attending physicians.

Abstract

CONTEXT: The impact of residents on hospital finance has been studied; there are no data describing the economic effect of residents on attending physicians. OBJECTIVE: In a community teaching hospital, we compared allowable inpatient visit codes and payments (based on documentation in the daily progress notes) between a general medicine teaching unit and nonteaching general medicine units. DESIGN: Retrospective chart review, matched cohort study. SETTING: Six hundred fifty-bed community teaching hospital. PATIENTS: Patients were discharged July 1998 through February 1999 from Saint Barnabas Medical Center. We randomly selected 200 patients in quartets. Each quartet consisted of a pair of patients cared for by residents and a pair cared for only by an attending physician. In each pair, 1 of the patients was under the care of an attending physician who usually admitted to the teaching service, and 1 was under the care of a usually nonteaching attending. Within each quartet, patients were matched for diagnosis-related group, length of stay, and discharge date. MAIN OUTCOME MEASURES: We assigned the highest daily visit code justifiable by resident and attending chart documentation, determining relative value units (RVUs) and reimbursements allowed by each patient's insurance company. RESULTS: Although more seriously ill, teaching-unit patients generated a mean 1.75 RVUs daily, compared with 1.84 among patients discharged from nonteaching units (P =.3). Median reimbursement, daily and per hospitalization, was similar on teaching and nonteaching units. Nonteaching attendings documented higher mean daily RVUs than teaching attendings (1.83 vs 1.76, P =.2). Median allowable reimbursements were $267 per case ($53 daily) among teaching attendings compared with $294 per case ($58 daily) among nonteaching attendings (Z = 1.54, P =.1). When only the resident note was considered, mean daily RVUs increased 39% and median allowable dollars per day 27% (Z = 4.21, P <.001). CONCLUSIONS: Nonteaching attendings appear to document their visits more carefully from a billing perspective than do teaching attendings. Properly counter-documented, resident notes could substantially increase payments to attending physicians.