Establishing a Compensation Model in an Academic Pathology Department

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1 Establishing a Compensation Model in an Academic Pathology Department William M. Hynes, MHSA, and Donna H. MacMillan, MT(ASCP), MBA Key Words: Academic pathology practice; Compensation; Salary model DOI: /WDYTWNWY31ACQE0X Abstract Formal compensation models can be a valuable tool in building a strong academic pathology department. A good compensation model can increase staff satisfaction and academic productivity. A critical element to developing a well-accepted model is that the model emphasizes the core values and priorities of the department. This article highlights how the Pathology Service at Massachusetts General Hospital (MGH) created a compensation model for its Anatomic Pathology and Laboratory Medicine division, from early discussions through rollout. It also examines the impact that the salary model has had at MGH in the 4 years since it was rolled out. The past 10 years have seen a significant increase in literature and practice for the use of formalized compensation models for physicians in all disciplines. Given the expectations of greater productivity and the realities of shrinking or constant reimbursement, providers have challenged the history of establishing compensation, often based on intangible factors, with a system that is transparent and rewards the activities of greatest value to the group. Academic pathology practice is not immune to this changing environment. Given the delicate balance of tripart missions and expectations, departments can benefit greatly from establishing formal models for determining staff compensation. Improved staff productivity, morale, and retention are among the benefits that can and should result from a well-designed compensation model. Massachusetts General Hospital Experience In January 2001, the chief of the Massachusetts General Hospital (MGH) Pathology Service convened a group of senior divisional leaders in anatomic pathology to evaluate how compensation could be better tied to staff performance. Historically, compensation decisions were at the discretion of the chief, who considered factors such as administrative role, academic productivity, and comparison with other staff with similar years of service. The chief s charge was simple: develop a compensation model that matched the values of the department and expectations of our staff. S8 S8

2 Developing the Anatomic Pathology Model Participation To move the discussion in a timely manner, the group was limited to 5 participants, 4 senior pathologists responsible for critical aspects of the mission (research, training and education, staff sign-out, and academic development) and the departmental finance director. Although this subset did not ensure direct representation of staff at each academic level or interest, it was decided this makeup would sufficiently represent all needs while being small enough to reach a quick consensus. The directive to the group was to be flexible and think globally beyond their own position toward what pathologists at all levels face in building their careers. Establishing Core Values The first exercise the group undertook, before any financial analysis or evaluation of current compensation, was to establish the core values of the MGH Anatomic Pathology division what it is we wanted to reward and how. Through the course of several meetings, we were able to establish these guiding values: academic performance and productivity as determined by Harvard Medical School (HMS) rank, clinical sign-out load and availability, generation of external funding, and administrative responsibilities on behalf of the hospital and department. These 4 criteria became the foundation of compensation for the anatomic pathology division. An additional core value established early in the process was that the model was meant to support and enable all staff for the future without negative impact on compensation. Thus, it was established that no staff person s salary would be cut as a result of implementation of the model. Financial Philosophy Before establishing a model and calculating compensation, the group also discussed how compensation would fit within the overall framework of the department. We determined that the level of funding for compensation each year would be the end product of our budget process. After determining our operational expenses, commitments to research and training, and margin needed to fund our academic mission for the future, we would distribute the remainder toward salaries, thus securing that the compensation model would not jeopardize the financial security of the division or the department. Components of the Anatomic Pathology Compensation Model Academic Component The most important value recognized in the department was academic performance. Thus, we created the academic component to recognize advancement of HMS rank. The major element of the academic component is the level of credit at each level. Salary credit by rank increases by steps, providing a salary increase for each academic promotion. The escalation in salary credit grows as rank grows, reflecting the fact that it is harder to move from associate professor to professor than it is to move from instructor to assistant professor. In addition to academic rank, credit is given for years since postresidency training. A defined dollar credit per year, up to a maximum of 10 years service, was included. The credit has 2 values: First, it provides a means to differentiate salary for seniority of newer staff. Second, it reflects the fact that as staff members continue in their careers, they gain more knowledge that increases their academic value. The 10-year maximum was based on the premise that at 10 years, the staff person s increased knowledge and academic value would be reflected through the differentiation from growth in academic rank. A third element of the academic salary is credit for a fellowship. This defined dollar amount credit is provided in recognition of the detailed knowledge gained in a postgraduate training program. Last, staff members with hospital leadership positions often have hospital appointments that are 1 step higher than their HMS rank. In these limited cases (only 2 staff), an additional credit was provided to the academic base. Administrative Responsibility Pathology staff members who assume major administrative roles within the department or hospital were credited with an administrative payment that represents their percentage of effort calculated at the established Medicare projected rate for a full-time pathologist as published in the Federal Register. In establishing this standard, the department sought to compensate consistently for the job, not the person doing the job. In this manner, the position of residency program director has an established value, regardless of the level of staff person in the position. Staff with defined administrative responsibility have their clinical sign-out expectations reduced accordingly. To assess who qualifies for administrative credit and for how much credit, a small committee was created to evaluate the job descriptions, including relevant information such as number of employees managed, time spent per week in activity, reviews of scheduled committees and meetings, and the ongoing nature of the responsibility. This small working committee reviewed the data submitted by administrative leaders and established new standards and credit levels. Subspecialty Heads of Service The MGH Anatomic Pathology division is a subspecialty practice, with staff members practicing in 14 S9 S9

3 Hynes and MacMillan / COMPENSATION IN ACADEMIC PATHOLOGY subspecialties. Each subspecialty service has a leader who is a senior clinician responsible for coordinating staffing, reviewing difficult cases with staff, and working with the training program and clinical services of the hospital to improve patient care and teaching. These leaders are provided a salary credit to reflect their roles. The amount credited varies per service, depending on the size and scope of the service and the number of practicing clinicians. Subspecialty leaders do not receive a reduction in their expected clinical service time. External Funding A direct funding element of the model is external funding. This can range from things such as National Institutes of Health funding to hospital or external laboratory directorship funding. Credit is given at the actual rate of salary and benefits generated from these outside functions. In our model, staff members could use a portion of this funding to supplement their income if they maintain full clinical loads. One challenge we encountered relative to external funding was the National Institutes of Health salary limits on salary for staff. Our model includes only actual dollars brought in from external sources to maintain budget neutrality. The uncompensated salary for people over the cap is absorbed by the academic salary component for these staff members. The cap currently impacts only the staff members at the professor and associate professor levels. Clinical Service The remainder of the salary model is derived from the clinical service responsibilities as measured by average relative value units (RVUs) per sign-out pathologist. To balance the service coverage of our subspecialty structure, we do not assign clinical income by a strict actual RVU basis. We assign work based on a modified RVU structure that adjusts traditional RVUs by service, which allows us to give RVU credit for autopsies and to adjust RVU credits on services in which dedicated fellows or other staff help support our billed activity. Services are weighted every 6 months to determine actual weeks on service required, with the expectation that all staff do the same level of modified RVU activity based on their clinical service load. Based on this balancing, we then establish a rate of RVUs per full-time equivalent (FTE) staff member. This number is multiplied by the percentage of sign-out responsibility and the value per RVU to generate a clinical service salary component. The dollar per RVU figure is based on the net revenue available for distribution, after factoring for practice expenses, administrative expenses, contributions to research and teaching, and an established operating margin to grow in the future. It also backs out the dollars previously committed for the academic component of salary. What is left for distribution is divided by the total RVUs generated for the most recent 12-month period to determine dollars per RVU. Under the anatomic pathology compensation model, as a staff person grows in his or her career, the percentage of salary from the various components will shift, with a growing portion being related to academic status. A sample for 4 clinically focused staff at different levels in their careers shows how salary makeup will change under the model Table 1. Creating a Laboratory Medicine Model Two years after the implementation of the salary model in anatomic pathology, we began discussions about applying the model to the laboratory medicine division. Despite being a separate division with a different professional focus, laboratory medicine is an equal part of the MGH pathology department. Therefore, it was desired and expected that the laboratory medicine model would be consistent with the model established in anatomic pathology. Although it was possible to incorporate some of the major elements into the laboratory medicine model, there Table 1 Examples of Salary Components From Clinically Focused Pathologists * Faculty Status Assistant Professor, Associate Professor, Full Professor, Full Sign-Out Instructor, Full Minimal Grant Support, Sign-Out Offset by Offset by Administrative Salary Component Sign-Out Full Sign-Out Administrative Responsibility Responsibility Academic Administrative Subspecialty head 5 8 External funding 12 Clinical sign-out * Data are given as percentages. S10 S10

4 was a need to adjust the overall model given the significant differences in clinical scope and responsibility. As a result, we were able to establish a new version for laboratory medicine based on consistency with anatomic pathology where appropriate, yet recognizing the differences in expectations related to clinical service. Developing the Laboratory Medicine Model Participation As with anatomic pathology, the first step in developing the laboratory medicine model was assembling a group to work on identifying values and establishing the approach for a compensation model. The director of laboratory medicine convened a group that represented all aspects of the division: physician and doctorally prepared directors, all academic ranks, those with direct patient care responsibilities, and those focused exclusively on directing a laboratory. A group of 4 professional staff members, along with the department finance director and divisional administrative director, met to review the anatomic pathology model and identify areas of commonality and difference. The group was flexible in its approach and discussion, which helped facilitate the process. The framework established by this small group was further enhanced and presented to the entire laboratory medicine staff for discussion at a staff meeting. Based on the feedback provided by the rest of the division s professional staff, the final model was established and implemented. Establishing Core Values As HMS faculty, the group readily accepted the values of academic productivity and performance that were identified in the anatomic pathology model. This was critical because there needed to be consistency in the overall department s view of its mission. Other common values with the anatomic pathology model were the recognition of administrative responsibility and the goal of outside funding. Another core value that emerged was related to the director s role in running the highest quality laboratory operations that met the needs of MGH patients and clinicians. To this end, we needed to build a method to accurately reward the effort and complexity of directing these operations. As part of this discussion, the group had extensive discussions about whether there was additional value to having a physician laboratory director. There were 2 potential arguments that supported such a case. First, there is a compensation market differentiation, and it was suggested that this differential be established in the model. Second, a case was made that a physician director could more effectively work with clinicians on issues of testing that would be of greater impact on clinical care. Although the initial model included a physician differentiation, it was removed in the final model owing to staff perception that it did not provide a measurable value of increased laboratory performance to warrant separate credit. The final core value established by the group initially and modified by the larger group in the end was the value of resident teaching. Unlike anatomic pathology in which resident teaching happens every day as part of the sign-out process, resident teaching in laboratory medicine is more lecture-based. The group believed that minimum levels of resident teaching, as measured by lectures given, needed to be established to set staff expectations. In addition, it was thought there was merit in rewarding staff who assumed large teaching loads. Components of the Laboratory Medicine Compensation Model Academic Salary Component and Administrative Credit The same components of rank, years posttraining, and fellowship that are the foundations of the anatomic pathology model were used in developing the laboratory medicine model. Likewise, calculation for administrative credit followed the same approach in both divisions. The process was made easier by the previously established benchmarks because some administrative roles in laboratory medicine mirrored those of anatomic pathology. Laboratory Director RVUs Whereas anatomic pathology clinical work has a quantifiable measure in RVUs, the laboratory medicine division is not as easily quantified. Therefore, we needed a method for measuring scope and complexity of positions. Our approach was to establish a modified RVU basis related to laboratory director effort. Credits were assigned to directors based on key elements related to laboratory operations, with each director accumulating RVUs for his or her role. Total RVUs for laboratory directorship were divided into the overall pool of hospital support for laboratory directors (net of academic and administrative credits) to establish director dollars per RVU. This measure was multiplied against the accumulated RVUs for each laboratory director to determine the clinical compensation level. Laboratory directors are assigned as 1.0 FTE initially. The percentage of effort related to director activity was reduced to reflect efforts related to research, outside directorships, and professional billable activity. The modified RVU method provided credits based on the following elements. S11 S11

5 Hynes and MacMillan / COMPENSATION IN ACADEMIC PATHOLOGY Budget The laboratory s nonsalary budget component was assigned RVUs based on overall size: budgets of less than $1.5 million in nonsalary expense were credited 1 RVU; budgets of more than $1.5 million in nonsalary expense were credited 2 RVUs. Directors who manage overall operations with assistant directors were credited with RVUs for the total amount of budgets within the operation (eg, the microbiology director received RVUs based on the budget for molecular diagnostics and main microbiology even though the assistant director managed the molecular testing operation directly). Budget management is a key expectation for laboratory directors, and effort and complexity are assumed to grow as budget grows. Number of Employees The number of employees within the laboratory director s control was a second point of RVU differentiation. Complexity in management grows as the number of staff to be managed increases. Laboratories with up to 30 FTEs under their directors were credited with 1 RVU. Those with more than 30 FTEs under their directors were given credit for 2 RVUs. Laboratory Schedule The hours of operation were a third factor of differentiation. RVU credit was given for each of the 3 possible shifts per day. Directors with 24-hour responsibility for 7 days per week were given credit for 3 RVUs, whereas a single shift operation produced 1 RVU. Laboratory schedules increase the complexity of balancing staff and identifying test menus and schedules for testing. Clinical Service Professional staff in laboratory medicine are compensated for professionally billed clinical services much in the same way as the anatomic pathology model works. A dollars per RVU is established based on the net revenues of the practice less costs related to administration; academic, teaching, and research support; and other divisional commitments. Each clinical laboratory service is weighed based on RVUs generated. Individual staff are credited for clinical salary based on sign-out schedules for that service. Determination of the percentage of effort assigned for clinical work is based on the RVU per staff member established for anatomic pathology. External Funding As with the anatomic pathology model, funds generated through grants are a direct contribution to staff compensation. Any grant support is paid based on approved budgets. A variation in the laboratory medicine model is related to support from outside medical directorships. Under the current model, for every dollar of revenue brought into the professional practice for providing laboratory director services outside MGH, half of the money is provided to the director in the role and half is retained by the professional practice to help offset indirect costs related to providing these services. Teaching Much of the teaching responsibility for laboratory medicine staff members is related to resident lectures. Although there is a standard expectation for teaching sessions, the division has established thresholds that when exceeded, allow additional compensation to staff members. This approach helps to promote interest in teaching while balancing the overall demands on the laboratory directors. Each staff person is expected to provide 25 lectures annually or semiformal teaching sessions as a member of the division. Staff members who commit to more than 35 teaching sessions are given an additional salary credit, and professional staff with more than 50 resident teaching sessions are given an even higher credit. A comparison of the 2 models is given in Table 2. Implementation Challenges and Issues Once the models were finalized, the department needed to effectively roll out the changes to staff, incorporate the new model into its financial framework, and manage exceptions or outliers to the model. The departmental finance director worked closely with the chief of service and divisional directors to establish a process for incorporating the new models into the department as the new approach to professional staff compensation. These efforts included a focus on the following: Communication We worked actively to communicate how the model worked and the standard levels of credits for the different components of the model. Staff presentations were used to introduce the model. In these presentations, we used detailed examples illustrating how an individual staff member s compensation would change over the life of an academic career given academic promotions, administrative responsibilities assumed, and years of service. The departmental finance director also was available to review the compensation formula for specific individuals if requested. Integration Into Budgeting Annual calculation of salaries takes place in September, yet the budgets for the coming year are due in May. As a S12 S12

6 Table 2 Comparison of Salary Models for Anatomic Pathology and Laboratory Medicine Component Anatomic Pathology Laboratory Medicine Academic base salary Based on HMS rank; per year postresidency Based on HMS rank; per year postresidency training (set credit) training up to 10 y; for completion of up to 10 y; for completion of fellowship; for MGH fellowship; for MGH staff rank higher than staff rank higher than HMS academic rank HMS academic rank Administrative effort Percentage of effort based on chief/director Percentage of effort based on chief/director assessment multiplied by set compensation rate assessment multiplied by set compensation rate Clinical service Estimated RVUs based on weeks available for Estimated RVUs based on weeks scheduled scheduling divisional $ per RVU rate divisional $ per RVU rate Laboratory directorship (calculated under administrative effort) Estimated RVUs based on internally developed system for identifying laboratory director scope divisional $ per RVU rate External funding Direct salary support based on actual funds Direct salary support based on actual funds for grants; received for all activity half of direct funds paid by outside institutions for laboratory director role Subspecialty leadership Set rate by service based on size and scope of service Resident teaching Set rates established for >35 and >50 annual teaching sessions provided HMS, Harvard Medical School; MGH, Massachusetts General Hospital; RVUs, relative value units. result, we establish preliminary staff salary placeholders during the May budget process. As we approach September, the amount that will be distributed is adjusted based on the most recent information available. In recalculating the funding pool, we also need to make assumptions related to expected promotion activity in the coming year. The finance director works with the chief of service to project these changes into the model to achieve the goal of providing highest possible staff compensation while reaching the established operating margins for the pathology department. Salary Adjustments for Staff Exceeding the Compensation Model Because the new compensation model was overlaid on the existing departmental compensation structure, there are some staff who are paid more than the compensation model calculates. A fundamental principle of the implementation of the salary model was that no staff member who continued with the same level of effort and service would assume a reduction in salary. Furthermore, it has been a goal to try to give increases to all staff each year. The department s strategy for right sizing these staff members into the model is to limit annual salary increases for overfunded staff members to a much smaller growth rate than the general salary increase pool. Although staff compensation rates have grown from 3% to 8% during the past 3 years, staff who exceed the model have been capped at 2% to 3%. Routine Monitoring and Evolution of the Model Both compensation models were established with the goal of best matching reward of compensation with departmental values and priorities, and the components of the model were based on our best ideas at the time. However, based on our experience, we recognize that the model is not perfect. Therefore, on an ongoing basis, we have made modifications that we believe give us the best ability to promote superior staff performance. Among the changes adopted since 2002, or planned for the future, are the following. Recognition of Outstanding or Substandard Performance Perhaps the biggest challenge has been the model s inability to recognize above- or below-average performance on an annual basis. To remedy this shortcoming, we modified the model so that divisional directors have the ability to adjust by ±5% from the model calculation to account for performance during the past year. Recasting of HMS Academic Rank Credit We have adjusted the credits by rank during the past 4 years for inflationary growth and as incentive for promotion. In particular, we have increased the level of credit given at the assistant and associate professor levels. S13 S13

7 Hynes and MacMillan / COMPENSATION IN ACADEMIC PATHOLOGY Adjustment From Model for Staff With Research Funding A key principle of the compensation model in the past has been not to reduce salaries. At the same time, there are cases when staff secure additional external funding that if added into the salary model, will increase an individual s salary out of proportion with other staff members and will result in a salary decrease when funding is lost. To account for these rare cases, the department will withhold a percentage of academic salary credit in some cases. In return, the staff members are given a guarantee of continued salary support for some future period should funding be lost. Rethinking Duration of Credits We are reviewing the duration of the postresidency credit of 10 years based on the idea that academic rank differentiation should start at an earlier timeframe, such as 7 years. For the same reason, it is thought that the fellowship credit, currently without duration, should be offset after some period by the advancement in academic rank. These modifications, if enacted, would allow for higher values of the RVU credits for clinical service in anatomic pathology and laboratory director credits in laboratory medicine. Assessing the MGH Experience What has been the impact on the implementation of a formal compensation model in pathology? Has it had its desired effect of improving academic productivity? To assess the impact, we recently sent a survey to 34 anatomic pathology staff members who have been with the department since We asked the staff to indicate their level of agreement with different statements Table 3. Across all ranks, staff indicated they had a better understanding of how salaries are determined and an increased sense that compensation is more equitable under the compensation model. There also was across-the-board improvement in staff satisfaction, especially at the associate professor, assistant professor, and instructor levels. Professor and associate professor level staff did not identify an increased focus toward academic advancement, although this number was high for assistant professors and instructors. In addition to the survey, we reviewed our promotion performance since the model s implementation. Despite a mixed reaction to whether there was more focus on advancement, the trends indicate that academic advancement has increased steadily since the model s implementation in 2002 Figure 1. As a result, there has been a shift in the mix of our professional staff upward at the same time that we have made additional hires, almost exclusively at the instructor rank Figure 2. There are many possible explanations for the change in academic progress since In addition to the compensation model, a more robust promotions process, coupled with more aggressive career counseling, has had a major impact on overall advancement. It would seem that the compensation model worked well in conjunction with these other efforts to achieve the department s objectives. Next Steps The compensation models continue to evolve and to meet new priorities and challenges within the department and MGH. On an annual basis, the model is reviewed by our pathology executive committee to change criteria, add new elements, and adjust allocation levels. We will continue to Table 3 Massachusetts General Hospital Pathologist Survey Regarding Salary Model * Professor Associate Professor Assistant Professor/ (n = 5) (n = 6) Instructor (n = 8) I have a better understanding of how salaries are 3.6/ / /4.5 determined since the implementation of the salary model. Compensation decisions are more equitable since the 3.5/ / /5.0 implementation of the salary model. I have focused more on academic advancement since the 2.5/ / /3.0 implementation of the salary model. I have focused more on getting external funding since the 3.5/ / /3.0 implementation of the salary model. The structure of the salary model closely matches what is 3.5/ / /4.0 expected of me as a staff member. Implementation of the salary model has increased my 3.25/ / /5.0 satisfaction as a staff member. * Data are given as mean/median. Responses were made according to the following scale: 1, strongly disagree; 2, disagree; 3, neutral; 4, agree; 5, strongly agree. S14 S14

8 No. of Promotions FY 99 FY 00 FY 01 FY 02 FY 03 FY 04 Figure 1 Harvard Medical School (Boston) promotions for Massachusetts General Hospital Pathology Service staff (Boston) by fiscal year (FY). The salary model was implemented in No. of Staff Pathologists Instructor Asst Prof Assoc Prof Professor Figure 2 Massachusetts General Hospital (Boston) staff pathologist distribution by academic rank at Harvard Medical School (Boston) before (fiscal year [FY] 2001, black bars) and after (FY 2004, white bars) implementation of the salary model. Assoc Prof, associate professor; Asst Prof, assistant professor. make these changes to make certain that our pay reflects our core values and priorities. In addition, we have adjusted the model during the past few years to improve our market competitiveness at each academic rank based on more frequent review of national benchmark data. Conclusion The MGH experience has been a positive one. Since the implementation of the compensation model in 2001, we have greater staff satisfaction. Staff members have a better understanding of how salaries are determined and what is expected of them. This in turn is leading to greater academic productivity. In addition, the development and revision of the model is making it easier on a departmental basis to be more market competitive by each academic rank. Although it requires great up-front investment and reevaluation on an annual basis, development of a formalized compensation model will pay great dividends to an academic pathology department. From Pathology Service, Massachusetts General Hospital, Boston. Address reprint requests to Mr Hynes: Finance and Administration, MGH Pathology Service, 55 Fruit St, WRN 225, Boston, MA We acknowledge Robert B. Colvin, MD, chief of Pathology, MGH, for review of the article and suggestions on content. S15 S15

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