Resources Highest Paid Specialties Optimizing Your Case Mix to Improve Pay in Procedure-Based Specialties

Optimizing Your Case Mix to Improve Pay in Procedure-Based Specialties

January 7, 2026

18 minute read

case mix rvus payer mix site of service asc procedure-based residency finance practice optimization

Physician reviewing procedure schedule and reimbursement data on dual monitors - for Optimizing Your Case Mix to Improve Pay

The way most residents think about “making more money” in procedure-based specialties is backward. It is not about working more hours. It is about engineering your case mix.

If you are in a procedure-heavy field—orthopedics, cardiology, GI, interventional radiology, anesthesia, pain, ENT, ophthalmology, urology—your income ceiling is set less by how hard you work and more by which cases you do, in what environment, and how consistently. That is the game. You either learn it during residency or you spend your first 5–10 years donating money back to the system.

Let me show you how to fix it.

1. Understand the Money Engine: RVUs, Payer Mix, and Site of Service

If you do not understand how money flows, you cannot optimize anything. You are just “being a good doctor” and hoping the numbers work out. That rarely ends well.

The three levers that actually matter

RVUs per case
Payer mix (who is actually paying you)
Site of service (where the procedure happens)

Get those three right and you can work less and earn more than someone grinding twice as hard with a bad case mix.

A. RVUs per case: stop guessing

Work RVUs (wRVUs) are the basic productivity currency. For any procedure-based specialty, your income in employed models is usually:

Income ≈ (wRVUs × conversion factor) + base + bonuses

A few rough examples (these are approximate, change over time, and vary by code set, but the relationship holds):

Approximate RVU Comparison by Procedure Type

Procedure Type	Example wRVUs	Typical Duration
Minor in-office procedure	0.5–2	5–15 min
Simple diagnostic endoscopy	3–4	15–20 min
Interventional cath/PCI	8–25	45–90 min
Major joint replacement	20–30	90–150 min
Complex spine surgery	30–50+	3–6 hours

Notice something: more complexity does not always mean proportionally more RVUs per hour. Some “boring” procedures have phenomenal RVU density.

What to do in residency:

Ask attendings or your billing office for a basic wRVU list of your 20–30 most common procedures.
For each, note:
- wRVUs
- Typical room time
- Setup/turnover time
Calculate RVUs per hour for at least a few hallmark procedures. You will start to see patterns fast.

You are not doing this to turn into a coder. You are doing it so that when someone says, “You can build a great practice doing X,” you can quietly think, “No, that is a 2.5 RVU procedure that takes 45 minutes. Absolutely not as my bread and butter.”

B. Payer mix: the silent multiplier

Same procedure. Same RVUs. Completely different pay if the payer is commercial vs Medicaid.

At a high level:

Commercial insurance: Often pays a multiple of Medicare (e.g., 150–300% of Medicare rates)
Medicare: Baseline
Medicaid: Often below Medicare
Self-pay / cash: High variance; some procedures (aesthetics, certain pain, some ophtho) can be very lucrative

You cannot fully control this as a resident. But you can learn:

Which hospitals, clinics, and ASCs in your system have higher commercial payer volumes
Which attendings are known to have a “good payer mix” in their practices
Which service lines tend to attract which payer types (e.g., cosmetic vs reconstructive plastics; screening colonoscopy vs advanced IBD work)

You are not cherry-picking patients. You are choosing your practice environment. Big difference.

C. Site of service: hospital vs ASC vs office

Same CPT code → wildly different actual dollars depending on where it is done.

General pattern:

Hospital outpatient department (HOPD): Higher facility fees, more bureaucracy, often slower turnover
Ambulatory surgery center (ASC): Lower facility payment than HOPD but higher efficiency, lower overhead, more surgeon leverage
Office-based procedure: No facility fee, but potential to capture more of the global payment if you own equipment and space

For many procedure-based specialties, ASC + office-based procedures is the sweet spot for income and lifestyle.

2. Case Mix 101: Map Your Specialty’s Economic “Sweet Spots”

Every procedure-based specialty has a cluster of “workhorse” procedures that:

Have strong RVU per hour
Can be done in high volume
Are predictable and repeatable
Are not constantly interrupted by emergent chaos

That is your target case mix base. Then you add selectively on top.

Let’s look at a few examples.

Orthopedic surgery

Rough buckets:

High-RVU but low-efficiency cases
- Complex revision joints
- Multi-level spine
- Massive trauma cases
Moderate-RVU, high-efficiency workhorses
- Primary total knees/hips in a well-run ASC
- Single-level decompressions
- Rotator cuff repairs, sports procedures
Low-RVU, time-sink cases
- Long, complex non-operative visits that do not convert to surgery
- Small fracture management with tons of follow-up and minimal procedure pay

Well-compensated ortho surgeons generally:

Anchor their schedules with predictable primary joints / bread-and-butter sports in efficient settings (ASC)
Limit the percentage of revision / train-wreck cases that wreck the daily schedule
Push clinic toward evaluation that leads to a clear procedure path rather than endless “come back in three months” visits

Gastroenterology

Buckets:

High-efficiency, moderate-RVU procedures
- Screening colonoscopies
- Upper endoscopies
Complex interventions
- ERCP, EUS, advanced therapeutic endoscopy
Low-RVU time drains
- Chronic functional GI clinic visits with low procedure conversion
- High-need patients with minimal reimbursable intervention

High-earning GI docs typically:

Run tight endoscopy blocks with high on-time starts and short turnover
Build primary case mix around screening/surveillance scopes
Layer in a controlled amount of advanced procedures for differentiation and referrals

Cardiology / Interventional

Buckets:

Diagnostic caths + PCI
EP studies and ablations
Structural heart (TAVR, etc.)
Non-procedural clinic and imaging reads

The step most fellows miss: understanding which labs and which hospitals give them the best combo of:

Reasonable RVU rates
Efficient turnover
Solid payer mix

I have seen interventional cardiologists doing the same number of caths per month, but one working in a chaotic lab with bad turnaround and mostly Medicaid, the other in a well-run private ASC-ish environment with strong commercial volume. Income difference: 2–3×.

Anesthesia & Pain

For anesthesia, your “case mix” is often the cases your surgeons are doing. But you still have levers:

Block-heavy vs simple cases
High-acuity ICU-heavy programs vs bread-and-butter elective OR
Taking on pain procedures, regional anesthesia, or perioperative clinics

For pain specialists, the economics are sometimes extreme:

Short, moderate-RVU injections and minimally invasive procedures in ASC or office
Longer, complex cases that are flashy but destroy RVU/hour

Same pattern: best-compensated folks standardize on their efficient procedures, in an efficient facility, with a tolerable payer mix.

3. The Four-Step Protocol to Optimize Your Case Mix (Even as a Resident)

You are not an owner yet. You probably do not control your schedule. But there is a lot you can do.

Here is the protocol I push on residents and fellows who actually want to be intentional about income in procedure-based specialties.

Case Mix Optimization Protocol
Step	Description
Step 1	Learn RVU and payer basics
Step 2	Map current case exposure
Step 3	Target high-yield procedures
Step 4	Shape training and early job choice
Step 5	Refine case mix yearly

Step 1: Audit your exposure now

Do a 2–4 week snapshot:

List every procedure you participate in
For each case, jot down:
- Procedure type
- Approximate duration (wheels in to wheels out)
- Setting (hospital OR, ASC, office)
- Attending
- Elective vs emergent

Then, approximate wRVUs per case from:

Internal billing sheets
Online databases (even rough CPT benchmark data is fine)
Asking a coder or admin you get along with

You are not trying to be exact. You just want relative RVU/hour.

You will quickly see:

Which procedures are RVU-dense and efficient
Which are RVU-poor and time-consuming
Which attendings run efficient rooms with predictable lists

This becomes your internal map of “what actually pays in my field.”

Step 2: Decide your target case mix profile

You cannot have everything. The job with 90% sexy complex tertiary referrals and no bread-and-butter is usually a lifestyle and financial mess.

Define, in writing, your ideal distribution. For example, as a GI fellow:

60–70%: screening/surveillance colonoscopy and EGD
15–25%: advanced procedures (e.g., ERCP/EUS)
10–20%: clinic / non-procedural

Or as an orthopedic resident aiming for adult reconstruction:

60–70%: primary hips/knees
10–20%: revisions and complex deformity
10–20%: clinic / fractures / misc

The exact numbers can shift, but the key is this:

You choose a base of efficient, repeatable, mid-complexity procedures and cap the percentage of schedule-wrecking cases.

Without this, your practice will default to whatever the hospital needs filled. Which is usually not what is best for your income or sanity.

Step 3: Shape your training to match your target mix

Residents underestimate how much control they have here.

Specific moves:

Prioritize rotations with your “workhorse” attendings
- The surgeons or proceduralists whose lists match your target mix
- The labs/ORs where turnover is actually efficient
Ask explicitly for more of certain cases
- “I am really trying to get comfortable with bread-and-butter [procedure]. Can I scrub into more of your cases on Thursdays when you do those?”
Track your log with intention
- Most specialties have minimum numbers; you want target numbers for financial workhorses:
  - Example: “I need at least 300–400 colonoscopies where I am primary operator.”
  - Or “I want 200+ primary joints before graduation.”
Learn clinic filtering and triage
- Watch attendings who:
  - Efficiently identify who actually benefits from procedure
  - Avoid endless follow-ups that never lead anywhere
- This is how you build a clinic that feeds your desired case mix instead of clogging your schedule with low-value visits

You are basically reverse-engineering your future practice starting now.

Step 4: Choose your first job with brutal clarity

Most new grads choose jobs based on vague impressions:

“Seemed nice”
“Good location”
“They said I would be busy”

Busy doing what? That is the only question that matters.

When you interview, you ask:

“Can you show me anonymized breakdowns of case mix for someone 3–5 years ahead of me in this group?”
“How many [target procedures] does the typical partner do per month?”
“What percentage of my schedule, realistically, will be emergent or add-on?”
“What percent of procedures are in ASC vs hospital vs office?”
“What is the current payer mix by site?”

Then you test their answers against your target profile.

If your target is 60–70% efficient bread-and-butter ASC cases and the current partners are doing 80% hospital inpatients with scattered cases at weird times, you know what that means. You pass or adjust your expectations.

4. Advanced Levers: Efficiency, Scheduling, and Saying No

Once you are in practice, optimizing case mix is about discipline. You will always feel pulled toward:

“Interesting” but schedule-destroying cases
Hero complex: taking every last complicated disaster
Admin pressure: filling gaps no one else wants

You do not have to say yes to everything to be a good physician.

A. Build “anchor blocks” for high-yield cases

You want specific, protected time for your bread-and-butter procedures. For example:

Ortho: Two full primary joint days per week in the ASC
GI: Three scope blocks per week where your first case starts on time, last case is planned, and add-ons are capped
IR: Dedicated half days for core bread-and-butter interventions rather than only emergent hospital work

This creates:

Predictable RVU production
Less chaos
Easier staffing and turnover

bar chart: Mixed Hospital Day, Dedicated Scope Block, Clinic-Heavy Day

Same hours. Wildly different RVU output. That is why anchor blocks matter.

B. Use scheduling rules, not vibes

If you let schedulers and referring docs fill your day however they like, your case mix will drift.

You need written rules:

Which procedures you perform only on specific days/sites
Maximum number of long complex cases per day
Clear criteria for certain procedures (e.g., not offering low-value interventions)

Example for an ortho practice:

Tues/Thurs: ASC primary joints and sports (no revisions)
Wed: Complex revisions, odd cases, and trauma that truly requires main hospital OR
Cap at one complex revision per block unless absolutely unavoidable

This prevents “death by a thousand complex cases.”

C. Learn to say a professional “No”

You will be asked to:

Take cases that do not fit your target case mix
Fill clinic slots with low-value follow-ups
Add last-minute complex cases to a carefully built block

A script that works:

“For this type of case, I reserve specific OR days so I can do it safely and thoroughly. Let us schedule it on my next [complex day] instead of squeezing it into a high-volume block.”

Or:

“Given my current schedule and the setup this case requires, I cannot do it justice today. I can see them on [date] and book the appropriate time.”

You are not bailing. You are protecting patient safety and your long-term viability. Burned-out, overbooked physicians are not good doctors.

5. Common Case Mix Mistakes That Tank Income (and How to Fix Them)

I see the same patterns over and over.

Mistake 1: Chasing only high-complexity, “prestige” cases

Problem:

You become the go-to person for everything no one else wants
Your schedule is full of out-of-proportion time sinks
RVUs per hour plummet

Fix:

Cap the percentage of your schedule that can be complex or revision work
Make sure you have a strong base of mid-complexity, high-efficiency procedures that you actually like
Protect those blocks from encroachment

Mistake 2: Ignoring clinic structure

Clinic is not just “extra.” It is your case funnel.

If your clinic is filled with:

Non-procedural issues you cannot treat procedurally
Patients who are poor candidates or uninterested in intervention
Chronic, unsolvable problems with no clear plan

Then your OR / lab / procedure schedule will suffer.

Fixes:

Work with scheduling and referring providers on clear referral criteria
Build templates:
- New consults likely to need procedures
- Follow-up slots for post-op or post-procedure
- Limited slots for chronic without clear procedure indication
Use midlevels or collaborators for non-procedural chronic follow-up where appropriate

Mistake 3: Wrong site of service for high-volume work

Doing bread-and-butter cases exclusively in a main hospital OR when an ASC or office-based setup is feasible is like commuting in a dump truck when you could use a car.

Fix:

Early in practice, target groups that:
- Have ASC access
- Already run efficient high-volume days
- Are open to you shifting appropriate cases to ASC/office
Long term, consider:
- Partial ASC ownership
- Collaborating to build a new ASC or join an existing high-performing one

hbar chart: Hospital OR, ASC, Office-based

The exact numbers differ, but the pattern is common: ASC and office, when done well, usually beat hospital OR for day-in, day-out procedures.

Mistake 4: Never checking your own data

You cannot optimize what you do not measure. Too many physicians have literally no idea:

Which 10 procedures generate most of their RVUs
Which clinic templates lead to actual booked cases
Which referrers send the kind of patients that fit their expertise and practice model

Fix:

At least once a year (ideally quarterly):

Pull a report of:
- RVUs by procedure code
- Cases by site (hospital vs ASC vs office)
- Payer mix breakdown
Identify:
- Top 10 RVU-generating procedures
- Bottom 10 time-consuming, low-RVU procedures
Ask:
- Can I increase volume or efficiency of the top 10?
- Can I reduce or re-structure how I handle the bottom 10?

This loop is how you compound improvements over time.

6. Specialty-Specific Quick Wins (Residency and Early Practice)

Let me give you some ultra-specific, fast wins by specialty type. These are not universal, but they apply often enough that they are worth thinking about.