"First-of-its-kind PSH initiative demonstrates measurable impact on quality and costs"

[Carbocation1]

http://www.asahq.org/about-asa/news...s-kind-perioperative-surgical-home-initiative

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[Carbocation1]

"From 2013-2015, average length of stay for hip and knee replacements was reduced from 2.95 to 1.84 days. Over the same period, use of home health decreased from 47 to 13 percent and use of skilled nursing or inpatient rehabilitation facilities declined from 25 to 13 percent. The program has also resulted in a 35 percent decrease in 30-day readmissions and generated an average savings of $4,205 per surgical episode during the first four months. As a result, the hospital and participating physicians are currently on target to share approximately $400,000 in savings over the first year of the program for one service line alone. "

 

[Consigliere]

They are heavily pushing this crap and I just don't see how it could work.

 

[Planktonmd]

I would like to know what metrics they used to measure "improved outcomes" and who was the control group for that comparison.
Also when they talk about savings it would be interesting to know what things they spent less money on? and were they able to bill insurance for additional services involved in the surgical home, or was that free labor imposed on Anesthesiologists?
For example if the anesthesiologist did the pre-op visit for free instead of the primary physician, this is not savings, this is free labor imposed on anesthesiologists and money stolen from primary physicians.
And those people who will be sharing that $400,000 of "savings" how many hours of free labor did they have to put into the system?

 

[repititionition]

Guys, this is all a pre-emptive strike in the bundled payment wars.

The new paradigm will likely be one pie, multiple slices, with a whole lot of fighting about who gets how much at the table.

PSH is designed to increase the eventual payout to anesthesiology in these negotiations (fights). The problem is that they are not adding value (outcome/cost) - they are just adding more work.

It's the difference between someone figuring out how to go from making $100MM to $200MM per year. Some will find a way to enhance their value (get more for same work), and some will just work twice as much. The ASA chose the latter approach.

 

[pgg]

That article is light on actual details, but I think we've had this thread before ...

It's been about a year since that thread but I haven't seen anything to change my mind about it yet.

 

[Ignatius J]

"From 2013-2015, average length of stay for hip and knee replacements was reduced from 2.95 to 1.84 days. Over the same period, use of home health decreased from 47 to 13 percent and use of skilled nursing or inpatient rehabilitation facilities declined from 25 to 13 percent. The program has also resulted in a 35 percent decrease in 30-day readmissions and generated an average savings of $4,205 per surgical episode during the first four months. As a result, the hospital and participating physicians are currently on target to share approximately $400,000 in savings over the first year of the program for one service line alone. "

All of this is money out of a hospital's pocket though. How do they get money in savings with less utilization of the hospital and less stays? Makes no sense. I love shortening stays, but the hospital loses money.

There is some jumbled math going on.

I agree- this is just jockeying for bundled payments, not actually getting money in the hospital's pockets right now.

 

[chfo]

All of this is money out of a hospital's pocket though. How do they get money in savings with less utilization of the hospital and less stays? Makes no sense. I love shortening stays, but the hospital loses money.

There is some jumbled math going on.

I agree- this is just jockeying for bundled payments, not actually getting money in the hospital's pockets right now.

It's about hospitals getting paid for a 3 day stay but patients can leave after 2. One day of not paying for extra nurses, reduces overall cost.

THE PROBLEM WILL BE WHEN THE GOVERNMENT ONLY PAYS FOR 2 DAYS AND REFUSES TO PAY FOR THE EXTRA DAYS.

That's where all this bull**** will end up, and nobody wants to admit it.

Classic government. Turns bonuses into penalties, and we all suffer for it.

 

[repititionition]

All of this is money out of a hospital's pocket though. How do they get money in savings with less utilization of the hospital and less stays? Makes no sense. I love shortening stays, but the hospital loses money.

There is some jumbled math going on.

I agree- this is just jockeying for bundled payments, not actually getting money in the hospital's pockets right now.

Not true - hospital facility fees are paid based on DRGs, so there is huge incentive to minimize LOS (as long as you don't also increase bounceback readmits)

ETA: when CMS is the payer

 

[Psai]

We will pay you less to work harder, make up a bunch of useless statistics to dock your pay further and this will obviously lead to higher quality. Nothing says great care like kicking patients out of the hospital as soon as possible and miserable physicians

 

[kazuma]

During a conference I attended last year I remember Dr. Stead mentioned that one of the biggest things that contributed to cost savings in his model was the standardization of Ortho trays and prostheses.

 

[Mman]

All of this is money out of a hospital's pocket though. How do they get money in savings with less utilization of the hospital and less stays? Makes no sense. I love shortening stays, but the hospital loses money.

Because the hospital gets a flat fee and the less it costs to provide the service, the more money the hospital saves.


PSH stuff actually works when implemented correctly. My biggest concern is who controls the money and what and how will they move the baseline/target. For example, let's say you have a PSH for total joints. The hospital and involved MDs (surgeon, anesthesiologist, primary care, whoever) split the annual savings at some predetermined amount (say hospital gets 50%, surgeon 25%, anesthesiologist 20%, primary care 5%, etc). Well the first year you save $X. In the 2nd year are you still compared to the original baseline or is the previous year your new baseline and now you don't get any additional money for doing just as well as you did last year?

It's a good idea in concept, but the devil is in the details.

 

[loveumms]

It does work because it makes organizations look at ways to cut costs and improve care - anyone can implement a surgical home - it doesn't take an anesthesiologist. Simple things can have a measurable impact on cost. For instance, just using PO tylenol preop instead of IV tylenol intra op can lead to significant cost savings (this is rudimentary example to prove the point). Take this savings over hundreds or thousands of patients and it add up.

The fact of the matter is the medical landscape is changing and we can either sit on the stool and try to keep doing what we've done or we can try and reinvent ourselves and impact the perioperative arena. Someone is going to do it - anesthesiologists are the perfect physicians to head this. Fee for service is a thing of the past and this is why the hospitals care. Bundled payments are here and the above posters are right - it will probably be a fight to see how the reimbursement is divided up. I don't think that the PSH is only aiming to make sure we still get paid. It's a way to make sure we stay relevant and improve care. We are the best at decreasing costs by impacting efficiency and cutting waste (for instance the cost of preoperative evaluation goes down significantly when an anesthesiologist is in charge versus the surgeon through less testing). We also improve OR efficiency by running it.

I'm not saying its the best idea in the world but I don't hear anyone who is complaining coming up with anything better (and this has been debated over and over here and I always say the same thing - come up with something better). The fact of the matter is anesthesiologists do not need to be the ones administering anesthesia for most cases. Sorry, this is just the truth - and if you don't think so, please so me otherwise. I wholeheartedly believe medical direction is the best care and that we can truly make a difference if we want to.

 

[Psai]

You sound like a clueless mba graduate, not a physician. Cost savings, efficiency and other buzzwords just mean doing things as poorly as the public will bear without overthrowing the system. You want an easy way to decrease costs? Tort reform so physicians stop overtesting to fight lawsuits and allow for patients to die with dignity so we don't have million dollar workups and month long stays in the icu for people that are only alive in the most technical use of the term.

Nickle and diming physicians and patients with these incremental changes will not change anything substantially. If you spend 30 minutes turning over a room from 35 minutes, it is not as though you will be squeezing in another case. You will just be making people miserable

 

[chessknt]

You sound like a clueless mba graduate, not a physician. Cost savings, efficiency and other buzzwords just mean doing things as poorly as the public will bear without overthrowing the system. You want an easy way to decrease costs? Tort reform so physicians stop overtesting to fight lawsuits and allow for patients to die with dignity so we don't have million dollar workups and month long stays in the icu for people that are only alive in the most technical use of the term.

Nickle and diming physicians and patients with these incremental changes will not change anything substantially. If you spend 30 minutes turning over a room from 35 minutes, it is not as though you will be squeezing in another case. You will just be making people miserable

While not wrong, over here in reality where that won't happen until we are on the brink of financial collapse we know this is what is going to happen. If you guys dont pick it up they will just recruit midlevels to do it. This is a unique chance to get in on the ground level of an evolving care model in its infancy. You can think its dumb/stupid/wont work but the people who control 650B in purchasing power for your services think it is a fantastic idea.

 

[Carbocation1]

On a positive note, the job market for new grads should pick up once a slew of dinosaurs who sold out this specialty retire to avoid having this PSH crap shoved down their throats. How ironic.

 

[Psai]

Firestone was a very successful company and didn't lose out to Michelin because they didn't see that change was coming and failed to act. They tried to change their business structure but went about it the wrong way and couldn't keep up. Just because you see a threat doesn't mean you just go into something willy nolly with poorly done studies to justify your actions.

What the psh seems to me is an attempt to take away preops from primary care and cardiology and to also take postop followup from the surgeons for no pay. Why should I work more for no reason? How does that display value? It is just allowing yourself to be taken advantage of while taking money out of someone else's pockets without putting it into your own. Why is the solution to being replaced by midlevels in the or thought to be going into something that is even better suited for midlevels except that it is outside the or? Who benefits from the purported savings? I doubt that a single penny of it is going into physician pockets

 

[Ignatius J]

Because the hospital gets a flat fee and the less it costs to provide the service, the more money the hospital saves.


PSH stuff actually works when implemented correctly. My biggest concern is who controls the money and what and how will they move the baseline/target. For example, let's say you have a PSH for total joints. The hospital and involved MDs (surgeon, anesthesiologist, primary care, whoever) split the annual savings at some predetermined amount (say hospital gets 50%, surgeon 25%, anesthesiologist 20%, primary care 5%, etc). Well the first year you save $X. In the 2nd year are you still compared to the original baseline or is the previous year your new baseline and now you don't get any additional money for doing just as well as you did last year?

It's a good idea in concept, but the devil is in the details.

I think the hospitals My wife was in when she was in the hospital billed by the night. Could be wrong though. I remember them saying that we needed to be out by X time or you get charged for another night's stay. Like a hotel. It was weird.

 

[Ignatius J]

Not true - hospital facility fees are paid based on DRGs, so there is huge incentive to minimize LOS (as long as you don't also increase bounceback readmits)

Pardon my ignorance, but I am naive on this subject and just want to find out more- what is a DRG?

 

[Mad Jack]

All of this is money out of a hospital's pocket though. How do they get money in savings with less utilization of the hospital and less stays? Makes no sense. I love shortening stays, but the hospital loses money.

There is some jumbled math going on.

I agree- this is just jockeying for bundled payments, not actually getting money in the hospital's pockets right now.

Medicare hospital stays are per-instance, not per-day from my understanding. Shortening hospital stays opens up beds that can be used to create more instances of care. Private insurers may pay per day, but medicare is the dominant payer of many hospitals, so it's best to optimize things based upon their metrics and how to best get money out of their program.

 

[repititionition]

Pardon my ignorance, but I am naive on this subject and just want to find out more- what is a DRG?

Mad Jack's answer is spot-on.

Medicare hospital stays are per-instance, not per-day from my understanding. Shortening hospital stays opens up beds that can be used to create more instances of care. Private insurers may pay per day, but medicare is the dominant payer of many hospitals, so it's best to optimize things based upon their metrics and how to best get money out of their program.

 

[repititionition]

You sound like a clueless mba graduate, not a physician. Cost savings, efficiency and other buzzwords just mean doing things as poorly as the public will bear without overthrowing the system. You want an easy way to decrease costs? Tort reform so physicians stop overtesting to fight lawsuits and allow for patients to die with dignity so we don't have million dollar workups and month long stays in the icu for people that are only alive in the most technical use of the term.

Nickle and diming physicians and patients with these incremental changes will not change anything substantially. If you spend 30 minutes turning over a room from 35 minutes, it is not as though you will be squeezing in another case. You will just be making people miserable

1) Tort reform didn't materially change expenditures in Texas (though I agree, it must still be fixed)

2) End of life expenditure is a real problem. Fixing it would require rationing/allocation, and we weren't within 50 miles of that idea when they started using the phrase "death panels" about the ACA.

3) You are right: going too far right on the "efficiency" curve is not efficient. One problem with our current system is that it is both highly regulated and not optimized. What this means in practice is that the physician ceaselessly shovels the proverbial **** that shouldn't even be there in the first place (checkbox culture of medicine, driven by the ease of pushing administrative burdens on to physicians thanks to the EHR). There are no checks and balances on the demands placed on doctors, so they keep piling up with every new "great idea".

 

[loveumms]

You sound like a clueless mba graduate, not a physician. Cost savings, efficiency and other buzzwords just mean doing things as poorly as the public will bear without overthrowing the system. You want an easy way to decrease costs? Tort reform so physicians stop overtesting to fight lawsuits and allow for patients to die with dignity so we don't have million dollar workups and month long stays in the icu for people that are only alive in the most technical use of the term.

Nickle and diming physicians and patients with these incremental changes will not change anything substantially. If you spend 30 minutes turning over a room from 35 minutes, it is not as though you will be squeezing in another case. You will just be making people miserable

You sound like a clueless millennial medical student who thinks they know it all (you don't know what you don't know). I on the other hand know quite a bit about the surgical home and there has been tremendous changes made in organizations that have instituted some of the concepts. I don't have a MBA and don't need one. I actually think that the concept improves patient care so that is why I believe in the idea.

And as a matter of fact, if you shave off 5 minutes from turnover time it leads to significant savings over time. I don't really think that is what I would focus my time on - smoking cessation, diabetes optimization, prehabilitation are more likely to be more effective.

Keep trying to prevent change and making yourself miserable.

 

[nimbus]

3) You are right: going too far right on the "efficiency" curve is not efficient. One problem with our current system is that it is both highly regulated and not optimized. What this means in practice is that the physician ceaselessly shovels the proverbial **** that shouldn't even be there in the first place (checkbox culture of medicine, driven by the ease of pushing administrative burdens on to physicians thanks to the EHR). There are no checks and balances on the demands placed on doctors, so they keep piling up with every new "great idea".

Yep. There's an entire new category of health care worker called a scribe to help physicians with EHR. How is that efficient?

 

[Psai]

You sound like a clueless millennial medical student who thinks they know it all (you don't know what you don't know). I on the other hand know quite a bit about the surgical home and there has been tremendous changes made in organizations that have instituted some of the concepts. I don't have a MBA and don't need one. I actually think that the concept improves patient care so that is why I believe in the idea.

And as a matter of fact, if you shave off 5 minutes from turnover time it leads to significant savings over time. I don't really think that is what I would focus my time on - smoking cessation, diabetes optimization, prehabilitation are more likely to be more effective.

Keep trying to prevent change and making yourself miserable.

As soon as you whined about millenials, I knew your post was not worth reading.

 

[urge]

For example, since implementing a PSH pilot for adenoidectomy procedures in early 2015, Nationwide Children’s Hospital (NCH) in Columbus, Ohio decreased pharmacy costs by 32 percent and overall costs by 53 percent, saving nearly $50,000 across their first 19 cases.

50 grand on 19 T&A's? What the hell are they doing? Injecting gold in the IV?

 

[urge]

And as a matter of fact, if you shave off 5 minutes from turnover time it leads to significant savings over time.

Rarely makes money. Only if you can squeeze and extra case in the room. For most rooms in the nation, 5 min here are there are nothing. Not enough to get another 90 min case in the room.

 

[urge]

It's about hospitals getting paid for a 3 day stay but patients can leave after 2. One day of not paying for extra nurses, reduces overall cost.

THE PROBLEM WILL BE WHEN THE GOVERNMENT ONLY PAYS FOR 2 DAYS AND REFUSES TO PAY FOR THE EXTRA DAYS.

That's where all this bull**** will end up, and nobody wants to admit it.

Classic government. Turns bonuses into penalties, and we all suffer for it.

It's a race to the bottom, not the top.

We are digging our own grave.

 

[deleted171991]

1) Tort reform didn't materially change expenditures in Texas (though I agree, it must still be fixed).

FYI, even the most advanced tort reform in the US (Indiana) is worse than the rest of the world.

One cannot call it tort reform until less than 5% of physicians will get sued during their lifetime. Now it's almost 100%, in most states.

That's the reason there is so much less defensive medicine abroad. Many foreign doctors have never even heard about the concept. One must commit an egregious mistake to even have a day in court. Anything less than egregious gets thrown out.

You can cap the payments all you want, but physicians will not think and behave differently until they stop getting sued.

I admit freely: I will rather refuse to administer anesthesia in a high malpractice-risk case than gamble with my family's future. Rule number one of making money: never lose money. Rule number two: never forget rule number one. (Buffett)

 

[urge]

I think the hospitals My wife was in when she was in the hospital billed by the night. Could be wrong though. I remember them saying that we needed to be out by X time or you get charged for another night's stay. Like a hotel. It was weird.

What do you care? Your co pay is the same. They just wanted you out.

 

[Planktonmd]

On a positive note, the job market for new grads should pick up once a slew of dinosaurs who sold out this specialty retire to avoid having this PSH crap shoved down their throats. How ironic.

Actually the job market for new grads is great right now since residency programs have already started producing the kind of new grads required by AMCs and hospital CEOs, the kind that accepts lower pay and never rocks the boat.

 

[Mad Jack]

I think the hospitals My wife was in when she was in the hospital billed by the night. Could be wrong though. I remember them saying that we needed to be out by X time or you get charged for another night's stay. Like a hotel. It was weird.

Individuals get charged by the night, insurance companies do not. Those nightly charges represent just a fraction of the money the hospital would make if you weren't there and they could bill a new patient.

 

[pgg]

And as a matter of fact, if you shave off 5 minutes from turnover time it leads to significant savings over time.

Are you sending your hourly workers home 5 x N minutes early?

 

[Mman]

Are you sending your hourly workers home 5 x N minutes early?

As you allude to, turnover time only makes a big dent when you can get an extra case done in a room in the same block of time.

Example: 3 spine cases that take 3 hours each, first case starts at 0730. With 30 minute turnover time, you have 0730-1030, 1100-1300, and 1330-1630. With 35 minute room turnover, it is 0730-1030, 1105-1305, 1340-1640. Not a big deal. If you have a lot of short cases in a room and can save an extra 5 minutes between cases you might get an extra case done in that same block, though.

 

[Ignatius J]

What do you care? Your co pay is the same. They just wanted you out.

HDHP.

 

[Ignatius J]

FYI, even the most advanced tort reform in the US (Indiana) is worse than the rest of the world.

One cannot call it tort reform until less than 5% of physicians will get sued during their lifetime. Now it's almost 100%, in most states.

That's the reason there is so much less defensive medicine abroad. Many foreign doctors have never even heard about the concept. One must commit an egregious mistake to even have a day in court. Anything less than egregious gets thrown out.

You can cap the payments all you want, but physicians will not think and behave differently until they stop getting sued.

I admit freely: I will rather refuse to administer anesthesia in a high malpractice-risk case than gamble with my family's future. Rule number one of making money: never lose money. Rule number two: never forget rule number one. (Buffett)

Confirmed. "What would the judge say?" medicine is still alive and well in Texas.

 

[loveumms]

If you have 30 ORs

Actually there are many ways it can save money and not just if you can squeeze in an extra case although that certainly would be more efficient (especially for really long days - think T&A day). Another way - if you have nursing staff from 7am-3pm every day. If you go until 315, you have to shift staff around to keep that room open (either not starting another room or paying the nurses overtime). If you have shaved off 5 minutes off every case that day then you have prevented having to do either.

At my institution we perform roughly 45K anesthetics. Now granted many of them are endo/MRI/other off-site. But 5 minutes adds up to a tremendous amount of time.

It also gets non-hourly staff out earlier - constantly hearing people complain about how long they are stuck in rooms - well becoming more efficient shortens our day. There are so many inefficiencies at turn over. I used to get so upset as a resident watching the molasses drip. Felt like water boarding some days. It's been shown that when the surgical attending sits in the room between turn over, it goes faster. Why is that? Because there are people who are lazy and don't want to work. Some of the staff at one of the hospitals I worked in actually would drag their feet between cases after 11 - hoping they would have to start the last case.

 

[kazuma]

If you have 30 ORs

Actually there are many ways it can save money and not just if you can squeeze in an extra case although that certainly would be more efficient (especially for really long days - think T&A day). Another way - if you have nursing staff from 7am-3pm every day. If you go until 315, you have to shift staff around to keep that room open (either not starting another room or paying the nurses overtime). If you have shaved off 5 minutes off every case that day then you have prevented having to do either.

At my institution we perform roughly 45K anesthetics. Now granted many of them are endo/MRI/other off-site. But 5 minutes adds up to a tremendous amount of time.

It also gets non-hourly staff out earlier - constantly hearing people complain about how long they are stuck in rooms - well becoming more efficient shortens our day. There are so many inefficiencies at turn over. I used to get so upset as a resident watching the molasses drip. Felt like water boarding some days. It's been shown that when the surgical attending sits in the room between turn over, it goes faster. Why is that? Because there are people who are lazy and don't want to work. Some of the staff at one of the hospitals I worked in actually would drag their feet between cases after 11 - hoping they would have to start the last case.

Very true, used to see that kind of behavior every day in residency, and even sometimes in PP. However we usually have 10-20 min turnovers, 25 min max is the goal. On my pediatric general surgery or ENT lines we'll have 5-10 min turnovers. It's crazy fast.

 

[Mman]

If you have 30 ORs

Actually there are many ways it can save money and not just if you can squeeze in an extra case although that certainly would be more efficient (especially for really long days - think T&A day). Another way - if you have nursing staff from 7am-3pm every day. If you go until 315, you have to shift staff around to keep that room open (either not starting another room or paying the nurses overtime). If you have shaved off 5 minutes off every case that day then you have prevented having to do either.

At my institution we perform roughly 45K anesthetics. Now granted many of them are endo/MRI/other off-site. But 5 minutes adds up to a tremendous amount of time.

It also gets non-hourly staff out earlier - constantly hearing people complain about how long they are stuck in rooms - well becoming more efficient shortens our day. There are so many inefficiencies at turn over. I used to get so upset as a resident watching the molasses drip. Felt like water boarding some days. It's been shown that when the surgical attending sits in the room between turn over, it goes faster. Why is that? Because there are people who are lazy and don't want to work. Some of the staff at one of the hospitals I worked in actually would drag their feet between cases after 11 - hoping they would have to start the last case.

Just going to disagree. We are a bit bigger in size and we have made small improvements in turnover time over the years and are now actually quite good at it. It really doesn't make a big difference, though, until you start to be able to fit an extra case in. The difference between 3 and 315 is noticeable, but the difference between 230 and 245 is irrelevant even with that 15 minute difference, it only matters the small amount of time you are ending a case load right at the perfect time.

Getting more cases done by the same level of staffing is awesome. Getting a few people out 10 minutes earlier a handful of times a month isn't a big deal.

 

[Hoya11]

Actually the job market for new grads is great right now since residency programs have already started producing the kind of new grads required by AMCs and hospital CEOs, the kind that accepts lower pay and never rocks the boat.

Just wanted to share my big picture view. I have been doing PP OR Anesthesia few years now. I used to do chronic pain briefly.

When I was doing chronic pain the whole issue was getting patients. Volume. It was really shocking how hard this was and how much time you spend worrying about getting/keeping patients. And its the same in every specialty: IM fighting to do the pre-ops, get the new physicals, new patients, ect... IM Specialisits fighting to get the referrals from PCPs. Surgeons fighting to get referrals from specialists/PCPs. So once you get a patient(s), you feel like you earned/created this base of business. At the height of the career of a succesful specialist/surgeon you are making 500-800k ish in general.

The reality is: Anesthesiologists dont do that. We are parasitic. We stay in the hospital and whatever surgeons (indirectly from PCPs) bring in we latch on to and get a piece of. So Why cant we help them draw labs or do an H and P or whatever inane tasks they are asking? How much time will this really take us compared tot he bellyaching going on? Do you know what they go through to get patients? Want to go to a networking dinner after work/weekends? And why is there an expectation that making 350k working for an AMC is chump change, and that we need to be making the same 500-800k that they make or we are being ripped off?

What happened was, as the surrounding support systems (hospital admin, surgeons, etc) got wise to anesth docs making 800k, they said hey is that fair? maybe we should change the model... and thus the model is changing. And rather than "complacent millenials" too sheepish to say anything about the paultry 350k plus great benefits and no business concerns (getting pts, staying lucrative, etc)... I see it as a new generation of understanding providers willing to work with the changing system while granpa raked it in inappopriately for all those years and is now clint-eastwood-esque ranting about the good ole days.

You think what we do is worth more than 350k plus great benefits? Why? Why is it worth 500-800k? Just because it used to be?

 

[Planktonmd]

Just wanted to share my big picture view. I have been doing PP OR Anesthesia few years now. I used to do chronic pain briefly.

When I was doing chronic pain the whole issue was getting patients. Volume. It was really shocking how hard this was and how much time you spend worrying about getting/keeping patients. And its the same in every specialty: IM fighting to do the pre-ops, get the new physicals, new patients, ect... IM Specialisits fighting to get the referrals from PCPs. Surgeons fighting to get referrals from specialists/PCPs. So once you get a patient(s), you feel like you earned/created this base of business. At the height of the career of a succesful specialist/surgeon you are making 500-800k ish in general.

The reality is: Anesthesiologists dont do that. We are parasitic. We stay in the hospital and whatever surgeons (indirectly from PCPs) bring in we latch on to and get a piece of. So Why cant we help them draw labs or do an H and P or whatever inane tasks they are asking? How much time will this really take us compared tot he bellyaching going on? Do you know what they go through to get patients? Want to go to a networking dinner after work/weekends? And why is there an expectation that making 350k working for an AMC is chump change, and that we need to be making the same 500-800k that they make or we are being ripped off?

What happened was, as the surrounding support systems (hospital admin, surgeons, etc) got wise to anesth docs making 800k, they said hey is that fair? maybe we should change the model... and thus the model is changing. And rather than "complacent millenials" too sheepish to say anything about the paultry 350k plus great benefits and no business concerns (getting pts, staying lucrative, etc)... I see it as a new generation of understanding providers willing to work with the changing system while granpa raked it in inappopriately for all those years and is now clint-eastwood-esque ranting about the good ole days.

You think what we do is worth more than 350k plus great benefits? Why? Why is it worth 500-800k? Just because it used to be?

First of all: What determines your value and your income is supply and demand not the hospital CEOs or the surgeons.
Second: If you think you will be more valuable to the hospital CEO or to the surgeon if you volunteer to do their H&Ps and Order their labs, while letting intra-op anesthesiology become a nursing domain, then you are doing more damage to this specialty than those elders that you are accusing of selling out!
A nurse practitioner or a PA are more than capable of doing all these perioperative tasks at a fraction of the price, and it's only a matter of time before the CEO and the surgeon realize that they don't need an overpriced and overqualified nurse alternative like you.

 

[nimbus]

Just wanted to share my big picture view. I have been doing PP OR Anesthesia few years now. I used to do chronic pain briefly.

When I was doing chronic pain the whole issue was getting patients. Volume. It was really shocking how hard this was and how much time you spend worrying about getting/keeping patients. And its the same in every specialty: IM fighting to do the pre-ops, get the new physicals, new patients, ect... IM Specialisits fighting to get the referrals from PCPs. Surgeons fighting to get referrals from specialists/PCPs. So once you get a patient(s), you feel like you earned/created this base of business. At the height of the career of a succesful specialist/surgeon you are making 500-800k ish in general.

The reality is: Anesthesiologists dont do that. We are parasitic. We stay in the hospital and whatever surgeons (indirectly from PCPs) bring in we latch on to and get a piece of. So Why cant we help them draw labs or do an H and P or whatever inane tasks they are asking? How much time will this really take us compared tot he bellyaching going on? Do you know what they go through to get patients? Want to go to a networking dinner after work/weekends? And why is there an expectation that making 350k working for an AMC is chump change, and that we need to be making the same 500-800k that they make or we are being ripped off?

What happened was, as the surrounding support systems (hospital admin, surgeons, etc) got wise to anesth docs making 800k, they said hey is that fair? maybe we should change the model... and thus the model is changing. And rather than "complacent millenials" too sheepish to say anything about the paultry 350k plus great benefits and no business concerns (getting pts, staying lucrative, etc)... I see it as a new generation of understanding providers willing to work with the changing system while granpa raked it in inappopriately for all those years and is now clint-eastwood-esque ranting about the good ole days.

You think what we do is worth more than 350k plus great benefits? Why? Why is it worth 500-800k? Just because it used to be?

We may be parasites but we are essential parasites. We don't need additional parasitic middlemen who don't add value stealing a big chunk of the revenues we generate. How does a banker or an AMC add value for the patients, hospital or surgeon? Is that worth tens or hundreds of millions? That is what they are taking out of the healthcare system.

 

[Consigliere]

You think what we do is worth more than 350k plus great benefits? Why? Why is it worth 500-800k? Just because it used to be?

Absolutely. If you even need to ask this question as an allegedly practicing anesthesiologist, then I must seriously question whether you are actually an anesthesiologist.

 

[Hoya11]

First of all: What determines your value and your income is supply and demand not the hospital CEOs or the surgeons.
Second: If you think you will be more valuable to the hospital CEO or to the surgeon if you volunteer to do their H&Ps and Order their labs, while letting intra-op anesthesiology become a nursing domain, then you are doing more damage to this specialty than those elders that you are accusing of selling out!
A nurse practitioner or a PA are more than capable of doing all these perioperative tasks at a fraction of the price, and it's only a matter of time before the CEO and the surgeon realize that they don't need an overpriced and overqualified nurse alternative like you.

Im not suggesting being the pre-op/post-0p monkey and letting crnas do the intra-op. Im merely saying that maybe it IS a waste to have a preop nurse AND me. I can put the IV in, send the labs, bring into the room and start the case, and address issues in the pacu. Do you really need someone doing that inane preop interview and asking if you are safe at home?

 

[Hoya11]

We may be parasites but we are essential parasites. We don't need additional parasitic middlemen who don't add value stealing a big chunk of the revenues we generate. How does a banker or an AMC add value for the patients, hospital or surgeon? Is that worth tens or hundreds of millions? That is what they are taking out of the healthcare system.

The revenue we generate are determined by insurance payouts. Would you be content if insurance reimbursements went down by half, but we were able to keep 100% of it and no darn middle man was taking it? I only care about the bottomline.

 

[Hoya11]

Absolutely. If you even need to ask this question as an allegedly practicing anesthesiologist, then I must seriously question whether you are actually an anesthesiologist.

Im just playing devils advocate here. Top MD earners in my hospital are earning ~1 million per year. There are ortho/neuro surg. ENT and Optho and most other ortho/neuro are making 500-800k. Do you think as an anesthesiologist you should make just as much as these top specialized surgeons? Why? As I said they are bringing in the business and thus owning the ASCs etc...

Market forces ("supply and demand") ARE whats driving the changes to lower salaries for us. Its not CRNAs, its not Obama, its actual real life market forces at work equalizing things. Were still doing well, but yes you are antiquated if you think in this capitalistic system, in a specialty set up as ours is financially, that you expect to make as much as top surgeons. The evaporation of partnership track jobs IS due to market forces. AMCs are market forces. They evolved due to mismanagement and the early retirement goals of senior partners in PP groups. Are those not market forces?

Anyhow. I think more reasonable numbers are 300k to start with goal of 500k at peak. That I think compared to other specialties makes sense to me. What is the justification of making as much as Neurosurg?

I dont agree with AMC business people working us like dogs and taking a large piece of the pie.
I dont agree with hospital CEOs/admins making more than the doctors.
But I dont agree also that we should be outraged that we are not making 800k.

In 20 years when wall-street bankers are making 100k again (one can only hope), Im sure there will be an outraged contingent that feels they deserve the million dollar salary and bonuses and tax breaks that that particular generation had become accustom to.

 

[urge]

Getting a few people out 10 minutes earlier a handful of times a month isn't a big deal.

Epcially if done by cracking the whip. Staff satisfaction is more important than 5 min here and there.

 

[urge]

Im not suggesting being the pre-op/post-0p monkey and letting crnas do the intra-op. Im merely saying that maybe it IS a waste to have a preop nurse AND me. I can put the IV in, send the labs, bring into the room and start the case, and address issues in the pacu. Do you really need someone doing that inane preop interview and asking if you are safe at home?

Are you insane?

You can help with turnovers by mopping the OR yourself if you are interested.

 

[nimbus]

You think what we do is worth more than 350k plus great benefits? Why? Why is it worth 500-800k? Just because it used to be?

It depends on what you are doing. If you are stool sitting CRNA level cases then you probably deserve CRNA pay. However, if you are doing complicated cases requiring specialized skills and knowledge or are supervising a large volume of cases, then you deserve more. As you say, the market will decide.

 

[Pooh & Annie]

Are you insane?

You can help with turnovers by mopping the OR yourself if you are interested.

Judging by your delivery, you're young; your attitude is however very old school. That's not good. You should realize that while anesthesiologists are important, you're not. Unless, that is, you're on the far right of the bell curve generating great research or something.

Good, safe anesthesiologists are not hard to find. If you think you're great because you can get patients through a dangerous case, you're no better than somewhere in the middle of the curve. The folks who are safe, helpful, and easy to get along with are better than you.