Head & Neck pay is definitely lower! I practice in a non-academic tertiary care center and do most of the head & neck surgery in our institution. I do things like resecting mandible+tongue+FOM+neck skin+larynx and bilateral neck dissection in same patient. Or carotid artery resection and revascularization. I generate RVUs at the 71st percentile of MGMA and my pay is at the 27th percentile.
Totally agree with you on this one. That is one of the major disadvantages of H&N outside of a tertiary referral center. Let's say I were to do anterior FOM cancer across the midline - the medicare codes and reimbursement would be:
1) Direct laryngoscopy (CPT 31525) $143
2) Esophagoscopy (CPT 43200) $92
3) Bronchoscopy (CPT 31622) $133
4) Resection Ant FOM Cancer
w/ unilateral neck dissection (CPT 41335) $1874
5) Opposite neck dissection (CPT 38714) $1271
6) STSG 1st 100 cm2 (CPT 15100) $611 OR
6) Alloderm (CPT 15320) $278
You would think that you add the fee's up tight? So total for your work is $3791 - $4124.... But if you made that assumption, you'd be wrong.
You see, Medicare pays 100% of the first billed code, 50% for #2, 25% for 3 and 4 and NOTHING after that. So really, the reimbursement is around $2614. The operation may take 6 hours if you're doing by yourself. Then for the next 90 days - all care is now reimbursable and included in the global fee. So for the next 5-7 days that the patient is in the hospital and you are rounding, no reimbursement. The coordination of care for chemo/radiation therapy, if needed, not reimbursed. The post-op visits, non reimbursed.
Now, while you are operating, you are still paying for your office rent, malpractice, nurses, medical assistants, audiologists, front desk personnel, billers, coders, office manager, all of their benefits (medical, disability ins, etc). You still need to pay for your student loans, personal/professional disability and we haven't started to talk about contributions to your personal and employee's 401k plans (Did I mention that while you were in medical school and residency for 10 years, you've contributed little to none and now need to pay catch-up).
Because of this, it is not surprising that there are few private practice otolaryngologists that do not perform major H&N operations. When they look at the lost financial opportunities, they often will decide that they cannot make ends meet unless they give up that part of their practice and focus on the high-volume, low complexity, larger revenue producing operations.
Like adpinheiro, I enjoy H&N. One of the reasons I stayed in academics is that a portion of my practice is salaried and my choosing to do these does not affect my bottom line as much. However, since a portion is productivity based (and it is based on collections, not RVUs), I still do take a financial hit when I perform these operations vs the simpler ones mentioned.
I learned early in my residency what RVUs were, how to code, etc. Not all are as fortunate and the first year or two in practice can be a real eye opener.
Personally, I don't mind the PP ENTs sending the more complex, less revenue stuff to me and my partners. They are seeing tons of other things and trying to manage a practice on top of patient care. I, fortunately, don't have all of their worries with practice management, overhead, balancing office conflicts and personality issues, etc, etc.
When you get towards the middle of residency and start to think about the PP vs academics vs hospital employed vs what ever else - think about what role you want to have in the business side of medicine. To me, it's too much headache for the increased revenue and personal reimbursement.
As a side note, I read somewhere that the average ENT generates $1.2 million for their hospital. I suppose that may be why we see that hospital employed positions are starting to have much higher salaries and have RVU based bonuses.
Regardless, this is getting too long so I'll cut it short here.
Leforte
