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Is Head and Neck Surgery Salary lower?

Discussion in 'Otolaryngology' started by JPICK1, Feb 13, 2008.

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  1. JPICK1

    JPICK1

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    Hey all,
    I've become interested in otolaryngology primarily because of H/N surgery, however, i was surprised to hear that although you do a fellowship in H/N surgery your average reimbursement is actually lower when compared to a general ENT. I did a search and found no useful salary surveys that actually broke down the average reimbursements of different types of ENT surgeons. Is this true? In this case it must not be a very popular fellowship out of ENT.

    Thanks for any info. :thumbup:
  2. resxn

    resxn

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    H&N fellowships are one of those that can sometimes go unfilled, at least in the less competitive programs. The higher end ones (e.g. MD Anderson) are always filled and are tough to get.

    It's true that H&N cases reimburse poorly, but more importantly it's because they are high maintenance.

    Let's say I do a 41155 (Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection), but not the free flap--I'll leave that for the plastics guy. Let's say the patient already got trached for the sake of argument.

    The RVU for that procedure is 73.52 and the medicare allowable is $2600.20 (nice of them to tack on the 20 cents)

    Now let's look at 69346 (bilateral tubes). The RVU is 4.27, the medicare allowable is $153.49.

    So for the math, let's say the H&N case takes me 6 hours. How many tubes can I get done in 6 hours? Well, I can do 4 an hour fairly easily if I'm running two rooms. So I can theoretically get 24 done. That's a bit of overkill. But for the sake of argument let's look at the numbers--that's $3683.76. Ok, so if we use a more realistic number and say I get 18 cases in that timeframe--that's assuming 3/hr probably fairly low estimate, I still make $2762.82.

    Now, some people would say why the heck would I want to do 18 tubes instead of a cool case like the composite resection. Good question. Many wouldn't. I know I have no interest in doing 18 tubes in a day. But let's say I do 4 sets of tubes, 2 tonsils on kids under 12, and a FESS. That would add up as follows 4x153.49 + 2x268.51 + 895.43 = $2046.41.

    Well, I'm down $700, but I'm out by noon instead of 3 or 4PM so I have a lucrative afternoon clinic I can still do and make that up and more by 3 or 4PM. I won't have to round on the H&N patient for $0 for the next 7-10 days. I won't have as significant a risk of multiple complications. I won't need to see that patient every month for the next year.

    H&N cases are fun. They can be technically challenging and very rewarding, but they don't reimburse as well as general ENT for those reasons above.

    Additionally, it's hard, but not impossible to have a private H&N practice. That's why most are academic. There's several threads addressing this lower on the board.

    Now let's say I go to clinic one morning and do 3 Pillar Implant procedures. Ballpark charge in my area for that procedure is $2000 to make it an even number. The equipment overhead is about $650. I can do the Pillar procedure in about a total of 6 minutes from start to finish. Let's say I do the 3 in an hour because I want to post a bunch of stuff on SDN that morning. I just made $6000 minus $1950 for equipment expense, and I just netted $4050 for an hour's work and no global billing period and no rounding and low risk of complications and on and on.

    That's why H&N fellowships are not as popular today.
  3. JPICK1

    JPICK1

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    Thanks for the info!
  4. TheThroat

    TheThroat SDN Moderator Moderator Emeritus

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    resxn has answered this question with a longer post and more eloquently than I ever would (as he often does), but I'll add a few thoughts. In reality, a pure H&N private practice is a truly rare bird. Why? H&N patients need A LOT of postop care in the global period (read: no reimbursement) and often have complications. SO, residents (low income, hard working, relatively smart people) are really pretty helpful in taking care of these patients. SO, almost all pure H&N guys are in academics, which usually pays less than private practice. Going into H&N is a calling. If you love it, you HAVE to do it. I like H&N, and enjoy the cases that come my way. I wouldn't stand it if it were the only thing I did, though.
  5. DLmd

    DLmd Junior Member

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    Great Post Resxn:thumbup:
  6. BEN MD FRCS

    BEN MD FRCS

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    First off if you are going into H&N because you are thinking of wanting to make the big buck? Then you are already not a good canditate in my eyes.
    If you are interested in the $ rather then in the complexety of H&N then why don't you get into facial plastics and leave the H&N to people who have a passion about helping the group of patients who don't have good insurance if any because that's the majority of patientsin H&N.
    No Fellowship pays well
  7. resxn

    resxn

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    I'd have to disagree with that. A fellowship-trained pediatric ENT can make an exceptional amount of money compared to general ENT on average. Otology and Laryngology also make more than the general guy on average. Facial plastics is obvious.

    H&N does not. Rhinology really depends. Some make more, some just average.

    This is all accoriding to the MGMA.
  8. maverick_pkg

    maverick_pkg Vascular Surgery

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    for a general surgeon though, my guess, looking at the above figures is, that it doesnt pay less than other general surgery fellowships if one is in academics. u guys have any idea?
  9. millepora

    millepora

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    Very enlightening post, resxn!
  10. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    I think this whole issue of what pays and what doesn't pay depends on a number of things: 1. types of cases, 2. academic v. private practice, 3. incentive plans, and 4. lifestyle desires.

    Any ENT doctor, private or academic, can make a lot of money. In private practice, money is made by doing high volume, quick turnover, lower RVU procedures as well as by seeing a high volume of patients in the outpatient setting. In academics, it depends on what you do. If you are a head and neck surgeon, ultimately the income you bring into the hospital is going to depend largely on case volume, case complexity, and new patient visits in the outpatient setting. Yes, your private practice colleague may make the same amount by doing multiple tubes, tonsils, and sinus cases as you do by doing one "big whack;" however, generally speaking, the hospital also makes a lot of money by charging for drugs, equipment, nursing, and utilizing the facility for those 7-10 days. Plus, other physicians may consult on your patient for whatever other medical and surgical issues come up. Having a patient admitted with a head and neck cancer can generate a lot of money (even if it is a Medicaid patient).

    A number of institutions also look at RVU productivity, not just charges billed and collections. In fact, some institutions set RVU goals and award bonuses based on productivity above the RVU limit. RVUs are generated in the clinic as well as in the OR, and a savvy physician knows how to modify procedure codes and E&M codes to justify additional RVUs (complaint unrelated to original E&M, procedure unrelated, scheduling visits to be just beyond global day periods, making sure E&Ms are Levels III or IV, smoking cessation codes/counselling, scopes, doing your own FNAs, ultrasounds, or CT scans, etc.)

    The workload can be a tremendous burden. In the academic setting, you have residents who do a lot of the work. We all know this; we were all residents. In PP, you might have a hospitalist, a PA, or an NP who does your work. In academics, you don't pay for your resident. You may not pay for your NP or PA either, but you might in some circumstances. No personal overhead in academics. On the flip side of that, I know a few surgeons in my department who arrive at 6:30 and leave around 7-8pm; I arrive around 7 and leave around 6-6:30, and I think that's a long day.

    I think it boils down, again, to doing what you love doing. You gotta do that. Once you figure it out, then you will have a better idea of where you need to do it. And once you do, pick the right place that will maximize your income.
  11. resxn

    resxn

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    excellent post from the academic perspective, NPB
  12. maverick_pkg

    maverick_pkg Vascular Surgery

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    great post, thanks
  13. adpinheiro

    adpinheiro

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    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.

    As pointed out by others, I could generate more RVUs by doing simple cases. Some of my partners make twice as much as I do and don't work nearly as hard. I employ a PA to help me with rounds, consults, assist in OR and see patients in the office. I pay her salary which is charge to me as overhead.

    I have told my institution that I will become a General ENT doc, unless I can have a guaranteed RVU reimbursement or some sort of subsidy in order to continue doing head & neck. Head & neck cancer is a HUGE source of revenue for the institution. These patients get PET scans, CT scans, generate large OR fees for the hospital. They also bring large revenues from chemo and Radiation Oncology. These cases help the institution prosper while the individual head & neck surgeon suffers.

    Most folks in the community are not remotely interested in treating head & neck cancer. For reasons of economics and life style. And so they refer all patients for chemoradiation regardless of whether that is appropriate or not. Or, when that option is available, they refer patients to tertiary care referral centers - usually a nearby university hospital.

    Head & neck as a surgical specialty will die unless the economics change. The number of individuals able to do complex ENT cancer cases is small to begin with. The number being trained continues to dwindle. And I know several head & neck surgeons who then become general ENT practitioners for the reasons I have mentioned. Others become portals of entry for patients into Medical and Radiation Oncology without actually doing real oncologic surgery.

    And there, I have dismounted from my high horse!
  14. Leforte

    Leforte Member Moderator Gold Donor

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    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
  15. ZagDoc

    ZagDoc Ears, Noses, and Throats

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    Great information in this thread, much thanks all!
  16. maverick_pkg

    maverick_pkg Vascular Surgery

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    yeah great stuff. thanks guys
  17. badasshairday

    badasshairday Account on Hold

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    Cool thread.

    I don't get why H&N can't just get a stipend from the hospital? Obviously they are generating the hospital a ton of revenue.

    I see that anesthesiologists can get stipends based on their relative short supply, however this costs the hospital a lot of money while the gas docs aren't even generating the hospital income (I mean, they do indirectly, by keeping the OR going... but they aren't bringing in the cases like surgeons).

    As a 3rd year student, I am becoming really interested in ENT, mostly do to the breadth of the practice. You guys do some pretty amazing things.
  18. resxn

    resxn

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    Many are going to this model (not subsidized, but employed), however, the problem is that the reimbursement still isn't what is possible in private practice. The benefit is that it provides security. It also allows for PA's to be part of the practice, medmal to be paid for, and clinical overhead costs to be covered. Definitely, it is an increasingly popular choice.
  19. HeadNeckFellow

    HeadNeckFellow

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    Dear resxn, adpinheiro, theThroat, LeForte, and neutropeniaboy,

    I am a future head and neck fellow (current resident). If you feel comfortable, can any of you enlighten us as to your actual annual salary as a head and neck attending?

    What are people making as starting salary, 10 years in, and 20 years in at hospitals, academic settings, private practice, etc?

    What do you think the future holds?
  20. resxn

    resxn

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    In my area, which is a suburb of one of the largest cities in the country, new ENT's are being offered guarantees where the salaries are between $250-275k. In supersaturated areas, the guarantees are $175 or lower. In underserved areas I've seen guarantees in the $400+ range. In my area, it is still reasonably easy to expect your income to be as good or better than your guarantee amount.

    In 10 years, income will be drastically different. Essentially I see in any metro area, a private practice of <5 docs will not exist unless these people value independence more than income. To be private practice, you'll need to be in a mega-group of 20+ docs. More than likely I'd bet any group smaller will be a 501A (salaried by the hospital) or whatever version of that exists at that point.
  21. Fah-Q

    Fah-Q Senior Member

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    Why?
  22. resxn

    resxn

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    Unfortunately for physicians, the hospital lobby has deeper pockets, is better organized, more committed, less fragmented, and has more to lose. As such, if you look at how reimbursement will be distributed in the future, when a patient comes to a health care facility, the reimbursement will be based not what on what was done, but rather what the diagnosis code is. Hence, ICD-10 having 4x as many diagnosis codes to allow more specificity. The totality of the check is sent to the health care facility (hospital, ASC, clinic, etc) and the facility then divides up the check for disbursement to the various entitities participating in the care for that ICD-10 code.

    For example, you see a parapharyngeal space abscess in the ER. You take to the OR for I&D and because of poor IDDM control have the hospitalist consult for medical care while you handle the drain management and post-op care. The hospital will receive X dollars in reimbursement. They'll keep a portion for their expenses, give the hospitalist some, the radiologist some, the ER physician some, and you some.

    You can see that you will need to have a good relationship with the hospital. And by good I mean strong, and by strong I mean in terms of negotiating power. If you're a solo doc and you don't like how they reimburse you, they don't care. It's easy to replace one person. They'll just recruit someone in on salary and give them all referrals. However, if you're a group of 20 and manage 80% of what comes in to their hospital, it would be very hard for them to lose your group and replace you. They will be much more likely to negotiate more reasonable rates.

    Their other option, and the one they'd prefer, is to buy you out. You are employed and then they can tell you to do whatever they want. Only a few states protect physicians somewhat from this by making it illegal for corporations to practice medicine (TX and CA come to mind) but the hospitals are still getting around this with 501A programs in TX and the like.

    If you're not aware of this happening, please please please do your homework. Life is changing fast and you'll be in trouble if your not ahead of the curve on this one.
  23. Fah-Q

    Fah-Q Senior Member

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    Interesting. I guess I do need to do my homework. I was not aware that bundled payments were being implemented. I've heard a lot about the possibility of bundled payments but is this a done deal or just speculation at this point? Was this part of PPACA? Please provide me a link to read about this if you have one. What year is this supposed to start?

    Thanks.
  24. TeamZissou

    TeamZissou PGY1

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    +1
  25. resxn

    resxn

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