Save Cardiology - SOS Call

[sacrament]

An essential benefit of being an employed physician--and why innumerable private practices have sought refuge in the arms of the hospitals--is that you have some buffer against the vagaries of what the reimbursement patterns are from year-to-year. But having a largely stabilized salary is, of course, a double-edged sword. If you want to try to sweet-talk the hospital into putting a floor in place for you but essentially no ceiling... well, if they are desperate for an IC then they might bite. We all know people who wrangled their way into highly enviable positions.
Negotiations with respect to how your salary is going to be structured (e.g. salaried only, salary with RVU-based bonus, etc.) are not simple and in some desirable locations, there is no negotiation at all. Most of my job offers in "desirable" metro areas were: this is the offer, take it or leave it, there is no wiggle room, and if you don't like it we have fifteen other candidates who will love it. The IC market is not particularly healthy. It's not terrible, but it isn't a "seller's market." If you're picky about where you end up, your ability to dictate terms is nil.

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[bronx43]

If you work for a hospital, like many of us do or will, there is no excuse for your salary to budge lower than it currently is. I realize that is what the hospital receives. However, if the hospital is making money so are you as the physician. If anyone signs a contract knowing that reimbursements are increasing 50% and their salary is actually lower or not increased than they are a fool. Thats where a good healthcare attorney comes into play. I have seen it work for other physicians and cannot believe how much they get paid.

Supply and demand, my friend. This is exactly why I thought the biggest problem with cardiologist is training too many fellows. As sacrament said, you have zero bargaining power when there are 10 people with your same skill set willing to do your job for the same or lower pay.

 

[IMDoc607]

I guess there will always be complainers and negative people. Sacrament has somewhat of a point but name one job that allows you to bargain in desirable locations? In fact, if you're smart even in desirable locations you can negotiate. Without divulging my identity, I know of multiple physicians where I from that have used the same strategy im talking about. They are in different multiple specialties (cardio included) and have negotiated themselves contracts I would only dream of having. And they live in one of the most populated and desirable areas in the nation. They approached the hospital like this....if I bring in X amount of dollars then I would like x salary. For me, I don't plan on living there and would like to live in a place with less physicians because I think In some cases you are 100% right. However, if you bring in the money they will pay you....Is it harder to do it where they are? Sure! But it can definitely be done.

 

[sacrament]

I guess there will always be complainers and negative people.

I'm not complaining or being negative. I'm relatively content with my current situation. I make less than what you'll see reported as "averages" but A) I don't actually believe those figures are an accurate representation, and B) even if they were, I am very happy with my location and work-life balance. You can still make $500K as an IC but by and large you have to not care about having a life. The only IC I know who makes that kind of money is working >80 hours a week and doesn't take vacation. There are also many positions out there where the volume required to bring home that kind of money just simply doesn't exist or is too diluted, no matter how willing you are to work. I'm just being realistic about the current situation out there.

 

[IMDoc607]

So you do not believe a 50% increase in reimbursement as well as the ability of the interventionalist to now bill a consult fee will help increase salary? For example, every cath you now do can have a consult fee attached to it.

Hopefully, as many recruiters and other IC have told me the number of IC guys out there is going to drop pretty nicely in the next 5-7 years leaving more work for the upcoming generation.

 

[sacrament]

So you do not believe a 50% increase in reimbursement as well as the ability of the interventionalist to now bill a consult fee will help increase salary? For example, every cath you now do can have a consult fee attached to it.

Not every cath, at least not in an ethical fashion. If it was set-up and scheduled as an outpatient, you would hard-pressed to justify billing a "consult" when they arrive for the procedure. If one of your colleagues sees them as an inpatient and then asks you to "consult" on whether they need a cath or not, you can bill for it. In the grand scheme this doesn't amount to a tremendous amount of money, but sure, it helps. It will feel extremely silly and shifty to actually do this in practice, believe me. "Hey sacrament, I'm giving you a call because Mr. Jones in room 3554 needs a cath. But be sure to... uh... put in a consult though before you do it..."
In terms of whether I believe the (proposed) increase in hospital reimbursement will actually result in increased bargaining power at the table... maybe, but I'm skeptical. As the medical director of a very busy cath lab, I have become familiar with the economic realities at play here. First of all, no hospital system is going to rush to restructure contracts in a dramatic profit-sharing way based on a single year's increase in reimbursement, when it can just as easily disappear the following year. And second of all, while you may argue "well it doesn't matter, so long as you are making them money you deserve x% of it..." well that isn't how it really works. When our lab got back firmly in the black last year, it wasn't as though we were generating this pile of liquid cash that could be dispersed any which way. In this day and age, anywhere that a hospital can squeeze out some profit tends to be used to aggressively subsidize other non-profitable functions of the system. Money that cardiology generates isn't necessarily money that cardiology gets to keep and use--it is hospital system money that will be used to shore up whatever needs shoring up.

Hopefully, as many recruiters and other IC have told me the number of IC guys out there is going to drop pretty nicely in the next 5-7 years leaving more work for the upcoming generation.

The average age of an IC is several years older than a non-invasive cardiologist, plus ICs tend to drop out of cath lab work several years before they retire and effectively become non-invasive cardiologists, so I also think that this may happen.

 

[IMDoc607]

Not every cath, at least not in an ethical fashion. If it was set-up and scheduled as an outpatient, you would hard-pressed to justify billing a "consult" when they arrive for the procedure. If one of your colleagues sees them as an inpatient and then asks you to "consult" on whether they need a cath or not, you can bill for it. In the grand scheme this doesn't amount to a tremendous amount of money, but sure, it helps. It will feel extremely silly and shifty to actually do this in practice, believe me. "Hey sacrament, I'm giving you a call because Mr. Jones in room 3554 needs a cath. But be sure to... uh... put in a consult though before you do it..."
In terms of whether I believe the (proposed) increase in hospital reimbursement will actually result in increased bargaining power at the table... maybe, but I'm skeptical. As the medical director of a very busy cath lab, I have become familiar with the economic realities at play here. First of all, no hospital system is going to rush to restructure contracts in a dramatic profit-sharing way based on a single year's increase in reimbursement, when it can just as easily disappear the following year. And second of all, while you may argue "well it doesn't matter, so long as you are making them money you deserve x% of it..." well that isn't how it really works. When our lab got back firmly in the black last year, it wasn't as though we were generating this pile of liquid cash that could be dispersed any which way. In this day and age, anywhere that a hospital can squeeze out some profit tends to be used to aggressively subsidize other non-profitable functions of the system. Money that cardiology generates isn't necessarily money that cardiology gets to keep and use--it is hospital system money that will be used to shore up whatever needs shoring up.


The average age of an IC is several years older than a non-invasive cardiologist, plus ICs tend to drop out of cath lab work several years before they retire and effectively become non-invasive cardiologists, so I also think that this may happen.

I got ya.....I guess I am looking at this from my perspective. I will be an attending in 3 years at the earliest. I am just happy to see some good news for IC. I am sure no hospital will run and renegotiate. I bet they are salivating at using IC for more money now without giving them more money. However, I believe that if you work for a hospital system that isn't shady and unethical we should at least see a stabilization in salaries. I was at a conference recently and someone echoed exactly what you were saying. The area he's practicing starting salaries at 275-300 and then production. However, he mentioned that unless you are in rural areas (which he is not....hes outside NYC) then you will have trouble making >500. He also mentioned that its all about the business model of the practice you work for. One group we both know caths like crazy. Their IC guys make close to 7 figures but they work constantly. I wouldn't want a life like that anyway. I'll take my 300-400 and enjoy my life.

 

[sacrament]

By the way, in case I'm giving the wrong impression, let me state that I am one of those specialists who is completely unapologetic about how much money I make and feel like I probably deserve more. I am constantly involved in fine-tuning and improving our practice with the intent of making more money. I like money just as much as anybody, and I can always find a good use for more of it.
But my personal feeling on this is that it is more important to maximize your "dollar per hour" than your absolute income. Some people want to grind out as much money as they possibly can in their first few years, before the bottom falls out (worst case scenario) or before they personally burn out (inevitable), and then they can take a more reasonable job after their loans are paid off, etc. There is nothing inherently wrong with that, but this is something that each person has to decide for themselves after taking a long look in the mirror. Most of us have already burnt a lot of our "prime years" in medical school, residency, fellowship. I have a young child that I would like to actually see at the end of the day. Delayed gratification is the norm in medical training, but when we think about what it is that we're delaying we tend to think it's the money. At least, that's how I always viewed it. But my post-fellowship life is such a tremendous step-up just in terms of stress, hours worked, etc., that the money itself is just gravy. New grads should really consider how much longer they want to delay experiencing "real life" before chasing money down the rabbit hole.

 

[IMDoc607]

By the way, in case I'm giving the wrong impression, let me state that I am one of those specialists who is completely unapologetic about how much money I make and feel like I probably deserve more. I am constantly involved in fine-tuning and improving our practice with the intent of making more money. I like money just as much as anybody, and I can always find a good use for more of it.
But my personal feeling on this is that it is more important to maximize your "dollar per hour" than your absolute income. Some people want to grind out as much money as they possibly can in their first few years, before the bottom falls out (worst case scenario) or before they personally burn out (inevitable), and then they can take a more reasonable job after their loans are paid off, etc. There is nothing inherently wrong with that, but this is something that each person has to decide for themselves after taking a long look in the mirror. Most of us have already burnt a lot of our "prime years" in medical school, residency, fellowship. I have a young child that I would like to actually see at the end of the day. Delayed gratification is the norm in medical training, but when we think about what it is that we're delaying we tend to think it's the money. At least, that's how I always viewed it. But my post-fellowship life is such a tremendous step-up just in terms of stress, hours worked, etc., that the money itself is just gravy. New grads should really consider how much longer they want to delay experiencing "real life" before chasing money down the rabbit hole.

I like listening to you. I find you to be very insightful and realistic. Thank you for all your help.

 

[Myostatin]

Physician salaries in the world of hospital employment are not based on hospital technical fees, they're based on supply and demand. Hospitals make a killing on the technical fees generated by coronary procedures. The physician sees patients for $50 a visit, generates volume, takes on all the liability and meanwhile for a typical coronary intervention the hospital may make 5-15K (In profit) while the physician makes $600 or so (in revenue, not profit). This has been going on for years. How is it that hospitals in rural areas can afford to pay 500K for an interventionalist to join when you couldn't generate that income even as a high volume PCI operator, just based on professional fees? At the same time no hospital in a big city would ever pay that kind of salary to a starting interventionalist. We make tons and tons of money for hopsitals, those that are more desparate share a small proportion of those with us an enticement to work for them because its lucrative for them to have a cath lab. Those that are in popular areas (big cities) pay very little because they know they can find a doctor who will accept being financially raped in order to live in that location.

As for increases, sacrament has it exactly right... most of that is not real increase but just bundling of previously separate cpt codes, and even so its for technical fees not physician fees. CMS has us in the position that we count ourselves lucky, as a specialty, if our professional fees are not reduced on a dollar for dollar basis in a given year (entirely ignoring the fact that we still lose money year on year when accounting for inflation).

Its a sad state of affairs but unfortunately we have no lobby, and have failed over and over to stick together and say enough is enough, as a profession. Of course a lot of it our own fault as previous generations have abused the system to the point that nobody trusts us to police ourselves or act ethically when it comes to billing. For that we have to thank those who practiced in the "golden days" of medicine who cashed out with their boats and small airplanes... lol!

 

[IMDoc607]

Physician salaries in the world of hospital employment are not based on hospital technical fees, they're based on supply and demand. Hospitals make a killing on the technical fees generated by coronary procedures. The physician sees patients for $50 a visit, generates volume, takes on all the liability and meanwhile for a typical coronary intervention the hospital may make 5-15K (In profit) while the physician makes $600 or so (in revenue, not profit). This has been going on for years. How is it that hospitals in rural areas can afford to pay 500K for an interventionalist to join when you couldn't generate that income even as a high volume PCI operator, just based on professional fees? At the same time no hospital in a big city would ever pay that kind of salary to a starting interventionalist. We make tons and tons of money for hopsitals, those that are more desparate share a small proportion of those with us an enticement to work for them because its lucrative for them to have a cath lab. Those that are in popular areas (big cities) pay very little because they know they can find a doctor who will accept being financially raped in order to live in that location.

As for increases, sacrament has it exactly right... most of that is not real increase but just bundling of previously separate cpt codes, and even so its for technical fees not physician fees. CMS has us in the position that we count ourselves lucky, as a specialty, if our professional fees are not reduced on a dollar for dollar basis in a given year (entirely ignoring the fact that we still lose money year on year when accounting for inflation).

Its a sad state of affairs but unfortunately we have no lobby, and have failed over and over to stick together and say enough is enough, as a profession. Of course a lot of it our own fault as previous generations have abused the system to the point that nobody trusts us to police ourselves or act ethically when it comes to billing. For that we have to thank those who practiced in the "golden days" of medicine who cashed out with their boats and small airplanes... lol!

NYC blows dude....I don't know why you are shocked. Didn't you know this when you started there? I was just a meeting at the people from SCAI were very happy about this. As a son of a hospital employed physician, his salary was based on the amount of money he brought in. He showed that his practice brought in money so he is being paid very well and not even in a specialty field.