Subspeciality Salary

[BRAINTRAIN]

I know that Neurology is among the least earning fields and perhaps we can never make real big bucks...sigh...Knowing all of it we are here, so we are definitely not in for only money, but of money is still there in the agenda. Most of us, if not all, are going through this grind of MedSchool-Residency-Fellowships to ultimately make some money.

So folks please arrange these neuro subspecialities in the increasing order of average salary- Cognitive, Movement, MS, NeuroMuscular, Non-interventional Stroke, NCC, Epilepsy and Headache.

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[Elipsis]

Heads up I'm a student not a practicing neurologist, but I can tell you what I've learned from my attendings and my mentor in private practice. First, I think you should approach the question differently, i.e. you need to understand that your subspecialty per se is not what determines your salary.

Ways to make more money as a neurologist:
1. Practice in a community setting.
2. Practice in a community setting with a relative under supply of neurologists. No this does not mean you need to practice in a rural setting.
3. Know what you're doing.
4. Be efficient about the way you see patients and be efficient and intelligent about the way you bill for the work you do.
5. Do inpatient consults, take stroke call on weekends. You probably don't need a stroke fellowship for this, but it might help in the job search if you're not doing #2.
6. If you're doing a lot of outpatient work, be able to do some billable procedures, examples; EMGs, botox, etc.

I don't really get it when people say that neurologists can't make any money. I guess it's because a lot of neurologists are more interested in academics, which, like academics in all specialties, doesn't pay that well. In my area a neurologist with a stroke fellowship can get hired for a neurohospitalist position at 275k + bonuses depending on how much extra stroke call they want to take. That's an awesome salary regardless of your specialty.

 

[danielmd06]

A solid response.

 

[neurologist]

Agree. Excellent post.

Bottom line is that in general you make more money by doing more work.

The point about community setting vs academics is also a good one. Working in an academic med ctr you are likely going to be on a fixed salary -- you will always be pushed to do more work, but probably won't get paid more for doing it.

 

[bustbones26]

I don't really get it when people say that neurologists can't make any money. I guess it's because a lot of neurologists are more interested in academics, which, like academics in all specialties, doesn't pay that well. In my area a neurologist with a stroke fellowship can get hired for a neurohospitalist position at 275k + bonuses depending on how much extra stroke call they want to take. That's an awesome salary regardless of your specialty.

It is not that you cannot make money as a neurologist, you just will not "get rich" as a neurologist and have to work harder for it.

Now, I know that some will interpret my response as flaming other specialties; however, I would make the disclaimer that is not really the case.

Syncope:
Cardiology: Holter monitor, EKG, Stress Test = $$$$, all negative, so go see a neurologist
Neurology: Get and MRI (radiologist = $$$), Get an EEG maybe? = $$

Back pain:
Neurologist: EMG = $$, send to pain provider
Pain Provider: Do a nerve block, Do epidural, do radiofrequency ablation = $$$$

Headache:
Right now, insurances and medicare are making it very difficult to perform Botox for chronic migraine, You end up chasing your tail and no, you do not make money on it.

Again, this does not mean that it is impossible to make money, you just have to be savvy with your business and make sure that you are coding and documenting everything perfectly! For example, did you know that some insurances will pay for psychiatric screening at check in? Your documentation can be a template and if the insurance pays for the screening, we are talking and extra $50. Does not seem like much but adds up throughout the day.

Nerve blocks? There are a number of insurances companies that will outright deny occipital nerve blocks, but they will not deny trigger point injections? It is not inappropriate to perform a trigger point injection of the patient's upper cervical musculature and code for it. If you are performing said trigger point injection and "accidentally" block the greater or lesser occpital nerve, oh well You will have to code 723.8 or 723.9, must document neck pain (and they have it), document that everything else that has been tried over the past 30 days had failed, etc. etc.

We undercode as well!! With the amount of documentation we do in our notes, ALL of our patients should be level 4s. We have this impression that we must document time in/time out but this is not true. There are guidelines out there with a map to follow. Vague and harder to find than a unicorn, but if you find them, you can always fight your case.

Now, are video EEG studies on the EMU and sleep studies still fairly good money generators? I would not know?

As much as I hate to say this, during residency, we focus so much on our education, because of course, we want to pass our board. After that me must learn how to document and code things appropriately and attend these courses at whatever conferences we attend for CME. These courses are just as if not more important than general education. Additionally commentary from the crowd is where you learn the most. You will ALWAYS learn something. The other unfortunate part, once you crack the code, it will change again

 

[neglect]

Slight edit on Pain Provider: get MRI before you do anything, use opioids that work for pain in responsible ways, schedule patient for marginally effective nerve blocks, epidurals. If problem, see someone else who can deal with it.

I would second the undercoding bit. A neurologist tends to think, 'boy, that was easy,' but in reality it was the result of years of training and very good smarts that made the diagnosis and treatment plan easy. To other doctors, taking a history, gleaning relevant information out of the physical, and understanding the relevant labs and imaging data is nothing short of a level 98. Never bill for time.

Here's what I think in my ranking. Sadly, getting payment for taking a history and doing a physical and telling families terrible news and taking care of sick people? That's crazy. These are tightly grouped and overlapping.
1. Non-interventional Stroke, NCC, Epilepsy: rare, garner high salaries from hospitals to build programs that attract people.
2. NeuroMuscular, Movement, Headache: both have procedures, but both faces cuts
3. Cognitive, MS: lowest.

Just to affirm the overlapping nature here: I know an academic MS guy who doubles his salary by giving two dinner talks a week, sits on advisory panels, does some MS trials. And I know a mid career guy who does legal work, honestly, and let's just say he does well. Just as I know academic stroke people <200K, but love it and have resident and fellow protection.

So it's all what you like for yourself. The best thing about neurology is our massive under-representation relative to the diseases we treat. Don't like your position? Then you have only yourself to blame for not going elsewhere. Don't like your income? There are more patients out there.

 

[bustbones26]

Just to affirm the overlapping nature here: I know an academic MS guy who doubles his salary by giving two dinner talks a week, sits on advisory panels, does some MS trials. And I know a mid career guy who does legal work, honestly, and let's just say he does well. Just as I know academic stroke people <200K, but love it and have resident and fellow protection.

.

Back whenever I was a resident, I ended up at this big meeting for residents/fellows sponsered by Bayer were all of the attendings in the country regarded as MS gods showed up. They had a dinner for us and I recall this one doc bragging that we would go to mideastern countries as a consultant to hear cases and basically show their docs how to manage MS. Of course, this was followed by a tale of how he got detained in Iran as he was accused of being a spy and he had to flea the country?

 

[mrcmedman]

Back pain:
Neurologist: EMG = $$, send to pain provider
Pain Provider: Do a nerve block, Do epidural, do radiofrequency ablation = $$$$

Interventional Pain took a big hit this year in terms of reimbursement. Procedures like Fluoro-Epidurals, US-guided MSK injections, and spinal cord stimulator implantation do not pay as well anymore. For example, if you now do an in-office epidural, you will only get $70....I guess CMS finally got wiser.

I think the main point is that outpatient neurology usually does not pay as well. That is unless you have a good volume of patients on a daily basis and are proficient at some procedures (EMG, nerve blocks for headache, etc.). I have seen this done at some clinics, while at others, the doctors seem to struggle to seeing 6 patients in one day.

Of course, you can still make good money (>250k) by doing hospital consults, taking stroke call, doing EMU, working in neurocritical care, etc.

 

[bustbones26]

Interventional Pain took a big hit this year in terms of reimbursement. Procedures like Fluoro-Epidurals, US-guided MSK injections, and spinal cord stimulator implantation do not pay as well anymore. For example, if you now do an in-office epidural, you will only get $70....I guess CMS finally got wiser.

I think the main point is that outpatient neurology usually does not pay as well. That is unless you have a good volume of patients on a daily basis and are proficient at some procedures (EMG, nerve blocks for headache, etc.). I have seen this done at some clinics, while at others, the doctors seem to struggle to seeing 6 patients in one day.

Of course, you can still make good money (>250k) by doing hospital consults, taking stroke call, doing EMU, working in neurocritical care, etc.

Yes, interventional pain was placed on the chopping block this year; however, you can be savvy and they are as well. I can tell you that I once did a few trigger points on a patient with CIGNA (AKA Called I Got No Answer) and they reimbursed me just over $500 for the visit??? Obviously I did not complain? Again, I feel that this comes down to proper coding and appropriate usage of modifiers. I am sure that an interventional pain doc can greatly increase his/her reimbursement on a $70 epidural if they tack on the appropriate modifiers. In my area, all pain docs own their own surgery centers? This is a source of their revenue as well.

 

[neurolddoc]

Some general thoughts from the perspective of a single specialty group practice:

If you want to maximize your income potential, work for no one but yourself (in the long run). True, when you join a practice you will be an employee, but in the end the owners of the business are in the best position.

Have a diverse patient population. Sub-specialty expertise is an excellent thing to have and will enhance your practice but remaining diverse will be a hedge against one modality taking a big reimbursement hit.

Pay attention to the business of running your business. Don't be inefficient. Don't waste capital on nonproductive things. Don't be afraid to invest time or capital in new things that will benefit your potential earnings.

Adapt to change. Do not piss and moan about having to change how you practice (e.g. EHR's). Figure out how you can take advantage of its capabilities to enhance your revenue.

Leverage your time with diagnostic modalities that use a tech to do the technical component while you do the professional component; own the machine, employ the tech.

Elipsis, I have a position for you when you are done.

 

[Neurologo]

Some general thoughts from the perspective of a single specialty group practice:

If you want to maximize your income potential, work for no one but yourself (in the long run). True when you join a practice you will be an employee but in the end the owners of the business are in the best position.

Do you mean not to work for a hospital but rather join an independent group with partnership tract? I keep hearing solo practice is impractical now. You advice is much appreciated.

 

[neurolddoc]

I think that solo practice would be difficult in the current climate, especially if you are going to hang out a shingle and see what happens. The one circumstance where I think it would fly is to have a very low overhead operation where you have limited office expenses and spend most of your time in hospitals. That, of course leaves you vulnerable to the hospital hiring their own neurologist and displacing you.

My (admittedly biased) view is that a specialty group, properly run, will have the resources to roll with the punches as the healthcare system changes in the coming years. The last thing I would want to do is to work for a hospital. Over the last 25 years I have seen multiple hospital based specialty groups such as radiology, anesthesia, pathology work for years in an area, lose the contract and suddenly all the docs in the group are gone.