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True. Not a single person over 5’11”
Word is out about Allied Anesthesia (in Orange County). Hold the line, Laddies (and Lassies)
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It is why they went into peds.
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And then the buy in, don’t forget that!
Quad whammy! F that BS. I couldn’t work for one of these unfair groups. “You can make $1M” … sure. Only 18000 units needed, when your an abusive partner. Sounds amazing.
Just some rhetorical questions to add some perspective. I have the utmost respect for the following groups, and have friends at them as well.
How many years does it take to become a full professor at UCI? Once it's obtained, what is the increase in income?
Does Mission have a buy in?
How many years to partnership at NHAC? Are new hires expected to be team players and also take more call than partners, or can they leave whenever they want and have equal call?
As a partner what is the average income at Saddleback, Long Beach, and Kaiser OC?
Perhaps market forces will dictate that new hires can be like partners without contributing anything. Not sure what the offers are at other groups in OC currently. I'm not arguing with anyone regarding being a per diem -- sounds like an amazing life.
How many years does it take to become a full professor at UCI? Once it's obtained, what is the increase in income?
Does Mission have a buy in?
How many years to partnership at NHAC? Are new hires expected to be team players and also take more call than partners, or can they leave whenever they want and have equal call?
As a partner what is the average income at Saddleback, Long Beach, and Kaiser OC?
Perhaps market forces will dictate that new hires can be like partners without contributing anything. Not sure what the offers are at other groups in OC currently. I'm not arguing with anyone regarding being a per diem -- sounds like an amazing life.
I'll add the groups that I am aware of
Lakewood/Los Alamitos/Placentia Linda
Formerly Envision, now Napa
40 unit base + call stipends+ full asa units for blocks (call stipends add about $5 per unit avg per month)
No buy in, no seniority, new hires take same calls, schedule, rooms, vacation as senior docs. No partners or non partners
Productivity 1099 model. Stable groups
Hoag
48 per unit
2 units per block
No call stipends
Younger guys are the work horses
Productivity 1099
Orange coast
Synergy $37 per unit plus call stipends
No partners
St Mary
Somnia
Rough spot. Mostly per diems with high turnover
Stay away unless just chasing dollars from desperate hospitals
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Ok I'm dumb. Can someone explain this units per block to me? Why can some groups bill more units per block? Or is this just how pay is divided among partners, in which case it should even out over time right?
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All groups are billing the same amount. But internally they assign whatever value they want to pay the partners
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Unit value = total income / total units
The total units part is largely internal and not standard among groups. Some groups cap procedure units while others will give full value. Likewise, some groups lump stipends into total income while others keep them separate for call. So as you can see, playing with the numerator or denominator can affect the overall unit value.
This is why a unit value can only give so much information and one needs to dig deeper to understand the whole compensation model of a group. Just saying $X per unit isn’t enough…
What is overhead? How many units does each partner average? How are calls distributed? How does daily scheduling work? How efficient are the ORs? Are outpatient sites pooled into the unit value?
The total units part is largely internal and not standard among groups. Some groups cap procedure units while others will give full value. Likewise, some groups lump stipends into total income while others keep them separate for call. So as you can see, playing with the numerator or denominator can affect the overall unit value.
This is why a unit value can only give so much information and one needs to dig deeper to understand the whole compensation model of a group. Just saying $X per unit isn’t enough…
What is overhead? How many units does each partner average? How are calls distributed? How does daily scheduling work? How efficient are the ORs? Are outpatient sites pooled into the unit value?
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All of these sound either more fair or more financially lucrative than Allied kneecapping a new hire with a $10/unit deduction and worse scheduling.
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ASA units are 7 units for most named blocks. Can add 2units for ultrasound for some of them. Recently ultrasound became included for many of the common blocks.
Not all payers will pay the full amount for blocks, i.e. they don’t actually pay $300 for a 5minute interscalene block.
Our group tries to keep the block revenue neutral by crediting just 50% of the actual ASA units for the blocks. The actual revenues coming in from the blocks roughly equals the amount being paid out to doctors who do the blocks. This way, the doctors who do a lot of blocks get paid based on the amount of money the blocks actually bring in. Ideally the doctors who do fewer blocks don’t end up subsidizing those who do a lot of blocks although in our practice I think they still do to some degree. It’s not a perfect system.
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Main reason is to artificially inflate the base unit value for recruiting or if the older docs don't do blocks, they will under compensate them.
So if you reduce the block pay (pay 2 units per block), then you can take that revenue and boost the base unit value and make it sound like you pay more than a group with lower base but higher block pay.
Most new hires tend to underestimate the number of blocks done, so they will choose a higher base unit value, even though it likely reduces their overall pay
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Your post is quite disingenuous.
As nimbus stated, it has more to do with keeping things revenue neutral. No one is collecting $500+ for a block, so it makes no sense to pay out at those rates.
Do an adductor canal block for a TKA and billed 9 units? Here's $100.
How about that TEE you billed 12 units for? Here's $150.
So if anything, groups that cap procedure units have a more reflective true unit value, while yours is actually lowering it. To insinutate that this is done because "older guys don't do regional and don't want so much money going to the new guys" is just ridiculous.
Also, there are other benefits that you're missing. It makes things slightly more fair since that room with three TKAs is now only marginally better than the room with three lap choles. It also disincentivizes the bad actors from performing unnecessary procedures to pad their units.
Depends.
2 units for a block will completely discourage block placement, which ultimately reduces total revenue to the group. So it's generally short sighted to pay little for the block as it just reduces total revenue in order to artificially increase unit rate. Barely even worth the hassle and paperwork at that point.
Most groups that I have come across that pay so little tend to place few blocks because of it.
4-6 units is probably the middle ground.
You can put in place restrictions in order to minimize dilution (only pay for the block if billable, etc)
And if you fairly distribute cases, then it doesn't matter if a TKA is worth more
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You couldn’t be more wrong here. It seems you’re grasping at straws to make your argument.
Block placement is generally performed along the lines of standard of care. Have fun telling your surgeons that it’s not worth your time or effort.
And this theoretical decrease in revenue you’re talking about would likely amount to less than 1% of total collections. You’ll find more variation than that in your unit value every month. And again, it’s already been explained that this does not actually inflate the unit value but more accurately reflects it.
In a group of 10-20 people, that’s easier to do. In a group of 30-50+ people, it can become a logistical nightmare. It’s much easier to level the playing field and create far less disparity between the assignments each day.
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Maybe instead of basing partner/employee compensation on units, which is a broken system with arbitrary payments for some units but not other units, vulnerable to surgeon whim WRT scheduling and surgeon competence WRT case load and how many times per day startup units can be claimed, not to mention all kinds of opportunities for partners who are more equal than other partners to cherrypick surgeons and case lineups ...
... maybe just maybe people could be paid based on the time they're in the hospital, plus some tilt for undesirable shifts (call), plus something for necessary but unbillable administrative work.
But I guess that would reduce the fog that superpartners can use to obfuscate where the money comes from and where it goes.
... maybe just maybe people could be paid based on the time they're in the hospital, plus some tilt for undesirable shifts (call), plus something for necessary but unbillable administrative work.
But I guess that would reduce the fog that superpartners can use to obfuscate where the money comes from and where it goes.
Wrong on a few points.
I have been to multiple hospitals and Surg centers as locums. It's pretty standard that when I arrive, blocks are not common and surgeons don't request them because the prior anesthesiologists took too long to do them. The only standard care blocks were shoulders and total knees. Some surgery centers didnt even have an ultrasound or nerve stim.
Pec blocks, ESP, tap blocks, popliteal, axillary, supraclavicular, etc.
Second,
Blocks can easily add 5-10% of the revenue to a case. I typically seen reimbursement $200-600 per block depending on payor. Maybe if your group does all GI, then sure. But then paying 6-8 units for a block won't dilute anything either
Third
It's simple programming by the billers. They can set it up so that it pays the docs however you want.
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I’m just surprised at 48 bucks a unit, 2 units a block and most glaringly 0 call stipend for Hoag. I figured they were better than that. Seems to be working for them though.
Call stipend is another way to shift revenue around.
If you apply the same logic that's used to justify 2 units per block (blocks don't generate revenue) then call stipends also aren't revenue neutral (insurance doesn't pay more because you are on call). So often you will see groups that don't pay call stipends, also don't make the senior partners take as much call as the juniors.
If the senior docs don't take call, they certainly won't vote to shift revenue from the unit value into the call stipends. Thus they will always vote for the higher base unit value at the expense of call stipends.
Similarly, older groups with senior docs who arent block proficient will rarely vote to pay fairly for blocks at the expense of their own unit rate.
The fair alternative of course, is to assign everyone the same call amount and then let market forces work. Either the young docs will want call for the units or you can add call stipends to incentivize it.
I am not saying all groups function that way, but I am highly suspicious of groups with no call stipends and low block pay. Often the new hires don't understand how that negatively impacts their revenue. So I am generally suspicious of situations that tend to benefit the senior partners at the expense of the new hires and I am hesitant to just assume that the senior docs voted for that pay structure without any consideration for how it benefits themselves more than the non voting juniors. Coincidence? Maybe..
Let's get back to the topic at hand.
The changes in your group may seem miraculous to you, but it is actually happening all over in areas that are short staffed. Unfair groups are being FORCED to change because of the job market in order to recruit. See the "trouble recruiting" thread in the Anesthesia Club forum. Everybody is advocating for full pay/vacation/equality from day one in today's market, even many of the older posters.
The "young leadership" at allied are not fighting for a truly egalitarian group - the structure of your partnership track is proof they are still trying to get away with as much exploitation for their own benefit as the market will allow. I predict you will find it difficult to hire and they will be forced to make further changes. They are underestimating this market, in which many groups have gotten rid of their buy ins completely.
Below are the most common ways that partners exploit nonpartners:
1) Time - Long partnership track
2) Financially - Pay cut aka "buy in"
3) Sweat equity - Unfair call distribution
4) Cherry picking - Partners get the better rooms/schedules
Most places try to get away with one or two of the above. Your group is brazen enough to do all 4...pretty ridiculous...
As you yourself have stated:
1) 3 year partnership track (very long - many places have cut down to 1-2 or none at all)
2) ~20-23% buy in ($10 out of $45-50/unit) during that time, which is quite substantial
3) Sweat equity because nonpartners are taking more call and working the undesireable hours
4) Cherrypicking for partners who are guaranteed more units per day via a better schedule, during the easy day time hours
Nice that your group is moving in the right direction, but they still have a long way to go. I believe you are coming from a genuine place of thinking your group has improved significantly and wanting to share it. But having worked for 7 years, you are now one of the partners who have it good and are benefiting from the exploitation of non partners, which may be clouding your opinion. It is probably hard to think of yourself this way, and you may not be complicit or agree with it, but that statement is true.
The changes in your group may seem miraculous to you, but it is actually happening all over in areas that are short staffed. Unfair groups are being FORCED to change because of the job market in order to recruit. See the "trouble recruiting" thread in the Anesthesia Club forum. Everybody is advocating for full pay/vacation/equality from day one in today's market, even many of the older posters.
The "young leadership" at allied are not fighting for a truly egalitarian group - the structure of your partnership track is proof they are still trying to get away with as much exploitation for their own benefit as the market will allow. I predict you will find it difficult to hire and they will be forced to make further changes. They are underestimating this market, in which many groups have gotten rid of their buy ins completely.
Below are the most common ways that partners exploit nonpartners:
1) Time - Long partnership track
2) Financially - Pay cut aka "buy in"
3) Sweat equity - Unfair call distribution
4) Cherry picking - Partners get the better rooms/schedules
Most places try to get away with one or two of the above. Your group is brazen enough to do all 4...pretty ridiculous...
As you yourself have stated:
1) 3 year partnership track (very long - many places have cut down to 1-2 or none at all)
2) ~20-23% buy in ($10 out of $45-50/unit) during that time, which is quite substantial
3) Sweat equity because nonpartners are taking more call and working the undesireable hours
4) Cherrypicking for partners who are guaranteed more units per day via a better schedule, during the easy day time hours
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I understand your questions are rhetorical but I still find it enlightening to answer them:
Asking about UCI or Kaiser OC doesn't really make sense as these are employed positions. But I will still bite.
Asking about UCI or Kaiser OC doesn't really make sense as these are employed positions. But I will still bite.
Many years but with small jumps in income. Much more fair. Yes their equivalent of a "partnership" track is long but the financial buy in is minimal. No sweat equity as there is equal call distribution and autonomy to pick up shifts rather than being forced. No cherry picking as they are not productivity based.
Yes, similar to yours in terms of time and $ but no sweat equity or cherry picking with a much fairer overall compensation model. May have changed in the last few years, please correct me if I am wrong.
3 years to partnership with a sweat equity buy in ONLY, not financial - yes new hires are expected to be team players and take more call but they also are equivalently paid more and therefore make more $ then partners. If you work more hours, you are paid more $. What a crazy concept! They are not expected to be team players and take more call, but make 20% less per hour of work while doing so, all while getting hosed with worse rooms/scheduling like at allied.
Guessing 400-600k with 500 on average? What is the point being made here, that partners at Allied make significantly more than these other more reputable groups? It's possible. You'd have to tell us what the average income is at Allied? Even if you have it better as partners, it is partially due to making more $ off the backs of your non partners, and I think that is the problem that many on this thread are pointing out.
Yes, market forces do dictate that currently. Here is a question for you - what over the last 7 years have you contributed that new hires do not? Did you help establish the group, obtain contracts, manage relationships, set up the accounting and billing? Did you buy in to equipment or outpatient centers or take any kind of risk? Or do new hires provide and take advantage of the exact same services you do?
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You must be going to some truly dire places then. I have not experienced this at all at multiple private groups.
What I have seen is unnecessary procedures performed at places that tend to overcompensate for them. I’m talking about TAP blocks on patients that will stay intubated for days or popliteal/saphenous blocks for a small toe amputation.
To a case, yes. But to overall group revenue? Not much. Even if you disincentivize procedures, most routine cases (shoulders, knees, etc) will continue to receive nerve blocks. So really you’re just talking about a few less TAP or PECS blocks here or there.
You are too cynical. It doesn’t matter how blocks are compensated or if there is a call stipend so long as everyone is being scheduled fairly and have similar income potential. There are many groups like this, so I’m not sure why you are so hung up on nerve block compensation. Like I said, it tends to make things more fair at the end of the day.
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Probably depends on the area.
But two of the main groups mentioned here (allied and hoag) are probably the two largest groups in OC and neither schedule fairly or provide income equality. They also don't provide call stipends or pay well for blocks.
Nerve block compensation is simply a mechanism for elevating the base unit rate. The purpose of that depends on the situation. But new hires definitely need to be aware and not get lured in by a higher base unit and think they are getting paid more than a lower base unit with blocks and call stipends.
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Every system can and will be gamed. What defines fairness in our specialty is, “do the new hires have an equal shot to game the system?”
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There doesn't have to be gamesmanship or exploitation. And I'm sure we agree that some models are far more difficult to game than others.
I joined the group I'm with now because none of that crap happens. Work a day, get a point. Call shifts are skewed to higher point values, determined by the partners. Equal call. Rotating early out. Rotating vacation lottery to select your time off. Take less vacation, earn proportionally more. There's some room to tilt the actual cases you do in one direction or another, but in the aggregate everybody does everything (except cardiac which is a subset of partners).
I'm just saying that some people seem to be championing this opaque system of eat-whatcha-kill unit-based billing as some kind of supremely "fair" system, when in the actual real world it absolutely never is. And then there's puzzlement and consternation about why these lazy slacker layabout millennials don't want to work hard for these "fair" groups, but instead choose to go work like dogs for an hourly rate as a locums or choose the simpler life of an academic or AMC clock-punching employee.
In what way does Hoag "neither schedule fairly or provide income equality"?
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Yes.
Obviously a fair system requires equitable scheduling, but scheduling is always far more transparent than billing. The most important steps to take are the ones that make it harder to game the reimbursement or payment system.
New grads, and people otherwise inexperienced in the ways of the world, can tell immediately when they're being worked harder than peers or bosses. They often can't tell when the bizarre and opaque unit/insurance/reimbursement maze is being gamed to favor someone at their expense.
So, yes.
Yes. You have it exactly right.
Fairness starts with transparency. Some systems are inherently more transparent than others.
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We work on a modified ASA RVU productivity system and I can tell you that new hires pick up the intricacies of the schedule and billing system VERY quickly (a matter of days) and are able to maximize their production from the very beginning. It doesn’t take weeks or months to learn the system. Maybe it’s because they don’t have student loans or because they’re not saving up for a house but often it is the old timers who prioritize a relaxing day, eating lunch, or working with a favorite surgeon at the expense of unit production.
I agree that transparency and fair scheduling are important but I wouldn’t say scheduling is more transparent than billing. It’s 4th grade math….arithmetic.
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Physicians are notoriously bad with finances. Also simple math and arithmetic.
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They are also big acceptors of force fed cognitive dissonance (eg this is how it’s always been done and how it always will be with no room for practice management/compensation evolution).
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Niiiiiiice.
