400K salary in general surgery?

[dwade1984]

I am nearing the time where I need to commit to a certain specialty. its def. going to be a surgical specialty. I really love general surgery. However I am a really competitive applicant and everyone is trying to pressure me to go into ortho because of money and lifestyle. I am a hard worker so lifestyle is not a big deal however I do want to make a decent living. My question is how likely is it to make around 400K in general surgery? That is my dream salary, I know its easy to achieve in ortho but how about gen surgery.

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[Flank Pain]

400K! Doing what, boobs, pandering to drug companies? I thought those pay checks went the way of the Dodo after interventional cards hit the scene (nice call on that one surgery, even better than letting the flees basket the common duct). But really? 400k out of general surgery?

 

[dwade1984]

400K! Doing what, boobs, pandering to drug companies? I thought those pay checks went the way of the Dodo after interventional cards hit the scene (nice call on that one surgery, even better than letting the flees basket the common duct). But really? 400k out of general surgery?

I was thinking maybe a hardworking, efficient general surgeon somewhere out in the midwest might reach that. Oh well thanks for the reality check, makes my decision that much more difficult.

 

[thedrjojo]

I am nearing the time where I need to commit to a certain specialty. its def. going to be a surgical specialty. I really love general surgery. However I am a really competitive applicant and everyone is trying to pressure me to go into ortho because of money and lifestyle. I am a hard worker so lifestyle is not a big deal however I do want to make a decent living. My question is how likely is it to make around 400K in general surgery? That is my dream salary, I know its easy to achieve in ortho but how about gen surgery.

why is 400K your dream salary? what makes 400 much different than 350, or 300 for say? The utility of that last 50 or 100K really all that important compared to doing something you will enjoy????

And the norm is not to do general surgery, but to fellowship which can push up salaries, but even in Ortho, 400K will be pushing it and won't be seen until mid career, at which point 400k won't be the same as 400k now. Do what you want to do and not pursue the paycheck.

 

[SLUser11]

I was thinking maybe a hardworking, efficient general surgeon somewhere out in the midwest might reach that. Oh well thanks for the reality check, makes my decision that much more difficult.

Despite our overall feelings of unappreciation and under-compensation, there are still plenty of private practice general surgeons doing very well. They are usually the ones who take time to really learn the business side of surgery.

The sky is not falling yet. There are still plenty of general surgeons making $400K....they seem to be more concentrated in the midwest. Some are just working that hard and coding that well, and others have partial ownerships in outpatient surgery centers, etc.

 

[toxic-megacolon]

Your best bet is to build a time machine and go to 1987. But seriously, you can easily reach those kind of salary numbers, if you are willing to live in underserved areas of the upper midwest, such as ND, SD, Western NE, maybe northern MN/WI. A town ranging 5000-10000 people, but at least 300-400 miles away from any urban center. And at least 100 miles away from any medium sized city. But you'll be the only guy in town, or maybe with one partner and be technically on call 24/7. I saw a job recruitment ad for a General Surgeon near Fargo, ND for 460,000. But it was 1-in-2 call.

 

[SLUser11]

Your best bet is to build a time machine and go to 1987. But seriously, you can easily reach those kind of salary numbers, if you are willing to live in underserved areas of the upper midwest, such as ND, SD, Western NE, maybe northern MN/WI. A town ranging 5000-10000 people, but at least 300-400 miles away from any urban center. And at least 100 miles away from any medium sized city. But you'll be the only guy in town, or maybe with one partner and be technically on call 24/7. I saw a job recruitment ad for a General Surgeon near Fargo, ND for 460,000. But it was 1-in-2 call.

You can also live in relatively big cities like....oh, I don't know....Wichita, Kansas.....and make a pretty good living despite there being lots of surgeons in town.

 

[hope79]

Find something you love and figure out how to get paid for it -- that's happiness.

Life's far too short to be going into ANY kind of surgical field if you're not passionate about it. You'll be an unhappy resident, unhappy surgeon, unhappy friend and family member. Choose either general or ortho* because you love one of them and you'll make the 400K lifestyle work along the way.

*for most competitive ortho residencies, you'll need ortho-specific research in addition to grades and board scores, so I hope you've already considered and are engaged in that.

 

[Wustenfuchs]

There are easier ways to get 400k/yr than going through med-school and residency...
Maybe it's the way you put it...but my dreams are priceless. If your dream is worth 400K/yr*25yrs you're kinda hopeless...no offense!

 

[Svidrillion]

I do want to make a decent living. My question is how likely is it to make around 400K in general surgery? That is my dream salary...

The juxtaposition of 'decent living' in one breath with '400k' in another is a bit terrifying. May the Lord help pediatricians and psychiatrists in their indecent squalor.

Also, I've heard of a dream job, but this is my first introduction to 'the dream salary'. Is that like, 'Ever since I was a young child I've always wanted to pull down 400K/year'? By the way, the taxes in that bracket are already pretty steep and may get steeper. It ain't your father's 400K.

 

[dwade1984]

My dream job is being a surgeon and that is far more important to me than my dream salary. More likely than not I am probably leaning towards general surgery, its going to be a pain though to see my ortho buddies driving mercedes while I am still in debt from med school.

 

[Fah-Q]

dwade1984 -

Yes, you can make $400K in general surgery or psychiatry or pediatrics. Being a physician in private practice means you are running a business. Some physicians run their business better than others. The term "salary" implies that someone owes you money. In medicine you are paid for the services you provide for patients. You can work hard and earn a lot of money or not work hard and not make a lot of money, but it is up to you and is one of the aspects of medicine that make it a very attractive career. Don't ever apologize or feel ashamed about wanting to earn a lot of money to provide for yourself and your family. Do what you enjoy and do it well and someone will be willing to pay you for it.

 

[Mandiblespeaks]

dwade1984 -

Yes, you can make $400K in general surgery or psychiatry or pediatrics. Being a physician in private practice means you are running a business. Some physicians run their business better than others. The term "salary" implies that someone owes you money. In medicine you are paid for the services you provide for patients. You can work hard and earn a lot of money or not work hard and not make a lot of money, but it is up to you and is one of the aspects of medicine that make it a very attractive career. Don't ever apologize or feel ashamed about wanting to earn a lot of money to provide for yourself and your family. Do what you enjoy and do it well and someone will be willing to pay you for it.

Well said.

 

[Pilot Doc]

Your best bet is to build a time machine and go to 1987. But seriously, you can easily reach those kind of salary numbers, if you are willing to live in underserved areas of the upper midwest, such as ND, SD, Western NE, maybe northern MN/WI. A town ranging 5000-10000 people, but at least 300-400 miles away from any urban center. And at least 100 miles away from any medium sized city. But you'll be the only guy in town, or maybe with one partner and be technically on call 24/7. I saw a job recruitment ad for a General Surgeon near Fargo, ND for 460,000. But it was 1-in-2 call.

Above is an exaggeration. Plenty of $400K GS jobs in cities between 50K and 500K people between the coasts. Plenty of over $400K jobs. The working every day and night super busy jobs can pay $600+.

Do a search for posts by FliteSurgn. he's a practicing GS in a reasonable sized city in the midwest. He and his partners make above $500.

All that said, in every one of these cases a similarly busy ortho guy, in the current funding paradigm, will make 50% to 100% more. But if you want to make $400K, it's not at all hard to do in GS. (And $400K is a very reasonable goal despite all the "that's 52X more than the average american" griping.)

 

[DylanAsdale]

If money is that much of a drive for you, as to the point where you would base your specialty on it, why did you go into medicine in the first place? I sure know I'd rather be in the hands of someone who has a passion for saving lives rather than someone who sees me as a bag of money.

 

[plauto]

dwade1984 -

Yes, you can make $400K in general surgery or psychiatry or pediatrics. Being a physician in private practice means you are running a business. Some physicians run their business better than others. The term "salary" implies that someone owes you money. In medicine you are paid for the services you provide for patients. You can work hard and earn a lot of money or not work hard and not make a lot of money, but it is up to you and is one of the aspects of medicine that make it a very attractive career. Don't ever apologize or feel ashamed about wanting to earn a lot of money to provide for yourself and your family. Do what you enjoy and do it well and someone will be willing to pay you for it.

agreed x2. Earn is the key point here. Since when is being good and successful frowned upon? You're helping patients live better. Why do some people think it's wrong to get paid for it? When was the last time you were given something for free?

 

[Pilot Doc]

If money is that much of a drive for you, as to the point where you would base your specialty on it, why did you go into medicine in the first place? I sure know I'd rather be in the hands of someone who has a passion for saving lives rather than someone who sees me as a bag of money.

Get off the high horse.

1) He in no way suggested he was basing his specialty on money. If that were the case he'd be in ortho and wouldn't have to ask the question.
2)Even if he were basing his specialty choice on money, that doesn't mean he lacks empathy or a passion for patient care.

There are enormous personal sacrifices on the path to becoming a trained surgeon. Only a fool would not attempt to maximize the return for himself and his family who sacrificed alongside him.

 

[Wustenfuchs]

agreed x2. Earn is the key point here. Since when is being good and successful frowned upon? You're helping patients live better. Why do some people think it's wrong to get paid for it? When was the last time you were given something for free?

If "earn" is the key there are easier and more efficient ways to do it. The amount of currency on the market is limited. Therefore if one wants to "earn" he must take it from somebody else. One gets rich and in the process somebody gets poor and there's nothing wrong with it. It's a free market and if the product you make/sell is better than the competition's it's perfectly fine.
On the other hand, the goals one has are affecting the outcome. As long as Toyota wanted to be the "best" things were fine. When it decided to be the "biggest" **** hit the fan.
Same with doctors. If you want to be good at what you do and you end up being good patients will seek your services. Your name will associated with quality of care, efficiency, empathy and all the other attributes of an ideal health care provider. You'll overcharge the rich and undercharge the poor. When you draw the line you're still making money and maintain a good reputation.
To set for a 400k/yr income in the context of a free market is stupid. It's as if Dow Jones would come up with a goal of 90pt increase per day for the next 6 mo.

My dream job is being a surgeon and that is far more important to me than my dream salary. More likely than not I am probably leaning towards general surgery, its going to be a pain though to see my ortho buddies driving mercedes while I am still in debt from med school.

You're worried that your buddies will drive Mercedes before you? Wow...Get a BMW 335i...classier, more agile and half of the price of an S Klasse (which I assume you're craving for)... or even better than that, and cheaper, Subaru STI...But I'm afraid you don't give a **** on how a car feels, all you want is to show off.

 

[SLUser11]

stuff

When I saw you posted in here, I thought you'd include an obligatory shot at the midwest....or small towns in general. Props for the restraint.


Now if you'll excuse me, I have to go burn some biology textbooks.....

 

[PAgirl]

Despite our overall feelings of unappreciation and under-compensation, there are still plenty of private practice general surgeons doing very well. They are usually the ones who take time to really learn the business side of surgery.

The sky is not falling yet. There are still plenty of general surgeons making $400K....they seem to be more concentrated in the midwest. Some are just working that hard and coding that well, and others have partial ownerships in outpatient surgery centers, etc.

I know there are doctors out there who really know how to work the system and make more money as a result, but I always wondered how they learned. Do they learn from other business savvy doctors who they work with, or take some type of class, or what? I know I have a while before I have to know that kind of thing, but I really would like to be aware of the business side of surgery when the time comes, and I really don't know how one goes about doing so.

 

[Pilot Doc]

I know there are doctors out there who really know how to work the system and make more money as a result, but I always wondered how they learned. Do they learn from other business savvy doctors who they work with, or take some type of class, or what? I know I have a while before I have to know that kind of thing, but I really would like to be aware of the business side of surgery when the time comes, and I really don't know how one goes about doing so.

1) realize that at most medical schools and residencies the business training you get will be net neutral to negative. You are totally on your own to learn this.
2) Although you have awhile to go, start paying attention now. medical economics magazine was a good resource 10 years ago. I assume it still is.
3) The bulletin of the ACS has a fair number of practice management issues.
4) Like real estate, it's location, location, location. Aside from how many hours/week you work, the big drivers in overall compensation are payer mix and the ability to own a surgery center. These are largely factors beyond your control and depend on where you choose to locate.
5) If you can go to the ACS annual meeting as a student or resident there are some basic business of medicine classes. Some specialty organizations run formal practice management meetings for attendings. Dunno if they exist for surgery or not.
6) Once you get out, having a good accountant, a good practice manager and like-minded partners are important.

 

[Wustenfuchs]

When I saw you posted in here, I thought you'd include an obligatory shot at the midwest....or small towns in general. Props for the restraint.


Now if you'll excuse me, I have to go burn some biology textbooks.....

It gets pretty boring in Wichita huh?
I'm so sorry to disappoint you...
Bible burning happy hour is tomorrow...

 

[remo]

I'm in pretty much the same situation as the OP. How easy is it to switch from ortho to gsurg (or vice versa) if you decide during your intern year that you made a mistake?

 

[SLUser11]

I'm in pretty much the same situation as the OP. How easy is it to switch from ortho to gsurg (or vice versa) if you decide during your intern year that you made a mistake?

It's not very common. Most people who go from surgery to ortho were prelims with ortho as a goal the entire time. Also, it's sort of rare to have someone switch from a more competitive surgical subspecialty into general surgery, as the lifestyle is typically worse......although the ortho guys here work pretty hard.


Overall, the best idea is to decide on a career before you graduate medical school, otherwise it is universally painful. General surgery and orthopaedics are very different from eachother, and some MSIV rotations should help you decide which shoe fits better.

 

[Pilot Doc]

General surgery and orthopaedics are very different from eachother, and some MSIV rotations should help you decide which shoe fits better.

Adding on, GS and ortho internship are pretty similar to each other and both radically dissimilar to the life of an attending surgeon. It's not possible based on a few months of internship to know that ortho is a better fit for you than GS or vice versa.

 

[droliver]

VERY hard to net 400K doing general surgery unless you're getting subsidized and you're payor mix is cherry-picked. There's just not enough hours in the day to produce the revenue from procedures, and as consult codes and surgery CPT's are being devalued by Medicare/CMS it's going to get even harder.

Most surgeons who see a mix of Medicare and private insurance who are fairly busy will top out between 200-300K. While there are always unique circumstances like

1. super specialists in something like hernias or bariatrics who are out of network and will make more per case and do high volume
2. the increasingly rare GS who has a large endoscopy practice and can work in 6-8 scopes during an OR day between cases
3. physicians receiving generous stipends for call, practice support, or directorships

 

[SLUser11]

VERY hard to net 400K doing general surgery unless you're getting subsidized and you're payor mix is cherry-picked. There's just not enough hours in the day to produce the revenue from procedures, and as consult codes and surgery CPT's are being devalued by Medicare/CMS it's going to get even harder.

Most surgeons who see a mix of Medicare and private insurance who are fairly busy will top out between 200-300K. While there are always unique circumstances like

1. super specialists in something like hernias or bariatrics who are out of network and will make more per case and do high volume
2. the increasingly rare GS who has a large endoscopy practice and can work in 6-8 scopes during an OR day between cases
3. physicians receiving generous stipends for call, practice support, or directorships

In the above-mentioned areas of the country, endoscopy can be a large part of the general surgeon's practice. I do agree that the "glory days" are over, but there are still a lot of general surgeons making big money.

Having a good coder is probably essential....also knowing where else to make your money, e.g. surgery centers, is important. Honestly, I don't think it's as rare as everyone makes it out to be. That being said, I'm not shooting for that sort of income personally.

 

[Zoom-Zoom]

I agree. 400K is probably >75th percentile but it's not totally crazy.

 

[MossPoh]

They made 400k+ in my town. There were only two of them in the town and cranked it out. I spent two weeks with one of them and he was routinely in the OR from about 6:30 a.m. till 7 or 8 at night with a 40 minute lunch break and the occasional email check or snack between cases.

Honestly, that doesn't seem like the life I'd want.

 

[droliver]

I agree. 400K is probably >75th percentile but it's not totally crazy.

Keep in mind the insidious effect that incremental RVU adjustments downward will have. Each 1% decrease in reimbursement knocks your take home by ~2%+ while your overhead steadily goes up. The 20% medicare cuts would have been an effective 40% pay cut on Medicare benificiaries. Private payors index their rates to Medicare with (maybe) a small (and shrinking) premium of 5-15%.

In the near future 400K for almost all specialities will be extroidinarily rare I'd surmise as there's a lmiit to any increase in productivity you can make. Also keep in mind that Rep. Pete Stark (D-CA) wants to outlaw any financial interest by physicians in surgery centers or hospitals which clips a potential source of alternative revenue some surgeons now reap.

 

[thedrjojo]

Also keep in mind that Rep. Pete Stark (D-CA) wants to outlaw any financial interest by physicians in surgery centers or hospitals which clips a potential source of alternative revenue some surgeons now reap.

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

If Atul Gawande was correct in his analysis of McAllen, Texas (largest per capita for Medicare) vs the Mayo clinic, then I welcome Pete Stark's idea to keep financial interest separate.

 

[igap]

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

If Atul Gawande was correct in his analysis of McAllen, Texas (largest per capita for Medicare) vs the Mayo clinic, then I welcome Pete Stark's idea to keep financial interest separate.

In the article, Atul Gawande also extols the virtues of the Mayo Clinic. He describes their system, and states that they have very low costs per patient. I wonder how he feels now that the Mayo Clinic is beginning to stop taking Medicare patients.

http://online.wsj.com/article/SB10001424052748703436504574640711655886136.html

A quote from a Mayo Clinic rep in reference to Mayo Clinic's nearly one billion dollar loss last year from treating Medicare patients:

"Mayo Clinic loses a substantial amount of money every year due to the reimbursement schedule under Medicare," the institution said. "Decades of underfunding and paying for volume rather than value in Medicare have led us to this decision."

If it weren't for the fact that Mayo has the luxury of passing costs on to wealthy, cash-paying, patients then they probably would have dropped Medicare across the board long ago. At any rate, it is silly to compare the Mayo clinic to a Texas border town hospital.

 

[thedrjojo]

its a texas boarder city (the entire city, not just a single hospital) and in the article he discusses how El Paso has about half the costs of McAllen yet better rankings on all but 2 of the 25 metrics of care with a similar population, and one area he can pinpoint to the problem is physician stakes in areas of conflict of interest

 

[droliver]

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawandeIf Atul Gawande was correct in his analysis of McAllen, Texas (largest per capita for Medicare) vs the Mayo clinic, then I welcome Pete Stark's idea to keep financial interest separate.

The first practicing surgeon I meet who agrees with Dr. Gawande, will be the first practicing surgeon I meet who agrees with Dr. Gawande 🙂 Practicing in an isolated tertiary academic practice while promoting the brand Gawande will do that for you.

Keep in mind that Dr. Gawande also practices at the Brigham Hospital in Boston which is part of the "Partners Network", a coalition of blue blood hospitals in Boston who have leveraged their "brand" to force insurers to pay more then they pay competing hospital chains and physicians. The Boston Globe estimates that Partners and its doctors receive $800 million more every year than they would were they paid at rates similar to competitors. So before we laud Gawande in excess, maybe he should practice what he's preaching and resign from Harvard's teaching hospitals as they're part of the healthcare inflation in that market.🙄

If you're interested in this story of Partner's and how they're raising the cost of healthcare read the Globe's articles going back to 2008 "A healthcare system badly out of balance" (see here).

Now I don't begrudge the Partner's coalition move in Massachusetts, it's actually a model most MD's wish existed in their town for telling low-ball insurers to suck it.

A few points about the Mayo Clinic as well
1)Mayo does not take Medicare
2)Mayo does not take Medicare supplements for new patients.
3)The Dartmouth Study, touted by many as the proof of efficiency of the Model compared Medicare expenditures county by county, throughout the country. Mayo Rochester resides in a rural farming community, where Medicare usage would be expected to be low. But since Mayo does cares for virtually none of these Medicare patients, extrapolating the cost efficiency of Mayo is simply wrong.
4) Mayo's model is very much a boutique model, catering to the wealthy, those willing to pay extra or out of pocket for their care or those with very good indemnity insurance coverage. Mayo is not in network for virtually every HMO and PPO plan, based simply on the high reimbursements demanded by Mayo. Mayo quotes 2-4 times the cost for surgical procedures that those in the community at large get paid.
5)Mayo relies heavily on the$ 200-300M/year in endowment money each year, to supplement their payrolls, build their buildings, fund research, and fund their pension plan. The cost structure of the Mayo Clinic is prohibitive without this additional funding.

 

[thedrjojo]

The first practicing surgeon I meet who agrees with Dr. Gawande, will be the first practicing surgeon I meet who agrees with Dr. Gawande 🙂 Practicing in an isolated tertiary academic practice while promoting the brand Gawande will do that for you.

Keep in mind that Dr. Gawande also practices at the Brigham Hospital in Boston which is part of the "Partners Network", a coalition of blue blood hospitals in Boston who have leveraged their "brand" to force insurers to pay more then they pay competing hospital chains and physicians. The Boston Globe estimates that Partners and its doctors receive $800 million more every year than they would were they paid at rates similar to competitors. So before we laud Gawande in excess, maybe he should practice what he's preaching and resign from Harvard's teaching hospitals as they're part of the healthcare inflation in that market.🙄

If you're interested in this story of Partner's and how they're raising the cost of healthcare read the Globe's articles going back to 2008 "A healthcare system badly out of balance" (see here).

Now I don't begrudge the Partner's coalition move in Massachusetts, it's actually a model most MD's wish existed in their town for telling low-ball insurers to suck it.

A few points about the Mayo Clinic as well
1)Mayo does not take Medicare
2)Mayo does not take Medicare supplements for new patients.
3)The Dartmouth Study, touted by many as the proof of efficiency of the Model compared Medicare expenditures county by county, throughout the country. Mayo Rochester resides in a rural farming community, where Medicare usage would be expected to be low. But since Mayo does cares for virtually none of these Medicare patients, extrapolating the cost efficiency of Mayo is simply wrong.
4) Mayo's model is very much a boutique model, catering to the wealthy, those willing to pay extra or out of pocket for their care or those with very good indemnity insurance coverage. Mayo is not in network for virtually every HMO and PPO plan, based simply on the high reimbursements demanded by Mayo. Mayo quotes 2-4 times the cost for surgical procedures that those in the community at large get paid.
5)Mayo relies heavily on the$ 200-300M/year in endowment money each year, to supplement their payrolls, build their buildings, fund research, and fund their pension plan. The cost structure of the Mayo Clinic is prohibitive without this additional funding.

I just got me learned... thanks for this information.

I was just actually lectured in my Public Health and Preventative Medicine Clerkship (yes, 4th years at my school have a required 2 week public health rotation - mine was with the Trauma team so it was at least something somewhat relavant) about medical financing and she actually used his article as an example (she was a pediatrician and public health individual, not a surgeon), and while I wasn't really paying attention, I didn't get quite that story about Mayo clinic from her.

I admit to having a much more socialistic view of medical financing however, feeling that hospitals, clinics, etc should be run as nonprofit organizations, that physicians should be for the most part salaried with some volume based incentives and some practice based incentives, and that a single payer insurance system would be most affective in handling the issues, but I am also realistic and understand that you have to work within the system you have and I would rather see physicians get money from owning a share in hospitals or surgical centers rather than corporations if we continue in this system, so go chase your dream of 400K...

 

[Winged Scapula]

The first practicing surgeon I meet who agrees with Dr. Gawande, will be the first practicing surgeon I meet who agrees with Dr. Gawande 🙂

Thanks for that. I couldn't agree more.

 

[MossPoh]

I've tried explaining that to people and they just give me a blank stare (about Gawande that is). My undergraduate specialized in efficiency and usability engineering. His buddy Gladwell seemed to permeate through everything we did. I don't think many people read either of their writings very objectively. Kind of like watching a Michael Moore movie.

 

[Consigliere]

If money is that much of a drive for you, as to the point where you would base your specialty on it, why did you go into medicine in the first place? I sure know I'd rather be in the hands of someone who has a passion for saving lives rather than someone who sees me as a bag of money.

Oh brother.....🙄. See ya in 10 years.....

 

[MossPoh]

Oh brother.....🙄. See ya in 10 years.....

Hmmmm. I'm already pretty cynical. Ten years from now is going to be rough for me. I didn't go into medicine FOR the money but I seem to be one of the few that openly admits to liking money. It is neat, but doesn't win any points with the classmates who still have visions of saving dying babies in Africa and working in clinics in underserved areas. Granted, after a point there is limited returns on what you can do with that additional income except upgrade to a bigger boat or faster car. Both of which are still very fun toys.

 

[Yasergale]

Been a while since I visited these boards. Been in private practice for about 1.5 years. In my state, hospitals are not allowed hire physicians. Only mds are allowed to hire mds. Therefore in order to attract mds to underserved areas, the hospitals provide income guarantees, which is essentially a loan. For example: 450 K / year for 2 years. But you must serve an extra 3 years on your own. This means you must create a corporation aka your practice. The contract is between your corporation and the hospital. Before I lose you in this long winded explanation, I will get straight to the point:

1. 400k is no problem as long as you have at least 40% private insurance and no more than 10% "self pay." The rest can be Medical or Medicaid. This is not hard to achieve. Of course this depends on the types of cases....and its NOT doing your "big" cases, especially if you want lifestyle. Before starting a counterargument to this, please check your EOBs.

2. Most importantly, because you started the corp, you essentially write everything off everything. If you're reasonably good, no tax. This is because you claim the income guarantee as a "loan." I put it in quotes because you never pay the hospital back the money, it is written off over the agreed time you will serve the community your hospital is in.

3. Different from a salary from a hospital because, uncle sam will take a 1/3 from the paycheck upfront.

4. I used to think about what you guys think about, it's a waste of time. Just remember the supply and demand curve. General surgeon supply is awfully low. The reality is that you will be cherry picking your patients. If you are not happy with an insurance reinbursment, the trick is to take it for a month or two and then stop taking them. This will overflow to the next hospital who will lose money from taking them. Eventually, they stop taking them. Complications occur, the insurance comes back, and you ask for 2x the rate that medicare pays, which is how you are suppose to set up your Superbill anyways. Sort of what Partners did in Boston. You might not be able to pull that off in NYC or SF or other major cities, but eventually the basic forces of the market will catch up: supply low, demand high.....you set the price. But just travel out one hour from any those cities, you'll see what i mean. I will not name the insurance companies that I have done this too, but it becomes even more urgent if you provide excellent patient care and results, people will want to come to you. When I halted with Insurance X, the patients were disappointed. I just forwarded them what they paid me for a lap appy ($300 !). The patients understood. Insurance company either folds because of complaints or because of morbidity/mortality.

If you don't understand this, don't worry, alot of my collegues that work in the UC system or the Kaiser system have no idea. But in fairness to them, most mds don't want to deal with money, they rather just have it taken from them in their paycheck. You choose!

 

[plauto]

Been a while since I visited these boards. Been in private practice for about 1.5 years. In my state, hospitals are not allowed hire physicians. Only mds are allowed to hire mds. Therefore in order to attract mds to underserved areas, the hospitals provide income guarantees, which is essentially a loan. For example: 450 K / year for 2 years. But you must serve an extra 3 years on your own. This means you must create a corporation aka your practice. The contract is between your corporation and the hospital. Before I lose you in this long winded explanation, I will get straight to the point:

1. 400k is no problem as long as you have at least 40% private insurance and no more than 10% "self pay." The rest can be Medical or Medicaid. This is not hard to achieve. Of course this depends on the types of cases....and its NOT doing your "big" cases, especially if you want lifestyle. Before starting a counterargument to this, please check your EOBs.

2. Most importantly, because you started the corp, you essentially write everything off everything. If you're reasonably good, no tax. This is because you claim the income guarantee as a "loan." I put it in quotes because you never pay the hospital back the money, it is written off over the agreed time you will serve the community your hospital is in.

3. Different from a salary from a hospital because, uncle sam will take a 1/3 from the paycheck upfront.

4. I used to think about what you guys think about, it's a waste of time. Just remember the supply and demand curve. General surgeon supply is awfully low. The reality is that you will be cherry picking your patients. If you are not happy with an insurance reinbursment, the trick is to take it for a month or two and then stop taking them. This will overflow to the next hospital who will lose money from taking them. Eventually, they stop taking them. Complications occur, the insurance comes back, and you ask for 2x the rate that medicare pays, which is how you are suppose to set up your Superbill anyways. Sort of what Partners did in Boston. You might not be able to pull that off in NYC or SF or other major cities, but eventually the basic forces of the market will catch up: supply low, demand high.....you set the price. But just travel out one hour from any those cities, you'll see what i mean. I will not name the insurance companies that I have done this too, but it becomes even more urgent if you provide excellent patient care and results, people will want to come to you. When I halted with Insurance X, the patients were disappointed. I just forwarded them what they paid me for a lap appy ($300 !). The patients understood. Insurance company either folds because of complaints or because of morbidity/mortality.

If you don't understand this, don't worry, alot of my collegues that work in the UC system or the Kaiser system have no idea. But in fairness to them, most mds don't want to deal with money, they rather just have it taken from them in their paycheck. You choose!

I'm assuming this is more of a suburban/rural setting. Can you name off the top of your head the states that work this way?

 

[Winged Scapula]

I'm assuming this is more of a suburban/rural setting. Can you name off the top of your head the states that work this way?

May I presume you are asking about the comment that "in my state, hospitals are not allowed to hire MDs"? This is very common, in many many (if not all) states for non-academic hospitals. Even in academic hospitals you may be an employee of the university and not the hospital per se. It is not a suburban/rural phenomenon.

 

[plauto]

May I presume you are asking about the comment that "in my state, hospitals are not allowed to hire MDs"? This is very common, in many many (if not all) states for non-academic hospitals. Even in academic hospitals you may be an employee of the university and not the hospital per se. It is not a suburban/rural phenomenon.

I see, thanks for clarifying. I was also inquiring as to where this arrangement is common because this last post pictured a much brighter reality compared to the majority of the posts above.

 

[bronx43]

Been a while since I visited these boards. Been in private practice for about 1.5 years. In my state, hospitals are not allowed hire physicians. Only mds are allowed to hire mds. Therefore in order to attract mds to underserved areas, the hospitals provide income guarantees, which is essentially a loan. For example: 450 K / year for 2 years. But you must serve an extra 3 years on your own. This means you must create a corporation aka your practice. The contract is between your corporation and the hospital. Before I lose you in this long winded explanation, I will get straight to the point:

1. 400k is no problem as long as you have at least 40% private insurance and no more than 10% "self pay." The rest can be Medical or Medicaid. This is not hard to achieve. Of course this depends on the types of cases....and its NOT doing your "big" cases, especially if you want lifestyle. Before starting a counterargument to this, please check your EOBs.

2. Most importantly, because you started the corp, you essentially write everything off everything. If you're reasonably good, no tax. This is because you claim the income guarantee as a "loan." I put it in quotes because you never pay the hospital back the money, it is written off over the agreed time you will serve the community your hospital is in.

3. Different from a salary from a hospital because, uncle sam will take a 1/3 from the paycheck upfront.

4. I used to think about what you guys think about, it's a waste of time. Just remember the supply and demand curve. General surgeon supply is awfully low. The reality is that you will be cherry picking your patients. If you are not happy with an insurance reinbursment, the trick is to take it for a month or two and then stop taking them. This will overflow to the next hospital who will lose money from taking them. Eventually, they stop taking them. Complications occur, the insurance comes back, and you ask for 2x the rate that medicare pays, which is how you are suppose to set up your Superbill anyways. Sort of what Partners did in Boston. You might not be able to pull that off in NYC or SF or other major cities, but eventually the basic forces of the market will catch up: supply low, demand high.....you set the price. But just travel out one hour from any those cities, you'll see what i mean. I will not name the insurance companies that I have done this too, but it becomes even more urgent if you provide excellent patient care and results, people will want to come to you. When I halted with Insurance X, the patients were disappointed. I just forwarded them what they paid me for a lap appy ($300 !). The patients understood. Insurance company either folds because of complaints or because of morbidity/mortality.

If you don't understand this, don't worry, alot of my collegues that work in the UC system or the Kaiser system have no idea. But in fairness to them, most mds don't want to deal with money, they rather just have it taken from them in their paycheck. You choose!

Wow, this is excellent information. I would pay to follow you around your practice for a couple of days, and see this in action. Probably be more useful than most people's intern year.

 

[droliver]

I still say no way. Your revenue cannot keep up with the cuts in medicare and overhead inflationary pressure. If you think you will get paid 2x Medicare fees in the future you're mistaken. Expect Medicare rates with only a small premium from even your best payors whether you're in network or not.

 

[bronx43]

I still say no way. Your revenue cannot keep up with the cuts in medicare and overhead inflationary pressure. If you think you will get paid 2x Medicare fees in the future you're mistaken. Expect Medicare rates with only a small premium from even your best payors whether you're in network or not.

I was under the impression that gen surg and primary care were the winners amidst healthcare changes.

 

[droliver]

I was under the impression that gen surg and primary care were the winners amidst healthcare changes.

There are no winners but only "lesser losers" as the overall money for providers is going to shrink in Medicare budgets going forward. Cardiology, Moh's Dermatologists, and Rads have been the most upfront victims as yet.

Specialists of all types got dinged with a 20% cut per encounter by the elimination for consultation codes on Jan 1. That change will personally cost me $10,000-20,000+ this year based on the # of consults I see annually and will go up next year when private payors almost certainly do the same thing. Consider poor neurologists and endocrinologists who do practices with almost exclusively consult driven visits and are getting pinched on the diagnostic procedure end as well (EMG's, nerve conduction studies, DEXA scans, etc...)

 

[Winged Scapula]

droliver-re: consult codes

We were advised by our billers, at the end of last year, to start eliminating consult codes (which is essentially all of our new patients). As you note, it was a big hit and reduction in reimbursement.

However, they are now advising us to go ahead and use consult codes for all but Medicare and ACCCHS (Arizona's Medicaid program, which has dozens of plans which I cannot keep straight). They had not gotten verification from any insurance companies that they were going to follow CMS rules and may still pay for consults.

My fear of course is that the codes will be rejected/denied but figure I'll try it with a few quicker payors and see what happens. Might be worth talking to your billers as well if you see a lot of consults. I'm sure all the insurance companies will eventually come around, but if I can delay it as long as possible...

 

[45408]

The first practicing surgeon I meet who agrees with Dr. Gawande, will be the first practicing surgeon I meet who agrees with Dr. Gawande 🙂 Practicing in an isolated tertiary academic practice while promoting the brand Gawande will do that for you.

Keep in mind that Dr. Gawande also practices at the Brigham Hospital in Boston which is part of the "Partners Network", a coalition of blue blood hospitals in Boston who have leveraged their "brand" to force insurers to pay more then they pay competing hospital chains and physicians. The Boston Globe estimates that Partners and its doctors receive $800 million more every year than they would were they paid at rates similar to competitors. So before we laud Gawande in excess, maybe he should practice what he's preaching and resign from Harvard's teaching hospitals as they're part of the healthcare inflation in that market.🙄

If you're interested in this story of Partner's and how they're raising the cost of healthcare read the Globe's articles going back to 2008 "A healthcare system badly out of balance" (see here).

Now I don't begrudge the Partner's coalition move in Massachusetts, it's actually a model most MD's wish existed in their town for telling low-ball insurers to suck it.

A few points about the Mayo Clinic as well
1)Mayo does not take Medicare
2)Mayo does not take Medicare supplements for new patients.
3)The Dartmouth Study, touted by many as the proof of efficiency of the Model compared Medicare expenditures county by county, throughout the country. Mayo Rochester resides in a rural farming community, where Medicare usage would be expected to be low. But since Mayo does cares for virtually none of these Medicare patients, extrapolating the cost efficiency of Mayo is simply wrong.
4) Mayo's model is very much a boutique model, catering to the wealthy, those willing to pay extra or out of pocket for their care or those with very good indemnity insurance coverage. Mayo is not in network for virtually every HMO and PPO plan, based simply on the high reimbursements demanded by Mayo. Mayo quotes 2-4 times the cost for surgical procedures that those in the community at large get paid.
5)Mayo relies heavily on the$ 200-300M/year in endowment money each year, to supplement their payrolls, build their buildings, fund research, and fund their pension plan. The cost structure of the Mayo Clinic is prohibitive without this additional funding.

👍 Fascinating post. I never cease to be amazed at how many more aspects of the story there are.

 

[droliver]

droliver-re: consult codes

We were advised by our billers, at the end of last year, to start eliminating consult codes (which is essentially all of our new patients). As you note, it was a big hit and reduction in reimbursement.

However, they are now advising us to go ahead and use consult codes for all but Medicare and ACCCHS (Arizona's Medicaid program, which has dozens of plans which I cannot keep straight). They had not gotten verification from any insurance companies that they were going to follow CMS rules and may still pay for consults.

My fear of course is that the codes will be rejected/denied but figure I'll try it with a few quicker payors and see what happens. Might be worth talking to your billers as well if you see a lot of consults. I'm sure all the insurance companies will eventually come around, but if I can delay it as long as possible...

Kim,

right now you can still use the consult codes for everyone but straight Medicare, Medicaid, & Tricare. However, it is absolutely clear the private insurers will follow their lead when the dust settles. We've already gotten notification from a few of the Blue Cross & United Health administered Medicare+ plans that (although they could still accept consult codes) we are no longer to file encounters as such. That's clearly where it's headed.