An Alternate Take on Private Equity in Anesthesia

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NumTacos

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Then why are partners leaving his practice despite one of the most severe non competes ever?
Most of the partners I know in all markets regret PE and say it was a bad decision for the practice… good for those who took the buyout and got out but otherwise not.
They’re trying to move toward an employed model in USAP - maybe it’ll work… but there’s lots of overhead to cover. There’s easier work for more money and definitely more money per hour out there. But if you have to be in a location where they own the market 🤷‍♂️

Maybe the suddenly terrible economy and loss of investment wealth will change the anesthesia market.
 
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Then why are partners leaving his practice despite one of the most severe non competes ever?
Most of the partners I know in all markets regret PE and say it was a bad decision for the practice… good for those who took the buyout and got out but otherwise not.
They’re trying to move toward an employed model in USAP - maybe it’ll work… but there’s lots of overhead to cover. There’s easier work for more money and definitely more money per hour out there. But if you have to be in a location where they own the market 🤷‍♂️

Maybe the suddenly terrible economy and loss of investment wealth will change the anesthesia market.
Until they can reign in on the crnas. I doubt that will happenn

Simply not enough “providers” for the demands of cases. You simply can’t be going 3 or even 4 rooms strong to 7pm at small community hospitals daily in MD only models. That gets old.

So question for those in MD only models (with ob) How many rooms are running past 7pm? And how many calls on average each month in house?

My best guess it’s likely at least 5 or maybe 6 calls in house. It’s a lot.

But every practice is different and some cover 2 places or more.
 
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Private equity has no place in health care. People need to stop deluding themselves. Twenty percent (minimum) of the PE owned group’s collections are going to the PE group whose overall priorities not aligned with the healthcare providers’ mission. At least in an employed model the missions are (most of the time) aligned.
 
Until they can reign in on the crnas. I doubt that will happenn

Simply not enough “providers” for the demands of cases. You simply can’t be going 3 or even 4 rooms strong to 7pm at small community hospitals daily in MD only models. That gets old.

So question for those in MD only models (with ob) How many rooms are running past 7pm? And how many calls on average each month in house?

My best guess it’s likely at least 5 or maybe 6 calls in house. It’s a lot.

But every practice is different and some cover 2 places or more.
Zero in house calls here.
Come in at 3pm.
(OB and Trauma are optional).
I love my practice, location, income and flexibility.
 
Until they can reign in on the crnas. I doubt that will happenn

Simply not enough “providers” for the demands of cases. You simply can’t be going 3 or even 4 rooms strong to 7pm at small community hospitals daily in MD only models. That gets old.

So question for those in MD only models (with ob) How many rooms are running past 7pm? And how many calls on average each month in house?

My best guess it’s likely at least 5 or maybe 6 calls in house. It’s a lot.

But every practice is different and some cover 2 places or more.

MD only.

3-5 rooms past 1900. And some of those rooms go pretty late.

I personally take 5-6 MOR calls monthly (these are typically 24 hours). Partners take variety of calls with peel off times sequentially. No OB. Technically home. But it’s common to be in a room past midnight when on call. Maybe 60% of the time?
 
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Until they can reign in on the crnas. I doubt that will happenn

Simply not enough “providers” for the demands of cases. You simply can’t be going 3 or even 4 rooms strong to 7pm at small community hospitals daily in MD only models. That gets old.

So question for those in MD only models (with ob) How many rooms are running past 7pm? And how many calls on average each month in house?

My best guess it’s likely at least 5 or maybe 6 calls in house. It’s a lot.

But every practice is different and some cover 2 places or more.

We are a tertiary referral center, certified stroke center, level II trauma, busy high risk OB. Employed, mostly solo, save for 1 day per month. I have zero in house calls per month. We have the ability to opt out of OB, which I did, and OR call starts at 5pm and is from home with a 30min response time. We have 7-8 call positions per day, but they’re really just there so people no what days they are reliably going to work late. Similar to the above poster we typically have 3-5 rooms running past 7.
 
"My practice joined U.S. Anesthesia Partners in 2017, and one of the key drivers behind that decision relates to how the organization is structured. Specifically, each practice remains locally governed, and each clinical governance board is made up of local physician owners, like me, who make the key decisions about clinical protocols, recruitment, staffing, compensation, scheduling, hospital and payor contracting, supervision ratios—everything. Because these governance boards operate locally, what one board decides in Florida for their practice may be different than what another decides in Washington. Not once has our group been told how to practice medicine, nor whom we should or should not hire, nor has anyone mandated what our local compensation structure should be."

So the author/partners can just choose whatever salary/compensation they want? Sureeeee

It should read: We can determine how to divide the revenue after paying our PE overlords
 
Zero in house calls here.
Come in at 3pm.
(OB and Trauma are optional).
I love my practice, location, income and flexibility.
How many rooms are running at 5-7pm?

How big of a practice ?
Those questions and staffing models differ from place to place.
 
MD only.

3-5 rooms past 1900. And some of those rooms go pretty late.

I personally take 5-6 MOR calls monthly (these are typically 24 hours). Partners take variety of calls with peel off times sequentially. No OB. Technically home. But it’s common to be in a room past midnight.
You need a new job. Unless you are making 750k base.
 
"My practice joined U.S. Anesthesia Partners in 2017, and one of the key drivers behind that decision relates to how the organization is structured. Specifically, each practice remains locally governed, and each clinical governance board is made up of local physician owners, like me, who make the key decisions about clinical protocols, recruitment, staffing, compensation, scheduling, hospital and payor contracting, supervision ratios—everything. Because these governance boards operate locally, what one board decides in Florida for their practice may be different than what another decides in Washington. Not once has our group been told how to practice medicine, nor whom we should or should not hire, nor has anyone mandated what our local compensation structure should be."

So the author/partners can just choose whatever salary/compensation they want? Sureeeee

It should read: We can determine how to divide the revenue after paying our PE overlords
The issue is 600k/40 hrs a week (including call hours) on average with 10 weeks is becoming the standard w2 model. That’s what hca pays at many places. That’s what academic centers pay (mid 550s plus generous benefits). That’s what hospitals employee pays as well

U can choose to govern all you want and make 800k or more. But I can assure you without new blood coming into the partnership track. You will be working way more than 40 hours for that type of money.

But if you are happy with your own usap practice. More power to you. It’s the same with those local practices who sold to Sheridan 10-12 years ago. They managed themselves and many of the original sell out docs still work for the same practice. Faces come and go.
 
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May be paywall so I copy and paste some quotes,

“I’m asking a very simple question,” Xinis said to Ensign. “Where is he?”

““I do not have that information,” Ensign told the judge.”

“By the end of the 20-minute hearing, Xinis, appearing frustrated, had issued a new order: The Trump administration, she said, must file daily status updates with the court about the government’s progress getting Abrego García back to the United States.”

Personally if I were the judge. I’d order the Ensign detained in local jail tomorrow until someone else can find the Abrego back on US soil. Ensign pretty useless anyways with his I don’t know know arguments.

I’m sure they would find the dude real quick in that prison if a trump official ends up in contempt.

That would cause real problems in the trump administration ignoring the Supreme Court order by playing dumb.
 
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May be paywall so I copy and paste some quotes,

“I’m asking a very simple question,” Xinis said to Ensign. “Where is he?”

““I do not have that information,” Ensign told the judge.”

“By the end of the 20-minute hearing, Xinis, appearing frustrated, had issued a new order: The Trump administration, she said, must file daily status updates with the court about the government’s progress getting Abrego García back to the United States.”

Personally if I were the judge. I’d order the Ensign detained in local jail tomorrow until someone else can find the Abrego back on US soil. Ensign pretty useless anyways with his I don’t know know arguments.

I’m sure they would find the dude real quick in that prison if a trump official ends up in contempt.

That would cause real problems in the trump administration ignoring the Supreme Court order by playing dumb.
Jesus man this is starting to sound more and more like a Sam Peckinpah reboot: "Bring Me the Head of Abrego García."
 
Jesus man this is starting to sound more and more like a Sam Peckinpah reboot: "Bring Me the Head of Abrego García."
They know where he is. They are just acting dumb at this point. Considering they let American reporters go to the prison there. It’s all propaganda.
 
We get funnier and funnier stories


May be paywall so I copy and paste some quotes,

“I’m asking a very simple question,” Xinis said to Ensign. “Where is he?”

““I do not have that information,” Ensign told the judge.”

“By the end of the 20-minute hearing, Xinis, appearing frustrated, had issued a new order: The Trump administration, she said, must file daily status updates with the court about the government’s progress getting Abrego García back to the United States.”

Personally if I were the judge. I’d order the Ensign detained in local jail tomorrow until someone else can find the Abrego back on US soil. Ensign pretty useless anyways with his I don’t know know arguments.

I’m sure they would find the dude real quick in that prison if a trump official ends up in contempt.

That would cause real problems in the trump administration ignoring the Supreme Court order by playing dumb.
Pretty funny!
 
The issue is 600k/40 hrs a week (including call hours) on average with 10 weeks is becoming the standard w2 model. That’s what hca pays at many places. That’s what academic centers pay (mid 550s plus generous benefits). That’s what hospitals employee pays as well

U can choose to govern all you want and make 800k or more. But I can assure you without new blood coming into the partnership track. You will be working way more than 40 hours for that type of money.

But if you are happy with your own usap practice. More power to you. It’s the same with those local practices who sold to Sheridan 10-12 years ago. They managed themselves and many of the original sell out docs still work for the same practice. Faces come and go.
I think Usap’s new MO is moving to an employed model. I think they get it - finally- that no one is buying the partner track model… and I mean why would they?!?! When partners are leaving - lots of them. The issue for them remains they cannot match the market - like aneftp says 600k/40h/10 weeks vacation - in the current situation - high crna salaries, no surprises act, the aforementioned PE cut… they have to rely on their domination of market share in desirable locations. Y’all would drop dead if you knew what Nashville and MD were making (at least a little while ago when I was in the know - maybe it’s changed but I doubt it). The math isn’t mathing anymore
 
Until they can reign in on the crnas. I doubt that will happenn

Simply not enough “providers” for the demands of cases. You simply can’t be going 3 or even 4 rooms strong to 7pm at small community hospitals daily in MD only models. That gets old.

So question for those in MD only models (with ob) How many rooms are running past 7pm? And how many calls on average each month in house?

My best guess it’s likely at least 5 or maybe 6 calls in house. It’s a lot.

But every practice is different and some cover 2 places or more.
In house OB call, but you can give away OB shifts (people often want them do to financial incentives tied for OB).

We don’t have any other in house calls. Even our first call isn’t terrible, you might have one bad night a month.

Hospital wants coverage till 5pm, but we get paid for it. At 7, can only run 2 rooms due to nursing bottle neck which is great, for us. Fortunately majority of our surgeons don’t want to operate late ever. Only two will, but nursing has made a stink to admin about it.

Seems the MD model can be done but not all markets are as lucky as my group.

I can’t imagine the job described from one of the posters working those hours as MD only, unless you were making 7 figures.
 
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Y’all would drop dead if you knew what Nashville and MD were making (at least a little while ago when I was in the know - maybe it’s changed but I doubt it). The math isn’t mathing anymo
Higher or lower that 600K
 
In house OB call, but you can give away OB shifts (people often want them do to financial incentives tied for OB).

We don’t have any other in house calls. Even our first call isn’t terrible, you might have one bad night a month.

Hospital wants coverage till 5pm, but we get paid for it. At 7, can only run 2 rooms due to nursing bottle neck which is great, for us. Fortunately majority of our surgeons don’t want to operate late ever. Only two will, but nursing has made a stink to admin about it.

Seems the MD model can be done but not all markets are as lucky as my group.

I can’t imagine the job described from one of the posters working those hours as MD only, unless you were making 7 figures.
Those Md only models guys who work those hours (55-60 plus hrs) generally make 750-800k a year with 8-10 weeks off. So it’s a lot of money in their minds to keep humming and trucking along. Even doing 2 weekends (1 Friday /Sunday and 1 Saturday average 5-6 in house calls a month

But ask yourself. How is that any difference than making 550k/40 hrs a week and one weekend a month? And 10 weeks off? Those 15-20 hrs a week worked are easily worth $5000 extra of worth x 40 weeks worked (200k of extra worth) but forced on you to keep working

The numbers are the same. 550k/40 hrs vs 750k/55 hrs. Per hours wise.
 
I think Usap’s new MO is moving to an employed model. I think they get it - finally- that no one is buying the partner track model… and I mean why would they?!?! When partners are leaving - lots of them. The issue for them remains they cannot match the market - like aneftp says 600k/40h/10 weeks vacation - in the current situation - high crna salaries, no surprises act, the aforementioned PE cut… they have to rely on their domination of market share in desirable locations. Y’all would drop dead if you knew what Nashville and MD were making (at least a little while ago when I was in the know - maybe it’s changed but I doubt it). The math isn’t mathing anymore

I wonder if they still require the ridiculous 200k stock purchase? If so, it’s still a scam IMO.

Curious amyl, were able to unload your stock when you left? Good return? walk away from it?
You don’t have to answer if it’s something you’d rather not talk about.
 
I wonder if they still require the ridiculous 200k stock purchase? If so, it’s still a scam IMO.

Curious amyl, were able to unload your stock when you left? Good return? walk away from it?
You don’t have to answer if it’s something you’d rather not talk about.
If USAP Dallas is anything like USAP Florida. I know couple people who left their partnerships from west coast Florida usap, northern (jax) usap and a few from central Florida usap

It’s very difficult to get rid of private stock.

X years before it’s up for sale for the stocks. Etc.

Usap private stock like the private equity reit I purchased in 2008. I couldn’t get rid of the private equity reit till 2013. A full 5 years later.

Read the fine print.
 
Those Md only models guys who work those hours (55-60 plus hrs) generally make 750-800k a year with 8-10 weeks off. So it’s a lot of money in their minds to keep humming and trucking along. Even doing 2 weekends (1 Friday /Sunday and 1 Saturday average 5-6 in house calls a month

But ask yourself. How is that any difference than making 550k/40 hrs a week and one weekend a month? And 10 weeks off? Those 15-20 hrs a week worked are easily worth $5000 extra of worth x 40 weeks worked (200k of extra worth) but forced on you to keep working

The numbers are the same. 550k/40 hrs vs 750k/55 hrs. Per hours wise.

Yeah… I made nowhere near 750 for that call burden (and only had 4 weeks off).

Maybe some places.
 
Private equity has no place in health care. People need to stop deluding themselves. Twenty percent (minimum) of the PE owned group’s collections are going to the PE group whose overall priorities not aligned with the healthcare providers’ mission. At least in an employed model the missions are (most of the time) aligned.

You are correct that its not just PE but Anesthesia Management companies have no place in healthcare.... employed model is NOT the answer either - you will be hospital's bitch with zero buffer. 1099 employed maybe the answer - better yet 1099 FAIR partnership where everyone is equal - you eat what you kill. You want more call, more pay; you take on higher ASA - more pay, you do a lot of GI - more pay, etc. California in that sense has great protection laws for physicians. Once you get your privileges you can't get ousted when the next AMC comes knocking and the whole department leaves - I have lived that story many times its really a sad experience I am sure everyone read the press releases from NJ, Nevada, etc etc etc etc.
 
You are correct that its not just PE but Anesthesia Management companies have no place in healthcare.... employed model is NOT the answer either - you will be hospital's bitch with zero buffer. 1099 employed maybe the answer - better yet 1099 FAIR partnership where everyone is equal - you eat what you kill. You want more call, more pay; you take on higher ASA - more pay, you do a lot of GI - more pay, etc. California in that sense has great protection laws for physicians. Once you get your privileges you can't get ousted when the next AMC comes knocking and the whole department leaves - I have lived that story many times its really a sad experience I am sure everyone read the press releases from NJ, Nevada, etc etc etc etc.
Eat what you kill doesn’t work anymore in this day and age in 90% of anesthesia private practices.

My brothers place which existed for 30
Plus years as true private practice in LA blended unit system where he was president (he still runs the practice). Do more units. Get paid more. Very simple model.

Just inflation and declining reimbursement killed the practice.

Now they are a weird modified 1099 and w2 model. It’s hard to explain. They actually make more with hospitals gurantee and not have to worry about reimbursements
 
I wonder if they still require the ridiculous 200k stock purchase? If so, it’s still a scam IMO.

Curious amyl, were able to unload your stock when you left? Good return? walk away from it?
You don’t have to answer if it’s something you’d rather not talk about.
No. Not able to sell it. Won’t be able to sell - official word is no plans for a liquidity event. No dividends. Even they value it now as worth less than I paid for it. I don’t think I’ll ever be able to sell it. I consider that money gone - I’m pissed about it too… it is a scam. So no not a good return and not even my money back. Because I can’t sell it I can’t even take the loss on my taxes. 🐂 💩

I think they are moving away from a partnership model and towards an employed model - they aren’t offering competitive $ when you break it down per hour for the type of work it is or the liability involved.
 
You are correct that its not just PE but Anesthesia Management companies have no place in healthcare.... employed model is NOT the answer either - you will be hospital's bitch with zero buffer. 1099 employed maybe the answer - better yet 1099 FAIR partnership where everyone is equal - you eat what you kill. You want more call, more pay; you take on higher ASA - more pay, you do a lot of GI - more pay, etc. California in that sense has great protection laws for physicians. Once you get your privileges you can't get ousted when the next AMC comes knocking and the whole department leaves - I have lived that story many times its really a sad experience I am sure everyone read the press releases from NJ, Nevada, etc etc etc etc.
On a case per case basis I will disagree with you about hospital employed postions. There are some good ones out there. Sometimes you will get an administrator that understands stability in the anesthesia department is valuable. Sometimes you can get an administrator that will FAFO and get screwed in the process. I hear my old job in Indiana is like that - new ceo is a f—-er and has run all the anesthesiologists, crnas and AAs off. As a hospital employee now I’m the happiest I’ve ever been in anesthesia…. They may not be common but they’re out there.
 
On a case per case basis I will disagree with you about hospital employed postions. There are some good ones out there. Sometimes you will get an administrator that understands stability in the anesthesia department is valuable. Sometimes you can get an administrator that will FAFO and get screwed in the process. I hear my old job in Indiana is like that - new ceo is a f—-er and has run all the anesthesiologists, crnas and AAs off. As a hospital employee now I’m the happiest I’ve ever been in anesthesia…. They may not be common but they’re out there.
Management matters. I agree 100%.
Anesthesia management matters

We all know those chiefs who take 2-3 non clinical days and work much less and do not fight for their regular staff.

I have seen chiefs take a 750k salary. Work 2 days a week. Plus take 10 weeks off but strategically take Wednesday Thursday non clinical and pto on Friday and Monday off. It’s as clear as day on QGenda. How often this happens.

And the staff is left working for 500k no pay raises for 3 years with 10 weeks off. Daily grind difficulty in requesting vacation. Like wtf. And u wonder why 6 docs have left in the past 12 months.

Pigs get slaughter (the chiefs) unless they can try to move on to their next gig.
 
No. Not able to sell it. Won’t be able to sell - official word is no plans for a liquidity event. No dividends. Even they value it now as worth less than I paid for it. I don’t think I’ll ever be able to sell it. I consider that money gone - I’m pissed about it too… it is a scam. So no not a good return and not even my money back. Because I can’t sell it I can’t even take the loss on my taxes. 🐂 💩

I think they are moving away from a partnership model and towards an employed model - they aren’t offering competitive $ when you break it down per hour for the type of work it is or the liability involved.
The people who did the work are the same people who were screwed.
That blows.
Thanks for sharing.
 
No. Not able to sell it. Won’t be able to sell - official word is no plans for a liquidity event. No dividends. Even they value it now as worth less than I paid for it. I don’t think I’ll ever be able to sell it. I consider that money gone - I’m pissed about it too… it is a scam. So no not a good return and not even my money back. Because I can’t sell it I can’t even take the loss on my taxes. 🐂 💩

I think they are moving away from a partnership model and towards an employed model - they aren’t offering competitive $ when you break it down per hour for the type of work it is or the liability involved.
I'll be working for HCA soon and they offer a stock purchase program. After reading this, I'm hesitant to participate
 
I'll be working for HCA soon and they offer a stock purchase program. After reading this, I'm hesitant to participate
Are the hca stock options free? As part of ur pay package ? Excluding ur real compensation ?

The original usap partners stocks were free/included with the buyout option plus cash.
 
Are the hca stock options free? As part of ur pay package ? Excluding ur real compensation ?

The original usap partners stocks were free/included with the buyout option plus cash.


Unlike USAP, HCA is a listed and publicly traded stock with a long track record. It is a blue chip stock, as liquid as you can get. It looks increasingly unlikely that USAP will ever IPO. If @AppTrail has an opportunity to buy some HCA at a discount, he would be stupid not to buy.



IMG_3960.jpeg
 
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@amyl how much did you have to buy? I remember interviewing with usap ages ago when I was first looking…they wanted a 50k buy in of stock. I asked if I could sell back the stock at anytime, couldn’t get a straight answer of yes/no. Have you considered hiring an attorney (if it’s a lot of money)? What does your contract language say? Sorry you had to go through this and glad to see you’re off to better things (plus SC>TX, have you visited Greenville yet?)
This is definitely a good example for new grads/people seeking new employment with AMCs/PE. Get everything in writing, besides a buy-in also call/hours/rate
 
Unlike USAP, HCA is a listed and publicly traded stock with a long track record. It is a blue chip stock, as liquid as you can get. It looks increasingly unlikely that USAP will ever IPO. If @AppTrail has an opportunity to buy some HCA at a discount, he would be stupid not to buy.



View attachment 402332
For now it’s a good buy. The mednax /american anesthesiology buyout with stock options looked good for a while…just look what happened to mednax stock the last 12-13 years as stock market soared , MD stock tanked.

But gotta admit. Hospital stocks have soared under the ACA cause the law was written in favor of hospitals to collect more payments.
 
Are the hca stock options free? As part of ur pay package ? Excluding ur real compensation ?

The original usap partners stocks were free/included with the buyout option plus cash.
Employees have the option to purchase HCA stock at a 10% discount (4x a year I think).
 
@amyl how much did you have to buy? I remember interviewing with usap ages ago when I was first looking…they wanted a 50k buy in of stock. I asked if I could sell back the stock at anytime, couldn’t get a straight answer of yes/no. Have you considered hiring an attorney (if it’s a lot of money)? What does your contract language say? Sorry you had to go through this and glad to see you’re off to better things (plus SC>TX, have you visited Greenville yet?)
This is definitely a good example for new grads/people seeking new employment with AMCs/PE. Get everything in writing, besides a buy-in also call/hours/rate
I was supposed to buy 100k over 5 years but I left before the last year. Someone else just gave notice who hadn’t bought their 100k but had hit the 5 year mark and they are making that dr buy the rest. I wouldn’t mind if I could sell it at all - just could take the loss on taxes. It’s privately held stock so they can make the rules. They say you can sell 10% at the next liquidity event - which will happen if someone wants to buy USAP (so never).
 
Employees have the option to purchase HCA stock at a 10% discount (4x a year I think).
Well hopefully it’s a good return with hca stock.

I like what they have done with their own internal anesthesia locums division ) and just getting rid of Envison (I’m sure their management fee is around 15-20%)
Like if it cost 10 million to run anesthesia and Envison wants a 2 million dollar cut. That’s 12 million in operating costs. Cut out Envison. Pay docs and crnas a little more. Anesthesia costs go from 10 million to 11 million with pay increase but u actually save 1 million not using Envison. Seems like a win win (as long as the local ceo, coo and cfo) are smart enough to understand this.
 
Well hopefully it’s a good return with hca stock.

I like what they have done with their own internal anesthesia locums division ) and just getting rid of Envison (I’m sure their management fee is around 15-20%)
Like if it cost 10 million to run anesthesia and Envison wants a 2 million dollar cut. That’s 12 million in operating costs. Cut out Envison. Pay docs and crnas a little more. Anesthesia costs go from 10 million to 11 million with pay increase but u actually save 1 million not using Envison. Seems like a win win (as long as the local ceo, coo and cfo) are smart enough to understand this.

Folks in C-suite are never smart enough to understand this.

“Megan Friedman, DO. Director of Pacific Coast Anesthesia Consultants (Los Angeles):I’m sick of hearing that cutting anesthesia costs is the key to operational efficiency. Anesthesia service lines are constantly told to “be more efficient,” as if that alone will fix broader operational issues. Yes, timeliness and quick turnovers matter — but they’re just one small piece of a much larger puzzle, and often not the root cause of inefficiencies.
Real perioperative success — whether in hospitals or surgery centers — comes from smart scheduling, balanced case distribution, appropriate staffing, strategic utilization and recruiting the right surgeon mix with a sustainable payer profile. Hospitals invest heavily in technology and infrastructure, yet high-quality anesthesia staffing is often treated as an afterthought.
Anesthesia isn’t just a cost — it’s a foundational clinical service that touches nearly every patient and department: ORs, imaging, cath lab, endoscopy, labor and delivery and every procedural space across inpatient and ambulatory care. It can’t be cut or replaced without consequences.
Our goals are aligned with hospital and surgical leadership. When hospitals thrive — through volume, efficiency and payer mix — so do anesthesia services. It’s not us versus them. Sustainable performance requires collaboration, not finger-pointing. If systems want lasting, meaningful solutions, they need to stop squeezing anesthesia and start addressing the full picture of surgical services and operational strategy.”
 
Folks in C-suite are never smart enough to understand this.

“Megan Friedman, DO. Director of Pacific Coast Anesthesia Consultants (Los Angeles):I’m sick of hearing that cutting anesthesia costs is the key to operational efficiency. Anesthesia service lines are constantly told to “be more efficient,” as if that alone will fix broader operational issues. Yes, timeliness and quick turnovers matter — but they’re just one small piece of a much larger puzzle, and often not the root cause of inefficiencies.
Real perioperative success — whether in hospitals or surgery centers — comes from smart scheduling, balanced case distribution, appropriate staffing, strategic utilization and recruiting the right surgeon mix with a sustainable payer profile. Hospitals invest heavily in technology and infrastructure, yet high-quality anesthesia staffing is often treated as an afterthought.
Anesthesia isn’t just a cost — it’s a foundational clinical service that touches nearly every patient and department: ORs, imaging, cath lab, endoscopy, labor and delivery and every procedural space across inpatient and ambulatory care. It can’t be cut or replaced without consequences.
Our goals are aligned with hospital and surgical leadership. When hospitals thrive — through volume, efficiency and payer mix — so do anesthesia services. It’s not us versus them. Sustainable performance requires collaboration, not finger-pointing. If systems want lasting, meaningful solutions, they need to stop squeezing anesthesia and start addressing the full picture of surgical services and operational strategy.”
It's because they sit behind computer programming software that squirts out old style algorithms how what it is meant to be "efficient"

Does it matter if on room time is 80% vs 100%? If the surgeon is running over his time. Completely destroys the analytics. So the stupid admin decides to re do their block times to give the surgeon more time (say carpal tunnel is 30 min block time, but new slower surgeon takes 1 hr). So they move the block to 1 hr scheduling (makes sense) except that doesn't help with any efficiency. It just helps make their software and excel data sheets look cleaner.

They need to look at financials (how much overtime is being paid per case after 3/5/7pm. and staffing models).

This isn't rocket science. But unfortunately the USA system for healthcare is built on greed and many non profits are really operating like for profit hospitals. You cannot seriously call yourself a non profit when the main admin make in high 6 figures to mid 7 figures income.
 
Employees have the option to purchase HCA stock at a 10% discount (4x a year I think).
Yes to this and it can be sold whenever you want since it is publicly traded. Obviously short-term and long-term capital gains treatment applies so it is not necessarily an immediate 10% gain. Disclaimer - I’m an HCA employed anesthesiologist and I’ve done the ESPP from the day I started several years ago and it has worked out very well financially.
Then why are partners leaving his practice despite one of the most severe non competes ever?
Most of the partners I know in all markets regret PE and say it was a bad decision for the practice… good for those who took the buyout and got out but otherwise not.
They’re trying to move toward an employed model in USAP - maybe it’ll work… but there’s lots of overhead to cover. There’s easier work for more money and definitely more money per hour out there. But if you have to be in a location where they own the market 🤷‍♂️

Maybe the suddenly terrible economy and loss of investment wealth will change the anesthesia market.
The fact is that the underlying investment thesis for PE in anesthesia has changed, irrevocably so. I was there at the beginning and know better than most the original investment theory - gain scale, create back office efficiencies, level the playing field with payers and health systems and create better care delivery models backed up with quantitative information. Sounds like hyperbole now but the world is always crystal clear in the rear view mirror.

The flaw in the investment thesis, however, was that there was a limited investment horizon to achieve this before executing on the exit strategy: meaning one had to get into the market, grow quickly and then exit because the overall anesthesia market is fixed in size. One can only grow so much before there isn’t any more growth to legally achieve. PE is about growing a business, rationalizing business structure, maximizing EBITDA and then getting out. The original premise was to grow quickly, establish a best in class operation and then sell either to a larger strategic player or on the public market via IPO.

The problem, however, is that the runway ran out with the pushback from payers and the NSA. Once margin erosion ensued it became difficult/impossible to execute on the endgame and exit the business. The fact that all of the major players now are pivoting to “MSO services” should tell you everything you need to know about their view of the world. They are looking to grow top line revenue and EBITDA but MSO services are low margin businesses. USAP was designed to be a physician-owned entity that provided partnership like experiences to the clinicians and professionally managed services to the health systems. It does neither now and it was never intended to be an MSO business. They pivot because that is the only viable option they have.

The knock against all of the big vendors (I use that word intentionally) is that they largely continue to exist because they bind their clinicians with non-compete agreements. They increasingly do not have a rate advantage, their MSOs can be replicated and they are all recruiting from the same labor pool that increasingly has choices in terms of compensation. Their only competitive advantage is that they have non-competes.

Think about that from a business owner perspective - your competitive advantage is you have onerous no-competes with your employees??? There is no intellectual property, trade secret or loss of business that justifies this. I acknowledge that there may be recruiting costs that have value but a non-compete to protect that in perpetuity??

At this point in time significant portions of the large vendors’ revenue is coming in the form of subsidy support from health systems and it is being used to produce decreasing levels of margin. I have seen data to suggest that it is upwards of 30-40% for revenue to drive margins of 3-5%. This is not PE-level investment expectations.

It is a failing business model.

And in semi-disclosure mode, I helped develop the business model that is now failing. It made sense at the time but the world has moved on and it increasingly doesn’t make sense. Why should a health system pay a management firm and PE for services that don’t exist when the real work is being done at the bedside by the clinicians? Pay them more and eliminate the external overhead. Health systems are waking up to this fact and will work to insource hospital-based services across the board, not just in anesthesia. It will take a while but it will happen barring some barrier being erected through regulation or law.
 
Yes to this and it can be sold whenever you want since it is publicly traded. Obviously short-term and long-term capital gains treatment applies so it is not necessarily an immediate 10% gain. Disclaimer - I’m an HCA employed anesthesiologist and I’ve done the ESPP from the day I started several years ago and it has worked out very well financially.

The fact is that the underlying investment thesis for PE in anesthesia has changed, irrevocably so. I was there at the beginning and know better than most the original investment theory - gain scale, create back office efficiencies, level the playing field with payers and health systems and create better care delivery models backed up with quantitative information. Sounds like hyperbole now but the world is always crystal clear in the rear view mirror.

The flaw in the investment thesis, however, was that there was a limited investment horizon to achieve this before executing on the exit strategy: meaning one had to get into the market, grow quickly and then exit because the overall anesthesia market is fixed in size. One can only grow so much before there isn’t any more growth to legally achieve. PE is about growing a business, rationalizing business structure, maximizing EBITDA and then getting out. The original premise was to grow quickly, establish a best in class operation and then sell either to a larger strategic player or on the public market via IPO.

The problem, however, is that the runway ran out with the pushback from payers and the NSA. Once margin erosion ensued it became difficult/impossible to execute on the endgame and exit the business. The fact that all of the major players now are pivoting to “MSO services” should tell you everything you need to know about their view of the world. They are looking to grow top line revenue and EBITDA but MSO services are low margin businesses. USAP was designed to be a physician-owned entity that provided partnership like experiences to the clinicians and professionally managed services to the health systems. It does neither now and it was never intended to be an MSO business. They pivot because that is the only viable option they have.

The knock against all of the big vendors (I use that word intentionally) is that they largely continue to exist because they bind their clinicians with non-compete agreements. They increasingly do not have a rate advantage, their MSOs can be replicated and they are all recruiting from the same labor pool that increasingly has choices in terms of compensation. Their only competitive advantage is that they have non-competes.

Think about that from a business owner perspective - your competitive advantage is you have onerous no-competes with your employees??? There is no intellectual property, trade secret or loss of business that justifies this. I acknowledge that there may be recruiting costs that have value but a non-compete to protect that in perpetuity??

At this point in time significant portions of the large vendors’ revenue is coming in the form of subsidy support from health systems and it is being used to produce decreasing levels of margin. I have seen data to suggest that it is upwards of 30-40% for revenue to drive margins of 3-5%. This is not PE-level investment expectations.

It is a failing business model.

And in semi-disclosure mode, I helped develop the business model that is now failing. It made sense at the time but the world has moved on and it increasingly doesn’t make sense. Why should a health system pay a management firm and PE for services that don’t exist when the real work is being done at the bedside by the clinicians? Pay them more and eliminate the external overhead. Health systems are waking up to this fact and will work to insource hospital-based services across the board, not just in anesthesia. It will take a while but it will happen barring some barrier being erected through regulation or law.
I agree… the market just wasn’t there for the planned 2017 IPO… it is a failing business model and the non compete is the only thing keeping them going. Eventually things get so terrible that people will up and move their families… I did.
 
Employees have the option to purchase HCA stock at a 10% discount (4x a year I think).
Be sure you understand the details. Nationwide, many anesthesiologists "employed by HCA" are actually employed by the physician group PSG. They will show you the generic HCA benefits slides during your courtship and onboarding orientation, but then tell you "oh, turns out you don't get the ESPP via PSG, oops sorry.". Guess how I know.

I honestly thought my comp package as an employed HCA (i.e. PSG) doc was pretty decent. But between the poor 401k, lack of any other deferred comp, mediocre health plan, and the ESPP thing, benefits aren't a selling point.
 
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On a case per case basis I will disagree with you about hospital employed postions. There are some good ones out there. Sometimes you will get an administrator that understands stability in the anesthesia department is valuable. Sometimes you can get an administrator that will FAFO and get screwed in the process. I hear my old job in Indiana is like that - new ceo is a f—-er and has run all the anesthesiologists, crnas and AAs off. As a hospital employee now I’m the happiest I’ve ever been in anesthesia…. They may not be common but they’re out there.

I do not disagree that indeed there are some practices that happen to have an astute hospital admin … but remember most admins got there via squeezing thought the cracks stepping on others
etc most do not even have formal business or operational education. If you are lucky then it’s great but deathster, Napster, Eurovision, streamhealth, uspeepee etc are not the answer nor often working for huge hospital system as there employee either. Ther is always a “visionary “ who knows but one maneuver either cuts costs somewhere or increase salaries then work people to death …
 
On a case per case basis I will disagree with you about hospital employed postions. There are some good ones out there. Sometimes you will get an administrator that understands stability in the anesthesia department is valuable. Sometimes you can get an administrator that will FAFO and get screwed in the process. I hear my old job in Indiana is like that - new ceo is a f—-er and has run all the anesthesiologists, crnas and AAs off. As a hospital employee now I’m the happiest I’ve ever been in anesthesia…. They may not be common but they’re out there.

I do not disagree that indeed there are some practices that happen to have an astute hospital admin … but remember most admins got there via squeezing
Well hopefully it’s a good return with hca stock.

I like what they have done with their own internal anesthesia locums division ) and just getting rid of Envison (I’m sure their management fee is around 15-20%)
Like if it cost 10 million to run anesthesia and Envison wants a 2 million dollar cut. That’s 12 million in operating costs. Cut out Envison. Pay docs and crnas a little more. Anesthesia costs go from 10 million to 11 million with pay increase but u actually save 1 million not using Envison. Seems like a win win (as long as the local ceo, coo and cfo) are smart enough to understand this.
I don’t know where you get the time to post as many posts as you do life must be good…. See the post above hca doesn’t employ though hca and the benefits are not real benefits and the supposed savings are same money recycled internally …
 
I do not disagree that indeed there are some practices that happen to have an astute hospital admin … but remember most admins got there via squeezing

I don’t know where you get the time to post as many posts as you do life must be good…. See the post above hca doesn’t employ though hca and the benefits are not real benefits and the supposed savings are same money recycled internally …
Hca pays Envison X amount to provide anesthesia services for Hca facilities. There are many versions of this arrangement so like any hospital pays any anesthesia practice whether if it’s private or with a management company. It gets to a point it’s better to take it “in house w2” for hca

now you are correct hca doesn’t employed hca physicans “directly” in house. Just like any large entity including university or state owned or even private hospitals owned entity. They have a separate “physician management” wholly owned entities they will employe docs through. But the matter of the fact is it is still a hospital owned entity. Just like university of buffalo employed their residents through a different wholly owned entity so they don’t have to pay them the same benefits as their main entities

But the principal of the fact is it’s still hca employed w2 once they drop Envison. Just lip stick on a pig with different benefits.
 
Hca pays Envison X amount to provide anesthesia services for Hca facilities. There are many versions of this arrangement so like any hospital pays any anesthesia practice whether if it’s private or with a management company. It gets to a point it’s better to take it “in house w2” for hca

now you are correct hca doesn’t employed hca physicans “directly” in house. Just like any large entity including university or state owned or even private hospitals owned entity. They have a separate “physician management” wholly owned entities they will employe docs through. But the matter of the fact is it is still a hospital owned entity. Just like university of buffalo employed their residents through a different wholly owned entity so they don’t have to pay them the same benefits as their main entities

But the principal of the fact is it’s still hca employed w2 once they drop Envison. Just lip stick on a pig with different benefits.
Given the current environment what entity is the “ideal” employer? Without hospital support at this point anesthesiologists would be making 30 -50% less so someone has to be the employer. The private practice groups are as dependent on subsidy as anyone and most of the ones I know are more poorly managed than some of the vendors or hospital owned practices.
 
Given the current environment what entity is the “ideal” employer? Without hospital support at this point anesthesiologists would be making 30 -50% less so someone has to be the employer. The private practice groups are as dependent on subsidy as anyone and most of the ones I know are more poorly managed than some of the vendors or hospital owned practices.
Until hospital management figures it out. It will continue to cost them money to subsidize.

As many on these message board knows. I’m very critical of the ACA the way it was implemented. It’s it’s cost shifting. Taking money away from doctors and empowering hospitals to grow larger and larger. We have all seen in the past 10 -15 years since the ACA was passed the consolidation of hospitals.

The AHA continues to get continued growth from insurance payments while doctors get less and less.

But the aha makes such a killing on hospital services like surgery. They must kick back ancillary services like anesthesia

My sister true private practice went from a measly 300k subsidy (just to have free doc available 7-3) all Md model in 2019 to a ridiculous 12 million subsidy for 2025 now.

Yes some practices are poorly managed private or hospitals owned. But that’s a combination of hospitals demands of keeping rooms running after hours or number of locations they want to cover daily. And also on anesthesia management (anesthesia chiefs can abuse power as well and only care about their inflated chief salary and try to do less and less clinical work )
 
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