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Because our part of the job is harder. One is just putting a camera in and taking pics. The other is literally keeping the patient from dying
Anesthesia Private Equity News Article
- Thread starter ProPropofol
- Start date
Because our part of the job is harder. One is just putting a camera in and taking pics. The other is literally keeping the patient from dying
What nonsense. Anesthesia has become incredibly safe. There is 100% more skill in replacing a total joint than providing the anesthesia for a total joint-hence we we supervise 4 or more rooms.
The issue Anesthesia has is the govt pays us so little and our salaries are balanced with high commercial payments and/or stipends. A blended until rate of 50 for everything would keep things reasonable but USAPs crazy high rates leading an anesthesiologist to get more than the surgeon for a total joint is crazy and makes the specialty look bad.
The only area where I see anesthesia perhaps requiring more skill than any surgical specialty is neonatal peds
The rest of you are fooling yourselves. Our job is to get cases through the ORs quickly, efficiently, safely. Manage many cases at once. Anesthesia is too safe for one to one care-the cost doesn’t justify it. Managing many cases is also a skill, a different type, but managing one case is nowhere near the skill of a surgeon
The issue Anesthesia has is the govt pays us so little and our salaries are balanced with high commercial payments and/or stipends. A blended until rate of 50 for everything would keep things reasonable but USAPs crazy high rates leading an anesthesiologist to get more than the surgeon for a total joint is crazy and makes the specialty look bad.
The only area where I see anesthesia perhaps requiring more skill than any surgical specialty is neonatal peds
The rest of you are fooling yourselves. Our job is to get cases through the ORs quickly, efficiently, safely. Manage many cases at once. Anesthesia is too safe for one to one care-the cost doesn’t justify it. Managing many cases is also a skill, a different type, but managing one case is nowhere near the skill of a surgeon
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A total joint does not require much skill. They can’t even accomplish it without a rep telling them what to do. We are paid more for our expertise not just the anesthesia we provide. Yes anesthesia is safe. But things still go wrong and patients are getting older and sicker. When things go south it is us who has to save the patient. Ortho stress level is near zero.
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Maybe if you work in a surgery center with a bunch of athletes as the patient population…
Go deal with some surgeon complications and get back to us.
Also, the patients requiring the most skill usually pay the least ironically.
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Physicians are the worst when it comes to finances and organization. I can guarantee you that all the bickering above about who deserves more or which job is harder is exactly what the powers-that-be want to happen. Total waste of time.
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Our gi guys get paid like 3x what we do, don't feel sorry for them at all
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The only takeaway anyone from insurance companies/government/hospitals/bean counters reading this: "Commercial insurance overpays anesthesia"
Physicians are their own worst enemy.
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Just had one breathing breathing fine, the scope is out, just went into laryngospasm for no fuking reason…. ( I know I know, there’s a reason…) sats down to 40s
EGD was literally less than a minute, I was there with the patient for the next 15 minutes.
That’s why I should get paid more….
The following was my rant a few days ago, never posted.
Different folks different stokes.
As physicians, we “sell” our of knowledge and labor. When a company comes in and takes 20%+ right off the bat, I don’t appreciate that. On top of that, you have business people on top that literally opens their mouth to sell a service that I provide and that can make We, as physicians, have been drilled that we suppose to sacrifice our lives and health for the good of the patients. These talking heads, what exactly did they sacrifice for making more money for the company/shareholders? While pushing midlevels to save money and brainwashing everyone involved. To top it off, paying midlevels on hourly basis, better. Sure this is more about corporate medicine in general, but certainly pertaining to the state of anesthesia. Am I bitter? Hell yeah.
Do I understand those who will just come to “do their job”, get a pre determined pay check and benefits? Sure. I can appreciate that stability. Eventually, maybe I’d have to accept that’s “where medicine is going…”
For now, I’d stick to a group of people who started as physicians first, business man second. Rather than some entity that made no qualms to let everyone know what they’re really in the game for.
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Part2
What Happens When Wall Street Owns Your Neonatal Care or Anesthesia Practice? Part two
Myron Yaster MD and William Greeley MD, MBA
RON LITMAN
JUL 13, 2023
“No matter what anyone says, it’s always about money”. Mark Rogers MD
Today we continue our discussion of what happens when private equity (PE) buys and owns your anesthesia practice. Myron Yaster MD
To understand the world of PE funding and how it works is fundamental to understanding the economic forces driving the motivations and expectations of these Firms in Health Care. In general, one asset class of any pension fund or IRA portfolio is what is grouped as Alternative Investments. In the world of finance, the life cycle of alternative investments starts with Angel investors (startups), proceeds through Venture capital, matures through Private Equity and lands successfully as an IPO. In the third PE stage, a Firm generally manages somewhere between $100 M to $10 B in total assets divided over 7 – 10 investments in targeted businesses, where 50% or so will eventually fail; high risk, high return. The PE Fund managers have told the Institutional investors (pension managers) to expect at least a certain return on their investment (e.g. 5 – 7%). The PE Fund managers then make their money on an administrative fee (e.g., 2% of total assets) AND then on a 20% carried interest rate on any profits above the targeted 5 – 7% hurdle rate. So, PE Managers are especially incentivized and growth-driven to get to the carried interest rate. The PE Firms employ a widely used metric (EBIDTA- Earnings before interest, taxes, depreciation, amortization) to assess corporate profitability, and to choose and monitor their investment portfolio. The expectation is that the profitability will grow at least 3 – 5 times EBIDTA over 5 -7 years to meet the Institutional Investors’ expectations and the PE’s own expectations with carried interest rates. Knowing that 50% of their investment business ventures will fail, these losses are factored into the financing and profitability requirements of those businesses who succeed. Finally, the PE firms only get their money usually by exiting in the 5 – 7-year timeframe and getting a buyer at 3 – 5 times the purchase price.
So, the dynamics of PE investing has many important implications on the expectations and performance of physician practices. To quickly get to expected profitability (multiples of EBIDTA), there are short term fixes to revenue and expenses. In purchasing established physician practices, the typical strategy is to buyout the senior partners and then reset total cost of the practice at a lower level. This latter is typically done by hiring newer/younger practice members at a lower cost; the “churn and burn” strategy. As noted in both the Anesthesiology and Neonatology publications referenced above, revenue is increased by significantly increasing the price of professional services to insurers and other purchasing groups. When a physician management company (PMC) begins providing services in a facility, the PMC typically renegotiates payer contracts. They might leverage their market power to negotiate higher payment rates from insurers, benefiting practitioners but potentially increasing prices for commercially insured patients. Additionally, PE firms will decrease administrative costs by using economies of scale through corporate functions, e.g., billing and collections, etc.” By standardizing care and improving managerial processes, PMCs might also be able to increase quality and lower costs”.2 Most of these short-term revenue and cost strategies are one-time events and do not address growth opportunities that in the long term are required for sustainability of increasing profitability.
The investment of PE firms in PMCs is the Achilles heel of the PMC model. Opportunities to extract costs and add revenue are not infinite. Insurance payers, the government and hospitals are beginning to push back. Private equity investors expect that they will have their investments (and any profits) returned to them in 3 to 7 years. For private equity interests to be sold at an acceptable profit, someone must be willing to buy. As noted by Crosson et al. “that purchaser could be either another private equity firm or a health care entity such as a hospital or a health plan. That purchaser (the “greater fool”?) will have to believe that further cost reductions can be made and/or that yet further revenue increases are possible without triggering counteractions either by payers, the government, or the involved physicians. Without willing purchasers, the private equity investment model collapses”4.
In my experience (BG) in evaluating several distressed anesthesia practices that are managed by PMCs that are PE supported, good Institutional citizenship is also lacking and a point of contention with Hospital Administrators and other physician colleagues. Fundamentally, supporting Quality Improvement and Patient Safety initiatives are not remunerative and consequently poorly supported, even in perioperative areas where this is “our turf” as anesthesiologists. In some practices, there is an administrative surcharge (millions $) charged by the PMC to the Hospital Adm. At time of contract renewal this charge has been challenged when good citizenship participation is underserved. Also, it is my view that PMCs backed by PE have focused on the most beneficial and profitable physician specialities. They have targeted sole, isolated, procedural based subspecialties (Neonatology, Anesthesiology, Cardiology, Dermatology, etc.) and stay away from complex practices such as multispecialty physician groups.
Finally, and most importantly, the goals of PMCs and PE may be at odds with physician professionalism. Indeed, our professionalism may be that the only real guardrail to protect the quality of care we provide to patients and the services we provide. The next few years will be especially challenging for all Health Systems and Hospitals where more than 50% will experience operating losses. This will require focused investment in growth opportunities, optimizing revenue performance and disciplined cost reduction. It is difficult to see how PMCs backed by PE will stay in this difficult economic environment in Healthcare to maintain profitability when other industries such as technology and finance are more attractive and profitable for investment.
Why PMCs funded by PE may fail will be due to several factors: the competition is better, execution is not fast and funding expectations are wrong. Medicine is a complex industry with many competing constituencies (Government, Insurers, the Patient, Health Systems, etc.) that must be addressed and accounted for. The economic fundamentals of PE investing may not be doable in this difficult, future Healthcare sector. The Finance and Technology sectors are accustomed to the principle of Moore’s law which describes the driving force of technological and social change, productivity, and economic growth. Over time, things get better, are faster, and cost less. Medicine is not there yet at all, and still a cottage industry. The consumer of care is not the payor, and the payor is the provider.
Many of you work or have worked for PMCs either with or without PE funding. Many of you work in organizations that are considering using PMCs to divest the problems of current reimbursement and faculty retention. We’d love to hear your thoughts and send to Myron who will post in the Friday Reader Response.
References
1. Crosson FJ. Physician Management Companies-Should We Care? JAMA internal medicine. Apr 1 2022;182(4):404-406. doi:10.1001/jamainternmed.2022.0001
2. La Forgia A, Bond AM, Braun RT, et al. Association of Physician Management Companies and Private Equity Investment With Commercial Health Care Prices Paid to Anesthesia Practitioners. JAMA internal medicine. Apr 1 2022;182(4):396-404. doi:10.1001/jamainternmed.2022.0004
3. Yu J, Tyler Braun R, Bond AS, et al. Physician Management Companies and Neonatology Prices, Utilization, and Clinical Outcomes. Pediatrics. 2023;151(4)doi:10.1542/peds.2022-057931
4. Lorch SA. Profits, Providers, and Private Companies: What Happens When Wall Street Owns Your Neonatal Care. Pediatrics. 2023;151(4)doi:10.1542/peds.2
Profits, Providers, and Private Companies: What Happens When Wall Street Owns Your Neonatal Care or Anesthesia Practice? Part two
Myron Yaster MD and William Greeley MD, MBA
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You worry about charging commercial insurers too much? Look at the latest United Health earning. It is making a boatload of $$$.
UnitedHealth shares rally as health care giant beats 2Q forecasts, eases care use concerns
UnitedHealth beat second-quarter expectations as an acquisition and more Medicare Advantage customers helped balance a jump in care use. The health care giant also raised the low end of its 2023 earnings forecast range on Friday after its profit jumped 8% to $5.47 billion in the quarter...
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You worry about charging commercial insurers too much? Look at the latest United Health earning. It is making a boatload of $$$.
UnitedHealth shares rally as health care giant beats 2Q forecasts, eases care use concerns
UnitedHealth beat second-quarter expectations as an acquisition and more Medicare Advantage customers helped balance a jump in care use. The health care giant also raised the low end of its 2023 earnings forecast range on Friday after its profit jumped 8% to $5.47 billion in the quarter...finance.yahoo.com
We are pawns in a game played by giants.
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It is kind of ridiculous how successful the insurance industry has been at framing these discussions. Any increased compensation for services is viewed as hurting patients by raising premiums and yet insurance profits keep rising. 🤔
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I sat in on a lecture given by two very influential, highly appointed "thought leaders" in public health policy in Ivory Tower academia positions.
One of them had the audacity to say "insurance companies are the only one looking out for the best interest of patients."
Her work, of course, is often sponsored by United. It's a rigged game. We are pawns.
One of them had the audacity to say "insurance companies are the only one looking out for the best interest of patients."
Her work, of course, is often sponsored by United. It's a rigged game. We are pawns.
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Premiums are going up at an incredible clip as they cover less and cut payments to physicians
It’s so sickening
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For our brothers and sisters in EM, the ACEP has finally caught up to the AAEM. Will the ASA ever weigh in?
www.linkedin.com
Leon C. Adelman, MD, MBA, FACEP, FAAEM on LinkedIn: #emergencymedicine | 77 comments
After years of tension over the corporate practice of medicine, the American College of Emergency Physicians and American Academy of Emergency Medicine (AAEM)… | 77 comments on LinkedIn
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Whoa. AmazingFor our brothers and sisters in EM, the ACEP has finally caught up to the AAEM. Will the ASA ever weigh in?
Leon C. Adelman, MD, MBA, FACEP, FAAEM on LinkedIn: #emergencymedicine | 77 comments
After years of tension over the corporate practice of medicine, the American College of Emergency Physicians and American Academy of Emergency Medicine (AAEM)… | 77 comments on LinkedIn
ASA should do this. I know they won’t. But they should…
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The fact Napa REQUIRES people who work for them to get an ASA membership…. That ought to say something.
That seems illegal to require your employees to be a member of any organization. It would be like saying you have to be a registered Republican to join a practice or something. And since the ASA has a PAC it’s even worse.
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From PAAD.
Sounds like the acquisition of MACMGI (NorCal) by Envision in 2013. Pre-sale this used to be one of the most desirable groups in the country. We got a few “refugees” from this group.
“From anonymous in response to when private equity buys anesthesia practices
I wanted to share my own experience as a member of a group that was acquired by private equity. The chronology of that acquisition, and the "natural history" of the group after acquisition, is perhaps illustrative. As you point out, PE groups have been avidly acquiring practices in the last decade, fueled in large part by low interest rates creating an "era of free money" (https://fortune.com/2023/04/13/inflation-interest-rates-fed-era-of-free-mone/ - "The era of free money may finally be ending) and the lure of cash-generating physician practices. My group was acquired by a major national player as part of this trend.
I joined that practice straight out of training and was congratulated by members of my department on learning I had landed a job with the group - it had a stellar reputation in the area. Compensation was as equitable as possible - a group blended unit with a negligible proportion added for base units. Essentially, we were compensated for the time we spent in the OR - plus call stipends. At the time, I thought little of the fact that a large number of hires were being brought into the group. Fast forward a year later, and, with the acquisition, I was given a two-week window in which to stay with the group or leave. On offer: fixed unit compensation amounting to approximately a ~30% reduction, plus a 50% reduction in stipends. Overnight, I was being paid far less for the exact same work. Their upfront cost: monies paid to the group shareholders to buy the practice.
Where did that excess money go? Obviously, the private equity group "sweeps" that cash. The theory being that low-end market rates for the actual anesthesia care plus increased insurer reimbursements equals profit. So what are the problems? Let's enumerate some of them:
Employee Morale: In the deal I was part of, about 30% of the workforce was excluded from the financial benefits of the transaction. This included some people who were denied partnership in the year they ought to have been, for what ended up being very tenuous reasons. The main reason: not to dilute the share value of a deal in progress. This exclusion had a predictable effect of plummeting morale and a strong sense of us vs. them in terms of junior members versus former partners. Many junior hires, in quick succession, hit the eject button. This in turn gives rise to...
Reductions in the Quality of Care: As a formerly premier group now offering below market rates, the group was not able to maintain it's workforce and indeed was not able to attract the talent that it formerly was able to. Certainly, the group was able to tread water for some time. However, surgeons and hospital leadership will eventually notice. This results in...
Negative Impact on Reputation and Contractual Relations: Several years after the deal, the anesthesia group was implicated in a very public, very tragic death - the culmination of the mentioned reductions in quality of care. In short order, the group's contracts were terminated. As of writing, this group is no longer in existence. However, let's not forget about...
Moral Hazard: When private equity firms take control of medical care, they introduce a moral hazard, as they prioritize profit which may lead to compromised patient care. There are numerous documented examples of private equity groups pressuring physicians to prioritize billing over appropriate medical care, raising the costs for all of us and potentially leading to poor medical decision-making: taking back that kid with a URI, instead of cancelling the procedure, for example. The contributes to...
Devaluation of the Medical Profession: Lawyers are actually prohibited by the American Bar Association from fee sharing (https://www.americanbar.org/groups/professional_responsibility/publications/model_rules_of_professional_conduct/rule_5_4_professional_independence_of_a_lawyer/). On the other hand, when a physician works for a private group owned by publicly traded company, some of the value of their work is distributed as dividends. These rules are in place for attorneys for a reason, including those outlined above: ethical conflicts and devaluation of the profession.
My experience probably represents an extreme end of how wrong things can go. Regardless, when private equity and medicine mix, there is certainly a lot of room for things to go wrong.”
www.pressreader.com
macmgi.com
Sounds like the acquisition of MACMGI (NorCal) by Envision in 2013. Pre-sale this used to be one of the most desirable groups in the country. We got a few “refugees” from this group.
“From anonymous in response to when private equity buys anesthesia practices
I wanted to share my own experience as a member of a group that was acquired by private equity. The chronology of that acquisition, and the "natural history" of the group after acquisition, is perhaps illustrative. As you point out, PE groups have been avidly acquiring practices in the last decade, fueled in large part by low interest rates creating an "era of free money" (https://fortune.com/2023/04/13/inflation-interest-rates-fed-era-of-free-mone/ - "The era of free money may finally be ending) and the lure of cash-generating physician practices. My group was acquired by a major national player as part of this trend.
I joined that practice straight out of training and was congratulated by members of my department on learning I had landed a job with the group - it had a stellar reputation in the area. Compensation was as equitable as possible - a group blended unit with a negligible proportion added for base units. Essentially, we were compensated for the time we spent in the OR - plus call stipends. At the time, I thought little of the fact that a large number of hires were being brought into the group. Fast forward a year later, and, with the acquisition, I was given a two-week window in which to stay with the group or leave. On offer: fixed unit compensation amounting to approximately a ~30% reduction, plus a 50% reduction in stipends. Overnight, I was being paid far less for the exact same work. Their upfront cost: monies paid to the group shareholders to buy the practice.
Where did that excess money go? Obviously, the private equity group "sweeps" that cash. The theory being that low-end market rates for the actual anesthesia care plus increased insurer reimbursements equals profit. So what are the problems? Let's enumerate some of them:
Employee Morale: In the deal I was part of, about 30% of the workforce was excluded from the financial benefits of the transaction. This included some people who were denied partnership in the year they ought to have been, for what ended up being very tenuous reasons. The main reason: not to dilute the share value of a deal in progress. This exclusion had a predictable effect of plummeting morale and a strong sense of us vs. them in terms of junior members versus former partners. Many junior hires, in quick succession, hit the eject button. This in turn gives rise to...
Reductions in the Quality of Care: As a formerly premier group now offering below market rates, the group was not able to maintain it's workforce and indeed was not able to attract the talent that it formerly was able to. Certainly, the group was able to tread water for some time. However, surgeons and hospital leadership will eventually notice. This results in...
Negative Impact on Reputation and Contractual Relations: Several years after the deal, the anesthesia group was implicated in a very public, very tragic death - the culmination of the mentioned reductions in quality of care. In short order, the group's contracts were terminated. As of writing, this group is no longer in existence. However, let's not forget about...
Moral Hazard: When private equity firms take control of medical care, they introduce a moral hazard, as they prioritize profit which may lead to compromised patient care. There are numerous documented examples of private equity groups pressuring physicians to prioritize billing over appropriate medical care, raising the costs for all of us and potentially leading to poor medical decision-making: taking back that kid with a URI, instead of cancelling the procedure, for example. The contributes to...
Devaluation of the Medical Profession: Lawyers are actually prohibited by the American Bar Association from fee sharing (https://www.americanbar.org/groups/professional_responsibility/publications/model_rules_of_professional_conduct/rule_5_4_professional_independence_of_a_lawyer/). On the other hand, when a physician works for a private group owned by publicly traded company, some of the value of their work is distributed as dividends. These rules are in place for attorneys for a reason, including those outlined above: ethical conflicts and devaluation of the profession.
My experience probably represents an extreme end of how wrong things can go. Regardless, when private equity and medicine mix, there is certainly a lot of room for things to go wrong.”
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Medical Anesthesia Consultants Medical Group, Inc. (MAC)
As of Jan. 1, 2023, Medical Anesthesia Consultants (MAC) will no longer provide anesthesia services in the Northern California region.
macmgi.com
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It sounds like exactly like that.From PAAD.
Sounds like the acquisition of MACMGI (NorCal) by Envision in 2013. Pre-sale this used to be one of the most desirable groups in the country. We got a few “refugees” from this group.
“From anonymous in response to when private equity buys anesthesia practices
I wanted to share my own experience as a member of a group that was acquired by private equity. The chronology of that acquisition, and the "natural history" of the group after acquisition, is perhaps illustrative. As you point out, PE groups have been avidly acquiring practices in the last decade, fueled in large part by low interest rates creating an "era of free money" (https://fortune.com/2023/04/13/inflation-interest-rates-fed-era-of-free-mone/ - "The era of free money may finally be ending) and the lure of cash-generating physician practices. My group was acquired by a major national player as part of this trend.
I joined that practice straight out of training and was congratulated by members of my department on learning I had landed a job with the group - it had a stellar reputation in the area. Compensation was as equitable as possible - a group blended unit with a negligible proportion added for base units. Essentially, we were compensated for the time we spent in the OR - plus call stipends. At the time, I thought little of the fact that a large number of hires were being brought into the group. Fast forward a year later, and, with the acquisition, I was given a two-week window in which to stay with the group or leave. On offer: fixed unit compensation amounting to approximately a ~30% reduction, plus a 50% reduction in stipends. Overnight, I was being paid far less for the exact same work. Their upfront cost: monies paid to the group shareholders to buy the practice.
Where did that excess money go? Obviously, the private equity group "sweeps" that cash. The theory being that low-end market rates for the actual anesthesia care plus increased insurer reimbursements equals profit. So what are the problems? Let's enumerate some of them:
Employee Morale: In the deal I was part of, about 30% of the workforce was excluded from the financial benefits of the transaction. This included some people who were denied partnership in the year they ought to have been, for what ended up being very tenuous reasons. The main reason: not to dilute the share value of a deal in progress. This exclusion had a predictable effect of plummeting morale and a strong sense of us vs. them in terms of junior members versus former partners. Many junior hires, in quick succession, hit the eject button. This in turn gives rise to...
Reductions in the Quality of Care: As a formerly premier group now offering below market rates, the group was not able to maintain it's workforce and indeed was not able to attract the talent that it formerly was able to. Certainly, the group was able to tread water for some time. However, surgeons and hospital leadership will eventually notice. This results in...
Negative Impact on Reputation and Contractual Relations: Several years after the deal, the anesthesia group was implicated in a very public, very tragic death - the culmination of the mentioned reductions in quality of care. In short order, the group's contracts were terminated. As of writing, this group is no longer in existence. However, let's not forget about...
Moral Hazard: When private equity firms take control of medical care, they introduce a moral hazard, as they prioritize profit which may lead to compromised patient care. There are numerous documented examples of private equity groups pressuring physicians to prioritize billing over appropriate medical care, raising the costs for all of us and potentially leading to poor medical decision-making: taking back that kid with a URI, instead of cancelling the procedure, for example. The contributes to...
Devaluation of the Medical Profession: Lawyers are actually prohibited by the American Bar Association from fee sharing (https://www.americanbar.org/groups/professional_responsibility/publications/model_rules_of_professional_conduct/rule_5_4_professional_independence_of_a_lawyer/). On the other hand, when a physician works for a private group owned by publicly traded company, some of the value of their work is distributed as dividends. These rules are in place for attorneys for a reason, including those outlined above: ethical conflicts and devaluation of the profession.
My experience probably represents an extreme end of how wrong things can go. Regardless, when private equity and medicine mix, there is certainly a lot of room for things to go wrong.”
PressReader.com - Digital Newspaper & Magazine Subscriptions
Digital newsstand featuring 7000+ of the world’s most popular newspapers & magazines. Enjoy unlimited reading on up to 5 devices with 7-day free trial.
Medical Anesthesia Consultants Medical Group, Inc. (MAC)
As of Jan. 1, 2023, Medical Anesthesia Consultants (MAC) will no longer provide anesthesia services in the Northern California region.
Also PAAD is crushing it with good content lately. Cheers to Myron Yaster.
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I don’t even do peds but I find their emails and linked articles to be worthwhile reads.
To be honest. Anesthesia “quality” rarely matters these days. That’s just corporate speak when tragic deaths happen so very infrequently. It’s the simple hard hard hard truth guys.
Quality metrics doesn’t matter. It’s manipulation of data. You telling me when surgeons or patients or technology (instruments not ready) delays are 95% NOT CAUSED BY ANESTHESIA. that’s the simple truth.
I cannot stand people who speak quality has gone down. This is helped by two things
1. Case selection bias. Most surgeons are not stupid. They will shift their more difficult cases elsewhere to more tertiary care centers.
2. Technological advances in anesthesia
Yes. There can a Dr rex CRNA patient killer. There can be I’m freaked out Joan Rivers MD
Killer in gi suite. (See. I’m trying to be fair and balance with both CRNA and MD errors)
Quality metrics doesn’t matter. It’s manipulation of data. You telling me when surgeons or patients or technology (instruments not ready) delays are 95% NOT CAUSED BY ANESTHESIA. that’s the simple truth.
I cannot stand people who speak quality has gone down. This is helped by two things
1. Case selection bias. Most surgeons are not stupid. They will shift their more difficult cases elsewhere to more tertiary care centers.
2. Technological advances in anesthesia
Yes. There can a Dr rex CRNA patient killer. There can be I’m freaked out Joan Rivers MD
Killer in gi suite. (See. I’m trying to be fair and balance with both CRNA and MD errors)
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It’s the same with EM. Honestly wouldn’t mind a smaller less glamorous meeting if it meant they weren’t bankrolling it.
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Yes, sadly.
Pacira used to sponsor the hell out of ASA meetings too till they tried to silence that negative Exparel study via baseless litigation (which cost the ASA hundreds of thousands to defend I bet).
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The $3 Trillion Private Equity Bubble is Finally Bursting
were any of the buyouts leveraged w/ debt?
were any of the buyouts leveraged w/ debt?
Of course all leverage. Their hope is they hope to flip the company for profit in 2-3 years.
I posted before envision private buyout KKR LIKELY LOST $0 money even if the company had to declare BK.
1. KKR likely only spent 300-500 million of THEIR OWN MONEY. Not big in the overall scheme of a 9 billion dollar purchase. Everything else was borrowed from muitlple sources (including public pensions fund managers)
2. KKR takes huge transaction fees (20%) in any deal.
3. KKR raked 1 billion dollar profit the first 2-3 years of the deal of environs. Even after expenses they covered their initial down payment (300-500 million).
4. Add that they got likely 100 million from Covid money (the health care industry got 175 billion)
5. Once they started bleeding money they had no incentive to make interest only payments on debt.
6. They walk away.
The best way to describe is like the video showed with investment real estate.
Buy 5 homes with 20% down (1 million dollar homes)
So 1 million investment for 5 homes down payment
Home increases 20% in 2 years. Rent out homes for 2 years like Envison made profit for 2 years.
So those 5 homes now with 1.2 million
Sell all 5 homes for 200k profit each. 1 million dollar profit.
So 100% profit on their initial 1 million dollar investment.
Except private equity takes it to a higher leverage ratio. Instead of 20% down. They put down much less. Likely 5% less down payment and make the same 1 million dollar profit on those 5 homes
So the profit margin on investment is even much greater than a regular real estate investor.
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How do I get onto this gravy train?
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It’s literally legalized looting of the US economy on a massive scale.
The only saving grace will be if enough of these leveraged buyout deals go bad, private equity will eventually have trouble getting people to invest to raise capital.
I can’t wait for that to happen as PE fundamental business model is flawed and they usually don’t provide much in real value. Only they made US large institutional investors so much money over so long that they became part of many investment strategies - but I think the “pyramid scheme” is starting to crumble.
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These guys don’t care. That’s what I keep telling you guys.
Look at Steve cohen company (New York Mets owner). Dude is massive fraud. Him and the plotkin. Game stop fiasco guys. Massive insider trading in 2013. Only the minority dude (who’s also a fraud) went to jail. Minority Indian dude from Florida and his wife pediatrics. The two white dudes plotkin and cohen escape and keep doing their semi illegal stuff.
That’s why cohen bails out his plotkin buddy. It’s like the mafia.
They just have to make it big once and they are set for life.
Even if they lose money later on. They shelter their big bet money.
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There may be a few small cracks, but PE is not going away or flailing. Their bread and butter are industries in which the “customers” have no other choice and they can tack on as many fees as they want…nursing homes, prisons, low income single family housing. It’s abhorrent.
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You seem to care so- Plotkin and Cohen aren’t ‘white’.
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Jews aren't white?
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Jews are "Schrodinger’s whites, white or non-white depending on the politics of the observer."
The Nazis wouldn't have cared if a jewish person converted or was an atheist. They saw them as non-white. Same with White Supremacist groups today.
The far left sees Jews as "extra white" because of their success.
Not sure how the far left see Jewish persons of color.
I am Jewish BTW.
I can confirm that we jews are not at all comfortable with the white nationalist crowd
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I can confirm that we jews are not at all comfortable with the white nationalist crowd
Not too comfortable with the far left crowd these days either.
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I can confirm that we jews are not at all comfortable with the white nationalist crowd
Fortunately white nationalists make up a tiny percentage of white people and the far left is also a small percentage of the population.
In the end, you cannot beat demographics.
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Yeah it depends on both the observer and the observed depending on their own bias and the advantages and disadvantages of identifying one way or another.
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Can you summarize this hour-long YouTube video I'm not going to watch and explain what it has to do with PE in anesthesia?
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Sound has partners with ownership. I don’t work for them but at least they pull in a full salary and don’t have to buy into partnership. The docs at JPS in north Texas make 500k+ to start. I work locums there- and now they qualify for PSLF for student loans. Only other place in the area to get that is parkland
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Funny and true.
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How do they qualify for PSLF? I thought the newest PSLF rule was targeted at Kaiser (not for profit) system docs. Isn't Sound for-profit?
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i think it matter more about what hospital you're staffing. If it's a hospital for the underserved or indigenous, it'll qualify.
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I’m pretty sure it is based on your employer’s tax ID being a non-profit. On the certification of eligible employment form it doesn’t ask what hospital you staff.
“Qualifying Employment
Qualifying employment for PSLF isn’t about the specific job that you do for your employer—it’s about who you work for. Use our employer search tool to see if your employer qualifies for PSLF.”- Joined
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Exactly. Apparently the new rule for TX and CA means that if you staff at a non profit regardless of your employer it qualifies. I’m seriously thinking of taking a FT position given my 400k debt. Until now there were no options but academics
