Buy in still a thing in current market?

[neutro]

Increasing market rates for anesthesiologists/CRNAs and declining reimbursement from insurers mean more and more hospitals will have to provide/increase stipends for anesthesiology practices. Anesthesia pay tied only to billing will no longer be sustainable for a majority of anesthesia practices. This is simple supply and demand. Yes, there is a risk of the hospital management deciding to try to provide care at a more affordable price either with employment or a different group, but I think the market has shown repeatedly this is usually a disaster (especially going to national group). Below is a link to a hospital management consultants essentially saying this. If you're a private group making below 50% MGMA or are supervising 3-4:1, you should be negotiating for a (higher) stipend.

Stipends for private practices.

"In years past, patients were more likely to bear the burden of high anesthesia costs. Many anesthesia groups chose a strategy of not contracting with payers and instead balance billing their patients; the No Surprises Act put an end to that in 2022. The act also established an out-of-network ratesetting methodology that was very slanted in favor of payers. This has effectively negated anesthesiologists’ ability to use contract termination as a negotiation tactic, seriously undermining their ability to obtain better rates. As a result, payers get the benefit of keeping the anesthesiologists in their network, and at low rates.However, since the hospital cannot survive without anesthesia, it often finds itself with no alternative but to make a major financial commitment to supporting its anesthesia providers"

I’ve read that before as well as the article embedded in hyperlink.

It essentially states anesthesia is cost of doing business - just like nursing, or as per them - electricity or plumbing.

Doesn’t really talk about how PP can mitigate this except “early intervention” and even it comes to financial support from the hospital to keep up with the market.

To me, by definition it means that anesthesiology billing can no longer cover expenses of its human capital.

It doesn’t really talk about strategies and what is the best work model for anesthesiologists.

Things have changed since OON billing gone and Medicare differential 1/4, and as population ages it will only get worse.

---

Members don't see this ad.

 

[amyl]

just fyi. Neutro prns for us at a level one trauma center w high patient acuity… he’s not just an asc guy

 

[neutro]

thanks amyl.

and NICMAN - I am sorry actually - I do not mean to go back and forth with you and criticize your practice and way of doing things.
It's your livelihood and it's important to fight for it - as should everyone.

 

[NICMAN]

thanks amyl.

and NICMAN - I am sorry actually - I do not mean to go back and forth with you and criticize your practice and way of doing things.
It's your livelihood and it's important to fight for it - as should everyone.

No problem. I am actually having too much fun and should t be so critical. I don’t mean for it to be personal.

Look, my larger point was to simply point out that running a business including negotiating for and actually collecting payment for professional services—including the management and leadership of a business—is not dead or unviable. Quite the contrary in fact it could be making a resurgence. Once the baby boomer bloat in health care services diminishes around 2040 I feel like my last 5-10 years could actually be very lucrative. Right now it is financially rewarding (above market rates) and I don’t work in some rural single-site hospital, but a group of hospitals with two trauma centers and over 140 employees in our states 2nd largest metropolitan area.

I am simply trying to reframe for this community what it means to “make a profit” and “get subsidies”. Our contract spreadsheet has dozens of lines for additional payment of professional services for trauma call at three different hospitals and other services like teaching medical students etc. These extra fees add to the overall “profit” of our corporation. Which when combined with a high level of operational efficiency and economies of scale across multiple locations we are able to maximize “profit”.

Now technically our company makes zero profit because it is all distributed to shareholders (and not double taxed), but my larger point is that we shouldn’t be so narrowly focused on the negative downside of any payment outside of insurance collections. It is a mistake to only focus on the risks — especially in this environment of scarcity. Clearly everybody here understands this including you as you get premium payment for PRN work. What I am trying to do is to get people to push that vision a little higher from the individual perspective (the shift worker) to the organizational leadership perspective where we can make a much greater impact on our specialty.

And also to say that running a business isn’t a charity and we can and do get paid for our professional services (including management) and we shouldn’t feel sorry for it or that we are somehow “dependent” on our partners in hospital management because they (rightly) pay market rates for our professional services including those that don’t involve pushing drugs and tubes.

 

[NICMAN]

Amyl understands this as a USAP shareholder. surely those shares are still worth something right?

I think so.

 

[pgg]

Our group has a 1 year track and new joins earn 95% of what partners earn, but no profit sharing 401k during that year.

The difference is offset by the sign-on bonus. Overall it's approximately a wash. Maybe the track physician comes up short $5-10K.

We have no superpartners. Scheduling and call is equitable from day 1. So is vacation, though the new person's choices of specific weeks may be a little limited depending on when they start, if they weren't here for the annual vacation draft/lottery. Pay doesn't depend on the particular case or insurer or block-vs-no-block or turnover time, so there's no reason or ability to manipulate daily case assignments.


We do have a hospital subsidy as of last year. Not to rehash the definition of "profitable" but the group obviously had income > expenses pre-subsidy and was "profitable" then - but long term viability was in question, given the recruitment and retention problems associated with offering an income that hadn't kept pace with the rest of the market.

I think it's an absolutely weird and twisted and wrong semantic argument to say that because a group negotiates a contract with a hospital to provide services for a fee ("subsidy") that the group is unprofitable. It certainly involves risk that the hospital may look for a less costly solution, but there's no denying that the hospital is getting a service in return for a fee.


I actually joined this group despite having better financial offers elsewhere, but I understand that I'm an unusual case. I was at the stage of my career where I felt that less money was OK in return for some of the other tangible and intangible benefits. Lots of reasons there ... kids grown, no debts, positive net worth, pension & benefits from my military retirement, no ex-wives boats or airplanes to feed. I was tired of the locums grind, really wanted to find a pleasant private group with good partners and just wind down the last decade or so of my career in a locale that I'd like to live in until I die.

I figured that at some point market forces would bring our salaries up, though I was surprised (in a good way) to see it happen so abruptly last year.

At present recruitment is going well, though we'll still be ~10-15% understaffed even after our new joins start this summer. Even that isn't without a silver lining though because as a private group, fewer slices mean bigger pieces for everyone. I think this is a significant issue in the private vs employed debate that never really gets addressed in these threads: being understaffed always means more work, sometimes longer hours, but the hours themselves also tend to be busier. An employed doc at an understaffed hospital doesn't get paid more for the extra workload (they might if overtime is in the contract and is paid extra), and employers are always looking for more ways to squeeze more out of employees while giving them less. This is especially true of practices owned and run by venture capital and management companies. Partners at understaffed groups earns more in proportion to the work they do.

 

[Status Sciaticus]

We have a partnership track. I wish it was shorter but our hands are tied by our board of doctors.

I would've definitely pursued your group more aggressively had that 2 year partnership plan actually panned out.
If it goes that route in the future and the buy-in is nixed, you will have several people looking to work at your subgroup.

We have a buy in. Can't hire all the people applying for a job with us.

You have a gaggle of applicants lining up to be paid less than market value?

Our group has a 1 year track and new joins earn 95% of what partners earn, but no profit sharing 401k during that year.

The difference is offset by the sign-on bonus. Overall it's approximately a wash. Maybe the track physician comes up short $5-10K.

We have no superpartners. Scheduling and call is equitable from day 1. So is vacation, though the new person's choices of specific weeks may be a little limited depending on when they start, if they weren't here for the annual vacation draft/lottery. Pay doesn't depend on the particular case or insurer or block-vs-no-block or turnover time, so there's no reason or ability to manipulate daily case assignments.


We do have a hospital subsidy as of last year. Not to rehash the definition of "profitable" but the group obviously had income > expenses pre-subsidy and was "profitable" then - but long term viability was in question, given the recruitment and retention problems associated with offering an income that hadn't kept pace with the rest of the market.

I think it's an absolutely weird and twisted and wrong semantic argument to say that because a group negotiates a contract with a hospital to provide services for a fee ("subsidy") that the group is unprofitable. It certainly involves risk that the hospital may look for a less costly solution, but there's no denying that the hospital is getting a service in return for a fee.


I actually joined this group despite having better financial offers elsewhere, but I understand that I'm an unusual case. I was at the stage of my career where I felt that less money was OK in return for some of the other tangible and intangible benefits. Lots of reasons there ... kids grown, no debts, positive net worth, pension & benefits from my military retirement, no ex-wives boats or airplanes to feed. I was tired of the locums grind, really wanted to find a pleasant private group with good partners and just wind down the last decade or so of my career in a locale that I'd like to live in until I die.

I figured that at some point market forces would bring our salaries up, though I was surprised (in a good way) to see it happen so abruptly last year.

At present recruitment is going well, though we'll still be ~10-15% understaffed even after our new joins start this summer. Even that isn't without a silver lining though because as a private group, fewer slices mean bigger pieces for everyone. I think this is a significant issue in the private vs employed debate that never really gets addressed in these threads: being understaffed always means more work, sometimes longer hours, but the hours themselves also tend to be busier. An employed doc at an understaffed hospital doesn't get paid more for the extra workload (they might if overtime is in the contract and is paid extra), and employers are always looking for more ways to squeeze more out of employees while giving them less. This is especially true of practices owned and run by venture capital and management companies. Partners at understaffed groups earns more in proportion to the work they do.

which location is this? PM works if you'd like ot keep it private.

 

[kidthor]

I think you’re looking at a subsidy too negatively. Recognize almost all departments of the hospital are not net positive. The OR, OB and (I think?) ED are generally the only areas that make money. All other departments receive a subsidy and by your definition are “non viable”.

Absolutely correct. If anything we should change away from the word subsidy and into something more positive… if the ASA was smart they’d dedicate resources to that rather than come in with stupid things like “physician anesthesiologist”.

 

[nimbus]

Absolutely correct. If anything we should change away from the word subsidy and into something more positive… if the ASA was smart they’d dedicate resources to that rather than come in with stupid things like “physician anesthesiologist”.

Stipend like all other specialties.

 

[NICMAN]

Yes, I work overnight call at a level one trauma center doing high risk OB and fielding strokes etc while supervising 3 CRNAs. Getting a trauma subsidy is pretty standard and to say that it is “unprofitable” and “not viable” and ultimately imply that this is unsustainable is simply to show that one is not in touch with the reality of the business of hospital anesthesia.

 

[Howard888]

Per ASA 80-85% of groups/practices have subsidies now. It is a part of business.

However, it does place your group at risk of being replaced at any facility that has a stipend-either by someone else offering to do it cheaper or facility deciding they can and force employment.

Back to the original posting-this uncertainty is a huge reason why any buy in over a year or 100k just isn’t worth it in todays world.

Throw in that CRNAs and other expenses will continue to rise while rates will not and you are buying into something that will likely be less income generating than it is now, particularly in terms of real dollars adjusted for inflation.

Cash now>>>>cash later. Get the big sign on and salary now

 

[GassYous]

Per ASA 80-85% of groups/practices have subsidies now. It is a part of business.

However, it does place your group at risk of being replaced at any facility that has a stipend-either by someone else offering to do it cheaper or facility deciding they can and force employment.

Back to the original posting-this uncertainty is a huge reason why any buy in over a year or 100k just isn’t worth it in todays world.

Throw in that CRNAs and other expenses will continue to rise while rates will not and you are buying into something that will likely be less income generating than it is now, particularly in terms of real dollars adjusted for inflation.

Cash now>>>>cash later. Get the big sign on and salary now

No one can do it cheaper that's why everyone is getting stipends

 

[Pharmado]

No one can do it cheaper that's why everyone is getting stipends

That’s true, but private equity companies have no issue with coming in and telling the hospital that they can do it cheaper if the hospital just covers some locums providers for a couple of years…then they tell the hospital they need a huge stipends because it just isn’t working out.

 

[amyl]

That’s true, but private equity companies have no issue with coming in and telling the hospital that they can do it cheaper if the hospital just covers some locums providers for a couple of years…then they tell the hospital they need a huge stipends because it just isn’t working out.

Case in point - the sound explosion replacement of oag in Portland discussed elsewhere here

 

[neutro]

Yes, I work overnight call at a level one trauma center doing high risk OB and fielding strokes etc while supervising 3 CRNAs. Getting a trauma subsidy is pretty standard and to say that it is “unprofitable” and “not viable” and ultimately imply that this is unsustainable is simply to show that one is not in touch with the reality of the business of hospital anesthesia.

Are the surgeons getting subsidy for providing trauma care?

 

[Howard888]

Are the surgeons getting subsidy for providing trauma care?

Yes they are at most places unless employed by hospital

 

[crash2500]

Are the surgeons getting subsidy for providing trauma care?

Yes
And Ortho getting stipends for Ortho trauma.
OB getting stipends for over night emergency coverage.

 

[Dr. Rude]

Yes
And Ortho getting stipends for Ortho trauma.
OB getting stipends for over night emergency coverage.

And general surgery and other specialists getting stipends for ER call.

 

[pgg]

Are the surgeons getting subsidy for providing trauma care?

It's a "stipend" and it's tots different than a subsidy!

 

[ans2021]

I would've definitely pursued your group more aggressively had that 2 year partnership plan actually panned out.
If it goes that route in the future and the buy-in is nixed, you will have several people looking to work at your subgroup.


You have a gaggle of applicants lining up to be paid less than market value?


which location is this? PM works if you'd like ot keep it private.

Yes we have a gaggle of applicants lining up to come to this job. Have to turn away a lot every year. Cost of living use to be well below average. Applicants here prioritize location above all else.

 

[NICMAN]

Are the surgeons getting subsidy for providing trauma care?

To your point, are trauma surgeons “profitable” by your definition? They sure get paid. And so do I.

And so do my partners.

So do my employees.

And I don’t see it changing anytime soon despite mercenary locums antiestablishment millenarians calling for apocalypse of our specialty.

 

[NICMAN]

I prefer to contribute to an important safety net of society by building working institutions that last rather than exploit the economic scarcity to maximize my own gain.

Not to say the taking advantage of safety net hospitals to make $700-900k plus income is per se bad or immoral (I have friends working the level 1 trauma locums gigs making this much 1099). I am just saying there is a better way.

 

[GravelRider]

I prefer to contribute to an important safety net of society by building working institutions that last rather than exploit the economic scarcity to maximize my own gain.

Not to say the taking advantage of safety net hospitals to make $700-900k plus income is per se bad or immoral (I have friends working the level 1 trauma locums gigs making this much 1099). I am just saying there is a better way.

“Exploit economic scarcity?”

That’s a little self-sanctimonious, don’t you think?

 

[nimbus]

Yes they are at most places unless employed by hospital

Our ortho trauma and neurosurgeons get eye popping stipends.

Our trauma/acute care surgeons are very well paid and a full time schedule for them is 6x24hr shifts per month with “backup” on their postcall days. They can get called in as backup for up to 2hrs on their postcall days but usually not at all. A couple of them are moms. A couple of others run vascular practices on the side.

 

[neutro]

To your point, are trauma surgeons “profitable” by your definition? They sure get paid. And so do I.

And so do my partners.

So do my employees.

And I don’t see it changing anytime soon despite mercenary locums antiestablishment millenarians calling for apocalypse of our specialty.

I hope as an experienced anesthesiologist you would know that that hospitals make majority of their revenue from downstream ancillary services such as labs, diagnostic studies and procedures.
Big one is facility fees.

These are all billed under the referring physician. The CEOs know this. They calculate the difference between salaries and net downstream revenue generation per provider.

It’s not the anesthesiologist that’s admitting or rounding on the patient or booking for OR. The decision is rarely with the anesthesiologist.

Why do you think hospitals are so hell bent in gobbling up PCP practices and cardiology practices? They do not care about their salaries or expenses.

My dad’s cardiac cath back in 2016 - facility fee 107k.

ACA has given all the power to hospitals and suppressed physician run business. It’s unfair.

This is also why facilities do not let anesthesiologists have equity at ASCs as they do not contribute directly to revenue. They are not referring physicians.

The point is, hospitals will subsidize and do income guarantee to many surgical specialties (except ortho - as I see still many of them are in PP). Because they know that they will generally be able to make multiples on income by employing and CONTROLLING them.

However, anesthesiologists to them are always “expensive” for this reason. It’s service they must pay for to be “available”. It’s like a law firm wanting a retainer.

Yes you can say that without anesthesiology service, you can kiss good bye to surgical facility fee revenue. But again, the point is - it’s the surgeon who decides when to do cases. They book surgeries. They have control.

Not all traumas go to OR. Being available for trauma call is required by hospital but it’s an expense that may or may not yield revenue generation. Yes it sounds horrible to think this way but believe me sitting on multiple budgeting committees that’s how they talk.

It’s all numbers to them. And the day that anesthesia number gets too big for their liking - they’ll go shopping.

 

[pgg]

To your point, are trauma surgeons “profitable” by your definition? They sure get paid. And so do I.

And so do my partners.

So do my employees.

And I don’t see it changing anytime soon despite mercenary locums antiestablishment millenarians calling for apocalypse of our specialty.

An apocalypse? As opposed to what? The slow degradation or stagnation of salaries and loss of income relative to inflation, that comes from not demanding market rates?

Hey I'm glad for the locums mercenaries. They drive up income for the rest of us who don't want to live in hotels.

I prefer to contribute to an important safety net of society by building working institutions that last rather than exploit the economic scarcity to maximize my own gain.

Hey, I hear you, man. Service to the public and society is important and noble. I spent 20+ years earning sub-market wages in the military to be part of that. I generally loved being part of that.

But institutions can't love you back. I got tired of the cynical exploitation of my and others' altruism by the people who froze military physician salaries between the 1990s and now because they knew they could both fool debt-averse premeds with a "scholarship" and capitalize on the pride of public service.

I know a GI doc now who refuses a call stipend from the hospital because he feels it's a physician's duty to be available and serve the public. Maybe you're like him. It'd be admirable if it wasn't naive, if it wasn't for the highly paid but worse-than-useless admin parasites he's really serving.

Physician salaries aren't what make healthcare expensive. They aren't a factor in limiting access to care.

No one should feel guilty about demanding a market rate for their labor. If you want to voluntarily accept less money to live someplace desirable to you (as our SF and NYC dwellers do), or to work for a pleasant private group instead of AMC (as I do), or to be a mommy-track day doc, etc etc, that's fine. But all of those people should be glad for the "mercenaries" who tell the service-first-sob-story admin pukes to pay them or go **** themselves.

 

[neutro]

^its funny
Last week an ASC reached out to me for 7-5 pm peds dental coverage - nasal tubes. Age 2-16. Autistic/ adhd etc
Do to do ivs and manage airway

Solo md
6-7 cases per day
No break/ relief
No one in pacu to monitor post op

I asked why there’s a need - they said the previous doc wants to do “research”. Didn’t buy it for a single minute.

Day rate 60% of market rate!!!

Then she tried to manipulate me saying that the rates are low because it’s “mission based”

I asked her frankly is your facility fees mission based also? No response.

Asked her to show me anesthesia billing - no response.


I’m so fed up of these people honestly.

 

[NICMAN]

I hope as an experienced anesthesiologist you would know that that hospitals make majority of their revenue from downstream ancillary services such as labs, diagnostic studies and procedures.
Big one is facility fees.

These are all billed under the referring physician. The CEOs know this. They calculate the difference between salaries and net downstream revenue generation per provider.

It’s not the anesthesiologist that’s admitting or rounding on the patient or booking for OR. The decision is rarely with the anesthesiologist.

Why do you think hospitals are so hell bent in gobbling up PCP practices and cardiology practices? They do not care about their salaries or expenses.

My dad’s cardiac cath back in 2016 - facility fee 107k.

ACA has given all the power to hospitals and suppressed physician run business. It’s unfair.

This is also why facilities do not let anesthesiologists have equity at ASCs as they do not contribute directly to revenue. They are not referring physicians.

The point is, hospitals will subsidize and do income guarantee to many surgical specialties (except ortho - as I see still many of them are in PP). Because they know that they will generally be able to make multiples on income by employing and CONTROLLING them.

However, anesthesiologists to them are always “expensive” for this reason. It’s service they must pay for to be “available”. It’s like a law firm wanting a retainer.

Yes you can say that without anesthesiology service, you can kiss good bye to surgical facility fee revenue. But again, the point is - it’s the surgeon who decides when to do cases. They book surgeries. They have control.

Not all traumas go to OR. Being available for trauma call is required by hospital but it’s an expense that may or may not yield revenue generation. Yes it sounds horrible to think this way but believe me sitting on multiple budgeting committees that’s how they talk.

It’s all numbers to them. And the day that anesthesia number gets too big for their liking - they’ll go shopping.

Very linear, one-dimensional business approach. This type of "NUMBER GO UP" simple aggregate systems approach that lacks the kind of strategic thinking that involves a multifaceted approach that maximizes asymmetric information advantage (that we as anesthesiologists possess) in order to rebalance market equilibrium (internally and externally as a market mover) and positively impact pricing decisions while aligning (and maximizing) the strategic interaction with the hospital partners.

You seem to be saying that all that matters is the individual (singular) microeconomic factors--and those taken together in aggregate with no type of interaction or external effects. You are ignoring the systems design components, the aligning and maximization of operational efficiency. Worst of all you are completely rejecting the interaction that strategic planning/execution might have on utilization, efficiency, and cost-per-unit. The best approach is to be a problem solver (the Marriott approach), become a low-cost/high-quality partner, be a leader in the scaling organizations while balancing supply-demand dynamics.

You treat our job as a replaceable cog in an indifferent economic machine. I view my job (aside from providing and leading excellent clinical care) as a leader-rancher in an ever growing stock of cash cows (perioperative services--which makes up about 60% of our hospital's revenue stream). My partners and I drive those cash cows through the process with efficiency through economies of scale (matching transient fluxes of supply-demand), operational efficiencies (from the administrative/leadership medical staff and surg-executive councils down to the running of the ORs and aligning anesthesia resources with OR resources on a constantly shifting basis), strategic planning (opening new service lines, scaling growth, reigning in surgeon excesses), human resources (recruitment and retention), quality improvement (credentialing and peer review--including for surgeons). What most people fail to understand is that the interests of hospital administration and anesthesiologist are almost perfectly aligned contra proceduralists/surgeons. We utilize this strategic interaction advantage (in some cases by removing self-serving surgeons from leadership positions through attrition and value-added propositions). In the end we shift from becoming an accounting "cost-center" to a strategic revenue multiplier and organizational growth engine. As a result our own revenue grows 5-15% each year making partners/stockholders better off. We might not be making as much as the mercenaries in this transient time of labor shortage but we are making somewhat of an positive impact IMHO on the lives of our patients as well as the specialty as a whole.

But thank you for the business lesson on why my hospital partners will eventually replace my partners and me with low-cost labor cogs.

 

[NICMAN]

And to PGG and Neutro, seriously, with deep respect to those who PRN/locums (which we leverage to our advantage as well. believe me--unless it is a former partner or CRNA who quit only to ask to do "moonlighting" only to take advantage of us)...

Yes, it is important that hospitals (and especially ASCs) feel/know the macroeconomic labor supply issues, but instead of going "lone wolf" we should apply some systems and strategic thinking--whether it be through entrepreneurship or organized labor--to maximize our value as physicians at the patient-physician, department, hospital, state, and federal level (including fighting the lowering scope-of-practice standards and "supervision" definitions).

You can't do that as a lone wolf. Again, I am not making any kind of moral or "purity/sanctity" argument against mercenary lone-wolfism. I reserve the right to push that button as my BATNA (best alternative to a negotiated agreement), and it is a very strong motivatingnegotiating factor as a collective BATNA for all the physician leaders in my group contra hospital administration. I am simply saying there is a better way for the future of our specialty.

 

[DirtDocMD]

And to PGG and Neutro, seriously, with deep respect to those who PRN/locums (which we leverage to our advantage as well. believe me--unless it is a former partner or CRNA who quit only to ask to do "moonlighting" only to take advantage of us)...

Yes, it is important that hospitals (and especially ASCs) feel/know the macroeconomic labor supply issues, but instead of going "lone wolf" we should apply some systems and strategic thinking--whether it be through entrepreneurship or organized labor--to maximize our value as physicians at the patient-physician, department, hospital, state, and federal level (including fighting the lowering scope-of-practice standards and "supervision" definitions).

You can't do that as a lone wolf. Again, I am not making any kind of moral or "purity/sanctity" argument against mercenary lone-wolfism. I reserve the right to push that button as my BATNA (best alternative to a negotiated agreement), and it is a very strong motivatingnegotiating factor as a collective BATNA for all the physician leaders in my group contra hospital administration. I am simply saying there is a better way for the future of our specialty.

I’ll not argue that maybe your approach has worked well, at YOUR facility. Perhaps you have one of the few CEO’s who actually LISTEN to “Anesthesia”, and realize we MIGHT actually know what we’re talking about when it comes to pre/intra/post-op efficiencies, scheduling, etc.

Unfortunately, what I, and 95% of the other anesthesiologists on this forum have seen, (at least since about 2005-ish), are administrators who look at surgeons as “moneymakers”, anesthesiologists as simply a “nuisance” that costs them money, and shady AMC’s with slick presentations as some sort of “solution” (when all they REALLY did was keep pay artificially LOW, and get Insurance co’s to reimburse them at rates they REFUSED to give smaller private groups).

If the Govt would simply get Medicare/Medicaid reimbursement into the $35-$40 per point range (where it easily SHOULD be, after 25 years of inflation), many of our problems would go away.

As for getting administrators to LISTEN, the only wake-up call I’ve seen, has been the recent rash of AMC failures.

If they’re (hospital admin) not willing to make an Anesthesia group’s day more EFFICIENT (better scheduling, address abusive/uncooperative surgeons), then the other option is to either make it more PROFITABLE (never-ending subsidy increases) or realize that folks are going to look elsewhere, to get the time /money they think they deserve.

 

[Coffee PRN]

Very linear, one-dimensional business approach. This type of "NUMBER GO UP" simple aggregate systems approach that lacks the kind of strategic thinking that involves a multifaceted approach that maximizes asymmetric information advantage (that we as anesthesiologists possess) in order to rebalance market equilibrium (internally and externally as a market mover) and positively impact pricing decisions while aligning (and maximizing) the strategic interaction with the hospital partners.

You seem to be saying that all that matters is the individual (singular) microeconomic factors--and those taken together in aggregate with no type of interaction or external effects. You are ignoring the systems design components, the aligning and maximization of operational efficiency. Worst of all you are completely rejecting the interaction that strategic planning/execution might have on utilization, efficiency, and cost-per-unit. The best approach is to be a problem solver (the Marriott approach), become a low-cost/high-quality partner, be a leader in the scaling organizations while balancing supply-demand dynamics.

You treat our job as a replaceable cog in an indifferent economic machine. I view my job (aside from providing and leading excellent clinical care) as a leader-rancher in an ever growing stock of cash cows (perioperative services--which makes up about 60% of our hospital's revenue stream). My partners and I drive those cash cows through the process with efficiency through economies of scale (matching transient fluxes of supply-demand), operational efficiencies (from the administrative/leadership medical staff and surg-executive councils down to the running of the ORs and aligning anesthesia resources with OR resources on a constantly shifting basis), strategic planning (opening new service lines, scaling growth, reigning in surgeon excesses), human resources (recruitment and retention), quality improvement (credentialing and peer review--including for surgeons). What most people fail to understand is that the interests of hospital administration and anesthesiologist are almost perfectly aligned contra proceduralists/surgeons. We utilize this strategic interaction advantage (in some cases by removing self-serving surgeons from leadership positions through attrition and value-added propositions). In the end we shift from becoming an accounting "cost-center" to a strategic revenue multiplier and organizational growth engine. As a result our own revenue grows 5-15% each year making partners/stockholders better off. We might not be making as much as the mercenaries in this transient time of labor shortage but we are making somewhat of an positive impact IMHO on the lives of our patients as well as the specialty as a whole.

But thank you for the business lesson on why my hospital partners will eventually replace my partners and me with low-cost labor cogs.

Ok be honest. How much adderall did you take before writing this

 

[ambiturner]

Ok be honest. How much adderall did you take before writing this

I was actually thinking maybe chatGPT wrote it!

Reading this is a good reminder why we all need each other and different models. Employment wouldn’t pay as much if there weren’t private groups on the front lines advocating for the specialty, and the popularity of higher paying employed jobs has forced old school predatory pyramid scheme private groups to either change their ways or go out of business. Let’s hope when the bull market ends there’s still room for both business models.

 

[kidthor]

I was actually thinking maybe chatGPT wrote it!

Reading this is a good reminder why we all need each other and different models. Employment wouldn’t pay as much if there weren’t private groups on the front lines advocating for the specialty, and the popularity of higher paying employed jobs has forced old school predatory pyramid scheme private groups to either change their ways or go out of business. Let’s hope when the bull market ends there’s still room for both business models.

Yes - or ChatGPT on some crystal, maybe.

But yes the best solution would be if anesthesiologists collectively advocated. But we're really bad at that and the ASA is a corporate captive entity. We need something like AAEM for anesthesiology.

As for all the lone wolf discusison - the fact that people are ejecting to do locums really helps us all. That people are now working on their own terms (locums) makes it philosophically easier for employers to realize they need to give employed-types what we want. Plus it's helping to drive up wages to their true market worth and empowering workers to know that they have a very good backup plan if they don't like their employer.

 

[DirtDocMD]

Yes - or ChatGPT on some crystal, maybe.

But yes the best solution would be if anesthesiologists collectively advocated. But we're really bad at that and the ASA is a corporate captive entity. We need something like AAEM for anesthesiology.

As for all the lone wolf discusison - the fact that people are ejecting to do locums really helps us all. That people are now working on their own terms (locums) makes it philosophically easier for employers to realize they need to give employed-types what we want. Plus it's helping to drive up wages to their true market worth and empowering workers to know that they have a very good backup plan if they don't like their employer.

Exactly.

How much is an anesthesiologist (or CRNA) worth??

They’re worth (usually) however much $$ it takes to:

A) Keep them from quitting.
B) Replace them if they DO quit.

This is not specific to anesthesia or medicine…..

 

[GravelRider]

Very linear, one-dimensional business approach. This type of "NUMBER GO UP" simple aggregate systems approach that lacks the kind of strategic thinking that involves a multifaceted approach that maximizes asymmetric information advantage (that we as anesthesiologists possess) in order to rebalance market equilibrium and positively impact pricing decisions while aligning (and maximizing) the strategic interaction with the hospital partners.

You seem to be saying that all that matters is the individual (singular) microeconomic factors--and those taken together in aggregate with no type of interaction or external effects. You are ignoring the systems design components, the aligning and maximization of operational efficiency. Worst of all you are completely rejecting the interaction that strategic planning/execution might have on utilization, efficiency, and cost-per-unit. The best approach is to be a problem solver (the Marriott approach), become a low-cost/high-quality partner, be a leader in the scaling organizations while balancing supply-demand dynamics.

You treat our job as a replaceable cog in an indifferent economic machine. I view my job (aside from providing and leading excellent clinical care) as a leader-rancher in an ever growing stock of cash cows (perioperative services--which makes up about 60% of our hospital's revenue stream). My partners and I drive those cash cows through the process with efficiency through economies of scale (matching transient fluxes of supply-demand), operational efficiencies (from the administrative/leadership medical staff and surg-executive councils down to the running of the ORs and aligning anesthesia resources with OR resources on a constantly shifting basis), strategic planning (opening new service lines, scaling growth, reigning in surgeon excesses), human resources (recruitment and retention), quality improvement (credentialing and peer review--including for surgeons). What most people fail to understand is that the interests of hospital administration and anesthesiologist are almost perfectly aligned contra proceduralists/surgeons. We utilize this strategic interaction advantage (in some cases by removing self-serving surgeons from leadership positions through attrition and value-added propositions). In the end we shift from becoming an accounting "cost-center" to a strategic revenue multiplier and organizational growth engine. As a result our own revenue grows 5-15% each year making partners/stockholders better off. We might not be making as much as the mercenaries in this transient time of labor shortage but we are making somewhat of an positive impact IMHO on the lives of our patients as well as the specialty as a whole.

But thank you for the business lesson on why my hospital partners will eventually replace my partners and me with low-cost labor cogs.

First off, I think some of your somewhat self-righteous preaching is misdirected. This would have been great to tell the anesthesiologists a decade or two ago as they were selling their practices to private equity for a quick buck. Much of the current state of our specialty was caused by those actions.

You seem to be sort of self aware in your preaching, but I think you should do a better job in saying it: your ability to maintain such a good relationship with your hospital administration is bolstered by the current state of the locums market. Your ability to walk away at any given moment and potentially make more money for your labor does a pretty darn good job at keeping your administration honest. What happens when the supply/demand dynamics shift back the other way? Maybe you will have ingratiated yourself enough with administration to keep you safe and insulated, but then again, maybe the administration will begin to see you as a cost they are willing to cut. I also think the terms “employed” and “independent” are a matter of semantics much the same way “stipend” and “subsidy” are semantics. Sure, the hospital is paying you for a service, but is there a line where independence is lost as that stipend becomes a larger and larger percentage of your income?

I think all buy-ins are dishonest.

 

[sbmed100]

Yes - or ChatGPT on some crystal, maybe.

But yes the best solution would be if anesthesiologists collectively advocated. But we're really bad at that and the ASA is a corporate captive entity. We need something like AAEM for anesthesiology.

As for all the lone wolf discusison - the fact that people are ejecting to do locums really helps us all. That people are now working on their own terms (locums) makes it philosophically easier for employers to realize they need to give employed-types what we want. Plus it's helping to drive up wages to their true market worth and empowering workers to know that they have a very good backup plan if they don't like their employer.

locums is a double edged sword - yes it creates efficiencies in the market that increase "wages" for anesthesiologists, but it also shows how replaceable all of us are. When we were a small private group we would tell admin ad nauseum how great we were because it was the same skilled people working with the same surgeons...

 

[abolt18]

Ok be honest. How much adderall did you take before writing this

I was literally laughing as I read his post, noting that every single buzzword in the administrative book he could think of was used, or chatGPT helped. Then this comment just made it better.

 

[caligas]

lol looks like someone woke up wrong side of the bed and is hell bent on babbling over terms he himself is defining and adamant over defending.

Maybe you’re on call and it’s busy lmao and frustrated.

I already told you - by default and all basic business definitions of profit/ income/ revenue - asking for subsidy means that you’re not profitable.
Subsidy is essentially “other income” in addition to collections.

It means that if your company needs to show real profit without subsidy, you’ll need to drop salaries or reduce expenses - which will mean majority of your group will leave.

It means that you’re not market pay without subsidy.

Thats it. I don’t need a 500 page essay countering that.

Thats the reality.

As the subsidy gets larger, the more risky and ubstable you become. Hospital wil, and is always looking for better options on yearly budget meetings. Perhaps not in rural/ non competitive areas where you live, but that’s the reality in my neck of the woods.

Also look up ProMedica / Toledo. They employ their anesthesiologists and CRNAs. Used to be a very successful and profitable company until they decided enough is enough.

So it’s not your decision as anesthesia leadership.

Again you don’t know anything. I’ve already pointed out your multiple fallacies. Im not going to engage with you or defend other anesthesia models and leadership and defend why one is better than other. That depends locally and regionally.

I could care about either of them.

Good luck with your company.

“by default and all basic business definitions of profit/ income/ revenue - asking for subsidy means that you’re not profitable”

Do you have any sort of reference or material to support this?

 

[pgg]

locums is a double edged sword - yes it creates efficiencies in the market that increase "wages" for anesthesiologists, but it also shows how replaceable all of us are. When we were a small private group we would tell admin ad nauseum how great we were because it was the same skilled people working with the same surgeons...

Locums isn't what it used to be.

5+ years ago a significant percentage of locums were doing locums because they weren't capable of holding a regular day job. Every bozo with clinical problems, personal problems, legal problems, could always find a new hospital to skip into and work for a while. They had few options. There was definitely a real problem with traveling incompetents and would-be assassins.

Look back just 5-10 years on this forum at some of the locums threads. It was NOT a respected career path. Locums were sketchy people.

These days locums is attracting a lot of capable people who have plenty of options, but the rates are high enough to coax them into the road life. My bet is that within a couple years most will tire of it and realize how ****ty the locums life actually is. That, and ordinary salaries will catch up at least most of the way.

Now, whether the average administrator understands any of that is another issue altogether. There are tangible benefits to having a stable group with the same faces showing up every day.

 

[periopdoc]

We still charge 10% of each month's income for the first year. Everyone makes partner at one year. Books are open and transparent, even to applicants. No special privilege to being partner except the right to vote. Hospital pays for relocation expenses.

 

[neutro]

“by default and all basic business definitions of profit/ income/ revenue - asking for subsidy means that you’re not profitable”

Do you have any sort of reference or material to support this?

No. Do you need to take a jump off a 500m cliff to know that you’re likely to die?

 

[Beeftenderloin]

locums is a double edged sword - yes it creates efficiencies in the market that increase "wages" for anesthesiologists, but it also shows how replaceable all of us are. When we were a small private group we would tell admin ad nauseum how great we were because it was the same skilled people working with the same surgeons...

Nick Saban (arguably) the greatest coach of all time was replaced in 48hrs. Literally everyone is replaceable.

 

[triggermaster]

Nick Saban (arguably) the greatest coach of all time was replaced in 48hrs. Literally everyone is replaceable.

The greatest coaches go to the nfl and stay there.

 

[ASA6]

Locums isn't what it used to be.



Look back just 5-10 years on this forum at some of the locums threads. It was NOT a respected career path. Locums were sketchy people.

These days locums is attracting a lot of capable people who have plenty of options, but the rates are high enough to coax them into the road life. My bet is that within a couple years most will tire of it and realize how ****ty the locums life actually is. That, and ordinary salaries will catch up at least most of the way.

I agree with the first part of your post. Locums is now a legit way to practice, and good capable anesthesiologists are doing it.

The second part I disagree with. I shouldn't because your way of thinking helps me, but I'm going to. So here goes: I have never slept in a hotel room or boarded a plane for locums in the almost two years I have been doing it. The farthest I have gone is an hour drive for an occasional weekend shift. My main locums job is a 30 minutes drive away. It might be going away soon, there is going to be another opportunity probably about 15 minutes from my house very soon. Now it helps I live in a medium to large size city, so there's plenty of opportunities. But this idea that you have to travel just as in true anymore. So many hospitals and groups are using Locums that there are plenty of local opportunities. It's also gives me a foot in the door to join the group should locums go away.

 

[Beeftenderloin]

The greatest coaches go to the nfl and stay there.

Not at all the point I’m trying to make, but sure, Belichick, whatever…

 

[narcotics999]

locums is a double edged sword - yes it creates efficiencies in the market that increase "wages" for anesthesiologists, but it also shows how replaceable all of us are. When we were a small private group we would tell admin ad nauseum how great we were because it was the same skilled people working with the same surgeons...

What is the big deal of “replaceable” if you can find a job Nextdoor with a possible bigger check?

 

[narcotics999]

Locums isn't what it used to be.

5+ years ago a significant percentage of locums were doing locums because they weren't capable of holding a regular day job. Every bozo with clinical problems, personal problems, legal problems, could always find a new hospital to skip into and work for a while. They had few options. There was definitely a real problem with traveling incompetents and would-be assassins.

Look back just 5-10 years on this forum at some of the locums threads. It was NOT a respected career path. Locums were sketchy people.

These days locums is attracting a lot of capable people who have plenty of options, but the rates are high enough to coax them into the road life. My bet is that within a couple years most will tire of it and realize how ****ty the locums life actually is. That, and ordinary salaries will catch up at least most of the way.

Now, whether the average administrator understands any of that is another issue altogether. There are tangible benefits to having a stable group with the same faces showing up every day.

My place: big metro suburban community hospital. Half anesthesiologists are locums. They are local, no travel, no hotels.

As long as there is demand/supply mismatch, locums will prosper.

 

[narcotics999]

I was literally laughing as I read his post, noting that every single buzzword in the administrative book he could think of was used, or chatGPT helped. Then this comment just made it better.

These buzzwords become a part of their muscle memory, coded in the brain stem reflexes, no cerebral cortex involved. lol

 

[neutro]

People need to learn to differentiate and distinguish between locums and independently contracted physicians.

It’s not the same thing.

The former is a lifestyle, more money, risky and not conducive to a family life in my opinion. Full time locums lacks stability.

The latter is going to be the next big thing in my opinion.

It’s an autonomous physician that carries their own malpractice insurance, benefits and contracts a fair pay arrangement for labor and works with them on a consistent basis. Basically 2-4 practices at a time per year. Or time split weekly, ie help group on their busier days.

The latter provides essential labor service and fills in shortages on a weekly and daily basis. The independent anesthesiologist is known to the community and focuses on building relationships.

Independently contracted physicians retain autonomy as they do their own schedule. Yet most I know work 40-50 hrs a week day time and they’re doing hard labor intensive cases.

They’re doing summer vacation relief, peri- holiday coverage and flip rooms for demanding surgeons that request it last minute.

They work with chairmen/ scheduler of group directly and have good collegial relationship.
Can either bill themselves or do an hourly/ daily rate.

They do not solicit surgeons or interfere in practice matters. Theyre an essential asset to the community. They provide work at a fair market (not locums rate).

They’re also critical in disaster stations where urgent staffing needs are needed by hospital ASC as they’re not tied to an employer. Or if a group exits and coverage is needed.

 

[narcotics999]

People need to learn to differentiate and distinguish between locums and independently contracted physicians.

It’s not the same thing.

The former is a lifestyle, more money, risky and not conducive to a family life in my opinion. Full time locums lacks stability.

The latter is going to be the next big thing in my opinion.

It’s an autonomous physician that carries their own malpractice insurance, benefits and contracts a fair pay arrangement for labor and works with them on a consistent basis. Basically 2-4 practices at a time per year. Or time split weekly, ie help group on their busier days.

The latter provides essential labor service and fills in shortages on a weekly and daily basis. The independent anesthesiologist is known to the community and focuses on building relationships.

Independently contracted physicians retain autonomy as they do their own schedule. Yet most I know work 40-50 hrs a week day time and they’re doing hard labor intensive cases.

They’re doing summer vacation relief, peri- holiday coverage and flip rooms for demanding surgeons that request it last minute.

They work with chairmen/ scheduler of group directly and have good collegial relationship.
Can either bill themselves or do an hourly/ daily rate.

They do not solicit surgeons or interfere in practice matters. Theyre an essential asset to the community. They provide work at a fair market (not locums rate).

They’re also critical in disaster stations where urgent staffing needs are needed by hospital ASC as they’re not tied to an employer. Or if a group exits and coverage is needed.

Independent contracted physicians are a california thing all the time (minus Kaiser, UC)

Cali anesthesia job market was not good before covid.