Buy in still a thing in current market?

[caligas]

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

As an avid base jumper, I disagree with both your definition of profit and your cliff jumping reference

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[caligas]

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

Seriously though, I can’t find any business or accounting source they says revenue from a stipend or subsidy must be excluded when calculating profit. Or maybe I’m misunderstanding your argument.

 

[neutro]

Seriously though, I can’t find any business or accounting source they says revenue from a stipend or subsidy must be excluded when calculating profit. Or maybe I’m misunderstanding your argument.

Not sure why people are giving dissertations and wanting explanations on basic definition of income and expense and profit and loss and overly complicating matters.

Consider an ice cream shop or any other normal business. Selling fried chicken. Grocery stores even. They’re not getting subsidies.

Ok. Anesthesia is a essential service. Got it. But the hospital - there are other options available. Maybe not in todays market but maybe down the road.

Do you think if they have a choice between a group that doesn’t NOT ask for a subsidy vs one that does - who will they give the contract to?

IMO the fact that subsidy is needed to maintain partnerships, retain anesthesia staff and continue business means that your services and product (your collections) is not sufficient to be positive on your books.

I don’t know how else to explain that. Accept it. Not sure why people are taking it personally. Anesthesia departments can no longer cover their own salaries.

This was not the the case 15 years ago. Was it?

Were subsidies needed then? No.

Because personnel cost was covered by collections. Perhaps the market was not as inflated. Perhaps share of Medicare payors was lower which is now worsened given aging population.

I already explained the difference why surgical specialties get treated differently. They are responsible for essentially all downstream revenue and facility fees plus the decision to bring patient to the OR.

It’s not anesthesia is it.

So people can save their rant on “leading a well executed peri-operative services department” and their high and mighty impression of themselves…

Don’t care. Doesn’t change the fact that you’re needing the hospital to bail you out. The issue is Medicare reimbursement and payments for call coverage to staff even when there are no cases. Both those things cost money. Not producing units while on call costs money. It costs money to be “available”, but that’s the nature of our busines.

Again - we are all replaceable.

Don’t take yourself too seriously.

 

[neutro]

As an avid base jumper, I disagree with both your definition of profit and your cliff jumping reference

Cool story.

 

[caligas]

Not sure why people are giving dissertations and wanting explanations on basic definition of income and expense and profit and loss and overly complicating matters.

Consider an ice cream shop or any other normal business. Selling fried chicken. Grocery stores even. They’re not getting subsidies.

Ok. Anesthesia is a essential service. Got it. But the hospital - there are other options available. Maybe not in todays market but maybe down the road.

Do you think if they have a choice between a group that doesn’t NOT ask for a subsidy vs one that does - who will they give the contract to?

IMO the fact that subsidy is needed to maintain partnerships, retain anesthesia staff and continue business means that your services and product (your collections) is not sufficient to be positive on your books.

I don’t know how else to explain that. Accept it. Not sure why people are taking it personally. Anesthesia departments can no longer cover their own salaries.

This was not the the case 15 years ago. Was it?

Were subsidies needed then? No.

Because personnel cost was covered by collections. Perhaps the market was not as inflated. Perhaps share of Medicare payors was lower which is now worsened given aging population.

I already explained the difference why surgical specialties get treated differently. They are responsible for essentially all downstream revenue and facility fees plus the decision to bring patient to the OR.

It’s not anesthesia is it.

So people can save their rant on “leading a well executed peri-operative services” lol no one gives a hoot. Someone else can do it too and cheaper. You’re not that special.

Again - we are all replaceable.

Don’t take yourself so seriously.

Ha. Not taking this seriously but you are saying things that are foolish and demonstrate a lack of basic accounting and business education. Trying to help you out so when you talk to people in a non anonymous forum you don’t embarrass yourself.

Profit = Revenue - Expenses

A group can exist that is profitable without a subsidy and is even more profitable with one. Also a subsidy is often not a gift or handout, its often payment for service such as covering anesthesia locations and call. It’s part of revenue, and profit is revenue minus expenses. And even if it WAS a handout it’s still revenue.

 

[neutro]

Ha. Not taking this seriously but you are saying things that are foolish and demonstrate a lack of basic accounting and business education. Trying to help you out so when you talk to people in a non anonymous forum you don’t embarrass yourself.

Profit = Revenue - Expenses

A group can exist that is profitable without a subsidy and is even more profitable with one. Also a subsidy is often not a gift or handout, its often payment for service such as covering anesthesia locations and call. It’s part of revenue, and profit is revenue minus expenses. And even if it WAS a handout it’s still revenue.

I was trying to dumb things down to you but yes sure, we can evaluate your books and bids etc.

I don’t have 5/6 hours to commit to you.

The fact remains:

If you’re asking for a subsidy, it means you cannot organically generate the revenue to sustain your own income and expenses. Let alone partner distributions.

You’re susceptible to being outbid.

The minute you’re outbid, partnership distributions goes away and you’re either employed by hospital or take a paycut or move. Or be at mercy of the new employer.

 

[caligas]

I was trying to dumb things down to you but yes sure, we can evaluate your books and bids etc.

I don’t have 5/6 hours to commit to you.

The fact remains:

If you’re asking for a subsidy, it means you cannot organically generate the revenue to sustain your own income and expenses. Let along partner distributions.

Ok. Well I guess we should fire our CPA firm as the last 20 years of k-1’s have shown a shareholder profit and we also are asking for an increase in our subsidy to support increased call burdens and coverage of additional anesthetizing locations.

 

[neutro]

Ok. Well I guess we should fire our CPA firm as the last 20 years of k-1’s have shown a shareholder profit and we also are asking for an increase in our subsidy to support increased call burdens and coverage of additional anesthetizing locations.

you can do what you want.
subsidy is given by the hospital so it’s subject to their decisions. Not yours.

You’re not able to generate income from anesthesia colkevtions to not need a subsidy.

That means you do not have the power or control when it comes to negotiations should there be a competing group.

You can be outbid.

 

[neutro]

Ok. Well I guess we should fire our CPA firm as the last 20 years of k-1’s have shown a shareholder profit and we also are asking for an increase in our subsidy to support increased call burdens and coverage of additional anesthetizing locations.

Yes. Keep asking for subsidies and channel that money as “partnership distribution”. Perfect.

Then hospital one day will literally say “F*** YOU”, we will bring anesthesia in house, treat you
Like nursing staff and have full control of you and your shifts.

It’s going to be very costly to employ an anesthesia group.

But, they’ll do it.

Like they have done it at multiple places.

In return they get control also. Control of personnel. Control of staffing. Control of hiring. Control of billing. Control of anesthesia chair. No more power to anesthesia group wanting to walk away. No more voting or partnership.

That’s what hospitals desire. Control is what they desire.

By making the groups a “subsidy addict” is how they do it.

 

[GassYous]

Yes. Keep asking for subsidies and channel that money as “partnership distribution”. Perfect.

Then hospital one day will literally say “F*** YOU”, we will bring anesthesia in house, treat you
Like nursing staff and have full control of you and your shifts.

It’s going to be very costly to employ an anesthesia group.

But, they’ll do it.

Like they have done it at multiple places.

In return they get control also. Control of personnel. Control of staffing. Control of hiring. Control of billing. Control of anesthesia chair. No more power to anesthesia group wanting to walk away. No more voting or partnership.

That’s what hospitals desire. Control is what they desire.

By making the groups a “subsidy addict” is how they do it.

These days you can't hire without a stipend supporting billings. The future of anesthesia reimbursement is dim as medicare continually cuts unit value despite inflation and the no surprises act took away any semblance of negotiations with insurance companies.

 

[sbmed100]

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

Replaceable not only in the sense of replacing the group you work with, but your actual position as an anesthesiologist with a CRNA/AA or even a sedation nurse. The market figures it out. Soon it will figure out you don't need a board certified anesthesiologist to provide sedation for cataracts.

 

[neutro]

These days you can't hire without a stipend supporting billings. The future of anesthesia reimbursement is dim as medicare continually cuts unit value despite inflation and the no surprises act took away any semblance of negotiations with insurance companies.

yes.
Payor differential plus money suck for hospitals for anesthesia being “available” on call has changed things along with rising market compensation.

I was recently talking to someone who is partner with one of the local PP groups and he straight up told me that they’re Thinking of getting out of “exclusive contracts” simply because the costs to THEM in terms of manpower required do not justify billing from call cases plus time commitment.

He further said being exclusive to a facility is a double edged sword which now requires a far deeper analysis of case and payor mix to match the resources and stress on existing staff.

 

[periopdoc]

You both understand what the other is saying. No point in continuing to hash it out.

In an accounting sense, his company is profitable, it just isn’t profitable without hospital support, making his company vulnerable to another company willing to do it for cheaper, unless his entire support is based on medical directorships etc completely funded by CMS via pass through funds.

On the other hand, most anesthesiologists I talk to consider a practice to be profitable when no support is needed from the hospital. It’s a metric of the health of the company, not an accounting term. There’s a gray area when all hospital support comes from pass through funding, but most anesthesiologists that I’ve talked to don’t even know about this kind of funding. Admin likes to take advantage of this lack of knowledge.

 

[dannyboy1]

Yes. Keep asking for subsidies and channel that money as “partnership distribution”. Perfect.

Then hospital one day will literally say “F*** YOU”, we will bring anesthesia in house, treat you
Like nursing staff and have full control of you and your shifts.

It’s going to be very costly to employ an anesthesia group.

But, they’ll do it.

Like they have done it at multiple places.

In return they get control also. Control of personnel. Control of staffing. Control of hiring. Control of billing. Control of anesthesia chair. No more power to anesthesia group wanting to walk away. No more voting or partnership.

That’s what hospitals desire. Control is what they desire.

By making the groups a “subsidy addict” is how they do it.

To what end. We are all hospital employees now. There is no incentive to do anything but punch a clock. Most of us are shift workers so we can give a crap about efficiency. Wouldn’t the hospital rather have a PP model (even though a stipend would be needed) to create incentive ?

 

[neutro]

To what end. We are all hospital employees now. There is no incentive to do anything but punch a clock. Most of us are shift workers so we can give a crap about efficiency. Wouldn’t the hospital rather have a PP model (even though a stipend would be needed) to create incentive ?

I don’t if I I understand the post.
Yes in this particular situation, hospital contracted to another group for on call coverage. Essentially subcontracted the undesirable parts of the job. I believe it’s 24/7 OB coverage that was outsourced.

Not sure what to make of these hybrid models.

Again labor shortage, explosion of ASCs and offsite anesthesia demands daytime coverage where majority of revenue comes from. As an anesthesia group you have to make tough decisions and cut the dead wood.

 

[aneftp]

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.

I don’t necessary agree regarding bad and good locums. As anything in life. The truth is somewhere in between.

Having been in the locums market on/off the past 20 years. I’ve gotten to get a ton of contacts and networking on the “locums” trail in between my regular full time jobs.

Look. I don’t claim to be a super star or anything. But I’m competent. I work hard (when I want to). I get along with surgeons and peers. Always invited back even places that become full and get random texts from previous chiefs there asking if I’m available even after 2 plus years away.

Yes. There are some bad actors on the locums market. Even in 2024. Even university owned facilities took a bad locums (and they weren’t even short staff) a few months ago at my friends place.

The non board certified docs tend to go to surgery centers.

But the bad locums docs go anywhere even in today’s market. Like bad crnas. People will slice through the cracks and when they show up at ur facility. U just make due and try to give them easier assignments simply because u need the warm body

So bad locums docs exist in 1990s, 2000s, 2010s, and now 2020s.

Anesthesia has gotten very technically “safe”. Bad locums can hide for a long time. It’s their clinician judgment that gets them in trouble. Not the technical skills.

 

[neutro]

You both understand what the other is saying. No point in continuing to hash it out.

In an accounting sense, his company is profitable, it just isn’t profitable without hospital support, making his company vulnerable to another company willing to do it for cheaper, unless his entire support is based on medical directorships etc completely funded by CMS via pass through funds.

On the other hand, most anesthesiologists I talk to consider a practice to be profitable when no support is needed from the hospital. It’s a metric of the health of the company, not an accounting term. There’s a gray area when all hospital support comes from pass through funding, but most anesthesiologists that I’ve talked to don’t even know about this kind of funding. Admin likes to take advantage of this lack of knowledge.

Yeah…sorry…

Definitely the latter for me.

 

[neutro]

I don’t necessary agree regarding bad and good locums. As anything in life. The truth is somewhere in between.

Having been in the locums market on/off the past 20 years. I’ve gotten to get a ton of contacts and networking on the “locums” trail in between my regular full time jobs.

Look. I don’t claim to be a super star or anything. But I’m competent. I work hard (when I want to). I get along with surgeons and peers. Always invited back even places that become full and get random texts from previous chiefs there asking if I’m available even after 2 plus years away.

Yes. There are some bad actors on the locums market. Even in 2024. Even university owned facilities took a bad locums (and they weren’t even short staff) a few months ago at my friends place.

The non board certified docs tend to go to surgery centers.

But the bad locums docs go anywhere even in today’s market. Like bad crnas. People will slice through the cracks and when they show up at ur facility. U just make due and try to give them easier assignments simply because u need the warm body

So bad locums docs exist in 1990s, 2000s, 2010s, and now 2020s.

Anesthesia has gotten very technically “safe”. Bad locums can hide for a long time. It’s their clinician judgment that gets them in trouble. Not the technical skills.

A lot of locums just do locums because they want 1099 pay and ability to set their own retirement/ benefits/ tax benefits.

Thats a very big part of all this.

 

[NICMAN]

Hold on, I am waiting for my adderall to kick in.

Since nobody really wants to understand my fancy terms like market equilibrium and strategic interaction, operational efficiency economies of scale and information asymmetry let tell a couple of stories:

Hospital 1 has a PP anesthesia group 10 miles down the road. Level 2 trauma center. They are our competitors. They ask for like $4 MM increase in their subsidy. They literally say “we will go out of business without this stipend/subsidy.” The RFP that sucka’ and get some group that rhymes with “Storkpar” they sign a contract. ASC says “sure we can do this MUCH cheaper than the other group however have a line-item in the fine print that they do not pay for “premium” labor (that’s independent contractors like those posting here—you know who you are).

Everything is great until the first quarter where they present a bill for, what do you think? How much? You got that right! $4MM, but FOR A QUARTER! It ended up being around $15 MM additional premium labor for the year.

Another hospital up north not to far—hospital employed group. Hospital secretly sold the contract to a group (rhymes with PAPA—but say it like they do down south in Alabama). Anesthesiologists and CRNAs come to work one day to find PAPA has cut their salaries and benefits. They are somebody else’s bitch now. People leave. Two wrongful death lawsuits later and millions in premium labor payouts and they are barely recovered.

Meanwhile we go to our hospital and say “hey geez, real bad what happened to those other groups dontcha know. That must have been real tough for those hospital VPs who got fired over those blow ups. BTW, we need about $xxMM more to run this whale. Whadyasay?”

Guess what? We got what we wanted. Probably cuz we are a better group but also definitely because we are simply better at a lower cost and we STILL manage to pull more money than those other anesthesia groups (well, after the huge sign on bonus runs out that is).

Fact is I know some USAP divisions that have a subsidy/stipend to revenue ratio of like 40% and hospitals are gladly paying them. People who run those are — my guess — making pretty good money.

Anyways, my adderall has worn off.

 

[aneftp]

A lot of locums just do locums because they want 1099 pay and ability to set their own retirement/ benefits/ tax benefits.

Thats a very big part of all this.

Yes. Absolutely 100% true regarding tax benefits of 1099

But I was responding to the other poster saying the stigma of locuns is they were usually bad 10 plus years ago

But getting back to 1099 benefits. I only paid 21% effective federal tax rate on my w2 job which ain’t bad.

If you are married and make less than pretax 500-550k w2 with university benefits and 401a/403b//457b. Socking away 70k plus pretax plus itemized deductions plus hsa plus flex account. A 1099 job full time doesn’t make much sense for me unless it’s generating more than 600k with no calls or weekends which is hard to get

So I kinda of do hybrid. I don’t do much extra work at my w2 job. And the rest is 1099 side income

 

[periopdoc]

A lot of locums just do locums because they want 1099 pay and ability to set their own retirement/ benefits/ tax benefits.

Thats a very big part of all this.

Me me me me me

 

[neutro]

Hold on, I am waiting for my adderall to kick in.

Since nobody really wants to understand my fancy terms like market equilibrium and strategic interaction, operational efficiency economies of scale and information asymmetry let tell a couple of stories:

Hospital 1 has a PP anesthesia group 10 miles down the road. Level 2 trauma center. They are our competitors. They ask for like $4 MM increase in their subsidy. They literally say “we will go out of business without this stipend/subsidy.” The RFP that sucka’ and get some group that rhymes with “Storkpar” they sign a contract. ASC says “sure we can do this MUCH cheaper than the other group however have a line-item in the fine print that they do not pay for “premium” labor (that’s independent contractors like those posting here—you know who you are).

Everything is great until the first quarter where they present a bill for, what do you think? How much? You got that right! $4MM, but FOR A QUARTER! It ended up being around $15 MM additional premium labor for the year.

Another hospital up north not to far—hospital employed group. Hospital secretly sold the contract to a group (rhymes with PAPA—but say it like they do down south in Alabama). Anesthesiologists and CRNAs come to work one day to find PAPA has cut their salaries and benefits. They are somebody else’s bitch now. People leave. Two wrongful death lawsuits later and millions in premium labor payouts and they are barely recovered.

Meanwhile we go to our hospital and say “hey geez, real bad what happened to those other groups dontcha know. That must have been real tough for those hospital VPs who got fired over those blow ups. BTW, we need about $xxMM more to run this whale. Whadyasay?”

Guess what? We got what we wanted. Probably cuz we are a better group but also definitely because we are simply better at a lower cost and we STILL manage to pull more money than those other anesthesia groups (well, after the huge sign on bonus runs out that is).

Fact is I know some USAP divisions that have a subsidy/stipend to revenue ratio of like 40% and hospitals are gladly paying them. People who run those are — my guess — making pretty good money.

Anyways, my adderall has worn off.

Everyone understands those terms. Atleast I do. Plus more - like geographical arbitrage.

You don’t seem to understand that each market and competition, staffing is different and you’re applying what works for you to regions where things simply don’t work like that.

I’m not here to disagree with you.

I personally have my reservations on practices needing life support in terms of subsidies and what really that means long term.

Everything in life comes at a price.

 

[aneftp]

Hold on, I am waiting for my adderall to kick in.

Since nobody really wants to understand my fancy terms like market equilibrium and strategic interaction, operational efficiency economies of scale and information asymmetry let tell a couple of stories:

Hospital 1 has a PP anesthesia group 10 miles down the road. Level 2 trauma center. They are our competitors. They ask for like $4 MM increase in their subsidy. They literally say “we will go out of business without this stipend/subsidy.” The RFP that sucka’ and get some group that rhymes with “Storkpar” they sign a contract. ASC says “sure we can do this MUCH cheaper than the other group however have a line-item in the fine print that they do not pay for “premium” labor (that’s independent contractors like those posting here—you know who you are).

Everything is great until the first quarter where they present a bill for, what do you think? How much? You got that right! $4MM, but FOR A QUARTER! It ended up being around $15 MM additional premium labor for the year.

Another hospital up north not to far—hospital employed group. Hospital secretly sold the contract to a group (rhymes with PAPA—but say it like they do down south in Alabama). Anesthesiologists and CRNAs come to work one day to find PAPA has cut their salaries and benefits. They are somebody else’s bitch now. People leave. Two wrongful death lawsuits later and millions in premium labor payouts and they are barely recovered.

Meanwhile we go to our hospital and say “hey geez, real bad what happened to those other groups dontcha know. That must have been real tough for those hospital VPs who got fired over those blow ups. BTW, we need about $xxMM more to run this whale. Whadyasay?”

Guess what? We got what we wanted. Probably cuz we are a better group but also definitely because we are simply better at a lower cost and we STILL manage to pull more money than those other anesthesia groups (well, after the huge sign on bonus runs out that is).

Fact is I know some USAP divisions that have a subsidy/stipend to revenue ratio of like 40% and hospitals are gladly paying them. People who run those are — my guess — making pretty good money.

Anyways, my adderall has worn off.

The original usap big 3 are still profitable. The one I know extremely well takes zero subsidy ….well duh take pay or mix is well over 60% commercial are most sites. It’s hard to F up with that type of commercial pay or mix even with increasing labor costs.

Don’t confuse the most profitable usap vs the ones who sold later on or even other usap divisions that form from taking over so so contracts.

 

[NICMAN]

Everyone understands those terms. Atleast I do. Plus more - like geographical arbitrage.

You don’t seem to understand that each market and competition, staffing is different and you’re applying what works for you to regions where things simply don’t work like that.

I’m not here to disagree with you.

I personally have my reservations on practices needing life support in terms of subsidies and what really that means long term.

Everything in life comes at a price.

Totally get that. What works for us in a big city doesn’t work in Iowa, or probably not in California.

And yes, there are trade offs. You seem to overstate the risk of a stipend but your answer is … to be an independent contractor? 1) you don’t think the premium labor cost of independent contractors are seen as a problem by administrators? 2) you don’t think independent contractors are going to be the #1 job to be cut once labor supply stabilizes?

The difference between independent contractors and a stable PP group is that independent contractors are nothing more than cogs in the economic machine while PP groups provide a lot more value (like controlling bad surgeons by having physicians staff leadership positions in the hospital who have authority to send letters and push through formal disciplinary measures through MACs.

Tell me again why you think your job is more stable than a PP doc? Because “you have a subsidy and I don’t”. Ok, you win.

 

[NICMAN]

The original usap big 3 are still profitable. The one I know extremely well takes zero subsidy ….well duh take pay or mix is well over 60% commercial are most sites. It’s hard to F up with that type of commercial pay or mix even with increasing labor costs.

Don’t confuse the most profitable usap vs the ones who sold later on or even other usap divisions that form from taking over so so contracts.

Yeah, don’t confuse what I am saying. I only used USAP as an example of a well run company that I know of that still makes money in some of their divisions despite fairly large hospital financial income. They still make money and the hospitals are also doing fine—it is not like the UAW and GM.

 

[NICMAN]

Yeah, don’t confuse what I am saying. I only used USAP as an example of a well run company that I know of that still makes money in some of their divisions despite fairly large hospital financial income. They still make money and the hospitals are also doing fine—it is not like the UAW and GM.

AND, USAP is still cheaper for those hospitals I know of than NAPA and Northstar even with slightly higher hospital financial income due to more reliable and efficient service.

 

[NICMAN]

Me me me me me

Yeah, but a private practice group can write off the accountants that do all of those things for us automatically without any effort on our part and near zero tax/legal liability and all I have to do is pay $550 to my personal CPA to file my personal taxes. I know it isn’t available to everybody but all I am saying is it is a good deal if you happen to have the opportunity.

Private practice ain’t dead man!

 

[neutro]

Totally get that. What works for us in a big city doesn’t work in Iowa, or probably not in California.

And yes, there are trade offs. You seem to overstate the risk of a stipend but your answer is … to be an independent contractor? 1) you don’t think the premium labor cost of independent contractors are seen as a problem by administrators? 2) you don’t think independent contractors are going to be the #1 job to be cut once labor supply stabilizes?

The difference between independent contractors and a stable PP group is that independent contractors are nothing more than cogs in the economic machine while PP groups provide a lot more value (like controlling bad surgeons by having physicians staff leadership positions in the hospital who have authority to send letters and push through formal disciplinary measures through MACs.

Tell me again why you think your job is more stable than a PP doc? Because “you have a subsidy and I don’t”. Ok, you win.

1. No job is stable. business that you personally control is more stable, ie not with interference from admin or your own partners that may have other interests. Autonomy is important for some. I also have partners btw - but very few. I can’t share too many details at this time because I personally don’t have any at this time given my work model/project in underway; but Im a very straight forward person and I will share details soon.

2. One employer is never stable for various reasons IMO. Diversified risk. Many unhappy employed anesthesiologists left and right, feeling stuck - taking s**t from super partners and boomers everyday for the dangling carrot. Non competes. Imagine you get into a conflict with your chairman and that guy is supposed to write your LOR? I knew a doc like that - his employer blocked his lateral move and he gained 150lbs due to depression and was stuck under his control. He's still there. It’s sad.
Learnt my lesson.
With AMC - only money talks. Priorities change. Loyalties change. AMCs/ admins and hospitals lie all the time. Docs generally are good. Gotta keep em honest in any case. It’s not about loyalty to one business at all.
As a man your responsibility is your family. If you’re unhappy - you’re not going to be able to contribute to them. To me that’s vvvip. More than work.

3. Employment comes at an opportunity cost and lack of flexibility. Unless you’re an IC and free and able to take over contracts at short notice or when the demand arises from ASC/ hospital - being employed - you can’t do it. Thats the goal.
One of my really good friends was doing independent contracting and the hospital liked him - they offered him chairmanship. Job never advertised. He’s set for life. Im happy for him and no asks me to cover for his excess days plus vacation. I m getting credentialed there for him. Point is - Real opportunities are created and found in life; they don’t come through by working for someone IMO. They don’t always come through gaswork or job sites.

I don’t need the money. I’m good. At this point in my life I can take real risks. If it doesn’t work out, I’ll join a practice I know. I love them. But I know I’ll go there answering all questions and exhausting my journey and I’ll be fully satisfied as a doctor.

In any case, I’ll retire by 52 if all goes well. So I have 12 years left, granted I manage to live that long. Life’s short.

4. I’ve been mentored by ICs that have done this as a career. Your real value is in your skills and ability as an anesthesiologist. Market it, bill your cases, do it old style way if you want. Why not?

Do it with a handshake and to be helpful to those who provide opportunity.
it’s entrepreneurship. You can call it a niche practice.
I charge market amount. Nothing more nothing less. I’m not locums. I do the professional thing of finishing cases and I only leave when day is done or when I’m not needed. I don’t charge overtime or 1.5 or watch the clock and increase time.

Anything less I consider abandonment of patient and group. Countless times I’ve ended up taking calls unintended…lol.. It’s not *just* about money.

So these are my ethics and on this basis I have been fortunate enough to have continued work. I didn’t change myself, this is how I am. I was the same person when you inquired about the position with us too btw. I was doing IC at that time too. I think we talked about this. I looked back at our messages.

5. If you’re talking about me - humbly, I am blessed - I have more work than I can handle. Over time I made contacts, networked and again did things the right way. I never solicit surgeons. I know anesthesiologists who do and undercut the groups who sent them. Not my thing. Surgeons have also tried to solicit me to provide coverage while I am covering for another group. I say no loud and clear and notify then people I work for. I keep it clean. I dont play politics.
I show up to work and do my cases and leave. I believe in honest man’s work - which is $/ hours worked and labor charge. Thats the only model that makes sense to me as an anesthesiologist in today’s crazy anesthesia world.

I don’t know if I answered you.

If anesthesia goes south, I’ll go back to pain medicine. I don’t want to. But at least it will pay the bills and I'll have my own clinic.

 

[aneftp]

Yeah, don’t confuse what I am saying. I only used USAP as an example of a well run company that I know of that still makes money in some of their divisions despite fairly large hospital financial income. They still make money and the hospitals are also doing fine—it is not like the UAW and GM.

Usap is not that well run to be honest. It’s the payor mix. Anyone can make money when commercials insurance is 60%.

A well run company is a small practice can still turn a profit with payor mix less than 40%.

Remember private equity immediately takes 20% cut. So you are in the hole 20% to began with.

Usap pulled out of my friends surgery center years ago after stealing their contract by saying they can provide this and that. It’s all BS marketing /c suite speak. But when they payor mix was 35% commercial. They had no way of making money so they left after 9 months. Bled money.

That’s what I mean by don’t believe the hype of efficiency speak. You put a tube in a patient. You wake up a patient. You turn over a room in less than 20 minutes from drop off pacu to starting next case. How much more efficient can usap be? Their only efficiency is negotiating with commercial payors and when it’s Medicare they have zero efficiency since it’s single payor. So their next efficiency is saving 5-6% billing fees. That stil won’t make up for the 20% overhead to pay the private equity

It all comes down to

 

[periopdoc]

Yeah, but a private practice group can write off the accountants that do all of those things for us automatically without any effort on our part and near zero tax/legal liability and all I have to do is pay $550 to my personal CPA to file my personal taxes. I know it isn’t available to everybody but all I am saying is it is a good deal if you happen to have the opportunity.

Private practice ain’t dead man!

Don’t know if my signature still shows, but it used to say “I think private practice anesthesia is the bomb.” I still feel that way.

I’m currently around 75% private practice 25% traveling locums 1099. Given the current environment, I would be closer to 50/50 if I wasn’t president of my group. I’d morph back to more private practice once the market settles.

 

[neutro]

PP and independent physicians are important to maintain balance in this competitive world.

As an anesthesiologist, given the disadvantage of not having a patient census and therefore no real practice equity - you have to be creative to make it work.

And that can mean different things for different people and it’s market dependent.

If you live in an area that’s dominated by two major hospital groups and the only opportunity you have is to be employed by either of them - you can’t really negotiate much if you’re tied to the area. In that case, you have to take what’s there in your market or you move.

Again these are all individual based decisions.

Money/ equity/ partnership cannot be the only determinant in life decisions.

 

[Burned_Out]

aVery 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.

The assymetrical approach that your one-dimensional business schema does not match the results. The ends do not justify the means. Therefore, via the Ericcson-Schlager-Klinger methodology, what is true cannot be true. When you describe the business model of your group as aligned amongst everyone as being singular, that cannot be true. A group is composed of many opinions and everyone acts in their own singular, selfish must I say, interests. A physician leader, like you, works to suppress those interests so that you may superimpose your own or that of your cabal of senior partners. Although the interests of hospital administration and anesthesiologists are almost perfectly aligned contra proceduralists/surgeons, they are in fact, aligned as a singularity. Hospital administration and the physician leader anesthesiologist like yourself are always collaborating to undermine the interests of the unwashed masses, especially those of the underlying, simpleton physician anesthesiologist. (Physician anesthesiologist not to be confused here with the more intellectually superior administrative physician anesthesiologist leader. Otherwise known as "Dear Leader"). The multiplicative effect of revenue growth through Dear Leader's actions is nothing more than extortion of hospital leadership to the view that they those uncouth mercenary CRNA's and physician anesthesiologists are exploiting and denying the sacred, moral fabric or tenet of providing care without compensation. Therefore, and I painfully must retort this over and over again, we must strategically put forth the view that only our PP group can match the hospital's interests in providing only the utmost, finest affordable care possible. Only then can we achieve the ends that we so adamantly strive to perfect!

 

[Sriddymopboi]

The assymetrical approach that your one-dimensional business schema does not match the results. The ends do not justify the means. Therefore, via the Ericcson-Schlager-Klinger methodology, what is true cannot be true. When you describe the business model of your group as aligned amongst everyone as being singular, that cannot be true. A group is composed of many opinions and everyone acts in their own singular, selfish must I say, interests. A physician leader, like you, works to suppress those interests so that you may superimpose your own or that of your cabal of senior partners. Although the interests of hospital administration and anesthesiologists are almost perfectly aligned contra proceduralists/surgeons, they are in fact, aligned as a singularity. Hospital administration and the physician leader anesthesiologist like yourself are always collaborating to undermine the interests of the unwashed masses, especially those of the underlying, simpleton physician anesthesiologist. (Physician anesthesiologist not to be confused here with the more intellectually superior administrative physician anesthesiologist leader. Otherwise known as "Dear Leader"). The multiplicative effect of revenue growth through Dear Leader's actions is nothing more than extortion of hospital leadership to the view that they those uncouth mercenary CRNA's and physician anesthesiologists are exploiting and denying the sacred, moral fabric or tenet of providing care without compensation. Therefore, and I painfully must retort this over and over again, we must strategically put forth the view that only our PP group can match the hospital's interests in providing only the utmost, finest affordable care possible. Only then can we achieve the ends that we so adamantly strive to perfect!

What in the chatGPT is this

 

[neutro]

The original usap big 3 are still profitable. The one I know extremely well takes zero subsidy ….well duh take pay or mix is well over 60% commercial are most sites. It’s hard to F up with that type of commercial pay or mix even with increasing labor costs.

Don’t confuse the most profitable usap vs the ones who sold later on or even other usap divisions that form from taking over so so contracts.

Yes.
Its because those divisions were stellar businesses even before USAP took over. They remain stellar practices in my opinion.

 

[medicine2wallstreet]

Don’t ever do that in this climate. It still exists though, and ironically and even worse even still exists at USAP sites…..not worth it. Too many high paying jobs to start not to mention that group who has a buy in has a solid chance of earning even less by the time you have “bought in” as expenses continue to rise

There are unfortunately still classmates of mine that are getting taken advantage of with these buy ins. You either have a lucrative practice setup from everyone working extremely hard or from having a great payor mix. If you have a great payor mix that isn't something you helped create as a partner in the private practice. It just exists. These groups think that they're inherently valuable when they simply find themselves within a very financially favorable insurance ecosystem.

I thought I wanted private practice but turned it down for an AMC. Never thought I would do that. But 4 years of earning less than market value is too much to suffer through.

Sadly though some are still signing up for these positions and affirming the old partners that the buy in is still appropriate.

 

[DoctwoB]

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

surgeon lurker here, I find the arguments about stipends/subsidies somewhat hilarious.

The hospital wants you to provide an unreimbursed service, namely to have you available at the drop of a hat to provide care. They are not subsidizing you, they are literally paying you for your availability. I have yet to meet any other person willing to be "on call" in any other field without being paid for it.

If I want a lawyer available 24/7, I pay for it. Ditto for a plumber, gardener, or literally anyone else. Asking a hospital to pay you for this service is not greedy, it's common sense.

I get paid to hold a pager for the ER. If they didn't pay me enough I'd happily give it up.

It all comes down to market dynamics. If anesthesiologists are oversupplied in an area and the contract is in demand, they can demand you throw in freebies like unreimbursed call to get their business. But make no mistake, that is what it is, you offering the hospital a valuable service for free in exchange for the rest of their business. If undersupplied, you can say F U, pay me. There are hospitals where ER call for surgeons is not reimbursed based on local oversupply and surgeons wanting the referral source/business. In academic centers, usually taking call is part of your "payment" for the privilege of telling your mom you work for Man's Greatest Hospital.

 

[Volatile]

A buy in can absolutely be worth it if its the “right” job for you. I did locums for awhile and was offered several full time positions, some were hospital employed, some were AMCs. I ended up taking a private practice job with a pretty substantial buy in and now several years later I am very happy with my decision. Those other jobs were fine short term but I knew I would never be happy there in the long run. a few of my residency classmates chased money and have ended up switching jobs multiple times. My random advice from a stranger is pick the job that you will be happiest working at each day, makes life much easier.

 

[medicine2wallstreet]

A buy in can absolutely be worth it if its the “right” job for you. I did locums for awhile and was offered several full time positions, some were hospital employed, some were AMCs. I ended up taking a private practice job with a pretty substantial buy in and now several years later I am very happy with my decision. Those other jobs were fine short term but I knew I would never be happy there in the long run. a few of my residency classmates chased money and have ended up switching jobs multiple times. My random advice from a stranger is pick the job that you will be happiest working at each day, makes life much easier.

I'll agree with that. Although I think there is a difference in chasing money and ensuring a fair wage. If you're moving away from family to earn 650k that is a mistake.

But you also deserve to earn a fair salary. Not be down 600k from a 4 year buy in.

 

[Volatile]

I'll agree with that. Although I think there is a difference in chasing money and ensuring a fair wage. If you're moving away from family to earn 650k that is a mistake.

But you also deserve to earn a fair salary. Not be down 600k from a 4 year buy in.

I guess the 100+ academic anesthesiologists working down the street from me should all quit, they earn in the low $300’s. They are down well over $1mil from us every 4 years. How could they do this to themselves? It’s so unfair. Maybe the salary is one component, maybe they’re willing to take the large pay cut year after year to keep the job they enjoy. There is no minimum wage or “fair wage” in anesthesia. if you enjoy the work, hours, and salary then stay. If you don’t, move on. Good luck to you.

 

[BlueRug]

I guess the 100+ academic anesthesiologists working down the street from me should all quit, they earn in the low $300’s. They are down well over $1mil from us every 4 years. How could they do this to themselves? It’s so unfair. Maybe the salary is one component, maybe they’re willing to take the large pay cut year after year to keep the job they enjoy. There is no minimum wage or “fair wage” in anesthesia. if you enjoy the work, hours, and salary then stay. If you don’t, move on. Good luck to you.

Low 300s???

 

[aneftp]

Low 300s???

Most academic places have tier salary. Base is low 300s if you do ZERO extra work.

The male worker bees tend to bunk their academic salaries to the 400s pretty easily.

Never read pure numbers. There truth is always somewhere in between.

Also remember work load.

Some academics are cushy. 1:2 90% of the time. Some get non clinical days.

I tell everyone to look at entire picture

Like the VA caters to young women who want or who have young kids and older docs. Many Va pays in the 320-350k range on the low side. But they have some chill lifestyle and can call out sick and pop out 1-2 kids and get 12 weeks paid off (outside of their standard leave).
Similar with academic’s especially if they work for state institutions. Very similar benefits and liberal leave policy.

 

[GravelRider]

surgeon lurker here, I find the arguments about stipends/subsidies somewhat hilarious.

The hospital wants you to provide an unreimbursed service, namely to have you available at the drop of a hat to provide care. They are not subsidizing you, they are literally paying you for your availability. I have yet to meet any other person willing to be "on call" in any other field without being paid for it.

If I want a lawyer available 24/7, I pay for it. Ditto for a plumber, gardener, or literally anyone else. Asking a hospital to pay you for this service is not greedy, it's common sense.

I get paid to hold a pager for the ER. If they didn't pay me enough I'd happily give it up.

It all comes down to market dynamics. If anesthesiologists are oversupplied in an area and the contract is in demand, they can demand you throw in freebies like unreimbursed call to get their business. But make no mistake, that is what it is, you offering the hospital a valuable service for free in exchange for the rest of their business. If undersupplied, you can say F U, pay me. There are hospitals where ER call for surgeons is not reimbursed based on local oversupply and surgeons wanting the referral source/business. In academic centers, usually taking call is part of your "payment" for the privilege of telling your mom you work for Man's Greatest Hospital.

Surgeons around me used to fight to take ER call without a stipend when they were billing those appys and gall bladders out of network. That has all gone away, but taking ER call without a payment from the hospital was not that long ago.

 

[ucladoc2b]

Surgeons around me used to fight to take ER call without a stipend when they were billing those appys and gall bladders out of network. That has all gone away, but taking ER call without a payment from the hospital was not that long ago.

Specialist stipends for ED call have been around for a while (particularly for specialties like Urology, Optho, Hand, Plastics).

 

[neutro]

surgeon lurker here, I find the arguments about stipends/subsidies somewhat hilarious.

The hospital wants you to provide an unreimbursed service, namely to have you available at the drop of a hat to provide care. They are not subsidizing you, they are literally paying you for your availability. I have yet to meet any other person willing to be "on call" in any other field without being paid for it.

If I want a lawyer available 24/7, I pay for it. Ditto for a plumber, gardener, or literally anyone else. Asking a hospital to pay you for this service is not greedy, it's common sense.

I get paid to hold a pager for the ER. If they didn't pay me enough I'd happily give it up.

It all comes down to market dynamics. If anesthesiologists are oversupplied in an area and the contract is in demand, they can demand you throw in freebies like unreimbursed call to get their business. But make no mistake, that is what it is, you offering the hospital a valuable service for free in exchange for the rest of their business. If undersupplied, you can say F U, pay me. There are hospitals where ER call for surgeons is not reimbursed based on local oversupply and surgeons wanting the referral source/business. In academic centers, usually taking call is part of your "payment" for the privilege of telling your mom you work for Man's Greatest Hospital.

Well I hope you’d know CMS only reimburses anesthesia services 1/4th to 1/5th of commercial payors unlike surgery. The differential for surgery and other services is 15-30% less based on CPT. It’s not 1/4 or 1/5 which is from 1990s era. It’s archaic and ridiculously unfair. It will get worse with aging population.

Proposed solutions are more CRNA (which don’t really reduce cost of care), or reduced surgery (highly unlikely to happen).

Secondly, anesthesiologists do not really have any patient census so they’re not considered a referring service (hospital consider this as asset or equity and ability to derive ancillary revenue from this). So we are generally viewed as an expense. They view referring services and surgeons differently because they know that the marketing, work up, labs, facility fee will yield 3-4x their income from downstream revenue. Not the case for anesthesia unfortunately.

Again, anesthesiologists are viewed differently in this regard by hospitals compared to surgeons. The surgeon controls scheduling of procedure and therefore revenue generation from facility fee. This is why hospitals desire control of these services by employing them and want anesthesia companies to take on the risk of billing for these services.

Subsidy, income guarantee, etc is not the issue. The issue is real inherent value of “partnership” that’s dependent on handouts. Again each practice and set up is different, but this is why in-house anesthesia departments are popping up. Hospital admins are realizing that anesthesia management companies are just an expensive middle man.

It’s truly upto the local anesthesiologists and the hospitals and surgeons to see what’s the best set up for them. It may include AMC, it may be direct employment (where subsidy is built in), or it may be small PP (in small suburban hospitals with good payir mix).

It all comes down to market.

 

[medicine2wallstreet]

I guess the 100+ academic anesthesiologists working down the street from me should all quit, they earn in the low $300’s. They are down well over $1mil from us every 4 years. How could they do this to themselves? It’s so unfair. Maybe the salary is one component, maybe they’re willing to take the large pay cut year after year to keep the job they enjoy. There is no minimum wage or “fair wage” in anesthesia. if you enjoy the work, hours, and salary then stay. If you don’t, move on. Good luck to you.

Academia is different like the guy below you said.

In AMCs and true PP the overall work is similar. Thus pay should be similar is my point.

Doing 2:1 in academia with two CA1s in bariatric rooms should be compensated accordingly.

I'm not saying you made a bad decision. I'm just saying that not making fair market value while on the partner track is unfair in my opinion. Especially in today's market where 500k is almost standard across AMCs. And you aren't really buying ownership of a product like Amazon. You just get ownership of a payor mix.

 

[Dr. Rude]

Academia is different like the guy below you said.

In AMCs and true PP the overall work is similar. Thus pay should be similar is my point.

Doing 2:1 in academia with two CA1s in bariatric rooms should be compensated accordingly.

I'm not saying you made a bad decision. I'm just saying that not making fair market value while on the partner track is unfair in my opinion. Especially in today's market where 500k is almost standard across AMCs. And you aren't really buying ownership of a product like Amazon. You just get ownership of a payor mix.

Fair is a four letter word starting with F.
The market is what the market is.
Fair is a matter of opinion and depends on whose writing the check and whose cashing the check.

 

[Volatile]

Academia is different like the guy below you said.

In AMCs and true PP the overall work is similar. Thus pay should be similar is my point.

Doing 2:1 in academia with two CA1s in bariatric rooms should be compensated accordingly.

I'm not saying you made a bad decision. I'm just saying that not making fair market value while on the partner track is unfair in my opinion. Especially in today's market where 500k is almost standard across AMCs. And you aren't really buying ownership of a product like Amazon. You just get ownership of a payor mix.

I can assure you my job is nothing like the AMC’s I worked at previously. Night and day difference in workload. Thus why I never entertained any of their job offers. I’ve seen private practice and academic docs work much harder than me and some that don’t. you are correct, every job is different which is exactly my point. You can’t lump them together and say I should be making “x” amount, if I’m making less it’s unfair. What about the academic doc that’s gets a raise every year and ends up making much more than the incoming docs? They’re all doing the same job, often the newbies are working much much harder in academics and being paid less than the “full professors.” Looks like you’re still a resident, you’ll figure it out as you interview.

 

[Volatile]

Fair is a four letter word starting with F.
The market is what the market is.
Fair is a matter of opinion and depends on whose writing the check and whose cashing the check.

Exactly! Fair doesn’t exist in medicine nor does it exist in life. What’s “fair” for one person may be miserable for someone else. You either like your job and salary or you don’t. I know a guy making $700k a year to cover OB nights, he loves it. I wouldn’t do his job for double that.

 

[crash2500]

Academia is different like the guy below you said.

In AMCs and true PP the overall work is similar. Thus pay should be similar is my point.

Doing 2:1 in academia with two CA1s in bariatric rooms should be compensated accordingly.

I'm not saying you made a bad decision. I'm just saying that not making fair market value while on the partner track is unfair in my opinion. Especially in today's market where 500k is almost standard across AMCs. And you aren't really buying ownership of a product like Amazon. You just get ownership of a payor mix.

AMC and PP very different job. 50-60 hours per week vs 40-50. 8 weeks off vs 12-14. Being told what your practice is, vs control of your practice. No chance for increase in future earnings in AMC. Good private practice partners are making 25% more than AMCs and working 25 percent less.

 

[DazedWanderer]

Most academic places have tier salary. Base is low 300s if you do ZERO extra work.

The male worker bees tend to bunk their academic salaries to the 400s pretty easily.

Never read pure numbers. There truth is always somewhere in between.

Also remember work load.

Some academics are cushy. 1:2 90% of the time. Some get non clinical days.

I tell everyone to look at entire picture

Like the VA caters to young women who want or who have young kids and older docs. Many Va pays in the 320-350k range on the low side. But they have some chill lifestyle and can call out sick and pop out 1-2 kids and get 12 weeks paid off (outside of their standard leave).
Similar with academic’s especially if they work for state institutions. Very similar benefits and liberal leave policy.

Exactly. The advertised salaries for academics are usually not even close to the full picture. Low 300s, and people think wow terrible. They don't tell you that's the base for 35 hours per week and does not include any call, weekends, late pay, bonus, loan forgiveness, academic rank, etc. Many of these places your W2 earnings can be 50-100% above base if you include these shift stipends and incentive pay.