Cataract Surgery Anesthesia Models

[dhb]

It doesn't happen here.

At a private hospital here a plastic surgeon was billing 100k/year through the hospital billing but was driving a Ferrari...
I would be completely shocked if surgeons in the US were not taking cash from patients under the radar.

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[nimbus]

What kind of free market USA capitalist bs is that?
Dont't tell me people are not taking cash from people on Medicare under the table because that's what happens here. Some university professors were notorious for not even looking at the patient if he wasn't coming in with a 5k€ enveloppe for their surgery.

I’d be open to accepting “tips” if it didn’t break any laws.

 

[nimbus]

At a private hospital here a plastic surgeon was billing 100k/year through the hospital billing but was driving a Ferrari...
I would be completely shocked if surgeons in the US were not taking cash from patients under the radar.

I’ve heard rumors that some surgeons at places like HSS have opted out and do not participate in Medicare….but it’s only rumors and I don’t have firsthand knowledge. It would be hard for an anesthesiologist to do that since we don’t get to pick and choose our patients and some patients have Medicare.

 

[deleted941485]

I’ve heard rumors that some surgeons at places like HSS do not participate in Medicare….but it’s only rumors and I don’t have firsthand knowledge.

I feel like that would be easy to find out

 

[deleted941485]

I’d be open to accepting “tips” if it didn’t break any laws.

In Eastern Europe this is relatively commonplace

 

[nimbus]

In Eastern Europe this is relatively commonplace

When I was an intern in NYC, one of my attendings received a gold Rolex from a patient who was a foreign diplomat.

 

[deleted941485]

When I was an intern in NYC, one of my attendings received a gold Rolex from a patient who was a foreign diplomat.

Cool. For everyone else there's always amazon gift cards.

 

[dantt]

we dont have a dedicated housekeeping team just for cataract. so it take time for them to come and mop. also need to wait for room to dry.
getting interpreter easily increases length of preop by 2-3x

a full day of cataract is ~6 cataract

Jeez. Hospital? Hospital is unfortunately not the appropriate forum for routine cataract surgery.

 

[DrOwnage]

Why do you need a good preop for a cataract? It's a cataract. Can you lay there for fifteen minutes without dying? Then you can get a cataract.

Why does it take an hour? It's a 10 minute procedure. And if there's an hour between cases why does the nurse not place the iv? Strange.

There's nothing worse than a preop nurse who can't put in an IV...

 

[nimbus]

There's nothing worse than a preop nurse who can't put in an IV...

NYC is a different world when it comes to hospitals.

 

[IMGASMD]

NYC is a different world when it comes to hospitals.

I loved drawing morning labs on my 7/10 patients, on a good day.

 

[deleted126335]

I loved drawing morning labs on my 7/10 patients, on a good day.

I think that the same Phlebotomist working there 35 years ago who did morning blood draws: Ms. Unable. Her colleague was Ms. Refused.

 

[IMGASMD]

I think that the same Phlebotomist working there 35 years ago who did morning blood draws: Ms. Unable. Her colleague was Ms. Refused.

That’s the pair!

I especially liked the vent unit. “Patient refused…..” I always wondered, how?!

 

[GassYous]

What kind of free market USA capitalist bs is that?
Dont't tell me people are not taking cash from people on Medicare under the table because that's what happens here. Some university professors were notorious for not even looking at the patient if he wasn't coming in with a 5k€ enveloppe for their surgery.

???

 

[Gern Blansten]

When I was an intern in NYC, one of my attendings received a gold Rolex from a patient who was a foreign diplomat.

When I was intern, I was admitting an older patient with mental status changes. When it was time for me to leave the room, he pulled out his wallet and said, “So, what do I owe ya’?”
Not sure why I still recall that but it’s the only time a patient has ever tried to pay directly. Had lots who brought food items for the team days later. Always struggled trying to remember if they were happy with their care at the time so we could know it was safe to eat.

 

[nimbus]

When I was intern, I was admitting an older patient with mental status changes. When it was time for me to leave the room, he pulled out his wallet and said, “So, what do I owe ya’?”
Not sure why I still recall that but it’s the only time a patient has ever tried to pay directly. Had lots who brought food items for the team days later. Always struggled trying to remember if they were happy with their care at the time so we could know it was safe to eat.

That’s what the medical student is for

 

[dantt]

When I was intern, I was admitting an older patient with mental status changes. When it was time for me to leave the room, he pulled out his wallet and said, “So, what do I owe ya’?”
Not sure why I still recall that but it’s the only time a patient has ever tried to pay directly. Had lots who brought food items for the team days later. Always struggled trying to remember if they were happy with their care at the time so we could know it was safe to eat.

What'd you tell em?

 

[Mman]

The private insurances in this market play much closer to Medicare.

there is nowhere in the US that private insurance is paying anywhere close to medicare rates for anesthesia services. Doesn't exist. Even in the horrible reimbursement states it is probably 3x-4x Medicare for most payors.

Another thing to keep in mind with those great independently insured CRNAs is that you will personally be on the hook for anesthesia malpractice in the event of a bad outcome. It makes no difference that you are not an anesthesiologist, you will be financially responsible for their actions/mistakes as the "captain of the ship".

 

[anbuitachi]

I don't understand anything you're saying.

It's a cataract. What needs to dry? What do you need to wash? It's a cataract.

The preop goes from 30 seconds to 1 minute? It's a cataract.

A full day of cataracts is 12-20. Because it's a cataract.

huh, the room needs to be mopped. even if a cataract. i thought thats jhaco rules??
do you guys routinely not have people clean the room, and the equipments including your monitors??

not uncommon for surgeon to have cash paying patients. i dont know how common it is for anesthesia

 

[anbuitachi]

Jeez. Hospital? Hospital is unfortunately not the appropriate forum for routine cataract surgery.

patients are super sick

 

[Urzuz]

patients are super sick

But…to quote @GassYous …it’s a cataract…

If they were alive in the outside world prior to you meeting them, they can have cataract surgery at an ASC

 

[dantt]

huh, the room needs to be mopped. even if a cataract. i thought thats jhaco rules??
do you guys routinely not have people clean the room, and the equipments including your monitors??

not uncommon for surgeon to have cash paying patients. i dont know how common it is for anesthesia

No hospital, no JHACO

 

[anbuitachi]

No hospital, no JHACO

!!

 

[nimbus]

No hospital, no JHACO

Usually our scrub tech or circulator or charge nurse will give it the 30second mop, not the 10minute hospital mop.

 

[dantt]

It is possible, depending on volume.

12 cataracts by noon is 48 base units + 24 time, most likely. That’s 72 total units. At Medicare rates ($23/unit) that’s $1656 by noon, for one room.

A retina (1 more base unit) or a plastics (1 less base unit, I think) room doesn’t typically have the volume and therefore the startup units to keep up with the cataract room.


I don’t understand why some of you are saying that won’t work for MD only, even at Medicare rates. If said again, prove it with math. This is at an ASC, so ASC hours. What’s the typical rate for 7-3 for a MD at an ASC? $1200-1500? The Medicare only cataract room beats that by noon with an efficient surgeon.

Also, to be clear, if a CRNA only group gets this contract and they do their own billing they’ll bill at the exact same rates and units as a MD, and therefore make MD money. Want to make sure @dantt understands that, though it doesn’t appear they have a lot of options which is the case for most areas of the country.

Reviving the thread as I had a little bit of down time and was chatting with one of the CRNAs today. What exactly are the income expectations of anesthesiologists these days? Our cataract volume is not great but the person said there's plenty of money, especially for the amount of work required; people are expecting to retire after working for a few years and that's just not realistic.

To give a little bit of an update, we hired the PE group. We've had far better coverage than we ever had over the past few years. None of the people rotating through are comfortable doing blocks so we do our own when need be. If patients have been complaining about out of network charges, we haven't been hearing about them too much. Ironically, the CRNAs are far more efficient than the older semi-retired MD anesthesiologists who participate. The anesthesiologists cancel patients left and right, most ludicrously for a patient chewing gum a few hours before surgery.

 

[dantt]

It’s a cataract!

But that’s why @dantt can’t understand why we want to bill “crazy” amount for it. Because…… it’s a cataract.

My life is wasting in front of me, after I give a “good” dose of whatever we give…..

Until that one that just can’t stay still…. I am “freaking out”. “Why am I not out, I’d prefer to be out….” “He’s moving…..”

no ****ing ****. The patient is alive, head is 6 feet away from me, and you want him to walk out in 20 mins. I am good, not THAT good. And guess what? If the patient needs general, we can do that. If the patient needs general AND to be intubated. I can do that too…..

This happens not infrequently, We have the nursing staff help hold them down while we work our magic. This has always worked. If it does not work, next best option would not be general anesthesia/intubation. It would be end case immediately and turf to university for them to do the patient under general anesthesia.

 

[nimbus]

Reviving the thread as I had a little bit of down time and was chatting with one of the CRNAs today. What exactly are the income expectations of anesthesiologists these days? Our cataract volume is not great but the person said there's plenty of money, especially for the amount of work required; people are expecting to retire after working for a few years and that's just not realistic.

To give a little bit of an update, we hired the PE group. We've had far better coverage than we ever had over the past few years. None of the people rotating through are comfortable doing blocks so we do our own when need be. If patients have been complaining about out of network charges, we haven't been hearing about them too much. Ironically, the CRNAs are far more efficient than the older semi-retired MD anesthesiologists who participate. The anesthesiologists cancel patients left and right, most ludicrously for a patient chewing gum a few hours before surgery.

From an anesthesia perspective, eye centers are not interesting or lucrative. Many anesthesiologists find it a poor use of our training. There are much better places for anesthesiologists to work. As you witnessed, it is where unmotivated/uninterested anesthesiologists go out to pasture before the nursing home. We just left an eye center. Think of the most underpaid, uninteresting, and tedious part of ophthalmology. That is what eye surgery is to anesthesia. It should be better compensated to make up for the incredible boredom.

 

[Southpaw]

Reviving the thread as I had a little bit of down time and was chatting with one of the CRNAs today. What exactly are the income expectations of anesthesiologists these days? Our cataract volume is not great but the person said there's plenty of money, especially for the amount of work required; people are expecting to retire after working for a few years and that's just not realistic.

To give a little bit of an update, we hired the PE group. We've had far better coverage than we ever had over the past few years. None of the people rotating through are comfortable doing blocks so we do our own when need be. If patients have been complaining about out of network charges, we haven't been hearing about them too much. Ironically, the CRNAs are far more efficient than the older semi-retired MD anesthesiologists who participate. The anesthesiologists cancel patients left and right, most ludicrously for a patient chewing gum a few hours before surgery.

Income expectations are MGMA numbers. No different than you. You can google it. Medicare pays us, as a % relative to commercial, much less than they pay you. It's not a good combination when you add in the boredom that comes with eyeball anesthesia. Retiring after 'working a few years'? Come on dude, don't go to hyperbole so quickly. The extreme large majority of physicians are not retiring after a few years. Most of us are paying off increasing amounts of student loans for increasing amounts of time.

Comfortable doing blocks? You mean retrobulbar? Dude, needles in and around the eyeball are in your job description, not mine. My experience is that 99% of cataract surgery that I'm involved with is topical and a little versed for the 10-15 minute procedure.

I'm glad you're happy with your CRNAs. Keep them. My guess is over time they'll ask more and more and the relationship won't be so rosy. That's been my experience. I hope for your sake I'm wrong. Also, don't mistake efficiency for safety. Just because someone is doing what you want when you want it done doesn't make it right for the patient. I hope you can see that. Maybe you can't. Either way, best of luck.

 

[deleted875186]

I don’t think the risk of an anesthesiologist doing a retrobulbar block is worth it, if I was a patient I wouldn’t want my anesthesiologist doing one. Most anesthesia residents don’t ever get exposure doing them. There was a recent case below I think was brought up here before about an anesthesiologist doing eye blocks.

Anesthesiologist linked to West Springfield blindings loses medical license

An anesthesiologist linked to West Springfield eye surgeries that caused five patients to lose vision has resigned his medical license.

www.masslive.com

 

[kidthor]

Reviving the thread as I had a little bit of down time and was chatting with one of the CRNAs today. What exactly are the income expectations of anesthesiologists these days? Our cataract volume is not great but the person said there's plenty of money, especially for the amount of work required; people are expecting to retire after working for a few years and that's just not realistic.

To give a little bit of an update, we hired the PE group. We've had far better coverage than we ever had over the past few years. None of the people rotating through are comfortable doing blocks so we do our own when need be. If patients have been complaining about out of network charges, we haven't been hearing about them too much. Ironically, the CRNAs are far more efficient than the older semi-retired MD anesthesiologists who participate. The anesthesiologists cancel patients left and right, most ludicrously for a patient chewing gum a few hours before surgery.

I agree with the others... I'm never going to do an eye block, that's in the domain of optho surgeons. Feel free to have the CRNAs doing your optho blocks for you and good luck trying to throw the blame on them when things go wrong. Imagine explaining to a jury why the board certified eye expert left highly dangerous eye injections to a poorly trained non-physician - laziness is going to be your only answer.

 

[coffeebythelake]

I agree with the others... I'm never going to do an eye block, that's in the domain of optho surgeons. Feel free to have the CRNAs doing your optho blocks for you and good luck trying to throw the blame on them when things go wrong. Imagine explaining to a jury why the board certified eye expert left highly dangerous eye injections to a poorly trained non-physician - laziness is going to be your only answer.

And under supervision of said ophthalmologist. So no way getting out of blame.

 

[dantt]

An interesting complaint I saw. So we have tons of medicare and medicaid patients. Not so many commercial insurance patients. Are those anesthesia groups that follow the out-of-network for all insurances model out-of-network for medicare advantage too? Do the groups send blanket potential out-of-network notices to everybody or just the ones who are actually out-of-network? We do actually have a fair amount of medicare advantage. At least as far as clinic and surgical billing and coverage goes, we have to follow all of the same rules for medicare advantage as for the commercial payors (some restrictions on procedures, prior authorizations, etc).

 

[Hoya11]

An interesting complaint I saw. So we have tons of medicare and medicaid patients. Not so many commercial insurance patients. Are those anesthesia groups that follow the out-of-network for all insurances model out-of-network for medicare advantage too? Do the groups send blanket potential out-of-network notices to everybody or just the ones who are actually out-of-network? We do actually have a fair amount of medicare advantage. At least as far as clinic and surgical billing and coverage goes, we have to follow all of the same rules for medicare advantage as for the commercial payors (some restrictions on procedures, prior authorizations, etc).

yes the reimbursement for medicare advantage plans and even commercial medicare plans (like united medicare) is not significantly different from regular medicare and often exactly the same. So it would make sense to be out of network with them all.

I would imagine that the notice to the patients comes at the level of the ASC. Meaning that if a case is booked at the ASC for a patient with a medicare insurance plan, then the ASC secretary tells the patient that the anesthesia is out of network, it costs X, and this is the contact info if they have any more questions.

this thread is making me think i should go out of network... hmm... as the surgeon would you be pissed if the anesthesia group did this??

 

[coffeebythelake]

this thread is making me think i should go out of network... hmm... as the surgeon would you be pissed if the anesthesia group did this??

Since the surgeon will hear the brunt of the complaints about the billing i would imagine so.

 

[dantt]

yes the reimbursement for medicare advantage plans and even commercial medicare plans (like united medicare) is not significantly different from regular medicare and often exactly the same. So it would make sense to be out of network with them all.

I would imagine that the notice to the patients comes at the level of the ASC. Meaning that if a case is booked at the ASC for a patient with a medicare insurance plan, then the ASC secretary tells the patient that the anesthesia is out of network, it costs X, and this is the contact info if they have any more questions.

this thread is making me think i should go out of network... hmm... as the surgeon would you be pissed if the anesthesia group did this??

To clarify this particular anesthesia group is in network with medicare and medicaid but out of network with all commercial insurances. I never asked about the specifics but heard a recent complaint from a medicare advantage patient about being sent an out of network notice. I don't know if they got an out of network notice because they were actually out of network or whether this was a blanket statement letting everybody know that they may be out of network regardless of whether they actually are. Can you for example be out of network with united health care but in network with united health care medicare advantage? I didn't want to probe the details of this particular complaint as I don't have a stake in the surgical center but am forced to operate there anyways as an employee...for now...

 

[Hoya11]

To clarify this particular anesthesia group is in network with medicare and medicaid but out of network with all commercial insurances. I never asked about the specifics but heard a recent complaint from a medicare advantage patient about being sent an out of network notice. I don't know if they got an out of network notice because they were actually out of network or whether this was a blanket statement letting everybody know that they may be out of network regardless of whether they actually are. Can you for example be out of network with united health care but in network with united health care medicare advantage? I didn't want to probe the details of this particular complaint as I don't have a stake in the surgical center but am forced to operate there anyways as an employee...for now...

yes they are different plans, you can choose to be out of network with the UHC medicare but still in network with medicare. But not a lot of that situation makes any sense to me..

 

[dantt]

yes the reimbursement for medicare advantage plans and even commercial medicare plans (like united medicare) is not significantly different from regular medicare and often exactly the same. So it would make sense to be out of network with them all.

I would imagine that the notice to the patients comes at the level of the ASC. Meaning that if a case is booked at the ASC for a patient with a medicare insurance plan, then the ASC secretary tells the patient that the anesthesia is out of network, it costs X, and this is the contact info if they have any more questions.

this thread is making me think i should go out of network... hmm... as the surgeon would you be pissed if the anesthesia group did this??

As a surgeon with a reputation I don't like it...but at the same time, it's far better than paying a stipend to anesthesia. The only reason I can imagine it would make sense to be in network with medicare advantage is there are so many patients with it wed get complaints left and right or there were otherwise rules that would force them to take medicare advantage if they take medicare but that doesn't seem to be the case with the office/surgical side.