miamimd07

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Hi,

I've been hearing a lot of conflicting stories form practicing GI's about the lifestyle and overall satisfaction of their jobs and I was hoping someone could shed more light on the subject for me.
I was talking to a practicing GI in southern Cali,and he was telling me that the insurance companies are really cutting down (and will be continuing to do so) on the compensation for endoscopies, colonoscopies (i.e. all the way down to $150 and $400 respectively), etc. to the point where he is forced to work about 10-11 hours a day to make a decent living. Also, he claims that even afer practiicng for 25 years, it's difficult for him to find patients all the time and that he still needs to go around from different hospital to hospital ER's at times to get new patients- My question is, is this the norm, or is it simply because he's in a saturated market?

Also, how good can the lifestlye of a GI be out in private practice? Do you have to be prepared to work 10 hours + days for the good majority of your life, or is it more that you need to work your tail off for the first 5 years or so to build up your name, and then you have the option of doing mostly outpatient procedures and clinics, and not so much inpatient work?

Thanks
 

gbear97

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miamimd07 said:
Hi,

I've been hearing a lot of conflicting stories form practicing GI's about the lifestyle and overall satisfaction of their jobs and I was hoping someone could shed more light on the subject for me.
I was talking to a practicing GI in southern Cali,and he was telling me that the insurance companies are really cutting down (and will be continuing to do so) on the compensation for endoscopies, colonoscopies (i.e. all the way down to $150 and $400 respectively), etc. to the point where he is forced to work about 10-11 hours a day to make a decent living. Also, he claims that even afer practiicng for 25 years, it's difficult for him to find patients all the time and that he still needs to go around from different hospital to hospital ER's at times to get new patients- My question is, is this the norm, or is it simply because he's in a saturated market?

Also, how good can the lifestlye of a GI be out in private practice? Do you have to be prepared to work 10 hours + days for the good majority of your life, or is it more that you need to work your tail off for the first 5 years or so to build up your name, and then you have the option of doing mostly outpatient procedures and clinics, and not so much inpatient work?

Thanks
I'm rotating through colorectal service rt now, and I've heard attendings discuss whether nurse endoscopists will take over endoscopic procedures for GI docs. According to them, our current healthcare system cannot afford to colonoscopically screen the US population the way it should in accordance with current AGA guidelines.

Furthermore, there is a dearth of endoscopists in certain regions where people need services. Britain already successfully uses nurse endoscopists; a wealth of literature shows no significant difference between their outcomes tete a tete GI docs (recent NEJM). While one of my attendings rejected the notion that the AGA would ever relinquish such a lucrative part of their work, it's worth considering what's best for the patient population as a whole. You never know how your chosen field might change, but hopefully there is enough you enjoy about it to weather these changes.

Also, some of the lucrative procedures (e.g., ERCP, EUS) require more extensive training and regular maintenance of acquired skills. If you envision yourself doing these things, you may need to be associated with a high-volume hospital where you can maintain proficiency -- do a PUBMED search on incompetency --> morbidity in ERCP.

As far as your interest in private practice, medicine is like many other fields --if you've earned a reputation amongst your peers and clientele as an excellent physician, then patients will come find you. Thus, do something you enjoy and will excel at.

This is just what I've heard at my particular institution, take it FWIW. Hopefully a GI fellow roaming on SDN can better answer your questions.
 

wasatch

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I am looking to do private practice. Can anyone give me an idea what reimbursements are for doing screeing colonoscopies with and without biopsy. I want to see if it true that the fees have gone down so much that it is becoming cost prohibative to do this service. Thanks.
 
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core0

Which way is the windmill
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I'm rotating through colorectal service rt now, and I've heard attendings discuss whether nurse endoscopists will take over endoscopic procedures for GI docs. According to them, our current healthcare system cannot afford to colonoscopically screen the US population the way it should in accordance with current AGA guidelines.

Furthermore, there is a dearth of endoscopists in certain regions where people need services. Britain already successfully uses nurse endoscopists; a wealth of literature shows no significant difference between their outcomes tete a tete GI docs (recent NEJM). While one of my attendings rejected the notion that the AGA would ever relinquish such a lucrative part of their work, it's worth considering what's best for the patient population as a whole. You never know how your chosen field might change, but hopefully there is enough you enjoy about it to weather these changes.

Also, some of the lucrative procedures (e.g., ERCP, EUS) require more extensive training and regular maintenance of acquired skills. If you envision yourself doing these things, you may need to be associated with a high-volume hospital where you can maintain proficiency -- do a PUBMED search on incompetency --> morbidity in ERCP.

As far as your interest in private practice, medicine is like many other fields --if you've earned a reputation amongst your peers and clientele as an excellent physician, then patients will come find you. Thus, do something you enjoy and will excel at.

This is just what I've heard at my particular institution, take it FWIW. Hopefully a GI fellow roaming on SDN can better answer your questions.
It is unlikely that nurse endoscopists will take over. The nurse endoscopists in Britian do Flex sigs. There is now significant liability in doing this if colonsocopy is available (there was an article in one of the FP magazines equating it to malpractice). There is a danger that FP physicians may start doing them which has happened in some parts of the country depriving Gastroenterologists of there referral base. Both AGA, ASGE, and ACG are against anyone but colorectal surgerons and GI doing endoscopy.

Their are people that don't make money doing GI. Explanation - I am not a partner or a physician and don't see the practice financials, but I have worked for a very successful practice for four years and seen a number of successful and unsuccessful practices. The average reimbursement for medicare for a colonoscopy is around $170. So from a practice perspective if you are doing one colonoscopy an hour you are making less than a FP. Most of the unsuccessful practices use a very inefficent hospital based endoscopy center. If you have an efficent center you should be able to do a colonoscopy every 1/2 hour which at $340 an hour is more than an FP can dream of. Now this is for medicare. More patients are shifting to private plans with medicare part D. These pay the same as the negotiated rate with the plan. This is where the regional variation comes in. If you are in an area of oversupply then you may get less than medicare. If you are in an area of undersupply then you can get substantially more.

Now also remember in your clinic you see mostly consults as opposed to follow up. These have pretty nice renumeration $200-400. You can extend this further by getting a mid-level :) to see patients with chronic conditions such as HCV, IBD, or IBS which take a lot of time and do not reimburse well. A well trained mid-level can also see simple consults allowing you to shift more time into the endoscopy center. Also if you can generate a lot of upper endoscopy business then those reimburse better (same reimbursement but takes 15-20 min = 3-4 per hour).

Now the real trick to a successful (at least financially) practice as I see it. Own you own endoscopy center. There are two components paid in a colonoscopy. One is the professional fee and the other is the facility fee. If you have your own center then you collect both fees. The facility fee is $300-700 so you also have to be able to run your center for less than that. This is where having a good manager is paramount (unless you want to do this yourself).

As far as the lucrative procedures such as EUS or ERCP the problem is that they take longer for only slightly more money and have to be done in the hospital (see facility fee above). So there is some money there but it is not a pot of gold. That being said being able to do EUS will make you more marketable and being able to do ERCP will make your partners less likely to hate you.

Good luck

David Carpenter, PA-C
 

wasatch

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What areas of the country are good for opening a private practice endoscopy suite? I would think the larger cities out in the suburbs would be best. Are there any studies that show the density of GI docs in the country?

I thought medicare paid higher than just $170 per scope. That is not very good. What do private insurers pay per scope? Most of the patients will be older than 50 years and retired. I don't think most of these people will have any private insurance. Man, I hate this medicare/insurance crap. I guess that is why I need a good manager.
 

core0

Which way is the windmill
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What areas of the country are good for opening a private practice endoscopy suite? I would think the larger cities out in the suburbs would be best. Are there any studies that show the density of GI docs in the country?

I thought medicare paid higher than just $170 per scope. That is not very good. What do private insurers pay per scope? Most of the patients will be older than 50 years and retired. I don't think most of these people will have any private insurance. Man, I hate this medicare/insurance crap. I guess that is why I need a good manager.
The medicare rate is determined by your region, but most pay in the range of $170-200 from what I understand. The private insurance rates are negotiated at a rate of % of medicare. If you are in a good market 130-140% is supposed to be achievable. Bad market you are looking at 80-90% of medicare.

You are hopefully looking at joining a practice that already has an endoscopy centers. Some of the larger practices have multiple centers. Hopefully someone that understands the business is making these plans.

I was discussing this with my supervising physician today and he stated that he doesn't see how you can make money without a center. I pointed out without a center you are better off doing more consults and less endoscopy unless you can find a good center.

I have also seen the problem with joint venture centers recently. One of the major insurance companies and one of the major hospital systems are having a pissing match so the insurance with 35% of the market cant use the hospital system. This also applies to joint venture surgery or endoscopy centers. So 1) the physicians don't have a place to do endoscopy or if they have privleges in another hospital they are trying along with everyone else to book time. And 2) they are still responsible for 50% of the costs despite not earning anything there. Pretty sorry state.

David Carpenter, PA-C
 

docmeek

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I am a practicing colorectal specialist.

There are not enough specialists to do procedures/colonoscopies and one of two things will happen. Either primary care physicians will do them or physician extenders. It has to happen one way or the other. There is a current backlog that is enormous and the demographic suggests it will get far worse.

My bias is primary care physicians. Both the ACG and the ASCRS have position statements on how this training should occur to ensure safety and efficacy. They are not "completely against anyone but specialists doing it." Some specialist physicians feel threatened but the liability in colonoscopy is very small and I know the real numbers primary docs would pay to be able to do them, at least in my state.

My opinion: Change is good, no matter if you feel threatened. Let's stop people from dying from colorectal cancer!!

Dr. M
 
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