First topic: academics or private practice?

[JR]

First, I'd like to thank Andy for another excellent idea of this new sub-forum. We spent a lot of time on SDN discussing residency issues that we sometimes forget that it all is designed to lead somewhere.

For the first topic here I'd like to pose this question: in todays world of ever decreasing reimbursements, skyrocketing malpractice insurance, and increasing competition from other medical specialities, what do most current residents are thinking/planning on doing after graduation? I don't want this to become a "my way is better then yours" thread, I'd just like to hear people's reasons for what they are planning for the future.

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[ckyuen]

You know when you hear about starting salaries being so low, about 150k if you stop and think about how much money you lose your first year typically it's a very generous salary. I am 4 months into my job in private practice and luckily I have a tremendous amount of volume with my boss being out of town about one of every six weeks. I can see up to forty patients a day, average of about low 20's and do about 12-14 surgeries a week including lasers and minor procedures. With overhead averaging about 60% and me being in a extremely high cost of living area, you would have to collect conservatively 320k to cover your salary. add in benefits and you're more like at 380k. That's a lot of collections when you factor how many billable clinic days you have a year. about 225 when you take out holidays vacations and CME. I bust my tail to get referals and call every refering doctor to thank them for the referal and give them progress if they want me to see the patient the same day. I also take all walk ins, remember as a resident if your clinic closed at 5 pm and someone came in at 4:59 you would probably send them away. I just send my staff home and see the patient, especially if it's a referal. This has led to my volume building up much faster than average compared with new graduates and even with established MD's. But even with all this. It's really hard to collect 500k or take home about 200k. remember each surgery has post op visits that are unpaid, and in private practice people want results. I'm very lucky about 75 % of my cataracts come back 20/40 or better post op day one and about 50% are 20/25 or better post op day one. But have someone with K edema that you had to use hooks on and t blue on and I'll be in for a ton of post op visits to control that edema with po roids and aggressive topical steroids. The main thing is to love what you do, which I do, because of that I feel grateful for my "low starting salary". I did receive other offers and one from an HMO that was six figures higher than my current salary, but the socialized type of care did not appeal to me. I am much happier making six figures less than I would have been in the HMO where I would be penalized for providing the best care possible. Plus don't underestimate the power you have to get things done when you generate revenue and how your staff and the hospital will bend over backwards to make you happy. In an HMO good luck

 

[JR]

Thanks for your input ckyuen! I am glad you are enjoying private setting; can't wait to get there myself!

 

[medstud721]

12 cataracts a week($700/cat) = $436,000 in annual collections

25 pts a day(avg $100/pt) = $520,000 in annual collections

In your scenario you should be bringin in around $380K from your $950K in collections(40%) or you're getting burned.

Medstud

 

[Retinamark]

First, I'd like to thank Andy for another excellent idea of this new sub-forum. We spent a lot of time on SDN discussing residency issues that we sometimes forget that it all is designed to lead somewhere.

For the first topic here I'd like to pose this question: in todays world of ever decreasing reimbursements, skyrocketing malpractice insurance, and increasing competition from other medical specialities, what do most current residents are thinking/planning on doing after graduation? I don't want this to become a "my way is better then yours" thread, I'd just like to hear people's reasons for what they are planning for the future.

I always wanted to do academics, but the red tape is driving me insane. The crazy pedantic rules that IRB's use to hold up low or zero risk retrospective reviews are insane! It is making me seriously consider private practice instead. Why for example, should I have to get IRB approval to do a retrospective chart review or even to publish a simple case report?

 

[MPS]

Right, the red tape these days is amazing - it's changed for the worse since I started my PhD. The main problem with academia is that you're continually busting your gut to justify your existence - you need to get funding, publish and teach as well as see patients. In the UK, where your research performance is assessed 5 yearly, many medical academics find it hard to compete with their non-clinical colleagues.

 

[KHE]

12 cataracts a week($700/cat) = $436,000 in annual collections

25 pts a day(avg $100/pt) = $520,000 in annual collections

In your scenario you should be bringin in around $380K from your $950K in collections(40%) or you're getting burned.

Medstud

I'm coming over here from the optometry forum. (No, I'm not here to start a flame war or any of that lame stuff )

I read this post with interest. Older doctors screwing over young ones is fairly common in optometry. How common is it in ophthalmology or in other branches of medicine? I had a neurological condition a few years back and the neurologist that I was seeing told me that he got hosed twice by two different doctors when he was finished his residency.

Does medicine eat its young as much as optometry does?

 

[Retinamark]

I'm coming over here from the optometry forum. (No, I'm not here to start a flame war or any of that lame stuff )

I read this post with interest. Older doctors screwing over young ones is fairly common in optometry. How common is it in ophthalmology or in other branches of medicine? I had a neurological condition a few years back and the neurologist that I was seeing told me that he got hosed twice by two different doctors when he was finished his residency.

Does medicine eat its young as much as optometry does?

It definitely does happen, although hopefully it's not too common. THere are stories of young grad's joining a practice, doing lots of on call and seeing mostly blepharitis patients while the cataract referrals get fed by the secretaries to the old guy. Then when it comes time to consider partnership, the old guy says he doesn't think it will work out & gets a new victim. That's why it's really important to research a practice you consider joining. The drug & equipment company reps are great to talk to about this, because they often know the history of the practices they cover

 

[JR]

My understanding is that this is by no means uncommon. There is always a clause in the contract that lets the group not make you a partner at the end of certain period for whatever reason. And, just as correctly stated, there is always a "new victim" waiting to fill your shoes. I am strongly considering a solo private practice for that and many other reasons when I am done with residency. We'll see what happens...

It definitely does happen, although hopefully it's not too common. THere are stories of young grad's joining a practice, doing lots of on call and seeing mostly blepharitis patients while the cataract referrals get fed by the secretaries to the old guy. Then when it comes time to consider partnership, the old guy says he doesn't think it will work out & gets a new victim. That's why it's really important to research a practice you consider joining. The drug & equipment company reps are great to talk to about this, because they often know the history of the practices they cover

 

[ckyuen]

first your numbers calculation is very generous. I said 12-14 surgeries a week. not 12-14 cataracts. I did 2 cataracts, 4 pterygiectomies, 1 prp 1 focal , 2 lpi, one slt, one lid biopsy this week. 1400, 1500, 800, 500, 750, 280, 110. approx reimbursements. with mid 20's patients I usually have 2 half days of OR. so that's 4 days of clinic a week. Now remember with 12-14 cases. You have post ops. about 2.5 per a case per a week. not for the slt or lid biopsy only 10 day global so just about 1.25 post op visits per a week. Post ops on pterygia are a bear, much more post op work than cataracts. anyways for the 12 cases we are looking at about 27 or 28 post op visits a week I have b/c of my surgical volume. I see a lot of medicaid patients and the private insurer pays less than medicare for office visits. about 15% new patients for the 70 remaining visits or 10 new patients a week. also with medicare and the insurers here you can only bill one comp visit a year. so for new pts 10 of them about 10x100 avg, remember medicaid, and remaining 60 about 60 for 50 and 90 for 10. 1000, 3000, 900.
or 10240 a week. This does not include ancillary tests which are a lot of money. I just started this year and for a practice to build this quickly is pretty unusual. Most people I know see about a dozen people a day at the end of their first year. Now some weeks I have great weeks and collect almost twice the amount. some weeks not so good. my practice just got to this volume after 5 months. Also this assumes 100% collection. believe me this is unrealistic. Insurance companies deny just for the heck of it. Also How many docs work 50 billable weeks a year. None. take a way holidays we observe every holiday and then some state holidays, half day for christmas party, new years week, miscellaneous party here and there. and we have almost 14 holidays that's almost three billable weeks a year. 1 week cme, three weeks vacation, and we cut off about 7 billable weeks a year. so we have about 45 billable weeks. 45 x 10240 would be a lot of money but i did not have this volume for the first 5 months. also a lot of insurances find ways to not pay you your first year but changing dates you are par with them, costing you thousands of dollars. Please when people make those calculations, you have to take into account all of the variables.

 

[Retinamark]

Great post! That's very interesting. It's great to hear real life examples like this.
Only one thing I didn't understand though
- what excuses do the insurance companies use to not pay you in your first year & what do you mean by "changing dates you are par with them, costing you thousands of dollars"

 

[ckyuen]

They do a lot of things. For example if you code a pterygium but do not put progressive they will not pay saying it's not medical. They don't pay for allergic conjunctivitis, pinguecula, dry eyes. You have to put acute conjunctivitis nos, or spk which are covered. Another is that they will reject extended ophthalmoscopy with fundus photos some times, not always. Do a prp for pdr but if you don't list it as the first diagnosis they may send a rejection. Not always. It's very random. Some insurances will say many services like gonioscopy are bundled. Each has their own rules. Also they will send you a letter telling you, you're approved to be on their panel on february 1st, 2006, and here is your insurance provider number. THen on feb 21st they send you a letter that you are PAR with the insurance and for your prior three weeks you were not par so you will get the reduced nonpar rate like 20 buck for a comprehensive exam, no dollars for any surgeries.

 

[EYESURG]

That's just crazy. I hope you'll do great and for your practice to become better day after day. It's sad to see how medicine is being practiced now.

Why don't medical schools teach us all these loopholes and they spend most of thier time on alot of BS (in my openion) that we don't use in our future careers?

 

[ckyuen]

My residency focused on coding a lot but it is highly regional

 

[ckyuen]

I mean my residency focused on coding, but this was in Texas where the medicare carrier was trailblazer. Now i'm in the west and carrier is noridian and the rules are different.

 

[rubensan]

First, this is an excellent thread. We are very lucky to have ckyuen on this forum! A couple of questions (some dumb).

1. What does PAR stand for?

2. I like JR's idea of going solo after residency (though i secretly believe he is planning to become the next chair of doheny ). But, how much money do you have to front to go solo? What is the average cost of setting up shop?

3. What do people who are familiar with Kaiser think of working for Kaiser? After being there for 8 months (as an IM intern), the system, for all its flaws has many things going for it from a physicians stand point. You are salaried and you work for what you make. Malpractice, equipment, overhead is provided for you. Call is split with many. If they like you, they make you partner in 2 years. Sure your earning potential is significantly less when compared to the solo retina doc down the street, but i'm wondering if the hassel is less.

4. Anyone ever had a bad experience with non-compete or non-solicitation clauses?

 

[shiro1]

Well, there's a reason why coding courses at AAO meetings fill up so quickly. I'd recommend not only taking a class, but really studying your charge ticket. It's amazing what insurance companies choose to pay well for. They hardly make cataract surgery worthwhile, but pull out an eyelash and get $100! Whoo-hoo! Score!

 

[ckyuen]

No kidding, cut a lid lesion get almost 400 bucks, do a pterygium with conj autograft and get the same but it takes much longer. Office lacrimal procedures will make you wealthy quick but once you step into the OR to do that DCR you pay it back. My favorite words are doctor I have tears running down my cheek

 

[ckyuen]

Also this is why I advocate doing all types of procedures and not just focusing on cataracts. why b/c even getting 5 phacos a week is tough. and that won't make you rich. but add to that a couple of prps, focals, lpis, slt, probe and irrigate cannalicular system, epilation, lid lesion removals, pterygia, and you can build up quickly.

 

[ckyuen]

PAR means that not only do you have a number for the carrier to bill, but you have been approved to see their patients. That means you get the rates stated in your contract more or less, and patients with that insurance can see you and be covered.