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Discussion in 'Anesthesiology' started by wtyson, Mar 25, 2014.
Out of all the back and forth comments i've read in all the threads,this one has been the most straight forward,practical and encouraging.Thankyou,anesthesia is back on my menu.
Not my experience. What leads to administrative doors is being on committees in the hospital. Being at the meetings where you interact with the suits. They get to know your name, like you, etc. Our hospital has several older docs that are high up in administration. Universally they were all chief of staff at one point. They all set on various executive committees. They gradually worked their way up. Nothing to do with what type of doc or what revenue they generated. In fact most of them didn't generate much revenue (if any), but they were good at the politics of maneuvering in a large health system. If you want to end up as a CEO type than you need to go get an MBA and work you way up through corporate gigs that have nothing to do with being a doc.
But the regular old administration stuff? That's right up the alley of a hard working anesthesiologist. Unlike an orthopedic surgeon or cardiologist that might bring in revenue, you are in the hospital every day of the week and they see your face a lot more. Big name ortho surgeon might be in house only a few days a month when not in clinic or the ambulatory surgery center. Get on committees, be chief of staff, and get to know the higher ups.
As to the original topic, I have no idea what the future job market holds. The job market historically has had 3 major options. Work for academic department at a medical school, partner/track in a private group, or employee of either AMC or private group. I suspect it will continue to slowly morph away from the parternship option and more towards the last option. Not for all jobs, but for more.
In anesthesia as well as medicine, it's perpetual doom and gloom. If you read threads from this very forum 10 years ago people were talking about imminent single payer health system, drastic cuts to reimbursement, etc. 25 years ago it was even worse but their were no forums to talk about, we only know from asking those that were there and seeing the huge drop in residency slots filled.
I have no idea what the future holds. If you'd be happy working for a medical school department or working as an employee of an AMC for a reasonable paycheck of $200-$300K for 45-55 hours a week, then you will probably be happy regardless as long as you like the day to day job of being an anesthesiologist. If being your own boss and owning your own business are important, you probably won't be happy.
Here's your future:
Which may work for some; not I. If I didn't own my anesthesia group and have complete control over every aspect of it, I would quit medicine.
Tell us what specialties are NOT losing autonomy/being bought out. This is the state of medicine in general.
Why? You dislike the day to day job of caring for patients in the OR? Don't get me wrong, I thoroughly enjoy the business aspects of being an owner of a group. But if I couldn't, I'd be perfectly content as an employee of an AMC provided the pay was appropriate for the level of work I was doing. Let's be honest, it's not like most of us can just drop out of medicine and go find a $300K per year job doing something else next month.
It's just a tough situation for most of us to wrap our heads around, especially most of the prior generation. I'm sure most of us didn't graduate medical school thinking, "Oh it's going to be so great working FOR someone." Don't get me wrong, our salaries are excellent and even the bottom portion of our salaries are better than 90% of working people in this country. The thing is, like most of our medical colleagues who have control over their practice/lifestyle/etc, anesthesiology is becoming a field where doctors are being told how to do things by some guy in a suit in an office building somewhere MAKING BANK. We're becoming a field where we'll always have to answer to someone. Unless you go into pain and open your own practice, get ready to be just another working stiff. Basically, we're renters.
Scratch that. The better comparison is sports. Anesthesiologist are the athletes. We get paid well, and a few of the superstars may get some perks, but we'll never own the team.
The bottom end of our salaries is better than 99% of working people in the country (or at least 98%). And the rest of medicine is ending up in the same boat we are in. We don't see it because we aren't in their shoes, but it's gradually happening more and more. Anesthesiology isn't special in that regard.
It's modern medicine and it's unfortunate. I can't think of a specialty that is not increasingly shifting towards working as an employee of somebody else.
At our expense, there's a joke/analogy about the Charlotte Hornets in there somewhere.
Don't give up just yet. Some of us are still fighting the good fight...
Dear (anesthesia group) Board Member,
We are concerned (anesthesia group) shareholders who have taken an active interest in the valuation and potential sale of our company. As partners in what we consider the best and most equitable anesthesiology group in the country, we believe that the unprecedented valuation of (anesthesia group) not only runs contrary to its founding principles, but also discards the years of hard, dedicated work by those who have made our group exceptional.
The concept of fairness is as integral to (anesthesia group) today as it was at its founding in (date). This is not to be dismissed as some naive idealism but is the fundamental reason why we have been able to recruit and hire the best anesthesiologists in the country. Rumors of an impending sale have led to an impaired ability to hire new high-quality anesthesiologists. Fractures have begun to develop in the relationships between our partners, and are beginning to degrade the morale of our management company employees. As such, our future and the future of (anesthesia group) is dimming. Continuing to proceed with a sale is a disservice to ourselves, our legacy, and the community of (somewhere in the US).
So why then, are we even considering this? The main reason we are given is a predicted decrease in anesthesiologist compensation. This fear, combined with the allure of immediate financial reward, has prompted anesthesia groups across the country to sell themselves to outside business interests. Past forecasts, especially those concerning healthcare, have only proven the folly of prediction, as have the purported benefits of working for an anesthesia management company. From a purely financial point of view, why would a business interest, whose very existence is predicated upon the concept of return on investment, be interested in investing in a revenue-losing proposition? It simply doesn't make sense. The physicians are the losers in this zero sum game.
We would prefer to explore a more positive and long-term solution to the future, using the talents and motivation of our two hundred and forty-five member group to remain physician-leaders in anesthesiology and in the (regional) healthcare marketplace. In a time and age where medicine and the practice of anesthesiology are rapidly changing, we continue to hold fast to our core beliefs and our commitment to ourselves, our profession, and our community.
While we acknowledge the fact that new, competitive forces have emerged and our practice may be facing real challenges, we do not believe it is in our collective best interest to sell our company. We strongly believe that (anesthesia group) has the resources that will allow us to be adaptable and successfully navigate the challenges that lie ahead. We thank you for all of your hard work and efforts and look forward to working with you in further strengthening our company.
Sincerely, (names deleted)
What are AMCs going to do about bundled payments? Right now they can negotiate better reimbursement rates than small groups. Without that ability to get paid more for the same work, they have no competitive edge, and nothing of value to offer hospitals. Or if single payer comes about, same thing.
Anesthesia practices getting bought out and bid up like tulips ...
I'd really like to know the answer to this question. Are AMCs just out to make a quick buck with no long term strategic planning?
They have more negotiating power than any group in regards to private contracts as well as bundled payments. Who is in a better situation to tell a hospital or insurance company to stick it on a bundled payment proposal? A private group where that hospital contract composes 100% of their income or an AMC where it's BFD as a small percentage of their revenue?
That's actually part of the reason I think hospitals are going to try to turn away from AMCs in the next 5-10 years. They can't muscle them as easily as they can a private group. The independent private group is far more likely to work with the hospital (i.e. take slow prolonged cuts to their income).
They will better at leveraging their noncompetes. Small groups that are owned by the docs will often acquiesce and consent to be employed by the hospital AMC and not enforce their noncompetes. A corporate owner that controls all the noncompetes is less likely to fold.
Noncompete enforceability varies a lot by locale, doesn't it?
Seems like powerful motivation for hospitals to want nothing to do with AMCs.
I've read the argument here many times that an anesthesia group has exactly one asset of value - a contract with a hospital. And maybe a noncompete clause, IF enforceable.
I'm just wondering what's going to happen to all these private equity investors backing AMCs when the day comes that a hospital has no reason to keep the AMC around.
Is this practice buying frenzy just typical stock trader mindset, plow money into something in the hopes of a short term profit, before selling and leaving someone else with an asset with no intrinsic value? Can't get tulips out of my head.
It isn't "stock market trader", it's hedge funds. That's what they do. The buy an asset that they can leverage the value of and resell for a profit. Their usual timeline isn't more than 3-5 years. They have no interest in long term riches.
Non compete enforceability does vary. When enforceable, they provide incredible leverage. If I owned an AMC, I would think twice about entering a market where they weren't enforceable, unless there were fat guarantees so I made money even short term. I would hate to invest and be the fixer of the hospital's problem and then have the practice taken out from under me a few years later just as I was beginning to recoup my investment. If the hospital sees no reason to keep the AMC around after bundled payments, they will have to buy out the noncompete- or get a whole new department of providers.
I agree with Mman. I will fight to maintain our salaries, but under a "worse case scenario", with no debt and a house paid (or nearly paid off), I would be happy in my role either Medically Directing (as now) or even better, sitting my own cases for 250-300K/year. I enjoy anesthesia quite a bit.
Now, of course, we are worth MORE than that, but some things are beyond our control. So, if it came to that, I'd be o.k. I think.
And your post is exactly why groups are selling out. Why risk the unknown when an AMC will cut you a check for $2 million on the spot? Many groups are feeling the pressure all around: more regulations, more documentation, lower Medicare reimbursement and tougher negotiations with insurance companies. If the group is a premium one the partners can get an equity stake in the AMC making the sale more palatable. If the group isn't a premium one then the partners get a big fat check and guaranteed salaries for up to 7 years.
Groups receiving no subsidy and willing to increase services if asked by administration without demanding any compensation/stipend can continue to do business as usual. But, even those groups should consider merging with other groups to cope with the increasing regulation and get better reimbursement. Honestly, going it alone just doesn't make as much fiscal sense as it used to.
I've posted over and over again that AMCs will keep gaining market share. There will always be true private practice groups but their numbers are dwindling. Anyone going into this field needs to be realistic about his/her job post residency.
Half of all graduates in 2019-2020 will be employed by an AMC, hospital or academic center. That percentage will likely continue to increase with each graduating class until it reaches about 3/4 of the market. That's likely the saturation point.
For those of us thinking of anesthesia --> pain, crnas can now do pain fellowships.
This is exactly why AMCs will eventually collapse. None of them have been designed to be sustainable from the beginning, and once bundled payments come, there's no reason to have them around.
But isn't part of their spiel, "We'll fight for you and protect you when bundled payments come."
And that's exactly why they'll crumble. Hopsitals will go back to small groups with less bargaining power once bundled payments hit so that they have the upper hand in negotiations.
Not exactly. American has been in the business of running medical groups for a long time. It's not like they just started 4 years ago. They used to be just NICU docs I think. But there are distinctly different groups that have been purchasing anesthesia groups. Actual financial groups and hedge funds started getting in the game a few years ago looking to make a quick buck. I think that's different than the traditional AMCs that look at their purchases as long term cash generators.
If the AMC model collapses I think it will be from hospitals rebelling against it and having to deal with a massive corporation instead of just talking to the docs down the hall.
Hospitals will not go back to small groups with less bargaining power. Hopsitals themselves are consolidating into behemoths. What is more likely is a hospital will employ their own anesthesiologists...much like they are employing all of the surgeons. Then they don't have to bother negotiating at all with physicians.
Also likely. I'm honestly surprised AMCs ever even became a thing, as hospitals could easily have done this already and cut out the middleman.
In my state it is actually illegal for hospitals to directly employ physicians. Not sure if this is also the case elsewhere.
Around here they usually get around it by having a hospital group that they own in all but name, with which they have an exclusive contract that employs all physicians of all specialties within the hospital.
Ok so essentially like the Kaiser/Permanente Medical Group arrangement.
Exactly like that.
You are correct. Bundled payments are the primary driver of this. The insurance companies and government will send the lump sum of money for everything to the hospital and the hospital will dole it out as they see fit. Docs of all specialties will just end up employees of mega hospital systems. Big hospitals will continue to acquire small community hospitals around them.
We will basically end up with each area having a dominant hospital system (or a handful depending on the size of the city) that controls local health care and the dollars that flow into and out of it.
All you have to do is go to gaswork.com and it will almost immediately become clear to you that anesthesia is alive and well and most likely will be for quite some time. Will there be pay cuts? Maybe, but not anytime in the immediate future. IF it happens it will be insidious. This further highlights the need for future and current anesthesiologists who are active in the political community. We should all work together to ENSURE the future of the specialty, rather than sit back and speculate as to what may or may not happen to us.
Aren't most of those jobs amc jobs?
Gaswork.com is proof the specialty is sick and dying. Pay is low and most of the jobs are not good ones.
No idea what you're on about... It looks pretty good from where I'm standing. People have been dooming and glooming over this subject for decades.
Sort of like when a manufacturer moves a business to China: it looks real good to the Chinese and those businesses.
A specialty which pays 30-50% less today that it did just 5 years ago is in decline. While many specialties may be in decline Anesthesiology is in a steep decline.
With AMCs taking over the specialty the non physicians will take a bigger and bigger cut of the pie which leads to declining wages.
Will the pay level out? Yes, the market will force the decline to eventually level off as the companies won't be able to find new talent (such as yourself) to fill the vacancies.
The advertisements on Gaswork show the transition from a private practice type employment to a Management based one (hospital or AMC).
The paradigm shift in Anesthesiology is in full gear with most looking at "employee status" post Residency.
Salaries in the 200-300s is great if you are not just starting to save for retirement in your 30s, have been able to put equity into a home, and do not have over 300K in student debt. You're better off getting a middle management job somewhere for salary around 120k while working a lot less hours with a lot less stress. The real problem is that in medicine you now have a system where a few at the top are making a lot of money off the backs of a lot of hardworking doctors at the bottom while seeing none of the liability.
The loss of salary is a symptom of a much larger problem in medicine, which is the loss of autonomy. Doctors used to make a lot more because they had control. Medicine has become corporatized and so heavily government regulated that doctors have been reduced to relatively interchangeable cogs in a broken system. The loss of salary is just the most objective symptom of that change.
Even Blade admits that the future is reasonable if your expectations are reasonable. I agree with you, however, in that most new grads know we are not likely to get rich (subjective to be sure) in this field. But, it's still a very cool profession. I'm happy I chose it and for sure see that the grass is NOT always greener on the other side of the specialty spectrum.
It's useless to dwell on doom and gloom issues. Be active, and contribute to the state and national PACs. That's all you can do. Be a leader. Stay sharp. Lead by example. Work hard and take some pride in what you do. It's all you can do.
I make a very comfortable living. In the future it MAY be just a comfortable one instead of a VERY comfortable one.
You are f.cking crazy if you think that some chump middle manager making $120K/year doesn't have a boat load of stress. If anyone at that level and that salary range DOESN'T have stress, then lets just say that ignorance is bliss. He/She likely has a bullseye on his back by the young hotshot VP who has a great proposal to the senior VP on how he can save the company $1million over the next year by letting the low level manager do that job for $60K/year.
All that is happening is that market forces are entering medicine, which is somewhat new in terms of the impact being felt by physicians.
LOL! You must be joking? This sounds like something someone would say whose been making >500k their entire career and completely out of touch with reality. I'd rather be a physician at 31 making 300k and owing 300k any day over some middle management guy who likely won't even get to 120k until mid to late 30s. Add in the job security of a physican and it's not even close.
Ok, so far I've seen a lot of talking and circular reasoning, but not one iota of actual hard proof for all the doom and gloom. And thats all I'm gonna say for now.
Excellent post. You seem to had a good grasp of the issues facing Anesthesiology. As for "what are you missing" with an expectation of your salary range: $290-$350k. Absolutely nothing. This is a hard job with a lot of stress for that amount of money while an AMC takes 1/3 of what you generate for themselves.
While I'm not diminishing $300K (W-2) taxes eat up a lot of that money along with 401K, healthcare, HSA, dental, etc. IMHO, after you pay back your student loans the leftover money will place you squarely in the upper middle class.
It's doom and gloom from my perspective because the glass is 1/2 empty. It's all sunshine and roses for you because the glass is 1/2 full. I mean literally 1/2 full because just 5-7 years ago you could find jobs paying double what an AMC offers today. Those types of jobs are now scarce and will become even harder to find circa 2020.
If somebody's been making 500k their entire career, then it IS their reality. They are completely in touch with reality. And you are speaking in some future projected fantasy of how you will be. If you are generating 500k/year and getting 300 of it and getting nothing else in return, it is soul-sucking to say the least. If you are getting 1mil/year but generating 2, same thing. You sound like someone who has never forked over a **** ton of $$$ to the man. It always sucks to get ripped off, no matter how much you're making. And we are all gonna get ripped off.
Was there ever an abundance of jobs offering 600+k/year?
As a former military Flight Surgeon currently in residency training with zero debt and having practiced (and endured) in primary care to some capacity for some time, I will always be happy with the speciality I've chosen. I'm perfectly happy finding a job in an area that you might perceive as 'less desirable.' The very few malignant attendings in my program and perhaps more frequent malignant surgeons and ancillary staff don't make me regret my career decision; I just laugh and keep to myself how much I imagine that we're all in some movie show or TV program witnessing all the personality disorders when I run into those situations.
I know this view is not the most common on these forums and fully acknowledge that the 'doom and gloom' folks here have much more first hand experience of working for an AMC, and may have seen the 'glory days' of Anesthesiologists, in terms of compensation, pass by. It's laughable to suggest that med students go into surgical fields for the sole reason of job security if that's not also what they have a strong passion for. I am perhaps way off base and seemingly blind to what may be a horrible job market for my class in a couple of years, but many of you complaining need to stand back and see how well off you are.