Has this specialty improved or declined since you've been in it?

[Dr. Ice]

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Likewise. We're planning on selling it eventually to a PE group and just sit on the real estate and cash in on the rent check. Mailbox money.


Jeeeez.
Is this single specialty pain or multispecialty? How busy are you guys?

Pain (me), GI and ortho..we had a total joints guy who was cranking, but it wasn’t enough. I was doing bread and butter, stim trials and rfa but due to being collections based, and having access to a office suite for procedures, I was 50/50 office and asc as for as SOS. They couldn’t figure out a way to make me whole by incentivizing me to do all procedures in asc. It was bought 55% by a health system two years ago but they are slow as anything to bring volume to the asc and seem to continue to rely on the same players to produce volume there.

It’s a **** show

 

[BobBarker]

GI has gotten pretty bad from what I have heard. Facility fee in the toilet.

 

[BoardingDoc]

Pain (me), GI and ortho..we had a total joints guy who was cranking, but it wasn’t enough. I was doing bread and butter, stim trials and rfa but due to being collections based, and having access to a office suite for procedures, I was 50/50 office and asc as for as SOS. They couldn’t figure out a way to make me whole by incentivizing me to do all procedures in asc. It was bought 55% by a health system two years ago but they are slow as anything to bring volume to the asc and seem to continue to rely on the same players to produce volume there.

It’s a **** show

Yeah, I feel like the health system buyouts don't make sense. Invariably, they own some percentage of the ASC, but not the entire thing. Thus, it remains in their best interest to do as many cases at possible at the actual hospital as they get the entire facility fee instead of collecting only a share of it. I don't really understand their motivations unless they are grossly overloaded with cases that they're losing to other systems because of a backlog. On the previous ASC owner side, I also haven't seen this work out well. The one near me is part owned by docs and part by the local hospital. It's doing quite poorly and they're begging people to do cases there.

 

[Agast]

Pain (me), GI and ortho..we had a total joints guy who was cranking, but it wasn’t enough. I was doing bread and butter, stim trials and rfa but due to being collections based, and having access to a office suite for procedures, I was 50/50 office and asc as for as SOS. They couldn’t figure out a way to make me whole by incentivizing me to do all procedures in asc. It was bought 55% by a health system two years ago but they are slow as anything to bring volume to the asc and seem to continue to rely on the same players to produce volume there.

It’s a **** show

The incentive is that you are a shareholder. You are supposed to increase the value of your shares with productivity to attract more partners.

 

[Dr. Ice]

The incentive is that you are a shareholder. You are supposed to increase the value of your shares with productivity to attract more partners.

I am aware of how it should go..problem is when you are pro fee collections based on the practice side, they already start you with an abysmal base salary and you can’t count on distributions from asc to bolster income.

 

[bedrock]

GI has gotten pretty bad from what I have heard. Facility fee in the toilet.

any numbers you can share on the amount of cut in the GI facility fee?

I do think GI was overpaid for scopes the last decade given how quickly they can be done.

 

[BobBarker]

I think the facility fee is around $600 Medicare. It is less than $1000 HOPD.

 

[bedrock]

I think the facility fee is around $600 Medicare. It is less than $1000 HOPD.

Is that the approx current fee? Any idea what it used to be?

 

[CleanUp]

any numbers you can share on the amount of cut in the GI facility fee?

I do think GI was overpaid for scopes the last decade given how quickly they can be done.

Bedrock, I’d suggest you reconsider the time=money paid mindset. We have to exercise caution because one can apply it to what we do.

No, your epidural doesn’t take 5 minutes. It has taken you 4 years of undergrad, 4 years of med school, 4-5 years of training, likely paying more than 6 figures during education, forgoing >300+ (and likely more if you run the entire career) not to mention countless nights on calls, missed holidays, anniversaries , and birthdays. Yeah, it is “easy” for you but it is not easy. If you mess it up the consequences can be at best painful and traumatic and worse debilitating, paralyzing and cause death. Your clinical acumen has been sharpened throughout these years - that is worth something.

 

[callmeanesthesia]

Bedrock, I’d suggest you reconsider the time=money paid mindset. We have to exercise caution because one can apply it to what we do.

No, your epidural doesn’t take 5 minutes. It has taken you 4 years of undergrad, 4 years of med school, 4-5 years of training, likely paying more than 6 figures during education, forgoing >300+ (and likely more if you run the entire career) not to mention countless nights on calls, missed holidays, anniversaries , and birthdays. Yeah, it is “easy” for you but it is not easy. If you mess it up the consequences can be at best painful and traumatic and worse debilitating, paralyzing and cause death. Your clinical acumen has been sharpened throughout these years - that is worth something.

Amen!

 

[Ronin1]

Amen!

It’s a nice thought but we do get paid on production either through wrvu or collections. So efficiency matters. Unfortunately we don’t get paid enough for each procedure to mitigate the cost of training and individual risk.

Or do you think 1.95 wrvu or 104$ for a cervical epidural is good enough?

 

[BobBarker]

ChatGPT says that a Medicare facility fee for an ASC for a screening colonoscopy is around $400. It looks like commercials pay around $1000

 

[clubdeac]

Bedrock, I’d suggest you reconsider the time=money paid mindset. We have to exercise caution because one can apply it to what we do.

No, your epidural doesn’t take 5 minutes. It has taken you 4 years of undergrad, 4 years of med school, 4-5 years of training, likely paying more than 6 figures during education, forgoing >300+ (and likely more if you run the entire career) not to mention countless nights on calls, missed holidays, anniversaries , and birthdays. Yeah, it is “easy” for you but it is not easy. If you mess it up the consequences can be at best painful and traumatic and worse debilitating, paralyzing and cause death. Your clinical acumen has been sharpened throughout these years - that is worth something.

Exactly…wish someone would tell legislatures this. PAs just got FPA in my state. They are now equal to physicians in terms of freedom, scope of practice and potentially billing

 

[clubdeac]

It’s a nice thought but we do get paid on production either through wrvu or collections. So efficiency matters. Unfortunately we don’t get paid enough for each procedure to mitigate the cost of training and individual risk.

Or do you think 1.95 wrvu or 104$ for a cervical epidural is good enough?

The 1.95 wRVU for a CESI might possibly be the most undervalued cpt code we have

 

[bedrock]

The 1.95 wRVU for a CESI might possibly be the most undervalued cpt code we have

Agree!

 

[hyperalgesia]

The price we can charge for our services should be determined by consumer demand vs supply, not by some central committee in DC.

Most patients would be happy to pay $1k for a CESI if it actually works and lasts for a reasonable time.

But #healthcareisaright so...

 

[callmeanesthesia]

The price we can charge for our services should be determined by consumer demand vs supply, not by some central committee in DC.

Most patients would be happy to pay $1k for a CESI if it actually works and lasts for a reasonable time.

But #healthcareisaright so...

Would they though? I frequently have commercial patients delaying or deferring care because of deductibles. Pretty sure a lot of my patients only do injections because they don’t have to pay. Unfortunately for us, most of the high volume interventional practices are only possible in a setting where insurance covers most of the cost. Our field is a lot of wasted Medicare money.

 

[BoardingDoc]

Would they though? I frequently have commercial patients delaying or deferring care because of deductibles. Pretty sure a lot of my patients only do injections because they don’t have to pay. Unfortunately for us, most of the high volume interventional practices are only possible in a setting where insurance covers most of the cost. Our field is a lot of wasted Medicare money.

That's not limited to pain. That's every patient trying to get in to see their PCP towards the end of the year, every other specialist appointment that's magically harder to get after Sept, etc etc....

It's the same reason why I used to see a disproportionate amount of my BS primary care complaints in the ER coming from Medicaid patients. "It's free, so why would I wait to go see my PCP when I can just come here?"

 

[hyperalgesia]

Would they though? I frequently have commercial patients delaying or deferring care because of deductibles. Pretty sure a lot of my patients only do injections because they don’t have to pay. Unfortunately for us, most of the high volume interventional practices are only possible in a setting where insurance covers most of the cost. Our field is a lot of wasted Medicare money.

I think maybe a third of my pts would pay cash.

I also have a lot of pts with the attitude that "it's free so might as well".

It's really bad if pts can afford it but feel it's not worth their money. Why is it worth taxpayer dollars then?

 

[VA Hopeful Dr]

I think maybe a third of my pts would pay cash.

I also have a lot of pts with the attitude that "it's free so might as well".

It's really bad if pts can afford it but feel it's not worth their money. Why is it worth taxpayer dollars then?

I'm not sure that's a great barometer. I have patients routinely lose their **** because insurance won't cover the specific BP med I called in (despite the GoodRx price being like $10 for 90 days).

 

[bubaghanush]

I think maybe a third of my pts would pay cash.

I also have a lot of pts with the attitude that "it's free so might as well".

It's really bad if pts can afford it but feel it's not worth their money. Why is it worth taxpayer dollars then?

Everyone should have a copay for everything except yearly PCP visit. We are an academic hospital and the only one that takes Medicaid and county insurance in a fairly large catch area.

Charging a $10 office copay and $50 procedure copay would cut the useless visits tremendously and increase the percentage of those coming who are invested in their health.

 

[Ducttape]

on one hand, charging a copay for office visits to patients who are in difficult financial situations will in effect eliminate a significant portion of the population from getting routine healthcare; this could exponentially increase healthcare costs as they will go to Urgent Care or ER for conditions that could have been prevented by those healthcare visits.

this is a contributor to why healthcare is so expensive in our country, along with Big Insurance, Big Pharma, Big Hospital etc.


charging a copay for procedures is the other end of a spectrum. for the most part, most of our procedures are elective.

 

[callmeanesthesia]

I'm not sure that's a great barometer. I have patients routinely lose their **** because insurance won't cover the specific BP med I called in (despite the GoodRx price being like $10 for 90 days).

Sort of part of what I’m saying. Our (pain) treatments cost the medical system thousands of dollars per patients per year, and are completely elective, and many government insured patients are able to access them with no OOP cost. Treatments with proven mortality benefit (even if the NNT is high) that cost a few hundred dollars a year still have copays for many patients.

 

[nvrsumr]

We had $2 Medicaid copays in our state until a couple years ago. Govt decided it was too great of a burden and now zero

 

[BobBarker]

We are at $4 for Medicaid copays for office visits.

 

[Ferrismonk]

on one hand, charging a copay for office visits to patients who are in difficult financial situations will in effect eliminate a significant portion of the population from getting routine healthcare; this could exponentially increase healthcare costs as they will go to Urgent Care or ER for conditions that could have been prevented by those healthcare visits.

this is a contributor to why healthcare is so expensive in our country, along with Big Insurance, Big Pharma, Big Hospital etc.


charging a copay for procedures is the other end of a spectrum. for the most part, most of our procedures are elective.

I hear what you're saying, but I don't buy it. Most of my Medicaid patients drive nicer cars that I do and can somehow still afford cigarettes, alcohol, and marijuana.

It's a matter of priorities and responsibility, not the copay.

 

[Ferrismonk]

SOS is shifting to the office/OBL.

I see some insurances going that way, but every year I see the Medicare fee schedule go down for professional fees and up for facilities.

 

[SSdoc33]

I hear what you're saying, but I don't buy it. Most of my Medicaid patients drive nicer cars that I do and can somehow still afford cigarettes, alcohol, and marijuana.

It's a matter of priorities and responsibility, not the copay.

"most"?

some. but most?

 

[drusso]

I see some insurances going that way, but every year I see the Medicare fee schedule go down for professional fees and up for facilities.

That’s the old pattern—but it’s reversing.

CMS finally admitted that the facility gravy train created a Frankenstein of vertical integration, so the 2026 proposed rule tilts the field back. The new PE reweighting actually adds to non-facility (site 11) RVUs and cuts HOPD rates. Look at the tables: 64493, 64635, 62323—double-digit percentage gains in the office, mid-single-digit losses in the facility.

They’re trying to claw back dollars from the hospital cost centers that have been marking up an epidural like it’s a cath lab. For once, the independent doc with a C-arm and a lease payment wins.

The future isn’t HOPD—it’s the OBL suite next to Starbucks.

 

[callmeanesthesia]

That’s the old pattern—but it’s reversing.

CMS finally admitted that the facility gravy train created a Frankenstein of vertical integration, so the 2026 proposed rule tilts the field back. The new PE reweighting actually adds to non-facility (site 11) RVUs and cuts HOPD rates. Look at the tables: 64493, 64635, 62323—double-digit percentage gains in the office, mid-single-digit losses in the facility.

They’re trying to claw back dollars from the hospital cost centers that have been marking up an epidural like it’s a cath lab. For once, the independent doc with a C-arm and a lease payment wins.

The future isn’t HOPD—it’s the OBL suite next to Starbucks.

They’re cutting the HOPD physician reimbursement, but aren’t they still increasing the hospital facility payment by several percent? Ultimately less money for doctors, more for hospitals. Not something we should be cheering.

 

[drusso]

They’re cutting the HOPD physician reimbursement, but aren’t they still increasing the hospital facility payment by several percent? Ultimately less money for doctors, more for hospitals. Not something we should be cheering.

Yes, hospitals get their CPI bump, but CMS quietly re-weighted indirect PE to flow away from the facility side and toward office-based services. The “cut” to the HOPD professional line is just the mirror image of the office gain.

Translation: the hospital gets a slightly bigger facility check, but your professional RVUs there are worth less, while the same code in your office or OBL is worth more.

It’s not less for doctors. It’s less for employed doctors. Independent, site-11 PP docs finally caught a tailwind.

 

[giddyup]

its true that as a W-2 employee, it is tough to pay the tax man. there are diminishing benefits the more you earn. but there are still benefits, and it is not "half". the 60k+ pre-tax that goes to retirement is a nice hospital benefit. but there really are no good tax shelters as a w-2 employee.

anybody have any ideas about other tax shelters, im all ears. real estate is usually what i hear

I have done this using the short term rental "loophole" Basically, you need to have a short-term rental. You have to materially participate in it putting in more than 100 hours/year and you have to participate more hours than anybody else involved with the property. Then you need to get a cost segregation study of the property and they will figure out the quickly depreciating portion of the structure. Then you can write off a percentages of that off your W-2 income since you actively participated. I did this and was able to write off 250K - would have been more if I would have done it in a year of 100% bonus depreciation (the year I did it was 60%). Now, when you go to sell the property there is a depreciation recapture so you need to take that into account if you are not going to hold onto it.

 

[SSdoc33]

I have done this using the short term rental "loophole" Basically, you need to have a short-term rental. You have to materially participate in it putting in more than 100 hours/year and you have to participate more hours than anybody else involved with the property. Then you need to get a cost segregation study of the property and they will figure out the quickly depreciating portion of the structure. Then you can write off a percentages of that off your W-2 income since you actively participated. I did this and was able to write off 250K - would have been more if I would have done it in a year of 100% bonus depreciation (the year I did it was 60%). Now, when you go to sell the property there is a depreciation recapture so you need to take that into account if you are not going to hold onto it.

short term rental, like an airbnb? or monthly rent?

i file a joint return with my wife, so i would assume it could be either one of us who puts in the hours?

 

[giddyup]

short term rental, like an airbnb? or monthly rent?

i file a joint return with my wife, so i would assume it could be either one of us who puts in the hours?

it has to be an airbnb with an average stay of less than 10 days. monthly rent is always passive regardless of the hours. if youre married you add your time and your spouse's, you are considered one entity

 

[BobBarker]

Traditional SFR’s are no longer passive if you classify your spouse as a “real estate professional”.

 

[bedrock]

on one hand, charging a copay for office visits to patients who are in difficult financial situations will in effect eliminate a significant portion of the population from getting routine healthcare; this could exponentially increase healthcare costs as they will go to Urgent Care or ER for conditions that could have been prevented by those healthcare visits.

this is a contributor to why healthcare is so expensive in our country, along with Big Insurance, Big Pharma, Big Hospital etc.


charging a copay for procedures is the other end of a spectrum. for the most part, most of our procedures are elective.

BS

Even Medicaid pa

"most"?

some. but most?

Yes, most.

 

[SSdoc33]

BS

Even Medicaid pa

Yes, most.

Most of your Medicaid patients are cruising around in Porsche roadsters?

 

[DOctorJay]

just to clarify, in reply to your angry emoji, DOctorJay, that $53/wRVU would be an improvement for me...

yes, I'm angry for you!

 

[Ducttape]

Yes, hospitals get their CPI bump, but CMS quietly re-weighted indirect PE to flow away from the facility side and toward office-based services. The “cut” to the HOPD professional line is just the mirror image of the office gain.

Translation: the hospital gets a slightly bigger facility check, but your professional RVUs there are worth less, while the same code in your office or OBL is worth more.

It’s not less for doctors. It’s less for employed doctors. Independent, site-11 PP docs finally caught a tailwind.

so hospitals still get more, but doctors get screwed (the HOPD ones), and you are all excited about that?

truly you reveal each post that you are only interested in your little piece of the pie.

 

[CleanUp]

so hospitals still get more, but doctors get screwed (the HOPD ones), and you are all excited about that?

truly you reveal each post that you are only interested in your little piece of the pie.

I agree with your sentiment. I get it.

However, I seriously doubt if the hospital were to get more then the physician would get more as well.

I’m of the mind epidurals and the B&B things we do can be done in an office or ASC setting. I consider this a victory for the independent and lean physicians who don’t have the purchasing power, market capitalization, legal team, CFO making millions, 55 MAs, 12 RNs picking up phones, and cafeteria worker charging 10 cents for the ketchup.

I am cheering because the little guy, likely a physician, in a different setting is getting a boost. This person again does not have the protections of a hospital machine behind them.

 

[bedrock]

Most of your Medicaid patients are cruising around in Porsche roadsters?

Nice try. I’ve had several driving Lexus’s. Several driving new high end pick ups that cost $80,000, etc.

 

[bubaghanush]

Nice try. I’ve had several driving Lexus’s. Several driving new high end pick ups that cost $80,000, etc.

I've probably seen 4 Medicaid patient cars on my way to or back from lunch, and they were dingy even for me driving a 2012 Civic. I'd say about half my Medicaid patients don't even drive - have family and friends take them or they take medical transportation.

 

[drusso]

so hospitals still get more, but doctors get screwed (the HOPD ones), and you are all excited about that?

truly you reveal each post that you are only interested in your little piece of the pie.

What’s happening is a long-overdue correction in a system that’s been quietly stacked in favor of large institutions for decades.

Hospitals have lived off (SOS) arbitrage. They take the exact same CPT code, run it through a hospital tax ID, and magically it’s worth two or three times as much. That isn’t care. That’s rent-seeking with a stethoscope.

Independent physicians have been playing on a tilted field for years. We built efficient clinics, hired lean teams, took real financial risk, and still got paid less for the same service. The 2026 reweighting doesn’t fix everything, but it finally rewards office-based care more closely to parity.

When Medicare and commercial payers tie payment to the building instead of the clinician, you don’t get better medicine. You get fewer independent practices, higher costs, and less patient access.

Correcting that imbalance isn’t selfish. It’s survival for physician-led medicine and a small step toward undoing structural injustices baked into the fee schedule since the day “facility fee” entered the vocabulary. It is the root of all evil.

 

[BobBarker]

Yes, there are just a handful that have nice cars. Hairdressers most of the time. Cash business. Sometimes, unwed couples have the system figured out and keep the “wife” and kids on Medicaid.

 

[BobBarker]

@drusso you got to stop the AI posts. That last paragraph is how chat always drives home its final point.

 

[BobBarker]

Except for that last sentence. I think you added that.

 

[drusso]

@drusso you got to stop the AI posts. That last paragraph is how chat always drives home its final point.

If a machine can articulate what a decade of MedPAC reports, CMS rulemaking, and Becker’s summaries have been dancing around, maybe that says more about the clarity of the tool than the originality of the bureaucracy.

If the paragraph reads clean, concise, and painfully true, I’m fine letting the algorithm take partial credit. Someone has to help translate the alphabet soup of CMS logic into plain English and apparently, it’s not coming from Washington. Whether it's silicon or flesh, the same rule still applies..."they will never love you back."

 

[SSdoc33]

What’s happening is a long-overdue correction in a system that’s been quietly stacked in favor of large institutions for decades.

Hospitals have lived off (SOS) arbitrage. They take the exact same CPT code, run it through a hospital tax ID, and magically it’s worth two or three times as much. That isn’t care. That’s rent-seeking with a stethoscope.

Independent physicians have been playing on a tilted field for years. We built efficient clinics, hired lean teams, took real financial risk, and still got paid less for the same service. The 2026 reweighting doesn’t fix everything, but it finally rewards office-based care more closely to parity.

When Medicare and commercial payers tie payment to the building instead of the clinician, you don’t get better medicine. You get fewer independent practices, higher costs, and less patient access.

Correcting that imbalance isn’t selfish. It’s survival for physician-led medicine and a small step toward undoing structural injustices baked into the fee schedule since the day “facility fee” entered the vocabulary. It is the root of all evil.

this is a construct in your mind only in order to justify your personal world view.

it is not based in reality.

btw, how many medicaid patients did you see today? asking for a friend

 

[BobBarker]

@drusso did you add the last sentence?
Not picking on you, just curious. It sounds like you, not chat. Seeing if chat picked up on your personality.

 

[drusso]

@drusso did you add the last sentence?
Not picking on you, just curious. It sounds like you, not chat. Seeing if chat picked up on your personality.

drusso has achieved immortality...

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