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

[Ducttape]

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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.

agree.

most walk, take public transportation, or have friends/family drive.

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.

i read nothing in your - in my opinion - lousy statement that justifies continued attacks against employed physicians.


attack the medical system, okay. attack hospitals reaping in facility fees, okay. wanting correction for imbalance based on site of service, okay and i could get behind that....


attack and seemingly express joy that employed physicians get paid less, that is not okay.

 

[BobBarker]

@Ducttape why do you let the hospital pay you 50% market rate? Just go work for another hospital.

 

[CleanUp]

agree.

most walk, take public transportation, or have friends/family drive.


i read nothing in your - in my opinion - lousy statement that justifies continued attacks against employed physicians.


attack the medical system, okay. attack hospitals reaping in facility fees, okay. wanting correction for imbalance based on site of service, okay and i could get behind that....


attack and seemingly express joy that employed physicians get paid less, that is not okay.

You’re not being attacked my friend. You do not have capital calls. You do not have to spend more for supplies if the production line goes down. You do not have to pay for Worker’s Compensation claims. You do not have to pay more to onboard and recruit someone. These are all challenges of the private practice physician.

One employment model is not inherently better than the other. But I am suggesting is usually in the financial world and other markets risk and reward are tied together.

It seems to me you have a perceived attack that you are getting less and your fellow employed physicians are getting less. However, what Drusso is suggesting is if you look at the grand aggregate the field is still heavily tilted towards you in your favor.

What difference does it make if the hospital gets paid less but what hits your paycheck every two weeks is the exact same? To me that is the beauty and advantage of an employed system. You are heavily shielded.

 

[Ducttape]

so reducing rvus for hopd physicians is appropriate, because technically they are insulated?

how do you think employed physicians get paid? even salaried physicians have to reach a minimum for which they could be fired or have wages garnished or are on an rvu based system in which reduction of rvus affects their pay.




and guess what? admin clearly does not believe a word you say.

when facility fees are cut, what do you think admin does?

hint they cut the $/wRVU. they make contract negotiations requesting docs get less pay. they reduce staff. they request physicians do more with less support.



is the system biased in favor of hospitals? yes, and i am not arguing that aspect. i do support private practices (not PE) getting better reimbursement.

i am arguing that a pain physician should not be rejoicing that any of his compatriots are being negatively affected and seemingly expressing glee that that is happening.

 

[BobBarker]

Example of the BS we go through in private practice:


I took off today to do the SAFER and SRA modules required for MIPS. I paid $2000 for physician coverage for the day. I am greeted by this when I attempted to do them. I put away laundry and picked up dog poop, also pestered you guys more than usual instead.

 

[drusso]

so reducing rvus for hopd physicians is appropriate, because technically they are insulated?

how do you think employed physicians get paid? even salaried physicians have to reach a minimum for which they could be fired or have wages garnished or are on an rvu based system in which reduction of rvus affects their pay.




and guess what? admin clearly does not believe a word you say.

when facility fees are cut, what do you think admin does?

hint they cut the $/wRVU. they make contract negotiations requesting docs get less pay. they reduce staff. they request physicians do more with less support.



is the system biased in favor of hospitals? yes, and i am not arguing that aspect. i do support private practices (not PE) getting better reimbursement.

i am arguing that a pain physician should not be rejoicing that any of his compatriots are being negatively affected and seemingly expressing glee that that is happening.

It’s not about celebrating anyone getting paid less. It’s about recognizing that the medical value chain has been structurally inverted for decades.

Independent physicians assume real risk: capital, payroll, regulatory exposure, compliance costs, malpractice coverage, and payer negotiation, all without the insulation of institutional subsidy or guaranteed salary. Yet, for the same CPT code, the employed hospital-based physician receives a lower professional payment, while the system captures multiples of that amount through the facility fee. The distortion is not in the physician’s paycheck; it’s in the way CMS and payers distribute total dollars for identical work.

Correcting that imbalance isn’t punishment. It’s normalization. Site-neutral payment says that the cognitive and procedural effort of a physician has the same intrinsic worth whether it occurs in a hospital or an office. If an employed doctor’s wRVU rate is adjusted downward by the administration in response. In that case, that’s not caused by parity reform; it’s evidence that hospital employers have been monetizing the spread and keeping the margin...they've been juicing the Vig on the SOS.

 

[Ducttape]

reducing the employed physician wrvu is stating that their intrinsic value is less.

if the distortion is in the way that CMS and payors distribute dollars, why penalize employed physicians for that distortion, and instead focus on targetting the other entities benefitting (ie HOPD and ASC)? decreasing wrvus decreases physician paychecks. (and clearly we are now glossing over how admin will target physician paychecks as a method of maintaining profits)



targeting hospitals and correcting SoS differential by decreasing facility fees outwardly seem appropriate but i would argue that increasing office based fees to make up for the SoS differential is a much better way of correcting imbalance.

 

[drusso]

reducing the employed physician wrvu is stating that their intrinsic value is less.

if the distortion is in the way that CMS and payors distribute dollars, why penalize employed physicians for that distortion, and instead focus on targetting the other entities benefitting (ie HOPD and ASC)? decreasing wrvus decreases physician paychecks. (and clearly we are now glossing over how admin will target physician paychecks as a method of maintaining profits)



targeting hospitals and correcting SoS differential by decreasing facility fees outwardly seem appropriate but i would argue that increasing office based fees to make up for the SoS differential is a much better way of correcting imbalance.

The HOPD professional payment is inflated not because the physician’s work is greater, but because the system historically double-counts “practice expense” through facility overhead that the hospital bills separately. That inflation has been perpetuated for decades under the guise of budget neutrality and “relative value” adjustments.

When CMS lowers the professional component for HOPD work, it’s not declaring that employed physicians are intrinsically worth less. It’s acknowledging that the prior system paid twice for the same thing: once to the doctor, again to the building. Flattening that curve isn’t punishment; it’s alignment.

The philosophical premise of the Physician Fee Schedule was always “same work, same pay.” SOS differentials destroyed that principle and transferred billions in value from physician labor to hospital infrastructure. Every year that gap persists, independent medicine erodes and care costs rise.

Increasing office-based rates without touching the inflated hospital side perpetuates the imbalance. You can’t fix structural inequity by raising one end and pretending the other isn’t still overcompensated. Once the distortion is removed, both office and hospital physicians can be valued on the same plane by the work they do, not by the ZIP code of the facility or the leverage of their employer. No longer will it be enough for HOPD MDs to punch a clock. They, too, will have to learn to embrace the PP 5-9 lifestyle and eat more RVU pellets to maintain their Baller compensation.

 

[Ducttape]

call it what you want but disguising cuts to employed physician wrvu with suppositions about that it is social justice will ultimately cause harm to all physicians.



i would argue that no pain physician is currently adequately compensated by medicare, and private practice doctors are less adequately compensated than HOPD ones. cutting HOPD wrvu rates will not improve the current poor compensation of the PP docs. thats not fixing structural inequality - that is worsening the structural inequality between hopd physicians and their facility as it devalues the hopd physician component compared to the facility portion.

i stated previously that reducing facility fees is reasonable, but reducing wrvus for hopd physicians will have the opposite the long term effect.

You’re not being attacked my friend. You do not have capital calls. You do not have to spend more for supplies if the production line goes down. You do not have to pay for Worker’s Compensation claims. You do not have to pay more to onboard and recruit someone. These are all challenges of the private practice physician.

One employment model is not inherently better than the other. But I am suggesting is usually in the financial world and other markets risk and reward are tied together.

It seems to me you have a perceived attack that you are getting less and your fellow employed physicians are getting less. However, what Drusso is suggesting is if you look at the grand aggregate the field is still heavily tilted towards you in your favor.

yes for what you have to put up with on the financial front, i would counter that employed doctors have to put up with administrative constraints, staffing constraints, public health requirements (JCAHO) that are problematic in their own way.

how many meetings per month do you have to interact with some administrator telling you how to better perform your job/meet wrus? how often do you have to ask an administrator to try to do something new or different and be told that it is "not in the budget" or "thats experimental so no" or "lets do a review and circle around to it at our meeting next month"? how often are you forced to work with another physician or APP that does not practice in a manner that is commiserate with yours?

What difference does it make if the hospital gets paid less but what hits your paycheck every two weeks is the exact same? To me that is the beauty and advantage of an employed system. You are heavily shielded.

some hopd physicians are paid by wrvu. so they will get paid less if wrvus are cut. my bonus, little as it is, will be affected by wrvu cuts.

separately, i also would not put it above some hopd to change physician wrvu compensation rates based on reduced facility fees (but again, that is a separate than my express concern)

 

[SSdoc33]

Example of the BS we go through in private practice:


I took off today to do the SAFER and SRA modules required for MIPS. I paid $2000 for physician coverage for the day. I am greeted by this when I attempted to do them. I put away laundry and picked up dog poop, also pestered you guys more than usual instead.


View attachment 410888

LOL, whats a webiste?

they cant even spell "website" correctly

 

[clubdeac]

Here’s the real problem. They need to cut admin

 

[Dr. Ice]

Here’s the real problem. They need to cut admin

View attachment 410923

Yeah but they won’t…

 

[geauxg8rs]

Yeah but they won’t…

They will rebrand and say that hospitals need to “work smarter” and they will somehow spend even more on admin and less on patient care. Your doctors day free sandwich now doesn’t have any lettuce or tomato

 

[callmeanesthesia]

Here’s the real problem. They need to cut admin

View attachment 410923

Site neutral payments would go a long way toward fixing that - hospitals use the bloated facility fee to support all those extra administrators.

 

[callmeanesthesia]

They will rebrand and say that hospitals need to “work smarter” and they will somehow spend even more on admin and less on patient care. Your doctors day free sandwich now doesn’t have any lettuce or tomato

A friend was at a hospital where the doctor’s day reward was a single bag of chips.

 

[Ducttape]

wait.

doctors day reward?

 

[hyperalgesia]

A friend was at a hospital where the doctor’s day reward was a single bag of chips.

This shows how totally detached so called "leadership" is from the medical staff.

A bag of chips is 10x worse than nothing.

 

[geauxg8rs]

This shows how totally detached so called "leadership" is from the medical staff.

A bag of chips is 10x worse than nothing.

And if the CEO walked by he was allowed to have some of your sun chips

 

[Drhappyface]

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.

They can write off the entire value of the property in 1 year? How do they come value? That also means that you wont be able to write off anything from this property next year? Basically have to buy a new air bnb each year haha

 

[giddyup]

They can write off the entire value of the property in 1 year? How do they come value? That also means that you wont be able to write off anything from this property next year? Basically have to buy a new air bnb each year haha

No, you can write off the entire value of the quickly depreciating assets. Typically it is about 25 to 35% of the entire structure value, this does not include land value (that is usually 20% of the whole cost of the property). Say you buy a house for 1 million. Land worth 200k. Structure worth 800k. Get a cost segregation study and about 25 to 35% of that 800K are fast depreciating assets and rather than depreciating them over 29 years you can depreciate them all in year 1 (100% bonus depreciation is back this year). If you actively participate that comes off your W-2 income.

 

[SSdoc33]

No, you can write off the entire value of the quickly depreciating assets. Typically it is about 25 to 35% of the entire structure value, this does not include land value (that is usually 20% of the whole cost of the property). Say you buy a house for 1 million. Land worth 200k. Structure worth 800k. Get a cost segregation study and about 25 to 35% of that 800K are fast depreciating assets and rather than depreciating them over 29 years you can depreciate them all in year 1 (100% bonus depreciation is back this year). If you actively participate that comes off your W-2 income.

love this idea.

what about all of stuff you buy FOR the house. furniture, landscaping, etc? can that also be deducted? like say you make 30K/year off of the airbnb, but spend 30k in renovations, can you declare zero profits? or say spend more on home improvemetns than you make, can you deduct the loss off of your W-2 income?

 

[giddyup]

love this idea.

what about all of stuff you buy FOR the house. furniture, landscaping, etc? can that also be deducted? like say you make 30K/year off of the airbnb, but spend 30k in renovations, can you declare zero profits? or say spend more on home improvemetns than you make, can you deduct the loss off of your W-2 income?

Stuff you buy FOR the house (couches furniture etc) you can write off to negate profits but this does not come off your W2 income. Landscaping is fast depreciating and would be included in the cost segregation study - now if you buy new landscaping I'm not sure how that would work - you may have to get a new cost seg study which would not make sense because they cost 4K or you just write the new landscaping off to negate profits. I'd probably do the latter. If you spend more in stuff you buy and are negative it doesn't come off W2 but it carries over to the next year to negate those profits. only the depreciation from the cost seg study is active and only if you materially participate or have REPS status (or spouse has REPS)

 

[nvrsumr]

Had an on call message last evening. Been so many years had forgotten my password to access….

So yes has gotten better

Oh yeah just a confused patient trying to make an appt.

 

[clubdeac]

View attachment 410462

2024 Physician salary report: Results show increased earnings

Medcape's physician salary report for 2024 shows physician compensation is up, notably for self-employed doctors and those in the Midwest.

weatherbyhealthcare.com

Do you happen to know why specifically pmr is benefiting more than other specialities due to the changes? Seems odd

 

[pinstriped1992]

Do you happen to know why specifically pmr is benefiting more than other specialities due to the changes? Seems odd

My assumption would be a greater % of PM&R going into pain than years prior (with a huge dropoff of anesthesia) which comes with a large compensation increase. In addition, PM&R docs are more likely to be trained in regenerative therapies given their US training, and that would definitely provide a boost. I doubt inpatient PM&R is driving the change, though SNF work has always paid well.

 

[Ducttape]

im not sure about that. first, i dont know if they lump pmr trained pain in to a global pmr group or in a separate group like they seem to do with anesthesia pain. im pretty sure the data out there (which i cant access) puts pain medicine irrespective of training in to its own group.


my guess that pmr is in greater demand: needed physiatrists due to aging population, for positions in skilled nursing facilities and inpatient rehab, and these are bigger drivers than a smaller group of pmr docs going in to pain that are for unclear reasons being counted as pmr docs (rather than pain docs)

 

[pinstriped1992]

im not sure about that. first, i dont know if they lump pmr trained pain in to a global pmr group or in a separate group like they seem to do with anesthesia pain. im pretty sure the data out there (which i cant access) puts pain medicine irrespective of training in to its own group.


my guess that pmr is in greater demand: needed physiatrists due to aging population, for positions in skilled nursing facilities and inpatient rehab, and these are bigger drivers than a smaller group of pmr docs going in to pain that are for unclear reasons being counted as pmr docs (rather than pain docs)

The report doesn't have a category for pain medicine. In addition, many physiatrists are doing fluoroscopic guided procedures without fellowship training which would also increase their total compensation.

 

[Ducttape]

fluoroscopic procedures have been done for decades by physiatrists; that would not explain an increase in salary as fluoro procedures are already part of their practice.


i dont think Pain Medicine is the reason PMR has increasing salaries and i hope it isnt. PMR itself is underpaid.