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

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Better or Worse?

  • Better

    Votes: 13 34.2%

  • Worse

    Votes: 25 65.8%
  • Total voters
    38
BobBarker said:
Many bcbs employer plans don’t require auth, aarp/uhc med advantage, traditional Medicare, state employee insurance does not require auth. So at least 50% of the patients are no auth required.
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No auth doesn't mean both procedure and office visit get paid. At least in my neck of the woods. They'll just choose the lower billed service and only pay that.
 
we generally get paid for both. I’m sure we lose a little when they bundle the office visit but it still pays more than injection only.
 
BobBarker said:
I have 56 today
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What is your schedule template? I have 28 slots per day, all 15 minute time slots, from 0800-1130 and 1300-1600. I feel like I'm busting my tail, especially on clinic days. I do probably 1.75x the volume of the other guy in the practice. Even if I skipped lunch and went till 5 that would only be 37 patients. How is 56 possible? And do you prechart on all your patients?
 
stsa84 said:
What is your schedule template? I have 28 slots per day, all 15 minute time slots, from 0800-1130 and 1300-1600. I feel like I'm busting my tail, especially on clinic days. I do probably 1.75x the volume of the other guy in the practice. Even if I skipped lunch and went till 5 that would only be 37 patients. How is 56 possible? And do you prechart on all your patients?
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Hour and a half lunch is a lot of time. I’m nowhere near as fast as BobBarker but I had 38 on my schedule today (no kypho or SCS trial today though). 7-4, 15 minute gap for lunch. My staff stagger their lunch breaks. I mix clinic and procedures - about 1 clinic visit per hour. Picked up that idea from someone on here. I was really skeptical at first, but it means I can have one MA really taking her time rooming a patient, getting all the MIPS BS in the chart, making sure the imaging is pulled up and paperwork filled out, and taking a history from the patient, all while I’m doing procedures. That means when I go see the patient, new or follow-up, it rarely takes me more than 15 minutes (I don’t see the routine MBB f/u visits etc - those go to my NPs) so most of my follow-ups are “several procedures failed, what now,” or post-procedural pain that had to be double booked somewhere. I use an AI scribe (Insight), and when I’m done seeing the patient I double check the orders an coding, proofread the AI output, and then go back to procedures while the MA copies the note output into the chart and completes the note.
 
10 minute slots for all f/u office visits and injection/rfa. It takes longer than that to do a bilateral RF, but a cesi only takes two minutes so it evens out. Telemeds are double booked all through lunch. 20 min for scs trial and kyphos, 30 min si fusions, 20 min np. I pay the staff through lunch so they may get 15 minutes or they may get an hour but they are still paid so the expectation is to get started as soon as the afternoon patients begin arriving. I have done so many trials in my career that a bilateral cervical RF takes me longer than a trial. 90% of the time, I start with a big case at 7:20 and then office visits at 8:00am though. Usually double book post ops (not getting paid anyways), new patients due to the no show rate being 40%, also double book the early AM slots as they no show or arrive late routinely. I don’t eat lunch. I’ve lost about 70lbs from my peak in fellowship. I rather make more money than be obese again.

MA’s do most of the HPI. If it it is a good one from a surgeon referral, they might copy and paste it into the note. I type a sentence or three. Plan is just the procedure order and the macros needed for auth. I will also put in my 2nd and 3rd line plans typically to make the f/u easier.
 
BobBarker said:
10 minute slots for all f/u office visits and injection/rfa. It takes longer than that to do a bilateral RF, but a cesi only takes two minutes so it evens out. Telemeds are double booked all through lunch. 20 min for scs trial and kyphos, 30 min si fusions, 20 min np. I pay the staff through lunch so they may get 15 minutes or they may get an hour but they are still paid so the expectation is to get started as soon as the afternoon patients begin arriving. I have done so many trials in my career that a bilateral cervical RF takes me longer than a trial. 90% of the time, I start with a big case at 7:20 and then office visits at 8:00am though. Usually double book post ops (not getting paid anyways), new patients due to the no show rate being 40%, also double book the early AM slots as they no show or arrive late routinely. I don’t eat lunch. I’ve lost about 70lbs from my peak in fellowship. I rather make more money than be obese again.

MA’s do most of the HPI. If it it is a good one from a surgeon referral, they might copy and paste it into the note. I type a sentence or three. Plan is just the procedure order and the macros needed for auth. I will also put in my 2nd and 3rd line plans typically to make the f/u easier.
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This guy knows how to PP.

I usually have 40-50 (7-5) encounters on clinic days, 40-45 injections on procedure days (7-3:45), and 7-8 cases in the ASC (7-2). After getting efficient and good at procedures is one battle, and the other is macros/dot phrases which is the only way to survive the insurance/auth battle. Luckily, pain (especially spine) tends to be very problem focused and repetitive.

I don’t know why anyone would need 40 mins for a new E/M. I already know that I’m getting an MRI 95% of the time.
 
BobBarker said:
Well, I do own the business. So the take home is dependent on how well I can control costs. Which I do a good job a
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BobBarker said:
Well, I do own the business. So the take home is dependent on how well I can control costs. Which I do a good job at.
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You said the collections for both of you and your partner was less than 5m but i'm assuming more than 4m? So lets assume 2m per doc and with overhead probably around lets assume 40%, your pre tax is around 1.2m. Thats a awesome salary but not sure it would be worth being having the pressure/stress of fitting and seeing that many patients on the schedule. Rather have a HOPD job where I'm getting paid 600-700k for seeing 25-30 max
 
clubdeac said:
Hold up, you did 25 procedures AND 20 clinic visits in one day? How? Do you have 2 c arms? Seems impossible without a scribe and 2 c arms
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The other pain doc in my group routinely does 60 clinic visits/day with one PA. On procedure days he does half clinic, half injections and does 50 injections and 30 clinic visits (with the PA for the clinic side). This is the routine. Man's fast AF
 
If I had to spend 30 minutes on a new patient id quit. Seeing fewer patients is stressful. More patients makes the day go by faster.
 
Yes, I have done hopd also. I have to see twice as many patients it seems like to make about the same money. But my retirement is much better, I am an ASC owner (picking up a check today) and I have autonomy and pride of ownership. My reputation in the community I live is much higher as well vs when I was commuting to the hospital job.
 
Drhappyface said:
You said the collections for both of you and your partner was less than 5m but i'm assuming more than 4m? So lets assume 2m per doc and with overhead probably around lets assume 40%, your pre tax is around 1.2m. Thats an awesome salary but not sure it would be worth being having the pressure/stress of fitting and seeing that many patients on the schedule. Rather have a HOPD job where I'm getting paid 600-700k for seeing 25-30 max
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Where is HOPD paying 6-700?
 
paper_plates said:
Where is HOPD paying 6-700?
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You can even make 6 working in the ****ty northeast with base + bonus rvu. But again, it’s all w2. The gross salary of hopd W2 never will amount to that much no matter what the number
 
stsa84 said:
No paid vacation. Just don't earn when I'm not working. Usually take about 4 weeks. With no Fridays, often go away for long weekends though, using no time off or perhaps just a Monday off.
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makes sense, perfect schedule, goal to be similar to you but with 6 weeks off
 
What’s the point of making 1 mill a year if half goes to the government? PP gives you tax shelters, ownership, passive income through other revenue streams. I would do PP again in a heartbeat if I lived in the southeast or Midwest
 
Dr. Ice said:
What’s the point of making 1 mill a year if half goes to the government? PP gives you tax shelters, ownership, passive income through other revenue streams. I would do PP again in a heartbeat if I lived in the southeast or Midwest
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You really need a side hustle or real estate as a tax shelter! I agree a primary benefit of pp vs HoPD is the tax advantage, but you are magnifying the issue to be worse than it ought to be.
 
mdo1738 said:
Many places. I’m HOPD in the south, 600k would be a very bad year for me. And that’s only working 4 days a week. Multiple hospital jobs in the area where 7 figures is very feasible.
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Southeast and Midwest is where it’s at
 
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
 
SSdoc33 said:
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
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Municipal bonds, particularly with dropping interest rates. If you live in a state with high income tax they are even better.
 
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SSdoc33 said:
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
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When people say real estate..what does that mean exactly? Buying some apt in manhattan and renting it out and then selling it at some point?
 
Dr. Ice said:
When people say real estate..what does that mean exactly? Buying some apt in manhattan and renting it out and then selling it at some point?
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There are several options. The classic answer “I don’t want to fix toilets“ keeps many people away. For most busy Physicians, finding a reliable GP to manage a syndicate in which to invest is probably the best of both worlds. You get diversification of investment, significant tax benefits, with accelerated depreciation, and it’s almost completely passive. I strongly prefer fractional ownership and specific properties rather than these more vague funds. The argument for the latter is diversification, but I prefer to know that I own a specific percentage of a tangible property.

Based on the current market, single-family housing is not tenable in most markets. The relative cost of building and rental prices makes multifamily (apartments) cash flow better. While this is typically the case, it’s especially true in our current economy.

I’m not a licensed financial advisor, licensed real estate professional, and this is not a solicitation and all of the other qualifiers…
 
When you have a high, high W2 then you have to find a side business that you can generate some write offs. I had my farm and 5 c class rental properties. We sold 2 of the properties since the insurance costs got up to the equivalent of 3 rent checks and the property tax was one rent check. I kept the ones in my home town and have known my tenants forever.
 
Fractional ownership (passive) doesn’t generate any write offs. I had my wife classified as a real estate professional to make the typically passive rental properties no longer a passive activity and it allowed us to take the loss she generated against my W2. She owns the rental properties through her llc. I can’t write a check or anything for that LLC.
 
BobBarker said:
Fractional ownership (passive) doesn’t generate any write offs. I had my wife classified as a real estate professional to make the typically passive rental properties no longer a passive activity and it allowed us to take the loss she generated against my W2. She owns the rental properties through her llc. I can’t write a check or anything for that LLC.
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My wife has a small condo we rent and an LLC for her podcast

Any big check write offs from these side gigs?
 
I can think of lots of little to moderate ones. All of the equipment, TV’s, internet, phones, furniture for her podcast guest and ample food for them. Her car and a self employed 401k (if she makes any money) would be the biggest.


I thought you were a permanent bachelor, congrats!
 
clubdeac said:
My wife has a small condo we rent and an LLC for her podcast

Any big check write offs from these side gigs?
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She has a podcast? That’s neat what’s it called

My husband briefly wanted us to do one but I could see myself getting into trouble for saying the wrong things
 
stsa84 said:
I'm on track for over 8 this year. 28 pts/day, 4 days a week. Southeast.
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I'm a current fellow. Starting to look fit jobs. Whats the best way to look for HOPD position? Whats kind of starting salary should I be asking for? How long to get to where you are at? Lol
 
Drhappyface said:
I'm a current fellow. Starting to look fit jobs. Whats the best way to look for HOPD position? Whats kind of starting salary should I be asking for? How long to get to where you are at? Lol
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I've been out of fellowship for 4 years. Had a guaranteed salary of $400k for up to 18 months, to be followed by a production only model. I switched to the production model after about a year. Year 2 was about $550k, year 3 around $650k, and this year about $820k.

Started off with 15 minutes for return patients, 30 minutes for new, 15 minutes for most procedures, 30 minutes for RFA. I now just do 15 minutes for everything, and will probably soon change procedures to just 10 min (except RFA). Past that point, I'm not sure how much more efficient I'll be able to get. I don't want to work longer hours, or on Friday.

I'd reach out to hospitals in the area you want to be. Use any connections you may have from training. My current job, and the other jobs I interviewed at, were mostly through connections.
 
Drhappyface said:
I'm a current fellow. Starting to look fit jobs. Whats the best way to look for HOPD position? Whats kind of starting salary should I be asking for? How long to get to where you are at? Lol
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Utilize every resource you can. Training connections, device reps, reaching out to hospitals in the area where you want to go, ask folks on here, and scour the internet for job postings. I was using all those other sources and then found my eventual job on a random website while Googling for pain jobs in that area.
 
stsa84 said:
I've been out of fellowship for 4 years. Had a guaranteed salary of $400k for up to 18 months, to be followed by a production only model. I switched to the production model after about a year. Year 2 was about $550k, year 3 around $650k, and this year about $820k.

Started off with 15 minutes for return patients, 30 minutes for new, 15 minutes for most procedures, 30 minutes for RFA. I now just do 15 minutes for everything, and will probably soon change procedures to just 10 min (except RFA). Past that point, I'm not sure how much more efficient I'll be able to get. I don't want to work longer hours, or on Friday.

I'd reach out to hospitals in the area you want to be. Use any connections you may have from training. My current job, and the other jobs I interviewed at, were mostly through connections.
Click to expand...

Is this a PP or a HOPD employed position? How much control do you have over your productivity? For example, will your employer stand in your way if you need more staff, more pre and post procedure space, improved prior authorization process, marketing, etc in order to accommodate Q10 min procedures? Obviously, it makes no sense to impede your productivity but in my experience (HOPD) hospital employed night-school MBAs just expect you to do more with less.
 
NJPAIN said:
Is this a PP or a HOPD employed position? How much control do you have over your productivity? For example, will your employer stand in your way if you need more staff, more pre and post procedure space, improved prior authorization process, marketing, etc in order to accommodate Q10 min procedures? Obviously, it makes no sense to impede your productivity but in my experience (HOPD) hospital employed night-school MBAs just expect you to do more with less.
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I’m in PP and I do everything. Open all trays, turn over the room, grab pts from the lobby, etc. Obviously, I’m doing this WITH my staff…But two more available hands are very helpful.

I’ve come to realize that no matter how great my team of MAs and staff, they’re not incentivized like I am to keep the line moving and I am not above any portion of the work.
 
The big hospital in my town is losing 2 spine surgeons and a joint surgeon because they make no effort to support their productivity. They’re able to see a max of about 2 patients per hour. Similar issue with a hospital a couple hours away where we recruited our newest partner from. Doesn’t matter how good your $/wRVU is if the hospital admin won’t let you be productive.
 
Yes. I do nearly everything also. The past two weeks we have only had two MA’s for between 90 and 100 patients every day. I grabbed the patient and started seeing them before the MA countless times. I always open the trays. I clean up the procedure room as we go.
 
NJPAIN said:
Is this a PP or a HOPD employed position? How much control do you have over your productivity? For example, will your employer stand in your way if you need more staff, more pre and post procedure space, improved prior authorization process, marketing, etc in order to accommodate Q10 min procedures? Obviously, it makes no sense to impede your productivity but in my experience (HOPD) hospital employed night-school MBAs just expect you to do more with less.
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My experience thus far with hopd is that they are supportive of efficiency. I still don’t have my own MA, but there is a good amount of cross trained staff able to help. I’m in an office suite so procedures are turned around quickly and my tech is very good. I only started seeing patients in July and my right now I can churn out 22 procedures in the am and see about 20 patients in the pm. Will be switching to full day procedures soon once a week. The base is very good for my geographic location and they seem to know how to “get their moneys” worth. I am definitely not a fan of the obsession with press ganey scores and the weekly updates as to whether or not someone rated me as an 8 or a 10
 
It’s going to depend on your system. I have my own ma and a minimum of 2 RNs that function as scribes in the clinic. Our department makes a ton of money for the facility and they are well aware of it. They don’t try and hinder that. We blow away the other employed docs in the system
 
Ronin1 said:
It’s going to depend on your system. I have my own ma and a minimum of 2 RNs that function as scribes in the clinic. Our department makes a ton of money for the facility and they are well aware of it. They don’t try and hinder that. We blow away the other employed docs in the system
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How did you ever get nurses to be your scribes. I can’t even get them to scan meds into the mar. It’s bonkers
 
stsa84 said:
I've been out of fellowship for 4 years. Had a guaranteed salary of $400k for up to 18 months, to be followed by a production only model. I switched to the production model after about a year. Year 2 was about $550k, year 3 around $650k, and this year about $820k.

Started off with 15 minutes for return patients, 30 minutes for new, 15 minutes for most procedures, 30 minutes for RFA. I now just do 15 minutes for everything, and will probably soon change procedures to just 10 min (except RFA). Past that point, I'm not sure how much more efficient I'll be able to get. I don't want to work longer hours, or on Friday.

I'd reach out to hospitals in the area you want to be. Use any connections you may have from training. My current job, and the other jobs I interviewed at, were mostly through connections.
Click to expand...
With this volume and annual productivity I’m guessing your $/wRVU to be above $75
 
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