hospital vs. office practice??

[ether]

Hi all,

I've been an attending now for almost a year in a private practice group in an office setting. I like it so far. I may have an oppurtunity however to build up a pain program as basically the only pain guy in a 200 bed hospital.

Any advice on pros and cons of a hospital job vs. an office based jobs? Group practice vs. solo practice?

Thanks.

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[Aether2000]

Hospitals never get into bed with a physician without finding some way to screw him out of $$$. Hospitals have one goal: to make money for the hospital. It has nothing to do with providing services to those in need nor does quality of care matter to the hospital- as long as you are generating revenue for them. With respect to payor class mix: hospital based practices have a large percentage of medicaid (virtually non-pay) and self pay (non-pay) while they skim 2/3 of your income on all Medicare cases due to the site of service differential. Some major private insurances such as Anthem/Wellpoint now pay the physician medicare rates with a site of service differential, therefore you get screwed doing these cases in a hospital also. You are locked into whatever insurances and social programs the hospitals accept and cannot independently negotiate rates nor elect to opt out of insurances/social programs with inadequate reimbursement. Add on the fact that some hospital administrators are so sleazy they hire CRNAs to do pain medicine, the infinite calls and BS admissions of clearly chronic pain patients through the ER with no change in daily pain status, the calls at night from your obligatory medicaid population about why they need more narcotics, and the hassles with inept hospital credentialing committees that use 5 year old "White papers" to decide who is privileged for what procedures and you will soon discover financially it is in your best interest to divorce yourself as soon as possible from the money sucking hospitals. My strong preference is when possible, remain independent from hospitals at all costs. If you must join a group, then go to the local neurosurgeon/OSS and ask to join them. If there are none, then if there is a dominant IM group in town, try to rent space from them for your office....
Hospitals are rarely your friends, and in many cases can turn out to be the enemy when they align themselves with untrained or poorly trained individuals to compete against your private practice. They simply do not care...it is ALL about $$$$ for them.

 

[Tenesma]

i will disagree a tiny bit here - even though the over-arching theme of the hospital wanting money is accurate...

you can definitely set up a hospital based practice as an independent practitioner - the hospital benefits because they take the facility fees - you benefit because it can drastically cut your overhead, and since you are independent (ie: self-employed) you can choose which insurances to take or not to take... you also can limit your inpatient consultation exposure by stating that you only do consults on weekdays (and then in the chart write recommendations with f/u in your clinic after discharge and then sign-off) unless it is an emergency in which case they can discuss the case with you over the phone...

now this works best when the hospital is in dire straits and is willing to play nice just to have a profitable opportunity - if the hospital is big and strong they will bowl you over - therefore choose a hospital that has <100 beds

i know some people who are making ridiculous money and some who are barely making 200k in the hospital environment so the opportunities exist as long as you are careful

also the hospital will try to dictate care based on profitability - so no stimulator implants, no percutaneous discectomies etc...

 

[Aether2000]

True..if independent practice is permitted. Some pain physicians are now employed by hospitals and that is the scenerio I was speaking of...

 

[PMR 4 MSK]

I used to be hospital based, then went solo with my own fluoro, now I'm in a group with an ASC that has the fluoro. The basic rule of thumb is whoever owns the fluoro machine makes the most money. If you don't own it, you get the smaller share of the payments for the procedure.

One question to ask the hospital is where you'll do the procedures - if it's in the OR, that's more of a pain for the patients - more paperwork, bigger time investment, probably more costly. A dedicated outpatient suite would be best, especially one connected to the offices where you'll do the consults and follow-ups. Also see what other procedures they might do in there. The hospital I worked for tried once to get me to do procedures in the same room as the radiologists did barium enemas - I want a clean room.

 

[Mister Mxyzptlk]

The basic rule of thumb is whoever owns the fluoro machine makes the most money.

A lot of wisdom packed into one sentence.

Here's a relevant article: http://image.exct.net/members/27193/Singleton Article.pdf

 

[Disciple]

My strong preference is when possible, remain independent from hospitals at all costs. If you must join a group, then go to the local neurosurgeon/OSS and ask to join them.

Algos,

Do you feel that the benefit of getting oneself established in a community is worth the lower salary and decreased chances for partnership one would have
when joining a surgical group?

 

[MetroPain]

I also have the opportunity to do pain for a Hospital via the administration as long as I do all of my procedures at the Hospital owned ASC. There is an income guarentee, however, I do agree with Algos that you may be the hospiatl's slave if I take this offer. The reason why I am considering this scenario, is to try to get myself established in an area where I do not have a referral base. Is this wise?

 

[Tenesma]

i think it is wise because by default most community physicians would prefer to support the hospital... a guaranteed income can be changed into an incentive loan - just let them know that you will take x amount of dollars as an incentive loan, and that you want it forgiven after 1 or 2 years as long as you stay within the community for an extra 1 - 2 years... i am sure you could negotiate something that gives you some liquidity while you establish yourself and try to stay independent.

hospitals do it all the time (especially for general surgeons)...

 

[Doctodd]

I am currently in your situation where the hospital brought me in as an independent contractor, paid for most of the overhead while i grew the practice, made plenty of money off me, and now im in the position im in. Now the hospital isnt saitisfied with one doctor....they want as many pain docs as possible to do procedures. So it is no longer my office, and i have a nurse spy in my office all the time. I dont care anymore about overhead cuz it is worth the cost so that i can sleep at night knowing i am not the flavor of the month for the hospital. So, in summray, do it for awhile, but expect things to not always go your way, and you have to bend over sometimes. Im done bending over. Plus not to mention the fact that you will lose alot of patients cuz they cant pay the hospital deductible and extra cost for them! It is more expensive for a patient to have the same procedure in the hospital than at the office.

T

 

[Louisville04]

Plus not to mention the fact that you will lose alot of patients cuz they cant pay the hospital deductible and extra cost for them! It is more expensive for a patient to have the same procedure in the hospital than at the office.

T

I didn't realize there was a difference in cost for the patient. Is this for medicare patients as well?

Would a hospital prefer you 2 different injections (i.e. L4 TF and L5 TF) on different dates vs. the same day so they can bill more?

 

[Tenesma]

doctodd - two options -

1) set-up a practice across the street and make sure the largest referral PCPs have a vested interest in you - ie: they could be maybe investors in your clinic?

2) use your corporation to directly hire the pain doctors (and have the hospital provide guaranteed income loans to them as an incentive to move to your community), but those pain doctors would be under your control and you can charge them a management fee of x amount (or %) per visit/procedure...

I know a guy in connecticut who did #2 and he is making TONS - the hospital loves him (because he is keeping procedures in house) so they are treating him with silky gloves and TONS of perks, and he has physicians cycling trhough for an x year partnership track positions - even though i don't believe anybody has been able to make partner yet.... he is a great guy with a great sense of business

 

[ampaphb]

... and he has physicians cycling trhough for an x year partnership track positions - even though i don't believe anybody has been able to make partner yet.... he is a great guy with a great sense of business

Forgive me, but running new hires through the system with the lure of potential partnership never actually fulfilled is a sure sign of an a--hole, not the "great guy" you characterize.

My feeling is that if you interview for a position where the practice has done that to two or more prior physician employees, run, don't walk, away as fast as you can

 

[Doctodd]

doctodd - two options -

1) set-up a practice across the street and make sure the largest referral PCPs have a vested interest in you - ie: they could be maybe investors in your clinic?

2) use your corporation to directly hire the pain doctors (and have the hospital provide guaranteed income loans to them as an incentive to move to your community), but those pain doctors would be under your control and you can charge them a management fee of x amount (or %) per visit/procedure...

Tenesma.....re: #1.....i signed the lease this week and build out is happening as we speak...im hoping 4 weeks til we open. It is literally across the street from the new hospital. The primary docs send me plenty of business and things are rosey right now. Hopefully will stay that way. Im spreading lots of love.

#2.....maybe in a few years....i want to keep things simple. But i doubt the hospital will do that.

thx for the advice everyone.

T

ps....and ive been on the other end of that "partnership promise". Im not sure i can do that right now. I have a NP instead who is at the #2 hospital every day. To clarify, the soured relationship i have with hospital #1 is not the hospital im opening up next to. 2 different hospitals.

 

[Doctodd]

I didn't realize there was a difference in cost for the patient. Is this for medicare patients as well?

Would a hospital prefer you 2 different injections (i.e. L4 TF and L5 TF) on different dates vs. the same day so they can bill more?

They are admitted......for a procedure, so yes depending on their insurance they may have to pay a decent deductible and/or copay separate from mine. The hospital or an ASC doesnt make much on medicare patients....about $330, which is 3 times more than what the physician fee is. The hospital or ASC makes their money on workmans comp and PIP and insurances.

T