Hospital Wants to Hire an APP

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

dukethin

Full Member
7+ Year Member
Joined
Jun 12, 2017
Messages
13
Reaction score
9
I’m salaried and do pain 1-2 times a week. Rural hospital, only game in town. The rest of my time is anesthesia. Frankly, I prefer doing anesthesia. The pain clinic has a waitlist of 3 months and I think admin sees dollar signs that are waiting in a queue, with the potential for them to spend their dollars elsewhere. I’m really not interested in doing any more pain days such that the CEO can fatten his bonus through wildly exorbitant facility fees. Admin has brought up the idea of hiring cheaper, less skilled labor (an APP) to see consults and do some bedside procedures to reduce the waitlist and free me up to focus on the more advanced (aka better paying) procedures. It sounds like they expect me to take on this APP for nothing. I’m not willing to do that. What is a typical compensation model when one takes on an APP?
 
I’m salaried and do pain 1-2 times a week. Rural hospital, only game in town. The rest of my time is anesthesia. Frankly, I prefer doing anesthesia. The pain clinic has a waitlist of 3 months and I think admin sees dollar signs that are waiting in a queue, with the potential for them to spend their dollars elsewhere. I’m really not interested in doing any more pain days such that the CEO can fatten his bonus through wildly exorbitant facility fees. Admin has brought up the idea of hiring cheaper, less skilled labor (an APP) to see consults and do some bedside procedures to reduce the waitlist and free me up to focus on the more advanced (aka better paying) procedures. It sounds like they expect me to take on this APP for nothing. I’m not willing to do that. What is a typical compensation model when one takes on an APP?
half of all RVUs that the APP generates is fair.
 
Why not let the app see patients and you do procedures all day, a couple of days a week? If you negotiate good wrvu > $70 then you will boost your income quite bit?
 
Are you willing and ready to walk away? That's your only leverage
Yes. I would go practice anesthesia, no qualms with that. I already take full anesthesia call.

My concern with an RVU-based model is that I don’t control the means of the production or efficiency. I am at the whim of hospital room turnover, and inefficiencies of people I wouldn’t have hired but the nursing and support staff market is such that anyone with a pulse is considered adequate. I don’t really want to get involved in all of that.

Not to mention the decline of RVUs and the rise of exorbitant facility fees. The hospital does way better than I do with any of this. And the addition of an APP is their attempt to turn a good thing into a really good thing as a way of making up ground for other less profitable hospital lines of care.
 
Last edited:
They do better with anesthesia also. You get what, $500 for anesthesia for a lumbar fusion but they will get between $26000 and $75000? If you get a rvu rate of $70 you will make more doing pain per hour than doing anesthesia. You will make around $140 per office visit. You have to work much harder to make $140 doing anesthesia.
 
My concern with an RVU-based model is that I don’t control the means of the production or efficiency. I am at the whim of hospital room turnover, and inefficiencies of people I wouldn’t have hired but the nursing and support staff market is such that anyone with a pulse is considered adequate. I don’t really want to get involved in all of that.

And this is precisely why I left my old model amongst other things. When you are on RVUs you have to depend on the call center , scheduler, medical assistant, scheduler for the ASC, preop nurses, x-ray tech, PACU nurses, etc to make you get all the RVUs that you can. Too bad if they can’t hire someone or hire someone who is in adequate because you will suffer. You cannot make changes.

It doesn’t matter if you have a lineup of five spinal cord stimulators the nurses will throw a fit and there will be downtime between. Good luck squeezing in more epidurals per hour because there will be something silly like a bed hold or someone forgot to call the patient and remind them to stop taking their anticoagulation. You can’t win.

You are inherently in a system with conflicting priorities. You want to do more to get paid more. They want to do less because they get paid the same.

If you train all the ancillary staff, then you are doing the job of your employer. And essentially, then it begs the question why can’t you just go out on your own?
 
Yes. I would go practice anesthesia, no qualms with that. I already take full anesthesia call.

My concern with an RVU-based model is that I don’t control the means of the production or efficiency. I am at the whim of hospital room turnover, and inefficiencies of people I wouldn’t have hired but the nursing and support staff market is such that anyone with a pulse is considered adequate. I don’t really want to get involved in all of that.

Not to mention the decline of RVUs and the rise of exorbitant facility fees. The hospital does way better than I do with any of this. And the addition of an APP is their attempt to turn a good thing into a really good thing as a way of making up ground for other less profitable hospital lines of care.

This exactly the challenge of hospital employment. RVU expectations not consistent with the capacity of your staff or facility. I will bet that even if they put you in procedures exclusively, they could not keep up with the pace they expect from you. You need a well oiled machine that they can’t provide.
 
Is it even possible? I have not seen anyone has that kind of contract. It is usually supervision bonus and like 20% or less portion of wrvu they are generating
Anything is possible/negotiable if u make it happen
 
And this is precisely why I left my old model amongst other things. When you are on RVUs you have to depend on the call center , scheduler, medical assistant, scheduler for the ASC, preop nurses, x-ray tech, PACU nurses, etc to make you get all the RVUs that you can. Too bad if they can’t hire someone or hire someone who is in adequate because you will suffer. You cannot make changes.

It doesn’t matter if you have a lineup of five spinal cord stimulators the nurses will throw a fit and there will be downtime between. Good luck squeezing in more epidurals per hour because there will be something silly like a bed hold or someone forgot to call the patient and remind them to stop taking their anticoagulation. You can’t win.

You are inherently in a system with conflicting priorities. You want to do more to get paid more. They want to do less because they get paid the same.

If you train all the ancillary staff, then you are doing the job of your employer. And essentially, then it begs the question why can’t you just go out on your own?
Private practice and control of your process is paramount in pain medicine,
To the original poster, if your heart isn’t in pain medicine, don’t give your license up for the hospital to hire a mid level to pad their pockets without you getting anything in return and providing sh*tty care (midlevels making all medical care decisions while you only do injections). This model will fail over time, 100% of the time. The next step for the hospital is to fire you from pain, and hire a new grad to go to that model full time once you have trained the mid level, then rinse and repeat
 
And this is precisely why I left my old model amongst other things. When you are on RVUs you have to depend on the call center , scheduler, medical assistant, scheduler for the ASC, preop nurses, x-ray tech, PACU nurses, etc to make you get all the RVUs that you can. Too bad if they can’t hire someone or hire someone who is in adequate because you will suffer. You cannot make changes.

It doesn’t matter if you have a lineup of five spinal cord stimulators the nurses will throw a fit and there will be downtime between. Good luck squeezing in more epidurals per hour because there will be something silly like a bed hold or someone forgot to call the patient and remind them to stop taking their anticoagulation. You can’t win.

You are inherently in a system with conflicting priorities. You want to do more to get paid more. They want to do less because they get paid the same.

If you train all the ancillary staff, then you are doing the job of your employer. And essentially, then it begs the question why can’t you just go out on your own?
This is it exactly. I’ve recently had a complete meltdown of my staff bc I’ve added a few more procedures. I talked to their supervisor about efficiency and some of their inefficiencies who then talked to them. They are now super pissed that I “went behind their back” and complained. They all now hate me and are acting passive aggressive. So mature. Its a system problem like you say
 
Last edited:
This is it exactly. I’ve recently had a complete meltdown of my staff bc I’ve added a few more procedures. I talked to their supervisor about efficiency and some of them inefficiencies who then talked to them. They are now super pissed that I “went behind their back” and complained. They all now hate me and are acting passive aggressive. So mature. Its a system problem like you say
SAME! Man, must be common
Went to nurses to try and change their staffing to achieve more efficiency and staff is very pissed.
Makes me feel good it’s not just me
 
Yes. I would go practice anesthesia, no qualms with that. I already take full anesthesia call.

My concern with an RVU-based model is that I don’t control the means of the production or efficiency. I am at the whim of hospital room turnover, and inefficiencies of people I wouldn’t have hired but the nursing and support staff market is such that anyone with a pulse is considered adequate. I don’t really want to get involved in all of that.

Not to mention the decline of RVUs and the rise of exorbitant facility fees. The hospital does way better than I do with any of this. And the addition of an APP is their attempt to turn a good thing into a really good thing as a way of making up ground for other less profitable hospital lines of care.

Walk. "They will never love you back."
 
And this is precisely why I left my old model amongst other things. When you are on RVUs you have to depend on the call center , scheduler, medical assistant, scheduler for the ASC, preop nurses, x-ray tech, PACU nurses, etc to make you get all the RVUs that you can. Too bad if they can’t hire someone or hire someone who is in adequate because you will suffer. You cannot make changes.

It doesn’t matter if you have a lineup of five spinal cord stimulators the nurses will throw a fit and there will be downtime between. Good luck squeezing in more epidurals per hour because there will be something silly like a bed hold or someone forgot to call the patient and remind them to stop taking their anticoagulation. You can’t win.

You are inherently in a system with conflicting priorities. You want to do more to get paid more. They want to do less because they get paid the same.

If you train all the ancillary staff, then you are doing the job of your employer. And essentially, then it begs the question why can’t you just go out on your own?

Pure gold. New grads should tattoo this on the inside of their eyelids.
 
I wouldn’t even do any procedures if all have to be done in ASC or in the OR. You need to have your own clinic with a procedure room to be productive with rvu model so some can do 30 or more procedures on their procedure day. I only do implants, kypho, intracept etc in asc. Never do epidurals in that inefficient asc. I would ask them to have your own procedure room if not just enjoy anesthesia
 
I’m salaried and do pain 1-2 times a week. Rural hospital, only game in town. The rest of my time is anesthesia. Frankly, I prefer doing anesthesia. The pain clinic has a waitlist of 3 months and I think admin sees dollar signs that are waiting in a queue, with the potential for them to spend their dollars elsewhere. I’m really not interested in doing any more pain days such that the CEO can fatten his bonus through wildly exorbitant facility fees. Admin has brought up the idea of hiring cheaper, less skilled labor (an APP) to see consults and do some bedside procedures to reduce the waitlist and free me up to focus on the more advanced (aka better paying) procedures. It sounds like they expect me to take on this APP for nothing. I’m not willing to do that. What is a typical compensation model when one takes on an APP?
So regarding this, it’ll take a little leg work but what I do is I employ my APP under a LLC. I salary them with bonuses
I get 100% collections to my LLC out of which I bonus them.
Hard to do unless you work in PP group and already have hired APPs.

I agree that if you don’t have this set up, asking for certain percentage of collections is needed. Specifically, because hospital has more to benefit than you.
 
Is it even possible? I have not seen anyone has that kind of contract. It is usually supervision bonus and like 20% or less portion of wrvu they are generating
Yes. @Ronin1 has a setup similar to that in a HOPD.

They do better with anesthesia also. You get what, $500 for anesthesia for a lumbar fusion but they will get between $26000 and $75000? If you get a rvu rate of $70 you will make more doing pain per hour than doing anesthesia. You will make around $140 per office visit. You have to work much harder to make $140 doing anesthesia.
Not true. Quite easy to make $140 in anesthesia.
Epidural = 5 units. Blended rate at $50/unit. a 5 minute epidural on OB is $250.
Locums, $400/hr. sitting in an OR for 20 minutes on SDN/reddit ~$140.
a lap chole 7 units + 4 units time = 11 units @ 50/unit = $550/hr.
 
Yes. @Ronin1 has a setup similar to that in a HOPD.


Not true. Quite easy to make $140 in anesthesia.
Epidural = 5 units. Blended rate at $50/unit. a 5 minute epidural on OB is $250.
Locums, $400/hr. sitting in an OR for 20 minutes on SDN/reddit ~$140.
a lap chole 7 units + 4 units time = 11 units @ 50/unit = $550/hr.
two stim trials in 40 minutes with that sort of calculation. $70 x 36 or so?
 
How much is start value and 90 minutes op time for Medicare for L4/5 lumbar fusion?

I can see 3 refills only in 20 minutes.
I think the startup is 15 units + 6 units. so 21 x$35. so about $1100, which is about $730/hr worth of work. Still a respectable amount for being mostly on cruise control, no followup, and lack of procedural risk.

granted, you could generate 9 refills in 60 minutes ($140 99214 x 9 = $1260), but then you have to pay approx 50% overhead. so that becomes about $610, which is comparable to the $730 on an hourly basis.
 
I think the startup is 15 units + 6 units. so 21 x$35. so about $1100, which is about $730/hr worth of work. Still a respectable amount for being mostly on cruise control, no followup, and lack of procedural risk.

granted, you could generate 9 refills in 60 minutes ($140 99214 x 9 = $1260), but then you have to pay approx 50% overhead. so that becomes about $610, which is comparable to the $730 on an hourly basis.
RVU contracted Hospital employed pain docs like myself do not pay overhead so you are wrong about 50% part. I see about 1-2 NPs, 2-3 follow ups and a couple of procedures (including RFA) in an hour. On my surgery days in ASC, I am more productive than clinic days with advanced procedures.

You can not really beat relatively busy interventional pain docs with hourly rate.
 
Last edited:
RVU contracted Hospital employed pain docs like myself do not pay overhead so you are wrong about 50% part. Also there is no pain doc who is seeing follow ups or med refills exclusively. I see about 1-2 NPs, 2 follow ups and a couple of procedures (including RFA) in an hour.

You can not really beat relatively busy interventional pain docs with hourly rate.
I'm not wrong since I was talking to Bob, who owns his own practice. He most certainly pays overhead.

There are definitely pain docs who dont do injections. You will see many practices advertise 'non-interventional' pain management. I've seen several. Pill mills also come to mind.
 
RVU contracted Hospital employed pain docs like myself do not pay overhead so you are wrong about 50% part. I see about 1-2 NPs, 2-3 follow ups and a couple of procedures (including RFA) in an hour. On my surgery days in ASC, I am more productive than clinic days with advanced procedures.

You can not really beat relatively busy interventional pain docs with hourly rate.
You see 1-2 NPs, 2-3 fu and couple procedures in including RFA in an hr? If true, you're either super human or you're doing a huge disservice to your patients
 
has to be a unilateral RFA. No time for moving the probes, testing, burning the opposite side which is 2min 30s minimum much less placing the opposite side probes.
 
You see 1-2 NPs, 2-3 fu and couple procedures in including RFA in an hr? If true, you're either super human or you're doing a huge disservice to your patients
You saw his answer- money more important than care. Probably has some KOL deals..
 
There’s a guy in our practice who tries to do that volume. I’ve seen plenty of his fluoro pics. Never seen him get in an SIJ, needles for medial branch blocks are anywhere and everywhere all over the pedicle and his RFAs are low and lateral over the inferior transverse process. I’ve even seen a couple of his SCS trials where the top of the leads reach T 10 for low back and leg pain coverage. That’s a new one to me
 
You can not keep your practice busy if you suck at your job.

Of course I am not doing RFA every hour. I do it a couple a day. It was my bad if I made you think I do it every hour. Takes about 10 minutes for unilateral lumbar and cervical. I do not do sensory test but I do motor.

LESI, CESI, Mbb, SI and other simple procedures including joint/bursa usually no longer than 5 minutes unless complicated ones.

Looking at what I said, in average 1.5 NP 2.5 f/u, 2 sometimes 3 procedures an hour very doable if you develop efficient system, good support and if you have reasonably good hands. I don’t have to see unnecessary follow up patients after each mbbs or prescribe opioids to keep me busy. If you are good at your job then people will talk about you and come to you which keeps you busy. Once you are busy enough it is up to your efficiency. I don’t want my new patients to wait longer than 2 months and I had to develop efficient system to match the needs. I do my best for each patient as all of you do but it doesn’t necessarily mean that you have to think longer and take longer time for each patient. I also have a great NP who helps me alot for everything.

What makes you a good pain doc? To me, it is to make proper diagnosis (not diagnosing everyone with SIJ cause their pain is in their buttock), offer appropriate options and avoid unnecessary meds/injections and surgeries.
 
You can not keep your practice busy if you suck at your job.
This is absolutely not true if you work in a hospital neurosurgical setting. You’re fed endless injections and if they fail, oh well, they get surgery. Don’t need surgery? Oh well, see the NP. Injectionist never has to see them again.
 
This is absolutely not true if you work in a hospital neurosurgical setting. You’re fed endless injections and if they fail, oh well, they get surgery. Don’t need surgery? Oh well, see the NP. Injectionist never has to see them again.
We don’t even have a neurosurgeon. I would still blame your inefficiency not criticizing someone who can see more patients than you and still do a reasonable job.
 
You
We don’t even have a neurosurgeon. I would still blame your inefficiency not criticizing someone who can see more patients than you and still do a reasonable job.
you didn’t read the part I was responding to

The point was you can definitely keep a busy practice and suck at your job. Not saying you do but it’s easy to do in our field
 
SAME! Man, must be common
Went to nurses to try and change their staffing to achieve more efficiency and staff is very pissed.
Makes me feel good it’s not just me

Crazy that so much of us have the same experience. Just want to do better for patients and be efficient, everyone else is just working to make it through the day with as little productivity as possible.

Can you believe we've been waiting six months for our "financial executive" committee to approve us to do DRG? Can't count how many patients we've had to refer out.
 
DRG isn’t worth the hassle. Just put in standard leads.

That's a valid but separate topic of discussion. We shouldn't be prevented from doing a commonplace procedure because of pencil pushers not understanding it's the same CPT code as DCS.
 
seeing a ton of people is not a guarantee of doing a good job. doing an injection really quickly is not a sign of a good job.

it is a sign of factory medicine and in fact poor care.


if i wanted to, i could do a "TFESI" in 15 seconds. i could do bilateral RFA in 2 min 30 seconds - with 2 min lesioning.
 
Top