How bad is the CRNA problem. Will MDs always have a job

[deleted126335]

Generation me may settle working for less. But they won't work slave hours and they certainly will not take the majority of weekend calls.

There will always be a night/weekend differential. There will always be those who are willing to work 40 hours fo $X per week and those who work 60 hours for $1.5X per week.

If it comes to it and things get really bad, there are plenty of members of generation me who will get an attitude adjustment who will work what many consider "slave hours" today and lots of weekends if it means paying the mortgage, getting your kid braces, etc.

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[BLADEMDA]

Everyone will sell out one way or another eventually. Even the ones screaming that CRNAs are dirt and I'd rather be unemployed! Those jobs will not be sustainable. Huge subsidies make you a takeover target. Bills have to be paid, your kids have to go to college, you can only move so many times.
I think about this every time I consider selling out for the lure of PP. I'm pretty safe where I am.

So True.

 

[BLADEMDA]

Either way.

I am going to count on "generation me" to bail the profession of Anesthesiology!

I am not kidding. These new generation of working professionals don't give a crap. They don't want to work but maximize their income.

How does this relate to anesthesia?

We've all seen it. Those born between 1982-current. These are your new generation anesthesia professionals. And when we include next generation crnas along with anesthesiologists. Many will be unwilling to work 60 hours a week.

The next generation will cause havoc on the system. Who is going to work late? Who is willing to take weekend calls??

Trust me. I moved back to academic medicine and I see it first hand day in and day out. No one wants to work these days.

There are plenty of crnas who opposed the AANA as there are MDs who opposed the ASA.

The profession of anesthesia whether its MDs or crnas. It's moving towards working as little as possible these days. And the new generation will only magnify this problem further.

How will administrators deal with this? Than it becomes their problem not having enough staff coverage. There are only so many ASCs around for the no call no weekends. Hospitals need 24/7 coverage. Who's going to want to do that with salaries going down? I don't see crnas jumping in to provide this even for equal money as their MD counterparts.

The generation "me" will provide administrators a hard lesson how not to treat working professionals.

Great post.

 

[deleted307836]

I think the posts about my "generation" are laughably overblown. Trust me, there are plenty in this cohort with enough debt to want to take any work they can. I wouldn't apply what you read in a Time magazine article to a group of ambitious physicians and medical students.

That said, the emphasis on lifestyle will certainly remain. As Dr. Doze said, why make extreme sacrifices in your personal and family life for rewards that were once there but no longer will be?

 

[BLADEMDA]

There will always be a night/weekend differential. There will always be those who are willing to work 40 hours fo $X per week and those who work 60 hours for $1.5X per week.

If it comes to it and things get really bad, there are plenty of members of generation me who will get an attitude adjustment who will work what many consider "slave hours" today and lots of weekends if it means paying the mortgage, getting your kid braces, etc.

As usual Doze you are correct about the economics of work. If a CRNA won't do the job the AMC or CEO will find someone who will. Ditto for the MD (A).

While seeing into the future is very difficult the single payer system follows the public option. So, while the clock starts ticking this January with Obamacare the real clock is when President Clinton gets the public option added to the law in 2017.

I suspect after the public option is added circa January 2018 the demise of private insurance will take 3-5 years followed by a single payer system. Obama knew from the beginning his bill was a method to go from "here to there" with there being a single payer system.

The next thing we see as providers on the ground is more AMCs or Employed positions utilizing the collaborative model to save money for the hospital. I expect that to become more common in a few years.

The high paying existing groups with MD only providers are at risk under the new Obamacare paradigm. They can hold out as long as the hospital subsidy is low or zero and the public option isn't available. Once the public option is added these groups are toast. The Groups with the ACT can hold out if their subsidy is low or zero for a bit longer.

But, the majority of Groups in the USA, 50% or more, that receive a significant hospital subsidy are at risk of financial disaster under Obamacare unless they hire more CRNAs and move away from medical direction as Anesthesiologists retire or leave the Group.

With this kind of financial pressure down the road along with massive increase in rules and regulations many groups are selling out to AMCs. These AMCs then slash salaries and benefits for ALL anesthesia providers in order to maximize profits.

The end result of all this is that many Anesthesiologists see the end of private practice in 5-15 years. They are selling out or holding the line on expenses as the end game is clear.
New hires are faced with the dilemma of an employee model vs. a partnership track.
IMHO, nobody should take a partnership track without a clause for inclusion in the profits of the sale of the company after 12 months. That clause could be worth 1-2 million dollars.

 

[aneftp]

When will the public realize physician incomes including anesthesiologists are not the issue with healthcare in USA. Back when I was in med school physician incomes made up 17% of total healthcare cost in mid to late 90s.

Now in 2013 physician incomes make up less than 8% of total us health spending.

Congress and the white house know this. That's why they keep passing the doc fix.

 

[BLADEMDA]

They don't care. We are still rich in their eyes. CEOs look at us as high priced labor that they would love to replace with mid priced labor. The doc fix only gets passed because there are "too many" doc practices who are small businesses who would be badly damaged if not destroyed, thus jeopardizing care and access for many. When the number of docs who are small business gets small enough, and the number of docs who are employees of a health care system gets big enough- the doc fix won't get passed, because not enough people will be affected. Individual professional service fees are becoming less relevant.

Single Payer system. Obamacare is simply a transition from private insurance to a public option (next on the agenda) to a single payer system.

 

[BLADEMDA]

 

[aneftp]

The health premium subsidy is going to blow up the ACA budget. Even Dems are acutely aware yet the liberal media like MSNBC and CNN refuse to be fair and balance and report "worst case scenarios"

Notice the Obama administration has frankly stopped talking about the cost savings with the ACA and only highlight the benefits. Because we all know it's just cost shifting and zero savings. More and more companies will do what Walgreens did last week. Move their lower paid employees to the exchange and make the taxpayers pay for the subsidy. Same for many retiree people on company or even state pensions that include healthcare. They are going to be moved to the exchanges.

Wonder why Harry Reid doesn't want any CBO "re-scoring" of how much the ACA is going to cost.

 

[ProRealDoc]

So with all the information in mind, where do you all think the safest place to hide for the next 20 years would be, if I want to minimize Obamacare's impact on my income?

Do you recommend academics? I have the credentials and wonder whether I should leave my lucrative (almost 500K a year gig) to hide in an academic job hoping to continue earning 80% of my current income.

I worry that a massive exodus to safer academic jobs may take place at some point while we transition from Obamacare to a single payer system.

what say you?

 

[yappy]

Because ACA has been in the news a lot I've been reading up on the changes, how businesses are responding, and trying to understand the exchanges and the subsidies that Blade has posted. I know I'm a little late to the party; but, it seems that ACA is basically a massive transfer of wealth from people that are higher income to lower/middle income in the form of health benfits. WTF.

 

[aneftp]

So with all the information in mind, where do you all think the safest place to hide for the next 20 years would be, if I want to minimize Obamacare's impact on my income?

Do you recommend academics? I have the credentials and wonder whether I should leave my lucrative (almost 500K a year gig) to hide in an academic job hoping to continue earning 80% of my current income.

I worry that a massive exodus to safer academic jobs may take place at some point while we transition from Obamacare to a single payer system.

what say you?

Most academic places pay between 220-325K depending on experience and your negotiating skills. Of course there are regional (location) variations also.

But some academic places have really good benefits that can make up for some of the salary differences.

Most of us self employed "cheat" on our taxes and deduct health premiums from the business side (that's the legal part). Technically and legally with the ACA, self employed must re-add back those health premium deductions on the business side back onto their W2 wages they pay themselves. Why is this important? Because premiums for a family of 4 are easily approaching 15K a year with a high $5000-10000 deductible. Soon I anticipate premiums will hit 20K a year for many self employed. Since we make too much money, we won't get any subsidy. And since the ACA will start enforcing self employed to report actual premiums deducted on the business side onto their W2 wages, it's going to hurt a big illegal tax deduction many of us make.

This law has actually been in force since 2007 but the IRS hasn't really been auditing or enforcing it. Say you deduct 15K from your premiums on business side. If you pay yourself W2 wages of 150K. By law, you will have to re-add 15K back to your 150K W2 wages. In essence you will be getting taxed on the 165K W2 wages.....but I am so off topic...I'll get back on topic. Just love talking about taxes and write offs but it will affect self employed people and eventually "Cadillac union insurance plans"

Obviously academics is generally less "work" and more downtime. But you will still find yourself in the hospital pass 4pm-5pm most days even if you aren't doing anything due to meetings, lectures etc.

 

[Notanerd]

All this just really sucks. I really hope being at a program with a strong national name and doing a fellowship will protect me in the future. I can't even imagine doing pain and having that be my dad to day but I know that's what it's gonna come down too.

Critical care : lose pay and lifestyle
Obgyn can't see myself doing
Cardiac: heart cases are down and now I hear of people doing CC and hearts together
Regional : I would love but don't know how job security will be pay could be off the roof
Neuro: can't believe it's really a fellowship
Chronic pain: cool procedures can still work at a private practice can do cool procedures but the patient population is super tough.

Can't handle people saying " just do what you love " type crap anymore. That would be drinking beer and hanging out on a beach

 

[Dejavu]

Blade,

No doubt you are a good guy, but don't call me Slim, like you are about to start a bar fight or something.

I deserve better, if for no other reason than that I am your elder. I am sure your mother taught you to respect your elders.

Please do so.

If you don't agree with my post, fine, but mind your manners.

Also, when you type my user name, please get it right.

 

[D P356]

Blade,

No doubt you are a good guy, but don't call me Slim, like you are about to start a bar fight or something.

I deserve better, if for no other reason than that I am your elder. I am sure your mother taught you to respect your elders.

Please do so.

If you don't agree with my post, fine, but mind your manners.

Also, when you type my user name, please get it right.

in other words...

 

[BLADEMDA]

Blade,

No doubt you are a good guy, but don't call me Slim, like you are about to start a bar fight or something.

I deserve better, if for no other reason than that I am your elder. I am sure your mother taught you to respect your elders.

Please do so.

If you don't agree with my post, fine, but mind your manners.

Also, when you type my user name, please get it right.

Yes Sir, Dr. Dejavu. I'm happy to discuss the facts (ACA, AANA, Collaborative model, AMC takeovers, Mayo being ultra elitist, etc.) without using the term "slim."

 

[BLADEMDA]

All this just really sucks. I really hope being at a program with a strong national name and doing a fellowship will protect me in the future. I can't even imagine doing pain and having that be my dad to day but I know that's what it's gonna come down too.

Critical care : lose pay and lifestyle
Obgyn can't see myself doing
Cardiac: heart cases are down and now I hear of people doing CC and hearts together
Regional : I would love but don't know how job security will be pay could be off the roof
Neuro: can't believe it's really a fellowship
Chronic pain: cool procedures can still work at a private practice can do cool procedures but the patient population is super tough.

Can't handle people saying " just do what you love " type crap anymore. That would be drinking beer and hanging out on a beach

Suck it up and do a fellowship in Critical Care. Then, you can handle any case (cardiac, neuro, AAA, Bowel perf,etc) with ease. IMHO, guys like Seinfeld are much better positioned for the ACA---Single payer than most others with the exception being Pain and Pediatrics.


Protect your Arse Fellowships:

Critical Care
Pain
Peds

I didn't include Cardiac because of the glut in that area.

 

[BLADEMDA]

The health premium subsidy is going to blow up the ACA budget. Even Dems are acutely aware yet the liberal media like MSNBC and CNN refuse to be fair and balance and report "worst case scenarios"

Notice the Obama administration has frankly stopped talking about the cost savings with the ACA and only highlight the benefits. Because we all know it's just cost shifting and zero savings. More and more companies will do what Walgreens did last week. Move their lower paid employees to the exchange and make the taxpayers pay for the subsidy. Same for many retiree people on company or even state pensions that include healthcare. They are going to be moved to the exchanges.

Wonder why Harry Reid doesn't want any CBO "re-scoring" of how much the ACA is going to cost.

Correct. The "baton" is ready to be passed from Obama to Hillary Clinton in 2016. By 2017 the costs of the ACA will be clear and Hillary will push the public option to keep the budget from exploding. I think she gets it passed.

 

[BLADEMDA]

So with all the information in mind, where do you all think the safest place to hide for the next 20 years would be, if I want to minimize Obamacare's impact on my income?

Do you recommend academics? I have the credentials and wonder whether I should leave my lucrative (almost 500K a year gig) to hide in an academic job hoping to continue earning 80% of my current income.

I worry that a massive exodus to safer academic jobs may take place at some point while we transition from Obamacare to a single payer system.

what say you?

I advised a guy you know to take a nice Academic gig. I advise the same thing for you. If you know the person I'm talking about give him a call. Perhaps, we can all meet for dinner?

The benefits at his place are outstanding and worth a lot of money in salary terms.

 

[BLADEMDA]

Because ACA has been in the news a lot I've been reading up on the changes, how businesses are responding, and trying to understand the exchanges and the subsidies that Blade has posted. I know I'm a little late to the party; but, it seems that ACA is basically a massive transfer of wealth from people that are higher income to lower/middle income in the form of health benfits. WTF.

Unfortunately, the experts working for Medicare's actuary have (yet again[1]) reported that in its first 10 years, Obamacare will boost health spending by "roughly $621 billion" above the amounts Americans would have spent without this misguided law.


Obamacare Will Increase Health Spending By $7,450 For A Typical Family of Four


http://www.forbes.com/sites/theapot...pending-by-7450-for-a-typical-family-of-four/

 

[BLADEMDA]

Many insurers are cutting costs by slicing doctors' fees.


http://www.nytimes.com/2013/09/23/h...d=2&adxnnlx=1379955829-K2E4w+34QQLb9o/Azvvncw

 

[yappy]

Unfortunately, the experts working for Medicare's actuary have (yet again[1]) reported that in its first 10 years, Obamacare will boost health spending by "roughly $621 billion" above the amounts Americans would have spent without this misguided law.


Obamacare Will Increase Health Spending By $7,450 For A Typical Family of Four


http://www.forbes.com/sites/theapot...pending-by-7450-for-a-typical-family-of-four/

What I was trying to get at is that higher income people are going to be purchasing their own insurance, or receive it as compensation, and be on the hook for providing a subsidy for people who accept the insurance products that come out of obamacare... they're paying twice.

This is why I said that ACA is basically a massive transfer of wealth. I am starting to become discouraged because it's very difficult to get ahead now-a-days even if you're starting off in a lucrative career.

With every new tax, or form of tax, we're forced to be that much smarter, frugal, and leaner to meet our financial goals. It's extremely irritating and I'm feeling like things are only going to get harder unless there is a culture shift. Most people my age that I talk to are not ambitious and don't think about how their actions can influence their economic standing... they want security and a comfortable life without the risk or failure or hard work.

 

[BLADEMDA]

What I was trying to get at is that higher income people are going to be purchasing their own insurance, or receive it as compensation, and be on the hook for providing a subsidy for people who accept the insurance products that come out of obamacare... they're paying twice.

This is why I said that ACA is basically a massive transfer of wealth. I am starting to become discouraged; because, it's very difficult to get ahead now-a-days even if you're starting off in a lucrative career.

With every new tax, or form of tax, we're forced to be that much smarter, frugal, and leaner to meet our financial goals. It's extremely irritating and I'm feeling like things are only going to get harder unless there is a culture shift. Most people my age that I talk to are not ambitious and don't think about how their actions can influence their economic standing... they want security and a comfortable life without the risk or failure or hard work.

Of course Obamacare is redistribution of wealth. Obama is a tax, tax and tax some more socialist with little regard for capitalism. He actually despises Capitalism but in order to get his socialistic programs he puts up with it.

Get used to a big shift left and it isn't going to change.

 

[IlDestriero]

Most people are of very average intelligence, are afraid to take risks, and lack the courage to do what it takes to succeed. They will never, ever, support a culture change to spare the upper middle class professionals making several times the average family income.
The maximum federal tax rate used to be 90%. It will continue up again, govt driven reimbursements will decline, and there will be a national tax coming as well. Probably on everything except food. Also expect a further limitation on tax deductions based on income. It's inevitable. Accept it and move on.

 

[Silent Cool]

 

[BLADEMDA]

Most people are of very average intelligence, are afraid to take risks, and lack the courage to do what it takes to succeed. They will never, ever, support a culture change to spare the upper middle class professionals making several times the average family income.
The maximum federal tax rate used to be 90%. It will continue up again, govt driven reimbursements will decline, and there will be a national tax coming as well. Probably on everything except food. Also expect a further limitation on tax deductions based on income. It's inevitable. Accept it and move on.

I agree with everything in your post except "accept it". I plan on donating money to the GOP and will continue to oppose deficit spending, high taxes and massive expansion of social programs. I believe this path leads to the demise of the USA

Rand Paul has my support for the POTUS

 

[IlDestriero]

That's fine, but let's be real here, even if we elect an all Republican team, they'll still not make the hard choices and institute programs that will cost them votes until things are dire. Like the cost of Maobama care in another 10 years.

 

[Silent Cool]

That's fine, but let's be real here, even if we elect an all Republican team, they'll still not make the hard choices and institute programs that will cost them votes until things are dire. Like the cost of Maobama care in another 10 years.

I disagree. I'm a fan of Rand Paul in part because of his father and also because he has gone on record many times supporting the 'hard' cuts.

Honestly, I don't see Hillary winning. I think enough people hate her and have lost trust in the current administration that Rand has a chance. It's one of the few times I would consider donating some of my (paltry) savings to a politician.

 

[BLADEMDA]

That's fine, but let's be real here, even if we elect an all Republican team, they'll still not make the hard choices and institute programs that will cost them votes until things are dire. Like the cost of Maobama care in another 10 years.

At least we have a shot with Rand to stand up and try to save this nation. I'm betting he would rather save this country and serve 1 term than be pandering politician and serve 2.

 

[crnasuccs]

http://www.youtube.com/watch?v=xxQB1R8AF4A

 

[IdealGas]

http://www.youtube.com/watch?v=xxQB1R8AF4A

 

[Dejavu]

Yes Sir, Dr. Dejavu. I'm happy to discuss the facts (ACA, AANA, Collaborative model, AMC takeovers, Mayo being ultra elitist, etc.) without using the term "slim."

Somehow I knew you are not the type of guy who ever says, "I'm sorry"; you did not disappoint me.

Please continue on. But remember, if you haven't walked a mile in my shoes (CRNA to MD) or worked at Mayo, be careful while speaking of things about which you have no knowledge. It is okay to have opinions about me or Mayo, but that doesn't make them true or turn them into 'facts".

Do have a great day.

 

[BLADEMDA]

Somehow I knew you are not the type of guy who ever says, "I'm sorry"; you did not disappoint me.

Please continue on. But remember, if you haven't walked a mile in my shoes (CRNA to MD) or worked at Mayo, be careful while speaking of things about which you have no knowledge. It is okay to have opinions about me or Mayo, but that doesn't make them true or turn them into 'facts".

Do have a great day.

I do apologize to you. I am also quite familiar with the Mayo way. Let's move on.

 

[Dejavu]

I do apologize to you. I am also quite familiar with the Mayo way. Let's move on.

There is something we can agree on. Thank you.

 

[yappy]

At least we have a shot with Rand to stand up and try to save this nation. I'm betting he would rather save this country and serve 1 term than be pandering politician and serve 2.

Yes. I think it's best to find ways to change peoples mind. I agree that people will not be convinced by people who are earning a good living complaining about taxes; however, there has got to be another way.

I think the biggest problem is that most people are financially illiterate. I've seen people turn conservative when they start taking retirement, and their financial life, seriously.

We need people to stop seeing themselves as the people who will benefit from tax revenues and imagine themselves as people who will not be benefiting from tax revenues. Taxes start to suck when you're trying to meet financial goals that make things like SS, food stamps, Obama phone, etc. unimportant. Instead of helping you meet your goals (by being some sort of "forced" savings account) taxes become an impediment to your goals.

 

[happygilmore]

The least of all evils.

Id support him. Less govt is better govt when they suck this bad.

 

[BLADEMDA]

Large U.S. multinationals will find providing most employees with insurance too expensive if they are to compete in global markets, and dump their employees into subsidized public exchanges.

 

[KGflyboy]

Medicare’s actuaries expect health costs per person, across the entire population, to rise from about $50,000 in 2012 to about $74,000 in 2022. That’s about 20 percent of GDP, whereas Germany spends about 12 and Britain even less.

Large U.S. multinationals will find providing most employees with insurance too expensive if they are to compete in global markets, and dump their employees into subsidized public exchanges.

How was the per capita spending 50k in 2012? That seems crazy high. The average person only sees a primary care doc each year. 50k would mean the average person has pretty serious or expensive chronic health problems or a traumatic event requiring inpatient hospitalization or multiple surgeries.

I'm not saying you're wrong... I'm just saying that's pretty hard for me to comprehend if true.

 

[BLADEMDA]

How was the per capita spending 50k in 2012? That seems crazy high. The average person only sees a primary care doc each year. 50k would mean the average person has pretty serious or expensive chronic health problems or a traumatic event requiring inpatient hospitalization or multiple surgeries.

I'm not saying you're wrong... I'm just saying that's pretty hard for me to comprehend if true.

Medicare spending per beneficiary is quite high. I'll keep searching for an exact number per beneficiary.

Health Care costs/spending per person per year in the USA runs around $8900 per year.

 

[BLADEMDA]

 

[BLADEMDA]

 

[BLADEMDA]

 

[BLADEMDA]

We spend double what Canada does on health care per person

 

[jwk]

We spend double what Canada does on health care per person

Not that surprising since their care is rationed.

 

[KGflyboy]

So where did that $50k number come from?

 

[BLADEMDA]

So where did that $50k number come from?

About 10-15% of Medicare beneficiaries cost $50,000 per year. These individuals consume many heath care dollars and drive up the median number.

 

[ProRealDoc]

I advised a guy you know to take a nice Academic gig. I advise the same thing for you. If you know the person I'm talking about give him a call. Perhaps, we can all meet for dinner?

The benefits at his place are outstanding and worth a lot of money in salary terms.

Next time I'm in Fla, I'll let you know so we can get together for dinner. Would like to hear yours and his experience in academics.

 

[happygilmore]

= disaster

United States healthcare is dumb. Let's add more and more people to insurance but pay less and less! No law makers are addressing these huge problems, they just ignore them and try to pass half ass bills to get elected.

Yea gov't! Get elected then screw around.

 

[happygilmore]

We spend double what Canada does on health care per person

You know what amazes me about all this, anyone with half a brain knows our system will collapse if it continues in the direction it's going. Obamacare did nothing to address this.

Our leadership is ******ed.

 

[BLADEMDA]

My biggest concern in the immediate time frame is the public option. Obamacare as it exists today doesn't force most all MD (A) groups to go to a MD-CRNA model. But, the addition of the public option to the exchanges pretty much is a death sentence to the MD only as model. In addition, more MD-CRNA groups will be forced to sell to an AMC or become hospital employees.

The public option( medicare for all) is the end of the current model for private practice Anesthesia in the USA.