Insurance and Payments

[doctor712]

Hi All

So, question for all you amazing anesthesiologists out there....this one, GASP, revolves around finances.

I've read lots of threads that talk about how poor payor-mix, and getting paid by certain populations (i.e. medicare, medicaid etc) gives pennies on the dollar when it's time to bill and collect for pp anesthesiologists. So, that when you do that 6 hour heart case, and the patient doesn't have Cadillac insurance, but rather medicare, you are kind of SOL...

Can someone explain to me then, the logic for the other age of the spectrum: pediatric anesthesiology? I have heard that, generally speaking, pediatric anesthesiologists don't make salaries comparable to other sub-specialties of anesthesia, CCM, CT, no idea about OB...

A couple of assumptions here: so, IF the kiddies, at large, have insurance, and they are not on medicare like the 85 y/o, but are rather on mommy or daddy's Blue Cross or AETNA, or Cigna, then...why don't pediatric anesthesiologists earn more - generally - than just about every other area of anesthesia?

So, to think empirically about this, and I understand a couple of assumptions about kids and insurance, and maybe types of insurance, need to be made, but would it not then follow that Peds Anesthesiologists "should" make more than CT who are doing "medicare" cases day in and day out?

Assumptions:
1) same amount of procedures as older peeps
2) greater % have insurance overall
3) greater % have BETTER/higher paying insurance plans as compared to CT or Neuro for example
4) that, in fact, Peds is an underpaid specialty compared to others.

If all those fall true, why are they not compensated accordingly? Are there extra-insurance reasons here? I was once with a CT guy and he tried to explain the UNITS payment situation. Does that not fall true for Peds as well, and if so, I'd think you'd have as much to do, time wise and procedure wise, on kids than the +65 surgical population. Maybe not for T&As all day...hmmm...

What gives? I am very interested in this explanation...

As always, thanks!

Back to books!

D712

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[Consigliere]

The explanation is quite simple - Medicaid. The majority of kids coming to an academic medical center, where most pediatric anesthesiologists practice, are on Medicaid. Medicaid pays even less than Medicare so there you have it.

 

[Mman]

In , an individual anesthesiologist is not being paid for the case they are doing. Most groups divide up the total money collected and divvy it out in some roughly equal fashion.

Now there are different ways to go about doing that, but a true "eat what you kill" situation is extremely rare.



Our group is completely equal in terms of work and pay. The type of work you do might vary (peds vs cardiac vs pain vs OB vs whatever) but the overall hours and intensity we try to match up as evenly as possible and split the pay equally in the end.

In a situation where you are only getting paid for what you do, people have financial incentives to want to do only certain types of rooms or only work with certain surgeons. That isn't really good for camaraderie.

 

[sevoflurane]

4) that, in fact, Peds is an underpaid specialty compared to others.
D712

A busy ENT day can make almost as much as a heart. Especially if you are cranking 2.5cases/hour x 4.5 hours+ time = 11.25 cases.

Average heart is 'bout 50-60 units + time if I remember correctly. 'bout 4-5 hours start to finish for pump runs (skin to skin). Off-pump is a different animal and will create greater revenue for time spent in the OR.

Average T&A = 5 units + 11.25 cases in 4.5 hours = 56 units

Assuming same payor mix, you are looking at roughly the same compensation, maybe a bit more in the CT room..... but not by a lot.

You need to stay busy in the ENT room.

 

[sevoflurane]

Eat what you kill is very fair IF the schedule is made up fairly. (cases, no delays btw/ rooms, 7:30 starts, etc....)

There are modifications to the true eat what you kill mentality. They work great in certain groups. I love this set up.

If I leave at 11:00am and my partner is there until 5:00pm, he will make more than me, but I'll have more sunshine. If you want to work more, you ask your 58 y/o partner if he wants to go home so you can pick up extra cases. Simple as that.

Great setup IMHO.

 

[sevoflurane]

Eat what you kill is very fair IF the schedule is made up fairly. (cases, no delays btw/ rooms, 7:30 starts, etc....)

There are modifications to the true eat what you kill mentality. They work great in certain groups. I love this set up.

If I leave at 11:00am and my partner is there until 5:00pm, he will make more than me, but I'll have more sunshine. If you want to work more, you ask your 58 y/o partner if he wants to go home so you can pick up extra cases. Simple as that.

Great setup IMHO.

Of course, you and your partners need to be paid per blended unit. Otherwise, walk away from that group and find something more fair as the newbies will get medicaid/care as the oldies get PP insurance.

Always ask about this when interviewing.

 

[Mman]

Eat what you kill is very fair IF the schedule is made up fairly. (cases, no delays btw/ rooms, 7:30 starts, etc....)

There are modifications to the true eat what you kill mentality. They work great in certain groups. I love this set up.

If I leave at 11:00am and my partner is there until 5:00pm, he will make more than me, but I'll have more sunshine. If you want to work more, you ask your 58 y/o partner if he wants to go home so you can pick up extra cases. Simple as that.

Great setup IMHO.

I prefer the "we all make the same income" arrangement where if I go home at 9 AM today, I will be working much later tomorrow. Similarly if I pull long hours today, I know I will be getting out much earlier tomorrow.

If I want more money, I will take extra call or weekend shifts from somebody that doesn't want them at a predetermined rate that is always subject to negotiation.

Everybody wins because nobody cares if your cases are insured or not. It all works out in the end.

 

[doctor712]

Of course, you and your partners need to be paid per blended unit. Otherwise, walk away from that group and find something more fair as the newbies will get medicaid/care as the oldies get PP insurance.

Always ask about this when interviewing.

That seems REALLY key...thanks for all the answers Sevo and MMan!

 

[sevoflurane]

Everybody wins because nobody cares if your cases are insured or not. It all works out in the end.

Never an issue with a blended unit.

Both models work. I tend to like the eat what you kill setup because If I work I make more. If I don't, I have more time on my hands. I get exactly my share of the pie today and not tomorrow or in 2 weeks or "in the end". I'm never looking at the clock because if I'm in the hospital I'm generating income. If it's 9:00pm I might be a little tired, but I KNOW that leaving at 9:00pm I'm gonna have a good day at the bank. If I want... I can do it again tomorrow and the day after, and the day after that. It is an exact science and no grey area.

I'm big on being exactly FAIR to everybody in the group... minute by minute, case by case.

No system is exactly perfect, but some eat what you kill set ups are pretty close. I'm sure the same can be said for your set up.

 

[doctor712]

A busy ENT day can make almost as much as a heart. Especially if you are cranking 2.5cases/hour x 4.5 hours+ time = 11.25 cases.

Average heart is 'bout 50-60 units + time if I remember correctly. 'bout 4-5 hours start to finish for pump runs (skin to skin). Off-pump is a different animal and will create greater revenue for time spent in the OR.

Average T&A = 5 units + 11.25 cases in 4.5 hours = 56 units

Assuming same payor mix, you are looking at roughly the same compensation, maybe a bit more in the CT room..... but not by a lot.

You need to stay busy in the ENT room.

is that in more than one room? or are these 15 min cases...? are you really putting a child to sleep, cutting, waking up in 15 mins? WOW. if so, are you calculating time in there that you need to walk kid from pre-op, talk to parents, bring to pacu, answer the (100) questions mom and dad will have...?

so, in pp, everything comes down to units + hours? and units are all created equal? that is, a unit in PA is same as in rural Wyoming and same as LA, CA? (i don't mean overhead or expenditures or insurance costs, i just mean income of the unit...not how far it goes...)

D712

 

[doctor712]

Never an issue with a blended unit.

Both models work. I tend to like the eat what you kill setup because If I work I make more. If I don't, I have more time on my hands. I get exactly my share of the pie today and not tomorrow or in 2 weeks or "in the end". I'm never looking at the clock because if I'm in the hospital I'm generating income. If it's 9:00pm I might be a little tired, but I KNOW that leaving at 9:00pm I'm gonna have a good day at the bank. If I want... I can do it again tomorrow and the day after, and the day after that. It is an exact science and no grey area.

I'm big on being exactly FAIR to everybody in the group... minute by minute, case by case.

No system is exactly perfect, but some eat what you kill set ups are pretty close. I'm sure the same can be said for your set up.

Was this fairness an important reason you chose your specific group? Would you have passed on a group that did it MMan's way? Would this trump geography in your mind? Either cross town or cross state line...?

D712

 

[sevoflurane]

A unit can be worth $ 25, 35, 45, 55, 65+. Depends on insurance type/payor mix and subsidy (hospital).

Fairness was extremely important in making my decision. I'm not big on putting money in senior partners pocket while I create more than my share of the units. Just not fair and I don't like that mentality. It tends to create divisions within a group. It is a huge reason I don't like management firms. Someone will be pocketing your hard earned units while at the golf course. If you don't like it, a management company will can you without a thought. All they care about is a warm body to do the cases.

Partnership tracks are another angle.... A partnership track can be fair, especially since a lot of the hospital/administrative work has been laid down for you before you arrive. Just need to be aware of hidden agendas in some groups. (Continued Hierarchy despite partnership status)

Other major factors are location, income and lifestyle. You will usually loose out on one of those. I don't have location, but income and lifestyle.... well, let's just say I'm plenty happy and my drive to work is 9-12 minutes.

Age is another thing to look at. 1/2 our partners are >50 (retirement material). They tend to take more vacation... up to 14 weeks. Their pay checks are smaller.... Those of us who take less vaca can capitalize and make bigger deposits into the bank. It works out for both sides. Everyone is happy. Synergism.

For some, moving to dream land is a sacrifice (lifestyle and/or income or both) that some are willing to make. Some are willing to make this adjustment later on in life.

 

[jetproppilot]

Was this fairness an important reason you chose your specific group? Would you have passed on a group that did it MMan's way? Would this trump geography in your mind? Either cross town or cross state line...?

D712

Fairness is everything dude.
An anesthesia group is like a marriage.
If you run a fair group, equal money or a system like Sevo/Noyac have to keep money commensurate with time invested, equal vacation, etc people work harder..they invest themselves in the group....great work environment...low attrition....minimal (relevant) griping.

Docs in a group can disagree about alotta things sometimes but

It's hard to argue with

FAIR.

 

[imfrankie]

The explanation is quite simple - Medicaid. The majority of kids coming to an academic medical center, where most pediatric anesthesiologists practice, are on Medicaid. Medicaid pays even less than Medicare so there you have it.

Unless you are in Alaska where Medicaid banks. Also there are areas where Medicaid gets special commercial like rates. But generally Medicaid reimbursement is unconscionable.

 

[imfrankie]

Never an issue with a blended unit.

Both models work. I tend to like the eat what you kill setup because If I work I make more. If I don't, I have more time on my hands. I get exactly my share of the pie today and not tomorrow or in 2 weeks or "in the end". I'm never looking at the clock because if I'm in the hospital I'm generating income. If it's 9:00pm I might be a little tired, but I KNOW that leaving at 9:00pm I'm gonna have a good day at the bank. If I want... I can do it again tomorrow and the day after, and the day after that. It is an exact science and no grey area.

I'm big on being exactly FAIR to everybody in the group... minute by minute, case by case.

Agreed. None of this "I'll gladly pay you Tuesday for a hamburger today"

 

[geogil]

is that in more than one room? or are these 15 min cases...? are you really putting a child to sleep, cutting, waking up in 15 mins? WOW. if so, are you calculating time in there that you need to walk kid from pre-op, talk to parents, bring to pacu, answer the (100) questions mom and dad will have...?

so, in pp, everything comes down to units + hours? and units are all created equal? that is, a unit in PA is same as in rural Wyoming and same as LA, CA? (i don't mean overhead or expenditures or insurance costs, i just mean income of the unit...not how far it goes...)

D712

Ear tubes, tonsilectomies and adenoidectomies are pretty fast. Even with residents doing the cases, putting the tubes in takes only a couple minutes. If you mask the kiddo, the whole thing only takes a few minutes. Tonsils are fast too, even if you tube the kid (which is how they did it where I went to medical school.) Sometimes the rate-limiting step is room turn-around.

 

[doctor712]

Ok, thanks for the replies. Seems like you can earn in Peds from what I'm hearing, as long as you do VOLUME.

As for the fairness question, I totally get what Jet is saying, everything comes down to fairness of course, I was more wondering if Sevo specifically thought that MMan's setup was "fair"? Per se.

Re: kids and ear tubes, if it's just sleepy sleep for a few minutes, say 5, does this mean you use volatile and let it burn off really fast when you're done? Or, can you use TIVA in low-dose/concentration for something so short?

The question just morphed from money to medicine...sorry.

D712

 

[B-Bone]

Ok, thanks for the replies. Seems like you can earn in Peds from what I'm hearing, as long as you do VOLUME.

As for the fairness question, I totally get what Jet is saying, everything comes down to fairness of course, I was more wondering if Sevo specifically thought that MMan's setup was "fair"? Per se.

Re: kids and ear tubes, if it's just sleepy sleep for a few minutes, say 5, does this mean you use volatile and let it burn off really fast when you're done? Or, can you use TIVA in low-dose/concentration for something so short?

The question just morphed from money to medicine...sorry.

D712

in general, we don't even start IV's on BMTs. mask down +/- intranasal fentanyl, tubes in, gas off when the cottonballs go in, turn on side, ensure spont resps,and off to PACU. I try to preop 2-3 at a time in our "toy room" and keep te flow going. 3/hour is a good clip for me. If our surgeon has 2 rooms and 2 anesthesia providers, you can definitely more than double that.

 

[doctor712]

Cool. Thanks B-Bone.

D712