Need more evidence that residency slots are cash cows for hospitals?

Discussion in 'General Residency Issues' started by MacGyver, May 17, 2008.

  1. MacGyver

    MacGyver Membership Revoked
    Removed

    Joined:
    Aug 8, 2001
    Messages:
    3,759
    Likes Received:
    5
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  2. turquoiseblue

    5+ Year Member

    Joined:
    Jul 1, 2007
    Messages:
    601
    Likes Received:
    4
    Status:
    Resident [Any Field]
    Of course it's a cash cow (at least it looks like it)! Cheap labored resident doctors working at often less than the salary of a nurse per year (and actualy at 80 hour work weeks, it's calculated to be less than minimal wage--2 for the price of 1!!!), with just a handful of attendings running the show, no one else to pay! Not to mention medicare is covering the cost of the residents! So--make more residency spots!
     
  3. DadofDr2B

    DadofDr2B Member
    7+ Year Member

    Joined:
    May 20, 2004
    Messages:
    305
    Likes Received:
    2
    There is no mention of attending physcians, fellows, nurses and other costs associated with operating a hospital. Remember doctors receive only 6% of the cost of medical care. They can talk all day about the doctors cost but they should figure out something for the 94% of the other costs. Plus most of these patients will not pay or are unable to pay.
     
  4. Toohotinvegas33

    Toohotinvegas33 Currently Glasgow 3
    7+ Year Member

    Joined:
    Aug 17, 2006
    Messages:
    1,254
    Likes Received:
    7
    Status:
    Resident [Any Field]
    They want to train 250 residents in a 500 bed hospital (although it was operating at 220ish when it closed), seems a little too cozy to me.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  5. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Verified Expert Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,780
    Likes Received:
    27,118
    Status:
    Attending Physician
    You are assuming that all of those residents would be on inpatient rotations. If all 250 were IM, Surg and Psych residents you might be spread thin depending on how the beds were distributed, but I'l be that number would include EM, Rads, Derm, FP, etc. who don't "share" those 500 beds full of patients.
     
  6. aProgDirector

    aProgDirector Pastafarians Unite!
    Moderator SDN Advisor 10+ Year Member

    Joined:
    Oct 11, 2006
    Messages:
    7,897
    Likes Received:
    6,004
    Status:
    Attending Physician
    The rest of the sentence quoted is important.

    Of course residency slots are "revenue generating". So is selling lemonade for $0.05 on the corner. It's just not clear either is a "cash cow".

    In addition, the funding for GME is slowly drying up, and when Medicare really goes into the red (in 2017 or so) it will be first on the chopping block.
     
  7. Strength&Speed

    Strength&Speed Need more speed......
    10+ Year Member

    Joined:
    Dec 26, 2004
    Messages:
    719
    Likes Received:
    2
    yeah, i saw that too. that was some creative editing by McGyver. However, how much do you really think hospitals do make per resident? Average?
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  8. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Verified Expert Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,780
    Likes Received:
    27,118
    Status:
    Attending Physician
    Here is a lengthy read on Medicare Funding:http://www.amsa.org/pdf/Medicare_GME.pdf

    Hospitals generally receive $100K/resident who is an FTE; out of that comes salary, benefits, teaching salaries, etc. which are relatively easy to calculate. What is not are the indirect costs - ie, increased ordering of tests.
     
  9. elwademd

    2+ Year Member

    Joined:
    Jun 24, 2007
    Messages:
    558
    Likes Received:
    1
    Status:
    Attending Physician
    also not calculated are the indirect savings - i.e. residents sending patients home when the patients are ready versus private attendings keeping medicare patients in house until the appropriate days for the drg have been reached, or the medicaid/medical patient where the hospital gets paid per hospital day; residents seeing patients and recognizing acuity (or lack thereof) versus private attendings admitting patients over the phone, residents not actually using supplied/provided benefits, etc. ;)
     
  10. Strength&Speed

    Strength&Speed Need more speed......
    10+ Year Member

    Joined:
    Dec 26, 2004
    Messages:
    719
    Likes Received:
    2
    Thanks, I got the GME funding part...i was more referring to how much money the residents are bringing in by seeing patients relative to their low wages.

    as a side note...not sure why you included increased ordering of tests as a "cost". This is not a cost to the hospital as they will be getting reimbursed. If anything, its a money maker. Unless im missing something.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  11. Faebinder

    Faebinder Slow Wave Smurf
    10+ Year Member

    Joined:
    May 24, 2006
    Messages:
    3,507
    Likes Received:
    10
    Status:
    Attending Physician
    This is a big point that many dont see. The tests are reimburised. Did the resident order an extra Chest Xray? Well the hospital got the money for it.

    APD, we really gotta write that article.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  12. 8744

    8744 Guest

    Joined:
    Dec 7, 2001
    Messages:
    9,323
    Likes Received:
    168
    Status:
    Non-Student
    This "ordering more tests" thing is a big pet peeve of mine. More often than not my attendings order extra tests on my patients that I don't think are necessary. For example I read in my Tintinalli (the EM textbook) that CTs of the brain for syncope which by history is likely vasovagal or cardiac with no focal neurological findings are incredibly low-yield and not necessary (which I presume makes not ordering a CT the standard of care) but when I don't order one my attendings will mention to me that they added one to the orders anyway...just in case.

    I can understand why they do it and when I am in practice who knows but that I will be so afraid of being sued that I'll order tests willy-nilly but to blame excessive testing on residents is obnoxious. Actually, we order a lot of tests at academic hospitals because we generally see poorer and therefore sicker patients with poor follow-up and terrible compliance. If all of my patients were employed, suburban families with established relationships with their primary care physicians I'd be lot more comfortable sending them out without the $5,000 work-up for vague abdominal pain.
     
  13. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Verified Expert Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,780
    Likes Received:
    27,118
    Status:
    Attending Physician
    You don't know that necessarily to be true.

    Most people would be suprised at how much insurance companies don't pay for, refuse to pay for, or what little they pay for.

    Much of this stuff is written off, and if the patient has no insurance? The hospital is not getting paid for it as you can be darn sure that the patient doesn't pay his/her medical bills the vast majority of the time.
     
  14. turquoiseblue

    5+ Year Member

    Joined:
    Jul 1, 2007
    Messages:
    601
    Likes Received:
    4
    Status:
    Resident [Any Field]
    Hospitals shouldn't be about money anyways--they're supposed to be there to treat patients, save lives and improve well being--not make extra $$$. why? so a doc can buy that new tuxedo to go to the christmas gala? or buy a yacht or vacation home?

    Not that I want docs to make less money but hopefully no one is thinking that its about money money money or where's my money, after they treat a poor indigent patient in dire need of care.

    And it's sad that some want to keep the physician shortage going, by reducing the amount of residency spots, just because they think it will cut the doctor salaries down to have more doctors out there, i mean come on! Patients' lives r at stake and all anyone can think of is $.$.$.
     
  15. Dr Serenity

    10+ Year Member

    Joined:
    Jun 8, 2007
    Messages:
    289
    Likes Received:
    0
    In addition to that, isn't Medicare trying to tighten the screws in terms of what it won't pay for...especially when it comes to complications such as catheter-related UTI and vent-assoc. PNA? I assume that also goes for tests used in the diagnosis of said complications?
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  16. Dr Serenity

    10+ Year Member

    Joined:
    Jun 8, 2007
    Messages:
    289
    Likes Received:
    0
    Hospitals can't stay open without money to keep the place operating...I don't care whether the place is for-profit or nonprofit.

    In regards to your comments about doctors' salaries...this thread isn't discussing that...it's discussing payments to HOSPITALS, which is a completely different matter altogether.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  17. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Verified Expert Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,780
    Likes Received:
    27,118
    Status:
    Attending Physician
    Add Legionnaire's Disease to that list and you have a pretty good start!:rolleyes: (but that's another thread somewhere around here)

    No one is denying that hospitals make money by having residents, but to assume they are a "cash cow" is a bit ridiculous.
     
  18. 8744

    8744 Guest

    Joined:
    Dec 7, 2001
    Messages:
    9,323
    Likes Received:
    168
    Status:
    Non-Student
    Dude. Money (or cows, cowrie shells, wampum, virgin slave girls, or whatever is the medium of exchange in your society) makes the world go around for the simple reason that nobody works for free. Try getting your nurses, the techs, the janitors, and the cafeteria ladies (all essential to the running of a hospital) to buy into your "money is not important" riff.

    If this mother****er didn't pay well I'd drop it faster than a French Soldier drops his rifle at the first sight of German troops.
     
  19. 3dtp

    3dtp Senior Member
    Physician 10+ Year Member

    Joined:
    Nov 27, 2005
    Messages:
    663
    Likes Received:
    9
    Status:
    Attending Physician
    Amen brother, amen.


    Hospitals were not always paid for having residents. Back before there was medicare/medicaid, hospitals had residents because they worked for cheap. Cheaper than we do now. But, residency consisted of a 1 year internship and you went into practice. Unless you wanted to be a surgeon or something like that. It was once upon a time in a country far far away, a choice.

    Today it is no longer a choice. You have to complete residency to get credentialled, licenses, insurance reimbursement( ie a job). This has been a gradual evolution over time, but I think the evolution started in earnest in the 1980s when Medicare decided to use the prospective payment system or diagnosis related groups. (DRGs). DRGs were a scheme where Medicare paid hospitals a specific fee for a specific diagnosis (as defined by the ICD9CM or whatever version was in development then). If the hospital discharged the uncomplicated pneumonia in 3 days instead of 7 it still got paid the going rate for the full stay and pocketed the difference. On the other hand, if the patient got sicker and stayed longer, say 10 days, the hospital lost out on 3 days reimbursement.

    Hospitals didn't like this so they screamed that they had to be "reimbursed" for non-direct health care costs and residents were a big added burden on their system since they had to be supervised and taught. Amazingly congress and Medicare agreed and thus was born our present funding system.

    Hospitals liked this and soon saw that more residents meant more cash from the feds, more work being done and more revenue brought in through the residents. So, the residents began doing all the work, the attending would wander by at some point and scribble agree and fill in the requisite billing form. Medicare figured this out a few years ago and changed the rules and said, attendings, hospitals, you can't bill for a service your residents, whom we are paying, unless you actually do this service yourself or get your hands dirty in the procedure for the whole time! Teaching hospitals screamed, but it stuck.
    And hospitals also figured out that more residents meant more federal slush, so more resident positions were created until Medicare figured that out too and capped them. But not before hospitals screamed that they couldn't fill positions with US seniors, so could they pretty please have FMGs on Exchange Visas? Sure, said the feds. Have a J1. Maybe have more than one. Again, the surplus positions became embedded and now that the door is slowly closing, everyone outside looking to get in is screaming.

    Residents do make money for hospitals, clearly. They just don't make as much as they used to. Hospitals have become accustomed to the federal largess and built it into their cost/financing structures and will not give it up lightly. Residents have benefitted from this somewhat, also. Wages are substantially higher than they were pre-medicare days, inflation adjusted, working conditions are somewhat better, although it's somewhat hard to see this when we're in the trenches.

    When the 80 hour rule panic set in in earnest, hospitals accustomed to 100+ hour residents knew they had to do something. An obvious alternative were PAs. But residents made 36K or so, PA's double that. And they'd have to hire 1 PA per resident, possibly more. So a certain North Carolina institution, erstwhile known as EARL, decided to start a PA "residency." They published an article on it. I forget where. They justified it as an economic gambit to replace the 40 hours per resident they'd be losing to the newly enforced 80 hour rule. Their rationale: PAs at half the usual wages, since it's a "training" program, and we can make 'em work more than 80 hours since there's no rule for them, therefore, they will cost less than residents.

    Fortunately, market, licensing boards and PA lobbyists saw through this and the idea hasn't quite taken off...yet. But if there's a way to make pigs fly, you bet the CFOs are thinking about it and PA's beware!
     
  20. doc20

    5+ Year Member

    Joined:
    Oct 20, 2007
    Messages:
    381
    Likes Received:
    0
    Status:
    Attending Physician
    why blame Residents when the insurance companies are not willing to pay up or for the non paying patients?
     
  21. Strength&Speed

    Strength&Speed Need more speed......
    10+ Year Member

    Joined:
    Dec 26, 2004
    Messages:
    719
    Likes Received:
    2
    despite these reasons, I still think increased ordering of tests brings in money. no one has the stats though.

    still, is there anyone who knows generally how much revenue a resident generates versus what he/she costs? I can never seem to get a good answer on this, and its a relatively straightforward question.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  22. Strength&Speed

    Strength&Speed Need more speed......
    10+ Year Member

    Joined:
    Dec 26, 2004
    Messages:
    719
    Likes Received:
    2
    he's mostly not. he's just saying that residents order more tests, so when the patient is not paying, it costs the hospital more. The flip side is when the patient has insurance and it is paying for the tests, the hospital makes more money.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  23. turquoiseblue

    5+ Year Member

    Joined:
    Jul 1, 2007
    Messages:
    601
    Likes Received:
    4
    Status:
    Resident [Any Field]
    why don't we make more residency spots to fill the shortage of physicians? i think the answer of "we don't want to create more doctors because their salaries may go down" is pretty ludicrous. I'm sure we can spread ourselves pretty well over the country--particularly the rural areas.

    Also, i found that the cap puts residents who leave a program for whatever reason forever out of a job.........is that fair? and why does this happen in training--a time for learning, (we're not attendings yet)?

    I think cap funding is evil. More residency spots should be made, and there should be more funding out there, just like research has tons of funding all over the place--why can't doctors? I really don't like the way the residency system is set up. It actually has ruined a lot of people's lives that way.
     
  24. DadofDr2B

    DadofDr2B Member
    7+ Year Member

    Joined:
    May 20, 2004
    Messages:
    305
    Likes Received:
    2

    Understand that more residents means more attendings, more support staff, more equipment, more beds, more of everything. The cost of the resident must be added to all of the support staff and equipment it takes to support the additional resident. It is not cheap.

    I read somewhere that physicians' pay is no more than 6% of the healthcare expenses in the USA. Doctors as a per centage are not the problem with the cost of healthcare. Everyone should be grateful the doctors are so cheap.
     
  25. devildoc2

    devildoc2 Membership Revoked
    Removed

    Joined:
    Jul 11, 2003
    Messages:
    187
    Likes Received:
    0
    The difference between MD and PA residencies is that PA residencies are not funded by the federal government and hterefore the hospital has to eat the cost of their training.

    Hospitals would vastly prefer to have MD residency programs over PAs because thats a free 100k per year from the federal government that thtey wont get with PA residency slots.

    The only reason hospitals started PA residency slots at all was because they couldnt get MD residents because of the 1997 balanced budget amendment which cut off expansion of funds.
     
  26. MacGyver

    MacGyver Membership Revoked
    Removed

    Joined:
    Aug 8, 2001
    Messages:
    3,759
    Likes Received:
    5
    Doctor shortage is an absolute myth. USA ranks in teh top 5 in the world in number of doctors per capita. Creating more doctors will result in a further imbalance of cities that are supersaturated. Manhattan has a doctor on every freaking block of the city, and as a result healthcare costs per capita adjusted for cost of living is the highest in the country.

    More doctors = more diagnoses, tests, procedures. Its a case of supply-induced demand.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  27. MacGyver

    MacGyver Membership Revoked
    Removed

    Joined:
    Aug 8, 2001
    Messages:
    3,759
    Likes Received:
    5
    You're being incredibly disingenuous. PDs and others of the same ilk have been screaming forever about how having residents is a NET LOSS for the hospital because of the extra "training" costs involved. I think this link explodes that ridiculous myth.

    We can argue all day about how much $$$ residents bring in. But no longer are we going to listen to the liars who have the audacity to claim that residency costs are net losses for hospitals.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  28. 8744

    8744 Guest

    Joined:
    Dec 7, 2001
    Messages:
    9,323
    Likes Received:
    168
    Status:
    Non-Student
    I like my program and I get good training but at both hospitals where I work they absolutely need the residents to keep the huge volume of patients flowing through the department. The idea that we are a drain is laughable. If it wasn't, calling in sick would be greeted with complete indifference (as it is for the rotators from other services who are not very productive) and not the mad scramble to the call schedule to get the relief pitcher in as soon as possible. I'm not saying that we are as productive as our attendings and they do sacrifice a lot of their productivity to teaching but the net effect for the private EM groups who staff the department is positive, very positive.

    In fact, they pay us 55 bucks an hour (what they pay the PAs) to moonlight in the Urgent Care, low acuity side so in a way, this is a rough estimate of what we are worth.

    On the off-service rotations they are desperate, absolutely rabid, to have call covered by residents and the various services really start jonesing if they don't have enough residents to cover the call schedule.

    Don't let them BS you. I appreciate the opportunity to train but that doesn't mean I'm stupid.
     
  29. exPCM

    exPCM Membership Revoked
    Removed 2+ Year Member

    Joined:
    Apr 12, 2006
    Messages:
    919
    Likes Received:
    3
    Status:
    Attending Physician
    At one time I was on the GME committee at my hospital. In 2005, the hospital received right at $147,000 per resident from Medicare. Our residents were paid on average $45,000 plus benefits (health insurance with significant deductibles and copays and no dental insurance). Anyone who claims that hospitals don't make money from having residents is FOS IMHO.
     
  30. aProgDirector

    aProgDirector Pastafarians Unite!
    Moderator SDN Advisor 10+ Year Member

    Joined:
    Oct 11, 2006
    Messages:
    7,897
    Likes Received:
    6,004
    Status:
    Attending Physician
    Now wait a second....

    I never said that residents are a loss to programs. I just was trying to point out that it's not a huge gain either. It clearly used to be a huge gain in the past, but due to slow funding decreases and increasing costs / requirements, it's just not a huge moneymaker any more.

    Once you add all of the faculty protected time required by the ACGME, accreditation fees, RRC visit fees, GME office costs, residency office costs/coordinator salaries, recruiting costs, computers, etc, it ends up being not such a money makers.

    As I have mentioned many times in other threads (back me up on this Faebinder!), the real "money maker" in residents is the cost savings --> The cost of hiring other people to do what residents do. So the balance sheet for resident income from medicare minus direct resident costs might be slightly positive or even, but the money theoretically saved by not having to hire other people to work at night is potentially huge.

    I say "theoretically" and "potentially" because if hospitals were actually forced to decrease their reliance on residents (which will happen, if you're following the 56 hour thread), they will likely not replace many residents at night. Currently, the ED decides to admit a patient and an IM call or NF resident comes to admit them. If the NF resident goes away, it's much more likely that the hospital will have the ED write orders and admit the patient than replace the NF resident with someone else.

    So, my point is this: The direct costs of resident education continue to rise while medicare and especially medicaid funds are cut. In the past, this was a huge boondoggle and hospitals made out like bandits. Today, it's still a net positive for most but is much closer to a break even. The real "income" is in the cost savings that residents provide, since they are "willing" to work crazy hours and unpoular shifts, which would be very expensive to fill otherwise. I stand behind my prediction that in the next 10 years, Medicare funding for GME will be cut dramatically and this balance will become negative. Hospitals see this coming, and the interest in increasing resident class size is low.
     
  31. 8744

    8744 Guest

    Joined:
    Dec 7, 2001
    Messages:
    9,323
    Likes Received:
    168
    Status:
    Non-Student
    Man. Sometimes it would be so much simpler to write admitting orders for my patients in the Emergency Department than to wrestle with a typical ******* academic attending at 3AM. Practically, however, I don't see how it's gong to work. What if I start admitting every bull**** patient to the admitting service? How will they control who they admit and who they can get reimbursed for?

    We don't decide to admit patients, by the way. We recommend admission and the patients attending physician, whoever it is, decides to admit or not.
     
  32. Faebinder

    Faebinder Slow Wave Smurf
    10+ Year Member

    Joined:
    May 24, 2006
    Messages:
    3,507
    Likes Received:
    10
    Status:
    Attending Physician
    Unfortunately, APD is correct, it's the cost cutting and not the direct government money that seems to be the huge money making power of residents. Cutting the hours will indeed reduce that and make residency unworkable.

    Hence my idea of counting hours overlimit as moonlighting and billing for them but for the life of me I cant think of a solution to the "slow down" of residents other than "Academic Penalties" which will lead to residency becoming living hell as abuses start happening.

    Perhaps the answer is to go back to the old days of not receiving any money from GME for residents and simply allowing FULL reimburisement for resident procedures/actions. Unlike the money from GME, reimburisement is a flexible set of money and will increase or decrease to balance inflation.:(
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  33. DarksideAllstar

    DarksideAllstar you can pay me in bud
    7+ Year Member

    Joined:
    Dec 17, 2001
    Messages:
    2,151
    Likes Received:
    4
    Status:
    Resident [Any Field]
    Where I am doing residency (and I assume it is probably similar to other places) laboratory tests that are ordered on inpatients are not remibursed separately by insurance companies (they pay only a flat fee for diagnosis x). The clinical labs, and thus the hospital, lose money everytime an expensive esoteric test that a PGY1 thinks is important is ordered. Overall, the clinical lab loses money on inpatient testing and is better reimbursed by insurance on outpatient testing.
     
  34. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Verified Expert Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,780
    Likes Received:
    27,118
    Status:
    Attending Physician
    It is the same elsewhere. Hospitals are reimbursed by DRGs; it doesn't matter if they stay 1 day or 14 days, the reimbursement is bundled.

    This is why Rads will complain that they will not get reimbursed if you order a special study on a patient that can be done as an outpatient.
     
  35. DarksideAllstar

    DarksideAllstar you can pay me in bud
    7+ Year Member

    Joined:
    Dec 17, 2001
    Messages:
    2,151
    Likes Received:
    4
    Status:
    Resident [Any Field]
    And that is why people meet resistance when ordering esoteric laboratory tests on an inpatient basis when it has no impact on immediate clinical management. For example, a patient coming in with a PE and no risk factors does not need a full hypercoag work up while an inpatient (ie FVL, PT gene mutation, etc)-- do it as an outpatient (not to mention the fact that in the acute setting, the info you receive can be deceptive). The only time I could see it altering managment is if their is a storng clinical suspicion that there is an AT deficiency, which could have management implications. Anyway, I digress. Part of training is learning what studies (lab and radiographic) need to be ordered and when (outpatient vs inpatient). The teaching hospital is aware that there will be additional costs due to radiology/laboratory test misuse associated with having residents (not to say attendings are immune from misordering studies-- they aren't). Ah, good times.
     
  36. cchoukal

    cchoukal Senior Member
    Moderator 10+ Year Member

    Joined:
    Jul 10, 2001
    Messages:
    2,015
    Likes Received:
    160
    Status:
    Attending Physician
    Okay, maybe residents make money for the hospital and maybe they don't, but to point out that some (one) middle manager that no one has ever heard of somewhere in southern CA referred to residency slots as "revenue generating," and say that that "explodes that ridiculous myth" is, in my opinion, incredibly disingenous.
     
  37. core0

    core0 Which way is the windmill
    7+ Year Member

    Joined:
    Oct 1, 2006
    Messages:
    1,102
    Likes Received:
    15
    Status:
    Non-Student
    I think that the whole resident gains/loses money issue really depends on your payor mix. Take the hypothetical county hospital where no one has any insurance. There is no income here so unless you have labor that does not cost the hospital (ie residents) then there is no way to have anyone take care of the patients. Now take the theoretical hospital where everyone has insurance that pays 200% of the Medicare rate. In this situation the hospital would make more money by not having residents since they could charge for the services provided. In reality most hospitals are somewhere in between this. The better the payor mix the easier it is to replace residents with PAs or physicians. The worse the payor mix is the harder it is to replace the residents with anyone.

    Most county hospitals probably are similar to King-Harbor. Without "free" labor from residents it would essentially impossible to keep the hospital open. That is essentially what UC is saying about King-Harbor, that the payor mix is so bad that it is impossible to operate without 250 resident slots (really up to 500 FTEs if you count the hours). Most research intensive university slots can probably go either way. Losing residency coverage is probably revenue neutral if you replace them with a PA and hurts revenue if you have to replace them with a physician. For private hospitals with a good payor mix it rarely makes sense to have a residency for purely financial reasons.

    To devildoc2: One of the dirty secrets about PA post graduate programs is that they almost always make money for the hospital. To get into a PA post grad program you have to have a PA license. This means that the hospital can bill for your services. The amount of money that they can make off billing is more than they are paying the PA (usually 1/2 of what a new grad would make). Even considering any class time and inefficiencies that a new PA would have the reimbursement more than makes up for the cost. I know of at least one program that clears more than $200k from their post grad program.

    David Carpenter, PA-C
     
  38. DrDre311

    DrDre311 Makaveli
    2+ Year Member

    Joined:
    Apr 14, 2008
    Messages:
    655
    Likes Received:
    3
    Status:
    Resident [Any Field]
    A radiologist once told me his group actually got paid for 1 out of every 3 studies for which he billed, on average.

    In light of an earlier post about increased testing leading or not leading to increased revenue for the hospital, I wonder:

    Let's say you're at a hospital with PACS, so all imaging studies are actually on computer (i.e. no actual films, CT or whatever goes straight to computer). You're paying people to transport patients, techs to perform the scans, and IT people to keep PACS behaving; it doesn't matter how many imaging studies are performed, day to day--these people will cost the same amount of money to the hospital.

    So would it be fair to say that since there are no additional costs to the hospital if 30 extra CXR's, 20 extra CT's, 10 extra MRI's, etc. get ordered on a given day (I'm making up these #'s and assuming that the increase in studies is not great enough to necessitate additional personnel) then (even though Medicare pays crap or not at all, and people rarely pay a dime of their medical bills) the hospital has to see some extra cash from resident-ordered (say, from the rare insured patient) images?

    Or would the whole DRG concept negate what it?
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  39. aProgDirector

    aProgDirector Pastafarians Unite!
    Moderator SDN Advisor 10+ Year Member

    Joined:
    Oct 11, 2006
    Messages:
    7,897
    Likes Received:
    6,004
    Status:
    Attending Physician
    It depends how busy your rads department is. If they are fully booked, then the additional inpatient studies push some outpatient slots off the schedule, and it's a money loser. Same if the extra studies end up requiring overtime.

    Doesn't matter if the patient has insurance. All insurances now use DRG's, and pay a fixed fee basd on the diagnosis. You still get to bill "professional" fees -- i.e. I still bill a daily visit charge for each of my inpatients, and if you order a CXR you still get to bill the radiologist's fee for reading it, but you lose all the "technical" fees generated on the outpatient side. So all labs (which do not generate any professional fees) are all unbillable.

    And, just when we were getting the hang of DRG's, medicare is now moving to MS-DRG's instead.
     
  40. Faebinder

    Faebinder Slow Wave Smurf
    10+ Year Member

    Joined:
    May 24, 2006
    Messages:
    3,507
    Likes Received:
    10
    Status:
    Attending Physician
    :confused::confused::confused:

    Medical Severity Diagnostic Radiology Guidelines? And so dies a cash cow for the hospitals.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  41. sirus_virus

    sirus_virus nonsense poster
    2+ Year Member

    Joined:
    Nov 6, 2006
    Messages:
    1,254
    Likes Received:
    1
    Status:
    Non-Student
    No one was complaining about this resident "cash cow" eploitation until hospitals started claiming residents were actually costing them money. Used car salesman talk IMO. That is like punching someone in the jaw then blame them for hurting your fist.
     
  42. DrDre311

    DrDre311 Makaveli
    2+ Year Member

    Joined:
    Apr 14, 2008
    Messages:
    655
    Likes Received:
    3
    Status:
    Resident [Any Field]
    At my institution there is are multiple outpatient imaging centers (owned by the parent/sister hospitals) across the city; I'd have to ask some of the rads guys but I don't think our hospital's equipment is used for outpatients (except maybe some of the nucs stuff).
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  43. me454555

    me454555 Senior Member
    7+ Year Member

    Joined:
    Mar 29, 2003
    Messages:
    488
    Likes Received:
    6
    Status:
    Resident [Any Field]
    Why is it so hard to ask for a fair wage? We have some net worth/hr to a hospital b/c we generate $$ by pushing paperwork, writing orders, or helping attendings be more efficient. At the same time we also have costs, I.E. Lecturers, teaching time, insurance. Why can't we just get paid what we are worth? Bill for the stuff we do, at a reduced pay scale b/c theres an attending or get paid for each hr we work? I'm sick of seeing my hourly paycheck calculated off the 40hr work week when I'm on Q3 working 30hr shifts. I should be getting OT or some sort of reimbursment, the way it works in every other profession.

    The residence system is an arcaic throwback to the days of apprenticeship. We are one of the few groups in america w/very little lobbying power. Our one great stride? Limiting the work week to 80hrs when everyone else in america is expected to work for 40 and gets paid significantly more when they top that number in every other field.
     
  44. cchoukal

    cchoukal Senior Member
    Moderator 10+ Year Member

    Joined:
    Jul 10, 2001
    Messages:
    2,015
    Likes Received:
    160
    Status:
    Attending Physician
    The idea that "everyone else in America is expected to work for 40" is simply not true. I have a number of friends who work considerably more than 40 hrs per week and are paid salary without overtime. Plenty of people in "business" jobs regularly put in 60-80 hrs/week, especially at the begining of their career (like where we are in residency). Some of my friends got shiny new laptops and blackberries from their companies so that they could be expected to do work when they aren't even AT work. Know any lawyers in their 20s who work only 40 hours per week and make overtime beyond that? I don't.

    Of course, most of these people make considerably more money than residents do.
     
  45. Strength&Speed

    Strength&Speed Need more speed......
    10+ Year Member

    Joined:
    Dec 26, 2004
    Messages:
    719
    Likes Received:
    2
    fiddlesticks. the system is still nonsense. I think it's dumb and needs an overhaul.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  46. Finding Chi

    2+ Year Member

    Joined:
    Apr 25, 2008
    Messages:
    32
    Likes Received:
    0
    Status:
    Resident [Any Field]
    It's hard to organize residents for lobbying/collective bargaining. We are transient workers (3-5 yrs typically then we are out in the real world) who are too tired and spread thin to remember to do our laundry, let alone fight to restructure the entrenched medical education system. It's like hearding cats.
     
  47. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Verified Expert Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,780
    Likes Received:
    27,118
    Status:
    Attending Physician
    Trouble is, as pointed out above, you are not an hourly wage earner but on salary. The salary may suck for the hours you work, but nonetheless you are not entitled to overtime as a salaried worker.

    Most salaried workers do not get overtime and are expected to finish their work, without extra reimbursement, regardless of how long it takes. This is commonplace in all professional workplaces; my office manager is salaried, she doesn't get overtime if she stays late because she was gabbing when she should have been working.

    Residents don't get "credit" for that. The work hour restrictions were foisted upon residency programs and residents whether they wanted them or not and were not lobbied for by residents but rather public advocacy groups pressed OSHA who deferred to ACGME who caved in to the lobbying.

    While there are certainly salaried workers who make more than residents, many many professionals work more than 40 hrs per week. My mother, a small business owner does; my friend who does PR for PG&E does; another friend who works for EBay does, and so on. None of them get overtime either.
     
  48. me454555

    me454555 Senior Member
    7+ Year Member

    Joined:
    Mar 29, 2003
    Messages:
    488
    Likes Received:
    6
    Status:
    Resident [Any Field]
    That is the key point right there. It's not so much the work hrs but the lack of pay. Many people put in more than 40hrs a week but they are fairly compensated. Most people in business or law working 80hrs a week are making significantly more than we are
     
  49. me454555

    me454555 Senior Member
    7+ Year Member

    Joined:
    Mar 29, 2003
    Messages:
    488
    Likes Received:
    6
    Status:
    Resident [Any Field]
    Do they make more than 50k/yr? I'll bet the answer is yes. In the case of people owning a business, they are building up their business and thus have other assets working for them in addition to the their salary. My point isn't that we are the only group working more than 40 hrs a week, it's that where else in america do you have people w/4 years post bac training working 80hrs/week get paid what we do? No where. I'm ok w/working more than 40hrs a week but pay me fairly for my time. Like others have said, if I quit, they'd have to hire PAs to do my job @ significantly higher salaries.
     
  50. Winged Scapula

    Winged Scapula Cougariffic!
    Staff Member Administrator Physician Faculty Lifetime Donor Verified Expert Classifieds Approved 15+ Year Member

    Joined:
    Apr 9, 2000
    Messages:
    38,780
    Likes Received:
    27,118
    Status:
    Attending Physician
    And that's a reasonable argument, one you didn't clarify before.

    But the problem with paying residents more is that until "they" start defining it as a regular job instead of educational, what you make will be no more than a stipend. In some countries, you pay for residency rather than being paid.

    Residency is seen no different than a period of internship that anyone else does, except that we NOW get paid...we didn't used to in this country. PAs can practice somewhat independently and can bill for their services; residency is required to be able to do so.

    The argument that you spent 4 years in post-bac training doesn't wash for most because there are hundreds of post-docs who spent MORE than 4 years in school who don't make a resident's salary and when they finish will never approach what we make. Physicians are just not a sympathetic group and until the general public realizes what it costs to go to medical school, what responsibility we have as residents and what it would cost to replace us, there will never be a change.

    Increased education does not perfectly correlate with salary, despite us wishing it were so.
     

Share This Page