Nephrology is Dead - stay away

[NewYorkDoctors]

https://hcahealthcaregme.com/locations/hca-florida-westside-hospital/nephrology-fellowship/

my friend goes to this residency. they opened a renal fellowship LOL
they had one fellow only who graduated already
they have zero fellows now

this program is pending opening a cardiology, PCCM, and GI fellowship next year. those are the real hotcakes lol

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[Renal_Prometheus]

To summarize all of the complaints from neph graduates have had about this specialty. It’s the same ones year after year and it’s just tiring re-itering the same problems to naiive neph applicants every year.

1) Fellowship programs hire substandard applicants to fill unwanted spots to be used as scut work. Fellows are viewed as nothing more than warm bodies to take night calls. All the smiles you see during your interviews was a “ploy” to get you to give them 2 years of cheap labor.

2) High percentage of people going into nephrology are burnt out hospitalists or people failing to match more competitive specialties. Now, there is a significant rise of programs taking IMGs w/o US residency. Sounds like a real winner?

3). private practice is nothing like academia, requiring laborious driving to multiple hospitals and dialysis clinics every day. Lifestyle is worse than most IM sub-specialties.

4) low starting salaries with an onerous track to partnership(if granted at all).

5) senior partners view new hires also as “warm bodies” to fill their dialysis units with pts

6) Neph groups are notorious for not sharing revenue fairly even if you make partner. Senior guys are greedy, but you may not be able to figure that out from the initial employment contract.

7). Many nephrologist go back to hospitalist for better income/lifestyle.

8). Neph applicants seem unaware of what they are getting into. Why did you think it’s so easy to getting this specialty to begin with?

9). Sunken cost fallacy. Once you invest x numbers of years into the specialty, it’s hard to pull out even if you end up with a hopeless job with unfair pay.

Am I missing anything else? Hopefully future Neph applicants can learn something from previous generation of failures so they can minimize suffering to those who explicitly seek it.

 

[Renal_Prometheus]

Decline of Nephrology: 2 main reasons; 1) Financial: Anyone who do nephrology fellowship has financial loss is in the vicinity of $800,000 over 4 years (2 years fellow at 65,000 vs hospitalist at 300,000 or more, then a job with a deficit of 125K or more).

Let me ask all neph applicants this question. How do you feel if I take 800k from your bank account and ask you to take a job that requires you to work harder and get paid less than a hospitalist, even after partnership. Does it sound like a scam? Why wouldn’t you fully do your research before committing to this? Would you trust what the scammers(fellowship programs) say about how great their grads are doing when 1/3 of spots go unfilled. Or would you do independent research?

 

[Renal_Prometheus]

Nephrology is in a declining period where it’s really struggling to generate revenue. The profit margins on JVs are declining every year, which historically make up a large percentage of a groups income. What could possibly go wrong with joining a group and giving them 3 years of cheap labor and expect them to share revenue equitably with you as a partner? Surely they will overlook their own declining pie to make sure you have yours right?

 

[NewYorkDoctors]

I would like to dispel this notion of a nephrologist being a "doctor's doctor." That is such an outdated and antiquated term that refers to the pre-UpToDate era. Moreover I am not sure this term applies with lower quality physicians doing nephrology doing (outside of academic that is)

before UTD, the nephrologist "saw a bit of everything" since ESRD patients were on every medical and surgical service
The nephrologist also had to know systemic diseases fairly well since many systemic diseases affect the kidneys

but these days the nephrologist is no more the "doctor's doctor" that any other IM subspecialist or super subspecialist.

I envision a "doctor's doctor" conversation like an elevator conversation:

Cardiologist: Hi Dr Kidney. so our mutual patient on dialysis who has heart failure. I want to titrate up the ACEi but is there still any concern about hyperkalemia if on HD?
Nephrologist: the ACE receptors are present in about 10% in the intestines. so in theory this would still lead to potassium reabsorption in the GI tract. While this would not be the biggest issue, it might affect how well this patinet achieves potassium clearance and need a longer dialysis time. But if you need it for the cardiomyopathy., that is fine.
Cardiologist: thank you Doctor's Doctor!


of course it is true that Nephrologists (academic anyway) have a reputation of being "friendlier and more helpful" to the hospitalist/internist than some other subspecialists. this might have to with schmoozing for consults perhaps. but this varies of course

 

[Renal_Prometheus]

naturally too much stress and too little pay and she is now a hospitalist working half the year for pretty decent pay in new jersey and having a great time raising her kids.

It seems like most of your co-fellows have quit nephrology to do something else. Any of your cofellows still in private practice nephrology? This is despite graduating from a “prestigious” fellowship program.

 

[NewYorkDoctors]

It seems like most of your co-fellows have quit nephrology to do something else. Any of your cofellows still in private practice nephrology? This is despite graduating from a “prestigious” fellowship program.

i would say half are in PP (a few of them "have connections" and are successful... but key word "have family connections." a few others are in a "decent larger employer PP group without too much abuse but not the highest pay". the latter tend to be female and mothers. which is totallly cool) and half went back to hospitalist (usually male and fathers... which is cool)

of course this is not counting those who stayed on as faculty.
let's say a flelow who graduated from top prestigious NYC fellowship took a faculty job... gave some title called "assistant director of the PD Program" lol... started at $175K a year..... in the upper east side NYC ... before building up HD / PD panel of course... im sure he's higher now as he is an assocciate professor but still lol

 

[Renal_Prometheus]

i would say half are in PP (a few of them "have connections" and are successful... but key word "have family connections." a few others are in a "decent larger employer PP group without too much abuse but not the highest pay". the latter tend to be female and mothers. which is totallly cool) and half went back to hospitalist (usually male and fathers... which is cool)

About the same experience as me. About half of my co-fellows(including those 1 yr ahead and behind me) have quite nephrology for better paying specialties. Of those still in private practice nephrology, majority are unsatisfied with their income/workload and I still get messages about how their partners screwed them over. The majority of them are also on their 2nd and 3rd neph jobs. Just a complete failure of a specialty. And most of them were really enthusiastic about their jobs right after graduation. Specialty is a mess, and you really need to get lucky to land a job that pays well.

 

[NewYorkDoctors]

anyway the whole "doctor's doctor" trope is outdated much like most of this subspecialty

About Internal Medicine | What is an Internist | ACP

Looking for general internal medicine and internal medicine subspecialties information? Get answers to questions like, "What's an Internist?" and more now.

www.acponline.org

Internal Medicine physicians see the big picture. Their deep training and knowledge of the entire human body and its organ systems give them a unique perspective of how everything works in unison. They analyze, consider and make connections from multiple data sets, and identify solutions for optimal health outcomes. Internal medicine physicians are known as the "doctor's doctor" because they are often called upon by other medical professionals for their ability to connect the dots and help solve problems. Their expertise makes them vital to both patients and medical professionals.

dunno im not sure how many nephrologists are really "connecting the dots out there."

i'm sure the brilliant academic nephrologists can help "connect the dots" for complex multi-system cases that affect the kidneys.
think ANCA vasculitis that was ultimately diagnosed because the patient had proteinuria.
Cardiologist does echo and sees speckled pattern - does workup and diagnoses restrictive cardiomyopathy due to amyloidosis eventually. what a doctor's doctor!
Pulmonologist hears rales - does CXr and HRCT and finds NSIP and OP pattern - does CVD workup - SLE causing NSIP and OP - what a doctor's doctor!
Rheumatologist does a thorough physical exam and identifies the ACR clinical features of SLE, sees basic labs and sees hemolytic anemia - does workup and diagnoses SLE and throw in some MCTD features. Lotsa serologies ordered. what a doctor's doctor!
Hepatologist/GI sees elevated transaminases that is not due to statins, steatohepaetitis, or hepatitis A,B,C workup done by primary, a by the books workup is done - wow IgG4 disease. what a doctor's doctor

my point is all subspecialists have a diagnostic pathway they are trained on. this "doctors doctor" phenomenom is not unique to nephrology
any nephrologist who still thinks this way (is usually older) has his/her head so far up his/her *** that a gotta use a toothbrush up to *** to brush the teeth.

but in the community, I don't know how many dots are being connected other than points on google maps referring to how many HD centers, clinics, and hospitals the doctor is traveling to on a day to day basis

to the overworked hospitalist, I am sure any subspecialist who is helpful it figuring out a tough case and helping to reduce the length of stay is a "Doctor's doctor."

Addendum: everything is fine in my persona and work life lol.
Anyway the pathologist was the original "doctor's doctor." This makes more sense. Think tumor board or if you need a biopsy yourself (in my case a bronchoscopy or surgical lung biopsy by thoracic) were done and I wanted some more context, I would go talk to the pathologist in his/her office for a "doctor's doctor" consultation of sorts.

dunno why nephrologists are still "called the smartest doctor in the hospital." This might have been true in the era before UTD when nephrologists were the only ones reading Harrison's (lol) on a routine basis. but just being able to do a triple acid base equation or explain the historical context to why there is no more Type 3 renal tubular acidosis (older textbooks describe a combined form of 1 and 2 in kids they use to call Juvenile RTA but realize it was not a distinct clinical entity) does NOT make one the smartest doctor in the room (unless that room has med students and interns)

 

[sloh]

anyway the whole "doctor's doctor" trope is outdated much like most of this subspecialty

About Internal Medicine | What is an Internist | ACP

Looking for general internal medicine and internal medicine subspecialties information? Get answers to questions like, "What's an Internist?" and more now.

www.acponline.org

but in the community, I don't know how many dots are being connected other than points on google maps referring to how many HD centers, clinics, and hospitals the doctor is traveling to on a day to day basis

lol!!!!!

 

[NewYorkDoctors]

also I am reading the thread about Cardiology board exam and their test seems way harder than the renal boards

Renal boards is similar in format to IM boards only the questions are a bit more focused on renal topics.

reading the Cardiology boards it sounds intense. Not to mention taking the board exam for all the other nuclear, echo, etc... boards... smartest doctor indeed lol

 

[Renal_Prometheus]

i would say half are in PP (a few of them "have connections" and are successful... but key word "have family connections." a few others are in a "decent larger employer PP group without too much abuse but not the highest pay". the latter tend to be female and mothers. which is totallly cool) and half went back to hospitalist (usually male and fathers... which is cool)

One thing I like about this thread is we try to keep it real for neph applicants/fellows. When I talk to neph fellows, they are complete surprised that this is the real world nephrology today. It’s because nobody is telling them the truth. These Neph programs don’t like me talking to their fellows. People need the truth in brutal way.

 

[NewYorkDoctors]

it's called red-pilling (a reference to The Matrix)

again if anyone wants to live in the Blue Pill Matrix world (aka get some academic job, do seemingly important things, fight for grants, never make a ton of money but at least have fellows see overnight emergent HD for you) then that's fine.

 

[Renal_Prometheus]

One of the best explanations I've heard about nephrology and why it's non-competitive

 

[Renal_Prometheus]

Seems like many private practice experiences are the same

 

[NewYorkDoctors]

yep pretty much.
the pyramid scheme analogy is apt

I use the "paying tribute to your feudal lord, serf!" analogy.

edit: I just got my colonoscopy and EGD done recently, im already past my deductible and out of pocket max. I am a "straightforward" case with big visible veins (I work out) and told the GI and Anesthesiologist - go ham on my insurance lol.

they sure did lol . nephrology can't possibly touch this. sure i'm using an extreme but these payments all came from "1 hour of the patient's time."

I dunno what CPT code the anesthesiologist used but hot - **** that's a good gig for outpatient anesthesiologist

GI "office consultation" (I hand wrote my medical history and told him - i might have hemorrhoids and I have GERD not better with PPIs. I had H pylori twice before that I found myself on UBT and did quad therapy twice. I should stop eating from those halal street carts. here you go)

Colonoscopy:

Endoscopy:

Anesthesia:

Pathologist:

 

[Renal_Prometheus]

I like the explanation that your earning peak is higher than hospitalist, but your floor is lower. So if you were a gambling man, this specialty is ideal for you.

 

[NewYorkDoctors]

I like the explanation that your earning peak is higher than hospitalist, but your floor is lower. So if you were a gambling man, this specialty is ideal for you.

the only thing is the ceiling for Internal Medicine is quite high as well (assuming you open your own PCP GIM clinic and do a 99213 mill)

heck even doing "more hospitalist shifts in a yaer" has a higher ceiling than non-senior partner hogging up all the HD patient junior nephorlogy attending

 

[Renal_Prometheus]

How is a new grad supposed to grow their ESRD panel? You can go rural and solo, but it will take years to do build up a base. Plus your family may not like living rural. There’s competition even in rural communities. Or you can go metro, feed off the groups existing pt base, but be subject to the groups contract terms for partnership and distribution of ancillary revenue, which usually favors the people who wrote those contracts. Any new grads coming out thinking they can get rich after 2 yrs, make partner, be able to JV and collect directorship money is living in a pipe dream. The type of dream sold by fellowship programs who can’t get warm bodies to do their scut work.

 

[NewYorkDoctors]

its far easier to set up your own PCP panel and do a 99213 mill than it is to try to reach the top of the nephrollogy pyramid scheme

 

[NewYorkDoctors]

anyway I do some management for glomerular patients (not that I am an expert but I do like the "mystery" cases of nephrology and I send the path through the New York Presbyterian system in NYC here. this means if it ends up some rare case like C1q nephropathy or some new kind of amyloidosis, then they can go straight to CUMC to the world experts... but nope nothing like that yet for me). the local PCPs understand I do not do DM/HTN CKD management and there are plenty of other nephrologists for that. But I educated the local PCPs who refer to me a lot that if they see significant proteinuria in a non diabetic to go ahead and send it my way and ill make time for that patient, especially if its a young patient.

i will say the "best part" of nephrology is working up a glomerulonephritis, getting the diagnosis, and then treating it with immunosuppressants or other treatments to "save the kidney."

doing the whole House M.D. thing with my PAs and my internist friend/partner in awe over the workup (lol)

but ultimately this does not really "pay the bills" and is very labor / time / brain power intensive. it's purely a "hobby" of mine. my "day job" (primary subspecialty) pays for this "hobby."

 

[Renal_Prometheus]

What’s really bewildering is the surprising repetitiveness which IMG applicants throw themselves into the fire, get burned and regret doing neph years down the road. Whether it’s due to desperation or misinformation, you would be think with this many nephrologists working as hospitalists these days, people know it’s a bad idea. But hopium can play tricks on the brain. It’s almost like why do cults exist when everyone, but the victims, knows it’s a scam and a fraud. Why do people still fall for it. One word: “hope”

 

[NewYorkDoctors]

this is the same false hope that tricks people into invseting into the stock market without having any connnections

the stock market is rigged with inside trading and politicians changing laws to favor them and their lobbyists.

the nephrology PP market is rigged with senior partners hoarding everything. unless you have the insider connections, stay away from this Ponzi scheme

 

[Prehealth1011]

What’s really bewildering is the surprising repetitiveness which IMG applicants throw themselves into the fire, get burned and regret doing neph years down the road. Whether it’s due to desperation or misinformation, you would be think with this many nephrologists working as hospitalists these days, people know it’s a bad idea. But hopium can play tricks on the brain. It’s almost like why do cults exist when everyone, but the victims, knows it’s a scam and a fraud. Why do people still fall for it. One word: “hope”

I would be curious to know how much Nephrology pays in India/Pakistan. I know Cardiology is highly paid there, part of the reason why so many IMG cardiology applicants have extensive research in it before they start residency here.

 

[MD46]

I would be curious to know how much Nephrology pays in India/Pakistan. I know Cardiology is highly paid there, part of the reason why so many IMG cardiology applicants have extensive research in it before they start residency here.

Not sure about India, but a few local friends I spoke to who are from Pakistan say its dependent on private vs hospital setup.

Government hospitals believe it or not pay no more than $500-$1000 a month! Depending on experience. Salaried

Private practice is based on reputation etc but could be upto $2500-$5000 a month in a very well run practice. Specialist see 30-50 patients a day on average.

Obviously outliers are there but thats majority.

 

[Renal_Prometheus]

just a matter of one human not wanting to see harm come upon another human. You shouldn’t go into nephrology if you cannot psychologically withstand the possibility that it may not work out career wise. If you are in your 40s and the only breadwinner in the family, you really need rethink your motivations for doing a specialty. Getting in is the easy part; getting out is tougher to stomach when you have invested many years into this thing.

 

[NewYorkDoctors]

a cofellow of mine was a hospitalist in the midwest for a few years. decided he wanted to join a top NYC renal academic program
now he "made it pretty big" as a very successful PP nephrologist making some nice bank...



how?




he has family friends who are nephrologist who gave him HD privileges an djoint ventures, no buy-in partnership, set up office space

basically family connections.


if you have that going for you, nephrology is pretty sweet as if you can get the volume going on HD you can rival interventional cardiologist pay



But again ... LIMITED RESOURCES.

It's called "da one pah-cent" for a reason.

 

[Renal_Prometheus]

A lot of these fellowship programs are J1 waiver mills. People go there as attendings for 3 yrs to satisfy there j1 waiver, then try for better opportunities in private practice. Trying to get a decent private practice job as a j1 is impossible, as all employers are looking to take advantage of you knowing you can’t leave them. Plus you are only allowed to work in “underserved” areas which severely limits your opportunities.

 

[NewYorkDoctors]

that's like "you can look but you can't touch."
underserved areas are "ripe" for a nephrologist to set up his/her fiefdom and accumulate all the ESRD patients (albeit not many but can get a foothold).
so if you are a permanent indentured servant in the rural areas and never being allowed to become senior partner, then you truly have the worst of both worlds

 

[Renal_Prometheus]

last time I read up, about 1/3 of neph fellows are IMGs needing j1 waivers. It tells me either these people are severely misinformed about how bad neph private practice is for J1s, or they are severely desperate on getting any subspecialty possible. This phenomenon of wanting to be a subspecialist at all cost, even taking careers that are worse than a generalist, seem to permeate the psyche among IMGs.

 

[Renal_Prometheus]

A wise man learns from others mistakes. A fool learns from his own.

 

[Renal_Prometheus]

You typically think of doing a fellowship as a mutually beneficial relationship between the program and fellow. Each getting something out of the other. In nephrology, the fundamentals in private practice has deteriorated to a point where it’s now an exploitative relationship. Fellowships need to lie through their teeth to keep fellows from figuring out there’s no money in it for new grads and at least half will eventually end up as hospitalists anyways. The whole relationship dynamic changes when the fellow figures this out.

 

[Renal_Prometheus]

coming from an attending nephrologist

 

[Renal_Prometheus]

Nephrologists leaving for hospitalist medicine is just too prevalent.

 

[NewYorkDoctors]

yep there is a huge moral hazard for dialysis honestly

my prior director of nephrology is a legend in his day (aka fossil) and would mention before dialysis became a medicare benefit, some patients woudl be trucking along with creatinines of 25. a little furosemide here, reserpine (LOL) there, baking soda and kayexelate and the patients could be maintained well enough.

in my limited renal panel, I have a few patients CKD eGFRs in the 10-15 range. AV fistula already matured. I have a colleague who gladly takes on my patients (as I do not have HD privileges outside of occasionally ordering it if I ever covered MICU for a colleague) to start HD.
but with med management and DIETARY MANAGEMENT , these patients are trucking along just fine.

you betcha a nephrologist who incentivizes from HD would have already put the patient on by now.

moral hazard is an underrated reason why many people who do nephrology just have a huge distaste for it

 

[Renal_Prometheus]

What makes it even worse is that fellowship PDs will lie about private practice conditions in order to get cheap labor through the door. There will always be suckers who will fall for it.

 

[NewYorkDoctors]

its a race to the bottom honestly

anything to get "cheap labor" by the fellowship programs

some fellowship programs are not part of tertiary care programs and they open a fellowship

there is ZERO reason for that

 

[kacelius]

@RP and few others.... You have been religiously bumping this thread with nothing new to add. More than Nephrology is dead, this thread should die. It has run its course. All the information in this thread is only 1000 words worth and the rest is just regurgitation of the same information. I wonder if anyone is even moderating this.

 

[NewYorkDoctors]

@RP and few others.... You have been religiously bumping this thread with nothing new to add. More than Nephrology is dead, this thread should die. It has run its course. All the information in this thread is only 1000 words worth and the rest is just regurgitation of the same information. I wonder if anyone is even moderating this.

lol you mad bruh? 1 message? burner account lol . use your real account and share your academic title and affiliation if you really want to make a statement.
what aren't your proud of your subspecialty?
kaecilius lol. is your true alter ego Doctor Strange haha

if you read the comments of this thread you will see that we give great respect to the true academic fellowship programs and encourage all who want to be academic nephrologists to do so. but there are only so many academic faculty jobs out there.

most of the private practice jobs are abusive

the only logical reasons you are posting with a burner account would
1) your feelings are hurt and you need validation for your career choices. go get a hug from someone who cares about you lol.
2) you are part of a fellowship program that cannot get fellows. go pound some sand
3) you are trying recruit nephrologists to abuse but you cannot find any for your private practice. go hire a midlevel.


the thesis of this thread is not "die nephrology die."

It is to encourage those who want to do it to go in with eyes wide open

It is also to rescue those are not fully bought in from wasting years of their lives. If you find an issue with this, i question how sincere your motives are.

 

[kacelius]

FYI, I am not selling/buying anything here.
I am happy with my nonteaching hospital-based nephrology practice.
My feelings are not hurt for what you type here, moreover I am not offended at all for what is in this thread.
I don't disagree with lot of stuff posted here, but it's nothing new, it's the same info you all have posted here.
My only concern is you all type the same thing over and over and it does not serve any new purpose, other than thread bumping.
Maybe it makes you guys feel better by typing the same thing over and over.

 

[NewYorkDoctors]

FYI, I am not selling/buying anything here.
I am happy with my nonteaching hospital-based nephrology practice.
My feelings are not hurt for what you type here, moreover I am not offended at all for what is in this thread.
I don't disagree with lot of stuff posted here, but it's nothing new, it's the same info you all have posted here.
My only concern is you all type the same thing over and over and it does not serve any new purpose, other than thread bumping.
Maybe it makes you guys feel better by typing the same thing over and over.

you d*** right especially when RP and I get DMs from people thanking us for saving their careers.
Alternatively I have given advice in DM that if they really like nephrology and want to do academics, please be encouraged to do so.
my personal goal is to ensure no resident who failed to match cardiology or PCCM takes a cold call and scramble sinto a nephrology program. I have counseled them either to A) re-apply to desire field again after doing research or B) if you really think you could do nephrology do it next year for a bona fide top academic program

that is not public knowledge because it is in DM.

is your world view shattered now? did you think you were being clever trying to throw some shade? lol. well I hope you feel better venting your frustrations.

at the very least all doctors on here love to read this thread. everyone loves to stop to watch a highway accident.

have a nice career and keep on moving along.

 

[Prehealth1011]

I spoke to a nephro fellow who picked it because you start at 250k but I’ll be a partner after 2 years and I’ll be good. I don’t think sdn has a strong IMG/FMG presence. Definitely think there’s utility in keeping this thread alive.

 

[NewYorkDoctors]

remember everyone, the point of this thread is not "die nephrology die!"

the point is to give an eyes wide open second opinion to this subspecialty that has some good features (the doctoring part and pure academic nephrology) but a lot of warts from real life experience (albeit anecdotal... but like i said in previous thread you are never going to get a RCT on this topic lol. therefore the whole "there is no evidence for this so it does not exist" type of hubris comes from nephrology PDs who cant get fellows or senior partners who can't find someone to exploit lol)

 

[kacelius]

you d*** right especially when RP and I get DMs from people thanking us for saving their careers.
Alternatively I have given advice in DM that if they really like nephrology and want to do academics, please be encouraged to do so.
my personal goal is to ensure no resident who failed to match cardiology or PCCM takes a cold call and scramble sinto a nephrology program. I have counseled them either to A) re-apply to desire field again after doing research or B) if you really think you could do nephrology do it next year for a bona fide top academic program

that is not public knowledge because it is in DM.

is your world view shattered now? did you think you were being clever trying to throw some shade? lol. well I hope you feel better venting your frustrations.

at the very least all doctors on here love to read this thread. everyone loves to stop to watch a highway accident.

have a nice career and keep on moving along.

On the contrary, My world view is not shattered. You have made your point and you are helping out some People through personal messages and I really appreciate it. I also said I am not disagreeing with a lot of experiences shared here. But the point is this thread is here and it won’t go away even if you stop posting every week. All the information that is needed is already here. Why regurgitate the same info every week ?

 

[NewYorkDoctors]

On the contrary, My world view is not shattered. You have made your point and you are helping out some People through personal messages and I really appreciate it. I also said I am not disagreeing with a lot of experiences shared here. But the point is this thread is here and it won’t go away even if you stop posting every week. All the information that is needed is already here. Why regurgitate the same info every week ?

To reach more people who don’t bother to read the entire thread . If You are a proponent of conservation of energy , then fear not as it is not your energy that is being expended .

It also brings me a lot of dopamine and serotonin release to post on here .

 

[NewYorkDoctors]

anyway here is me trying to be helpful

here are the common dialysis billing codes and what CMS and commercial insurances tends to pay (in NY anyway)

here are the inpatient codes and the outpatient codes for adults and pediatrics

to start if renal fellows always wondered why their attendings always want the fellow to do on HD visits and write a note, it's because one note counts for 90935 then the attending checks it out also to get 90937. ka-ching! don't blame em though gotta get those RVUs up

as for outpatient, everyone strives to see their HD patients 4 times a month on HD (unless hospitalized)

IF all the patients can be localized within the HD center in a reasonable travel distance, then this is not too bad.

Let's say you have the luxury of going to just ONE HD center (yeah right).
You have a small panel of 20 patients.
They don't go to the hospital much and you see them 4 times a month.
You get paid $420.7 on medicare (more with certain commercial insurances)
That means each on HD visit is $105 or so.
That is about how much 99213 pays (after accounting for deductibles ) for a medicare patient anyway

issue is, you cannot bill 99213 + 90960 together as the patient did not go to your office.

maybe if the patient is cool and likes to go to your office on another date to review the HD monthly labs, nutritino reports etc... in an office setting then that's something i guess.

but other subspecialties can put a -25 modifier onto the office visit code 9921X and then bill other in office procedures and get that revenue to rise quite quickly.

Renal cannot really do this "easy sit in one place in an office" money making set up as it has no office procedures to be done outside of what a PCP can do. this is why I advocate for those who cannot get a good ESRD panel to consider GIM + non-HD renal.
Also do the USDIN emory renal radiology course, get certified, get a POCUS ultrasound like the butterfly IQ and start doing POCUS kidneys and bladders for 76705 to make some extra dough

so if you did the math, even if you are a successful nephrologist, it's not clear how this set up is easier than a 99213 mill for PCP other than ease of setting up a practice one way or the other.

but in reality, some junior nephs have to travel to multiple HD centers and basically have to do the same hard work as a 99213 mill as PCP but have to travel far more for this.

the math really does not add up favorably.

CPT Code	Modifier	CPT Name	Medicare NY Area1	My Fee Schedule
Medicare	Medicaid	Commercial
90935		HEMODIALYSIS ONE EVALUATION	83.82	83.82	0	81.04	Hemodialysis procedure with single evaluation by a physician or other qualified health care professional
90937		HEMODIALYSIS REPEATED EVAL	120.62	120.62	0	139.84	Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription
90960		ESRD SRV 4 VISITS P MO 20+	420.7	420.7			End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month
90961		ESRD SRV 2-3 VSTS P MO 20+	349.74	349.74			End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 2-3 face-to-face visits by a physician or other qualified health care professional per month
90962		ESRD SERV 1 VISIT P MO 20+	242.06	242.06			End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 1 face-to-face visit by a physician or other qualified health care professional per month
90963		ESRD HOME PT SERV P MO <2YRS	720.62	720.62			End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90964		ESRD HOME PT SERV P MO 2-11	618.14	618.14			End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90965		ESRD HOME PT SERV P MO 12-19	593.2	593.2			End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90966		ESRD HOME PT SERV P MO 20+	349.74	349.74			End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older
90967		ESRD SVC PR DAY PT <2	20.78	20.78			End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age
90968		ESRD SVC PR DAY PT 2-11	20.4	20.4			End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age
90969		ESRD SVC PR DAY PT 12-19	20.01	20.01			End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12-19 years of age

 

[Renal_Prometheus]

You don't see cards/GI people switching specialties late into their careers. But it's common in nephrology.

 

[sloh]

20 patients per month x 4 visits per month x 105 is only 100k! What does a large HD panel look like?

 

[NewYorkDoctors]

20 patients per month x 4 visits per month x 105 is only 100k! What does a large HD panel look like?

one of the renal attendings I trained under at a large academic upper east side academic renal program.. use to be a director of renal in the 70s and wrote lots of papers on renin and angiotensin1/2 went full private some time ago.

currently has a park avenue office. rounds at two hospitals in upper east side
the renal fellowship handles the renal fellowship.
the other "not learning cases" go to privates. he is one of the privates and goes around putting orders for HD, CRRT, etc... all the intensivists, surgeons, hospitalists love him as he is very receptive and gives his cell phone out.
he has 200 HD patients spraed across 4 HD centers - all within fair walking distance

he is in the 70s and took a career accumulating this

he made it big.

he is a "senior partner."

though he is solo. oh sure he has other solo doctors cover his patients if he is away and the such. but he does not employ junior partners to exploit. that is respect

 

[sloh]

one of the renal attendings I trained under at a large academic upper east side academic renal program.. use to be a director of renal in the 70s and wrote lots of papers on renin and angiotensin1/2 went full private some time ago.

currently has a park avenue office. rounds at two hospitals in upper east side
the renal fellowship handles the renal fellowship.
the other "not learning cases" go to privates. he is one of the privates and goes around putting orders for HD, CRRT, etc... all the intensivists, surgeons, hospitalists love him as he is very receptive and gives his cell phone out.
he has 200 HD patients spraed across 4 HD centers - all within fair walking distance

he is in the 70s and took a career accumulating this

he made it big.

he is a "senior partner."

though he is solo. oh sure he has other solo doctors cover his patients if he is away and the such. but he does not employ junior partners to exploit. that is respect

Great life. Can even get his steps in walking from HD center to HD center