Neurointerventional Radiology

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medicinestudent25

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I am a 4th year US MD student applying to residency in radiology. I am looking for information regarding neurointerventional radiology.
1) How is the job market for radiologist-trained neuro IR?
2) What is the salary range to be expected?
3) How is the elective case volume and call volume?
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This is only from my experience in what I’ve witnessed and heard and not necessarily generalizable.

1) You will find a job, but given it is a very small field, if you want to do more than read neuro and cover stroke you likely won’t be able to be choosy with where you work. Openings are fewer than neurosurg, far fewer than general rads.

2) salary is variable. Generally for stroke coverage you will be paid 50-75% more than a partnered radiologist, which is akin to an above average neurosurgery salary. But this depends on whether the hospital cares to incentivize their stroke coverage or not. A lot of of neuro IRs quit and went back to reading after hospitals enjoyed the stroke coverage but refused to bend when asked for significant subsidies.

3) For neuro IR with a reasonable outpatient referral base (aneurysms, AVM, dAVF, carotids) you will still be Q2-4 stroke call, with daytime 50-50 procedural and neuro reading.

I’d say neuro IR has the worst call schedule of all specialties in medicine simply because the stroke volume vastly outweighs everything else. Worse than trauma GS, neurosurg, and OB. It improves if your stroke coverage is diluted by body IRs covering some of that. You get paid appropriately to cover it if you don’t let yourself get taken advantage of.
 
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Great post from SeisK.

Stuff I'll add:
-NIR is unique in that there are pretty consistent volumes of LVO and aneurysms/AVM's per population size. I forget exactly what the numbers are but the figures per 100,000 apply nearly everywhere. So you can get a general idea of how many neurointerventionalists a particular market can support. As SeisK said, the places were there are going to be "less competitive jobs" are new areas without current stroke programs.

-The outpatient referral base is something you might have to build. Rads aren't used to or particularly well-trained at marketing themselves, but if a NIR wants an elective patient base, they're going to have work on snagging those referrals like a new neurosurgeon or orthopod would. Other than the procedures SeisK mentioned, there's a lot of possible IP/OP spine work. In my old group, our NIR's did the cervical punctures, most of the disc/spine biopsies, some blood patch work and some spine pain work. Most of the spine work isn't well compensated.

-NIR can overall be very stressful from the standpoint that you generally generate very low RVU's but also take a lot of call. Unless you're getting straight subsidies from the hospital for NIR support, most DR groups I've seen view their NIR's as a money sink.
 
NIR call sucks. Coming into the hospital in the middle of the night takes its toll over time. Its great when your young in your 20s but it gets old fast later on. The hospital mainly benefits. NIR procedures do not pay enough and you will have to negotiate call subsidies.
 
guytakingboards said:
Great post from SeisK.

Stuff I'll add:
-NIR is unique in that there are pretty consistent volumes of LVO and aneurysms/AVM's per population size. I forget exactly what the numbers are but the figures per 100,000 apply nearly everywhere. So you can get a general idea of how many neurointerventionalists a particular market can support. As SeisK said, the places were there are going to be "less competitive jobs" are new areas without current stroke programs.

-The outpatient referral base is something you might have to build. Rads aren't used to or particularly well-trained at marketing themselves, but if a NIR wants an elective patient base, they're going to have work on snagging those referrals like a new neurosurgeon or orthopod would. Other than the procedures SeisK mentioned, there's a lot of possible IP/OP spine work. In my old group, our NIR's did the cervical punctures, most of the disc/spine biopsies, some blood patch work and some spine pain work. Most of the spine work isn't well compensated.

-NIR can overall be very stressful from the standpoint that you generally generate very low RVU's but also take a lot of call. Unless you're getting straight subsidies from the hospital for NIR support, most DR groups I've seen view their NIR's as a money sink.
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Wait a second, the most common procedure NIR folks do is a diagnostic cerebral angiogram, which takes like 30-45 mins at most to do door to door, is an outpatient procedure, and is 22 (I think?) RVUs or something like that for 5v. At my program (high volume in pretty much every subspecialty of neurosurgery, interventional radiology, and related fields) NIR generates the most RVUs of everyone except spine. Some of our attendings do 8-10 per day of being in the angio suite. Where are you hearing that NIR is viewed as a money sink? Not trying to imply you're necessarily wrong, just isn't the same as my experience so curious about your perspective!
 
chord said:
Wait a second, the most common procedure NIR folks do is a diagnostic cerebral angiogram, which takes like 30-45 mins at most to do door to door, is an outpatient procedure, and is 22 (I think?) RVUs or something like that for 5v. At my program (high volume in pretty much every subspecialty of neurosurgery, interventional radiology, and related fields) NIR generates the most RVUs of everyone except spine. Some of our attendings do 8-10 per day of being in the angio suite. Where are you hearing that NIR is viewed as a money sink? Not trying to imply you're necessarily wrong, just isn't the same as my experience so curious about your perspective!
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How many days a week is each NIR doing 8-10 outpatient diagnostic angiograms? Probably 1, maybe 2.
 
chord said:
Wait a second, the most common procedure NIR folks do is a diagnostic cerebral angiogram, which takes like 30-45 mins at most to do door to door, is an outpatient procedure, and is 22 (I think?) RVUs or something like that for 5v. At my program (high volume in pretty much every subspecialty of neurosurgery, interventional radiology, and related fields) NIR generates the most RVUs of everyone except spine. Some of our attendings do 8-10 per day of being in the angio suite. Where are you hearing that NIR is viewed as a money sink? Not trying to imply you're necessarily wrong, just isn't the same as my experience so curious about your perspective!
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Personal experience in 2 large multi-specialty PP groups (both >100 rads). In particular with very detailed knowledge of RVU production and financials in the first group. My experience from my first group was corroborated by leadership in my second group, who was looking to exit themselves from the NIR game due to poor financials.

Both group are in large metroplexes (top 20 largest cities).

NIR's spend an overwhelming amount of their time not generating RVU's, particularly if they're most around for stroke coverage and don't have a lot of elective cases.

In my experience, a lot of small to medium sized hospitals see dollar signs in their eyes for potential comprehensive stroke programs but have no where near the volume to justify NIR coverage. But in many cases its needed to "keep the contract" so DR groups have to provide it.
 
Have heard there is demand for locums coverage for stroke centers (so NeuroIR can go on vacations etc). Given the stringency of joint commission certification of stroke sites, hospitals are often required to pay a great stipend to cover these services 24/7/365.
 
Cognovi said:
How many days a week is each NIR doing 8-10 outpatient diagnostic angiograms? Probably 1, maybe 2.
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Usually 2 days per week for the NSGY ones, 1-2 for the rads/neuro ones, though there's a lot of non-elective inpatient angio/embolization stuff that happens too. I see your point though, it's not the only source of RVU generation for any of them (the neurosurgeons operate, the neurologists attend on the inpatient side, and the radiologists do other procedural neuro stuff and read scans occasionally).

guytakingboards said:
Personal experience in 2 large multi-specialty PP groups (both >100 rads). In particular with very detailed knowledge of RVU production and financials in the first group. My experience from my first group was corroborated by leadership in my second group, who was looking to exit themselves from the NIR game due to poor financials.

Both group are in large metroplexes (top 20 largest cities).

NIR's spend an overwhelming amount of their time not generating RVU's, particularly if they're most around for stroke coverage and don't have a lot of elective cases.

In my experience, a lot of small to medium sized hospitals see dollar signs in their eyes for potential comprehensive stroke programs but have no where near the volume to justify NIR coverage. But in many cases its needed to "keep the contract" so DR groups have to provide it.
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Definitely has altered my perspective on this, thanks for sharing your experience. At my (large, academic) institution, my understanding is that the dual trained vascular surgeons generate the most RVUs out of anyone in our neurosurgery department other than the spine surgeons, but that may be due to other factors beyond my current level of understanding.
 
I can corroborate what guytakingboards is saying. NeuroIR is a big money loser in terms of RVU for any radiology group.
 
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Money loser for radiology group and often a money winner for the hospital. Some hospitals are now directly hiring the NeuroIR.
 
Strictly RVU based Neuro IR is a huge loser for the group. But as warrior said above big winner for the hospital. If your group covers Stroke, bleeds, PE, DVT, cold legs, nephrostomy and choly tube placement that is when you as a group have the leverage to say you are going to subsidize these clinical services and pay our group X amount. But if your group says no to everything or my favorite “I don’t feel comfortable with that” the hospital will hate you, and your group will hate you.
 
NDcienporciento100 said:
Strictly RVU based Neuro IR is a huge loser for the group. But as warrior said above big winner for the hospital. If your group covers Stroke, bleeds, PE, DVT, cold legs, nephrostomy and choly tube placement that is when you as a group have the leverage to say you are going to subsidize these clinical services and pay our group X amount. But if your group says no to everything or my favorite “I don’t feel comfortable with that” the hospital will hate you, and your group will hate you.
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So you're asking for a hospital subsidy, which boils down to the same thing. The hospital is paying for it, but it loses the group money otherwise.
Also, they can hate away it's not a popularity contest.
 
LegendaryBibimbap said:
So you're asking for a hospital subsidy, which boils down to the same thing. The hospital is paying for it, but it loses the group money otherwise.
Also, they can hate away it's not a popularity contest.
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So let’s be clear. If you are are a surgical or procedural specialist not employed by a hospital then the hospital pays you a substantial subsidy. You can’t make a living on the professional fee alone in these specialties.
 
LegendaryBibimbap said:
So you're asking for a hospital subsidy, which boils down to the same thing. The hospital is paying for it, but it loses the group money otherwise.
Also, they can hate away it's not a popularity contest.
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When the hospital pays the subsidy that means your group doesn’t have to pay it. Which means more money stays in your group’s pocket.
 
My understanding is NeuroIR loses money period in most practices, technical component included. The money the hospital makes is related to all the other services involved in having a comprehensive stroke center. Other surgical specialties make a lot of money for the hospital from the procedures alone. I don't actually know anything, this is just what I've heard.
 
LegendaryBibimbap said:
My understanding is NeuroIR loses money period in most practices, technical component included. The money the hospital makes is related to all the other services involved in having a comprehensive stroke center. Other surgical specialties make a lot of money for the hospital from the procedures alone. I don't actually know anything, this is just what I've The hospital makes tons of
LegendaryBibimbap said:
My understanding is NeuroIR loses money period in most practices, technical component included. The money the hospital makes is related to all the other services involved in having a comprehensive stroke center. Other surgical specialties make a lot of money for the hospital from the procedures alone. I don't actually know anything, this is just what I've heard.
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The hospital makes lots of money from neuro IR just like they make lots of money from trauma surgery. But the trauma surgeon is not making his living off of a professional fee for doing a surgery. And frankly, neither is any other physician doing surgery or procedures. Before somebody jumps on me, I’m talking about the professionals fee only which back in the day that’s actually how doctors made their living but not anymore.
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Actually plenty of physicians make a living off of professional component only, including a lot of radiology groups. They don't tend to make as much as groups that capture the technical component obviously. The problem with NeuroIR is even if you add the professional AND technical component, you still lose money on their cost. Unlike surgery.
 
LegendaryBibimbap said:
Actually plenty of physicians make a living off of professional component only, including a lot of radiology groups. They don't tend to make as much as groups that capture the technical component obviously. The problem with NeuroIR is even if you add the professional AND technical component, you still lose money on their cost. Unlike surgery.
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Read what I said. Surgeons and proceduralist.
 
LegendaryBibimbap said:
Actually plenty of physicians make a living off of professional component only, including a lot of radiology groups. They don't tend to make as much as groups that capture the technical component obviously. The problem with NeuroIR is even if you add the professional AND technical component, you still lose money on their cost. Unlike surgery.
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If a hospital makes 10 million dollars on an MRI machine but they had to pay 3 million dollars to buy the machine does that mean the hospital lost money? That is literally your logic. You’re saying that because the hospital has to pay neuro IR they are a loss even though they make tons of money off of Neuro IR that they could not make, unless they paid them.
 
The challenge with practicing VIR/ NIR in a traditional DR practice is that a successful VIR /NIR practice requires a significant overhead to build a comprehensive high end practice. Clinical infrastructure (office space /nurses/ medical assistants/ billers/ preauthorization/ EMR). The physician is taken away from reading imaging to perform nonprocedural clinical activities such as clinic, rounding on patients, seeing consults. A practice takes a great deal of time to turn a profit (3 to 5 years) and will often require a marketing budget and time to go to referring physician's offices. DR requires minimal if any overhead (usually it is home PACS stations etc) the rest is provided by the hospital including the technologists. So, all of the professional fees go into the DR profits . DR can read very quickly and insanely high volumes. Direct patient care is rarely ever that efficient. So, to most DR groups VIR/NIR may be seen as necessary evil and usually feel that the Interventional physicians don't carry their own weight and that the DR physicians are the ones subsidizing the IR salaries. This can lead to angst in the group.
 
One thing recently I have seen is radiologist-trained neurointerventionalists working with a neurosurgery group, rather than being part of a radiology group. Also, I think another option is working in academics. They will subsidize your salary and allow you to practice with more freedom.
 
I thought long and hard about how to explain this, but I just don't understand what's so confusing about the fact that not all specialties are profitable for a hospital
irwarrior said:
The challenge with practicing VIR/ NIR in a traditional DR practice is that a successful VIR /NIR practice requires a significant overhead to build a comprehensive high end practice. Clinical infrastructure (office space /nurses/ medical assistants/ billers/ preauthorization/ EMR). The physician is taken away from reading imaging to perform nonprocedural clinical activities such as clinic, rounding on patients, seeing consults. A practice takes a great deal of time to turn a profit (3 to 5 years) and will often require a marketing budget and time to go to referring physician's offices. DR requires minimal if any overhead (usually it is home PACS stations etc) the rest is provided by the hospital including the technologists. So, all of the professional fees go into the DR profits . DR can read very quickly and insanely high volumes. Direct patient care is rarely ever that efficient. So, to most DR groups VIR/NIR may be seen as necessary evil and usually feel that the Interventional physicians don't carry their own weight and that the DR physicians are the ones subsidizing the IR salaries. This can lead to angst in the group.
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Would you mind explaining to NDcienporciento100 the concept of an unprofitable specialty? Apparently they are having a hard time wrapping their mind around it.
 
LegendaryBibimbap said:
I thought long and hard about how to explain this, but I just don't understand what's so confusing about the fact that not all specialties are profitable for a hospital

Would you mind explaining to NDcienporciento100 the concept of an unprofitable specialty? Apparently they are having a hard time wrapping their mind around it.
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Medicare, and therefore private insurance, reimburses higher through DRG for complex stroke cases managed with mechanical thrombectomy, all other things being equal. The hospital stay for a stroke thrombectomy case reimburses extraordinarily well. That’s what ND is saying.

Yes the tech and prof component of a facet joint injection doesn’t pay a lot. The hospital stay for a complex, comprehensive stroke center patient pays a ton. The hospital sees that, and so would be financially incentivized to subsidize a neuro IR if they otherwise would not be able to recruit one.

Whether the subsidy makes it worth it depends on the details of the practice, the number of neuroIRs, and the subsidy.
 
LegendaryBibimbap said:
I thought long and hard about how to explain this, but I just don't understand what's so confusing about the fact that not all specialties are profitable for a hospital

Would you mind explaining to NDcienporciento100 the concept of an unprofitable specialty? Apparently they are having a hard time wrapping their mind around it.
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I think you need the education my friend. Bottom line: Neuro IR makes tons of money for a hospital.
 
The NeuroIR is a loss leader. That's why they need a subsidy. But if that means it makes a ton of money for the hospital, I guess so does the neuro ICU nurse.
 
LegendaryBibimbap said:
The NeuroIR is a loss leader. That's why they need a subsidy. But if that means it makes a ton of money for the hospital, I guess so does the neuro ICU nurse.
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Plain films are a loss leader. Radiologists should complain about those.
 
It is pretty hard to recruit neuroIR to cover stroke due to the frequency of call and the need to be within 30 minutes of the facility. Agree that the hospital has to provide services and so it will readily pay a hefty sum to have those services. The hospital generates so much money for taking care of patients and often get multiples of the medicare RVU depdending on insurance etc. Historically mammography was a "low RVU" and DR groups would complain about it. The DR groups would not pay the mammgoraphers what the mammographers felt they deserved. So they would leave. Hospitals ended up hiring them directly separate from DR groups to provide mammography. The mammographers brought in downstream revenue (biopsies/ filled OR with lumpectomy/ radiation oncology / medical oncology) and women often decided where the family would get health care an so it drove a lot of that as well.

Hospital administrators are fully aware of what is a necessary item and what is not and what the bottom line is and do not readily share that information with the physicians. They need to keep their beds full, the ICUs full, OR full and scanners full etc.
 
LegendaryBibimbap said:
They do. Plain films suck. What was your point here.
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You are the loss leader! The hospital would love to scan the patient and not have to employee you to read the exam, or “stipend you” to read. I interviewed with a group that was bragging to me about getting 20$ per X-ray read. Just to put that into context an X-ray pays 6-8$ Normally. They are getting a stipend.
 
Yes correct lol. Plain films are indeed a loss leader.

This is not a DR vs IR thing. I never brought up that comparison, I was simply stating financial realities. Looking through your post history, I realize now you're projecting your IR insecurities on this thread. This is no longer a useful conversation.
 
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LegendaryBibimbap said:
Yes correct lol. Plain films are indeed a loss leader.

This is not a DR vs IR thing. I never brought up that comparison, I was simply stating financial realities. Looking through your post history, I realize now you're projecting your IR insecurities on this thread. This is no longer a useful conversation.
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I don’t like when DRs start going on about how IR and Neuro IR make no money and are a loss. We are the reason you have the contract. Peds is a loss leader if you compare it to Neuro or Breast. If a neuroradiologist feels IR is a loss leader go to a hospital administrator and say to them we only want the neuroradiology contract from now on. No more reading CXR, US etc. We only want the contract to read CT and MR head, and spine because that is what is profitable. Let me know how far you get in that quest.
 
More and more places are splitting the VIR and DR contracts and it can be a win win situation. DR does not have to deal with the costs of IR and gets too keep higher margins and profits and the VIR group gets their stipend from the hospital and gets to have more clinical infrastructure and ability to practice higher end VIR that comes from the clinic.
 
Agreed, which is why I said earlier in the thread that hospital employed is the way to go. Unfortunately topic got derailed by insecurities.
 
The problem with pure hospital employment is the hospital for IR is full of paracentesis, drains, g tubes , biopsies and lines and all emergency bleeders etc. Outpatient asc/obl is highly rewarding with an outpatient clinic driving patients where you can do spine work, PAD, dialysis, fibroids, prostate work, oncology and even spinal cord stimulators and pain interventions etc.
 
I agree for the most part. A major issue that needs to be overcome is differential care. Example. You will almost never see shockwave in an OBL for example despite how well it works because they can’t afford it. In the hospital it is reimbursed and is used commonly. This is just one example but there are many more.
 
Agreed it is a true challenge of the OBL as drug eluting tech and covered stents etc may not be reimbursed the same. Some of these costs you may have to absorb or you take some of these patients to the hospital and do where they can absorb the costs.
 
irwarrior said:
Agreed it is a true challenge of the OBL as drug eluting tech and covered stents etc may not be reimbursed the same. Some of these costs you may have to absorb or you take some of these patients to the hospital and do where they can absorb the costs.
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Another major issue with this model specifically to IR is exclusive contracts. You will have an IR that may occasionally need or want to take a patient to the hospital to do a procedure on them. Many times the radiologist group will block that individual from getting credentials and claim because of their exclusive contract. 9/10 the IRs that are blocking them are doing paras and thoras and don’t even do the work that IR is wanting to bring in. But they block them anyway.it’s wrong and should not be allowed.
 
NDcienporciento100 said:
Another major issue with this model specifically to IR is exclusive contracts. You will have an IR that may occasionally need or want to take a patient to the hospital to do a procedure on them. Many times the radiologist group will block that individual from getting credentials and claim because of their exclusive contract. 9/10 the IRs that are blocking them are doing paras and thoras and don’t even do the work that IR is wanting to bring in. But they block them anyway.it’s wrong and should not be allowed.
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I think this is a divisive topic at best. My PP group has one hospital where somehow they unknowingly didn't renew their exclusivity clause and the med staff credentialed an independent IR that comes in and only does Y90's. He takes no IR call for that hospital; he certainly does no fluid management (thoras/paras/puss). That is a massively raw deal for my group at that hospital. It's not like there are infinite IR resources available. If that guy has cases scheduled my group loses the angio suite for sometimes hours, pushing back their entire schedule (of lower RVU producing cases).

On the one hand, props to that guy for somehow getting that deal. But I personally would fight that med staff level every time on behalf of my group and not feel bad doing so.
 
guytakingboards said:
I think this is a divisive topic at best. My PP group has one hospital where somehow they unknowingly didn't renew their exclusivity clause and the med staff credentialed an independent IR that comes in and only does Y90's. He takes no IR call for that hospital; he certainly does no fluid management (thoras/paras/puss). That is a massively raw deal for my group at that hospital. It's not like there are infinite IR resources available. If that guy has cases scheduled my group loses the angio suite for sometimes hours, pushing back their entire schedule (of lower RVU producing cases).

On the one hand, props to that guy for somehow getting that deal. But I personally would fight that med staff level every time on behalf of my group and not feel bad doing so.
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Then compete. Where is this IR getting Y90s from? Y90s in particular are rare to build a referral pattern for as this guy has to have a better relationships with the oncs and hepatologists in that hospital than your own IRs do. How bad is your IR rep in this hospital that this was even possible, exclusivity contract or not?
 
Y90 is unique. Most referrals come from the hospital tumor board. Even those IRs doing them in the outpatient lab have a foothold in a hospital and that’s how they get the referrals from the tumor boards in the hospital and they bring them in to their outpatient lab to do the case. It sounds like your group is a very weak group of IRs that probably do Pars, thoras, ports, the once a month bleeder in a level, 3 Trauma Center. The hospital administrator asks them why don’t you do Y90 and they reply “I didn’t learn that in my training, I don’t feel comfortable with that” and yet your group is mad because some IR wants to do y90 as if you guys were doing it anyway but you probably are not. This is a good thing. It serves the community and serves the patients the most important things. The para can wait man.
 
guytakingboards said:
I think this is a divisive topic at best. My PP group has one hospital where somehow they unknowingly didn't renew their exclusivity clause and the med staff credentialed an independent IR that comes in and only does Y90's. He takes no IR call for that hospital; he certainly does no fluid management (thoras/paras/puss). That is a massively raw deal for my group at that hospital. It's not like there are infinite IR resources available. If that guy has cases scheduled my group loses the angio suite for sometimes hours, pushing back their entire schedule (of lower RVU producing cases).

On the one hand, props to that guy for somehow getting that deal. But I personally would fight that med staff level every time on behalf of my group and not feel bad doing so.
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Wow what a legend. PP groups can't catch a break.
 
Not really. There are good PP IRs out there. But the ones that are successful are aggressive.
 
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