Outpatient Plastic Surgery and Anesthesia

[timtye78]

We had a "Practice Management" lecture at our program the other day. Eventually it went into billling, Medicaid/Medicare issues etc. I was getting rather bored (and depressed) so I asked the question to this billing specialist:

Where is the money in Anesthesia? What procedures pay the best? etc.

Her answer without even batting an eye, was outpatient plastic surgery gigs. Cash up front, no insurance, etc. Healthy patients, minimally invasive surgeries, etc.

No one talks about where to find these jobs! Everyone I talk to is talking about taking the s_ cases and slaving away in some big hospital full of big surgeries and sick patients while the 'partners' take 10,000 a month from you as 'buy in', and cherry pick the best paying patients. This might be a little exaggarated (sp?) but there is some truth in it?

Mil, Jet, attendings, etc. Where are these jobs, are they unattainable by new grads, etc. Do local groups take over these places too? Whats the scoop?

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[militarymd]

Are they attainable by new grads? No, unless you know someone.

Where are these jobs? Anywhere where there are successful plastic surgeons with paying patients.

Anesthesiologists who work there are frequently friends with prior association with the surgeons ( college, medical school, residency)

Also, plastic surgeons will frequently hire CRNA's....YES...they will hire CRNA's to minimize the cost of the practice. They will bill the patient for the procedure performed...including anesthesia costs....and then pay the CRNA a salary.

As a new grad, don't be expecting to find a job like that.

If I ever get the contract to a surgery center / plastic surgery center...and I plan on it in my future.....I will not be putting new grads in there to work.

The folks I put there will be:
1) board certified
2) minimum 5 years experience taking care of the sickest patients
3) friendly
4) good looking
5) good personality
6) GOOD schmoozing skills
7) FAST
8) buffed...guys would have rippling pecs....gals would have 34 to 36 C's and nice round asses

 

[jwk]

Remember that fees for plastic surgery offices and for doing plastic surgery cases in ASC's are often heavily discounted off the "normal" fee, and that may be part of the negotiating you might do for the opportunity to do those cases.

For example - full face lift and eyelids - maybe four hours of anesthesia time with a reasonable surgeon. The surgeon might be charging $15-20k for that procedure. If your "normal" per unit price is $60, you have 24 units just for time, not counting base units and modifiers. Let's guess 30 units total. That's $1800. But you probably will be asked to give a flat-rate for these cases so that the patient will know in advance exactly what their total cost for surgeon, facility, and anesthesia will be. So your $1800 fee based on time and units might be flat-rated to $1000 even, regardless of time or anything else.

That's still $250/hr for the actual work, but if that's all you did that day, it doesn't end up as good overall.

 

[MD Dreams]

Besides the money and the opportunity to work on your pecs, would anyone feel fulfilled doing these cases? Or is it all about the money?

 

[militarymd]

Besides the money and the opportunity to work on your pecs, would anyone feel fulfilled doing these cases? Or is it all about the money?

Surgery Centers are ALL about the money....otherwise, they would not exist.

 

[DrDre']

MMD,
Why 5 yrs exp? Only to "guarantee" they are fast? Or is it so they can handle an emergency without back-up if the **** hits the fan (even if it is 1:100000 chance?)?. Or is it so they have paid their "dues?"

Sounds like a great gig but I think I would suck a gun- might as well go into DDS...

Are they attainable by new grads? No, unless you know someone.

Where are these jobs? Anywhere where there are successful plastic surgeons with paying patients.

Anesthesiologists who work there are frequently friends with prior association with the surgeons ( college, medical school, residency)

Also, plastic surgeons will frequently hire CRNA's....YES...they will hire CRNA's to minimize the cost of the practice. They will bill the patient for the procedure performed...including anesthesia costs....and then pay the CRNA a salary.

As a new grad, don't be expecting to find a job like that.

If I ever get the contract to a surgery center / plastic surgery center...and I plan on it in my future.....I will not be putting new grads in there to work.

The folks I put there will be:
1) board certified
2) minimum 5 years experience taking care of the sickest patients
3) friendly
4) good looking
5) good personality
6) GOOD schmoozing skills
7) FAST
8) buffed...guys would have rippling pecs....gals would have 34 to 36 C's and nice round asses

 

[militarymd]

MMD,
Why 5 yrs exp? Only to "guarantee" they are fast? Or is it so they can handle an emergency without back-up if the **** hits the fan (even if it is 1:100000 chance?)?. Or is it so they have paid their "dues?"

Sounds like a great gig but I think I would suck a gun- might as well go into DDS...

I know there are those who disagree with me, but my observation is that people will learn a lot in the first 5 years after residency......

That first 5 years weed out those with personality disorders, bad work habits, bad skills, etc, etc.....

Finishing residency is a great hurdle, but there is a lot more out there then what residency teaches you.

Especially in this day and age of "you have reflux?" OK...you get "reglan, pepcid, and bicitra" mantra that residency programs seem to teach to all who pass through their hallowed doors.

 

[jwk]

MMD,
Why 5 yrs exp? Only to "guarantee" they are fast? Or is it so they can handle an emergency without back-up if the **** hits the fan (even if it is 1:100000 chance?)?

When your backup is "Dial 911", you better make damn sure you can handle ANYTHING. Most of us who have been out in practice a while can probably tell you some horror stories about ASC's and office surgery - some with anesthesiologists and/or anesthetists, some without.

 

[DrDre']

JWK,
I agree. When I was a paramedic, the saddest call I went on was a 4 yr who coded while being given a "MAC" by an oral surgeon. Long story short, he gave her a general using "small doses" of multiple drugs then ended up all kicking in. He thought she went into laryngospasm, suxed her twice, didn't open her airway. She coded as soon as I walked in and tubed her. She seized for 3 days then they withdrew care...

When your backup is "Dial 911", you better make damn sure you can handle ANYTHING. Most of us who have been out in practice a while can probably tell you some horror stories about ASC's and office surgery - some with anesthesiologists and/or anesthetists, some without.

 

[DrDre']

Thx MMD

I know there are those who disagree with me, but my observation is that people will learn a lot in the first 5 years after residency......

That first 5 years weed out those with personality disorders, bad work habits, bad skills, etc, etc.....

Finishing residency is a great hurdle, but there is a lot more out there then what residency teaches you.

Especially in this day and age of "you have reflux?" OK...you get "reglan, pepcid, and bicitra" mantra that residency programs seem to teach to all who pass through their hallowed doors.

 

[jetproppilot]

I know there are those who disagree with me, but my observation is that people will learn a lot in the first 5 years after residency......

That first 5 years weed out those with personality disorders, bad work habits, bad skills, etc, etc.....

Finishing residency is a great hurdle, but there is a lot more out there then what residency teaches you.

Especially in this day and age of "you have reflux?" OK...you get "reglan, pepcid, and bicitra" mantra that residency programs seem to teach to all who pass through their hallowed doors.

I was green and much slower when I emerged from residency in 1996.

Competent? Absolutely.

But you cant be a rokkstar in this business until after about 3-5 years in a busy private practice.

At my old gig we had the contract to a surgery center that did about 40 cases daily with one MD and 4-5 CRNAs. You cant take 15 minutes to do a pre op. You cant take 15 minutes to do an interscalene block. You cant take 15 minutes to induce a 2 year old, start the IV and turn the bed for the ENT dude doing the T&A. It was constant motion...pre-ops, interscalenes/femorals/sciatics/axillaries/inductions/PACU problems...etc etc. And like Mil said, you cant be just competent. You have to be competent and FAST.

So, Tim, the billing specialist was spot-on about surgery centers....but she forgot to add one salient characteristic a surgery center needs to make an anesthesia group alotta dough....volume. Obviously the more (good paying) cases you do, the better.

At the hospital, you cant take 15 minutes to put the cordis in the heart. We took 15 minutes to do the cordis, A line, and big peripheral. Take longer and you'll fall behind in the morning.....

When youre still a resident, think about this....not of course in your CA-1 year but as a CA-3 think about speed....try different ways to make yourself faster during an epidural/spinal/central line etc. This should be stressed more in residency. Will definitely help you when you get out.

You know you've got game as an aspiring partner when the partners are having to push their game to keep up with you. Try and stay ahead of your colleagues. Think ahead...organize in your head what needs to be done next...is it pre-ops in day surgery? Do you see a stretcher rolling back to room eight thats gonna be induced within five minutes? Is there a stretcher rolling to holding with the next TKA who's gonna need an epidural? Which surgeon is gonna finish in the next 45 minutes, and where is his next case? Has it been sent for? If not, tell the front desk to send for the dudes next patient. What other surgeons have pre-opped? Don't know? Then ask whatever nurse is running the front desk...."Has anybody preopped?"

Stay ahead. Think ahead.

 

[jetproppilot]

Besides the money and the opportunity to work on your pecs, would anyone feel fulfilled doing these cases?

Absolutely.

 

[bubalus]

Absolutely.

Every time I took the check to the bank.

 

[Noyac]

I know there are those who disagree with me, but my observation is that people will learn a lot in the first 5 years after residency......

That first 5 years weed out those with personality disorders, bad work habits, bad skills, etc, etc.....

Finishing residency is a great hurdle, but there is a lot more out there then what residency teaches you.

Especially in this day and age of "you have reflux?" OK...you get "reglan, pepcid, and bicitra" mantra that residency programs seem to teach to all who pass through their hallowed doors.

Funny you mention this Mil. We just posted an opening on gasworks and one of the requirements was 5yrs experience minimum.

 

[ckyuen]

60.00 a unit is a lot of money. doesnt medicare only give you guys like 17.00 a unit

 

[jwk]

60.00 a unit is a lot of money. doesnt medicare only give you guys like 17.00 a unit

1) Medicare doesn't pay for plastic surgery.

2) Medicare doesn't pay enough to cover an anesthetist' salary and benefits, much less an MD.

3) $60 a unit isn't that much considering what surgeon's make on some of their procedures, and the fact that MOST bills are significantly discounted for insurance, Medicare, etc. I'll bet there are plenty of groups whose non-discounted per unit rate is that much or even higher.

4) Try plugging in what you think you're worth per year - figure your total compensation, including benefits and pension arrangements. Then figure out how many units at what price per unit you'll have to bring in. Don't forget discounts and write-offs. $60 per unit shouldn't sound too high.

 

[SleepIsGood]

The folks I put there will be:
1) board certified
2) minimum 5 years experience taking care of the sickest patients
3) friendly
4) good looking
5) good personality
6) GOOD schmoozing skills
7) FAST
8) buffed...guys would have rippling pecs....gals would have 34 to 36 C's and nice round asses

Guess I have a few years to bulk up then

 

[militarymd]

Funny you mention this Mil. We just posted an opening on gasworks and one of the requirements was 5yrs experience minimum.

You guys are only asking the candidate to be "in the examination process".....seems that if one has 5 years experience, one should be board certified already.

 

[Noyac]

You guys are only asking the candidate to be "in the examination process".....seems that if one has 5 years experience, one should be board certified already.

Yes you are right. The hospital put the add in. I can guarantee the person we hire much less the ones we interview will be board certified.

I think it probably was overlooked since the anesthesia group told the hospital we wanted someone with 5yrs exp. And they didn't think about the board issue.

 

[rufio173]

The folks I put there will be:
1) board certified
2) minimum 5 years experience taking care of the sickest patients
3) friendly
4) good looking
5) good personality
6) GOOD schmoozing skills
7) FAST
8) buffed...guys would have rippling pecs....gals would have 34 to 36 C's and nice round asses

Sounds like an episode of nip-tuck. haha. Not that I've watched the show, but I've heard good things. Haha

Peace,
John

 

[militarymd]

Sounds like an episode of nip-tuck. haha. Not that I've watched the show, but I've heard good things. Haha

Peace,
John

What's "nip-tuck"?

 

[The_Sensei]

What's "nip-tuck"?

Some dumb-ass TV show about plastic surgeons.

 

[johankriek]

Funny you mention this Mil. We just posted an opening on gasworks and one of the requirements was 5yrs experience minimum.

I get around in my practice.. Im at like 7 places this year.. and ive seen some scary scary people who have been out a while... most of the new grads i have come across seem competent.. they are doing a much better job in residency these days

so i would absolutely hire new grads... no problem..

 

[militarymd]

..........
so i would absolutely hire new grads... no problem..

How could you hire anyone?

You don't believe in contracting with a hospital or surgery center in an exclusive manner.....therefore, you would never be in a position to hire anyone.....so I'm not sure what you mean with the above statement.

Unless, you DO believe in contracting with an organization in a manner which puts you in a hiring position, and then you would take new grads because this then allows you to profit from them??

 

[johankriek]

How could you hire anyone?

\so I'm not sure what you mean with the above statement.

\

it was hypothethical
if i were in a position of hiring.... aside from profiting from themm.. i would hire them .. i have seen enough of them to make a judgement .. they are very competent and FAST.. .

 

[militarymd]

.. they are very competent and FAST.. .

I've seen my share of new grads.....they have a thing or 2 to learn before they would meet my "high speed, low drag" criteria....

Plus...they're all pale and doughy from residency.....

 

[jetproppilot]

Plus...they're all pale and doughy from residency.....

Here ya go mil. No doughy stuff here in the big E-Z.

 

[militarymd]

Here ya go mil. No doughy stuff here in the big E-Z.

Alright Jet...

 

[johankriek]

Here ya go mil. No doughy stuff here in the big E-Z.

is that feces infested floodwater in the backround there? hope you are wearing boots..

 

[jetproppilot]

is that feces infested floodwater in the backround there? hope you are wearing boots..

Thats from a trip to Bradenton Fla a few months ago. Where I grew up.

 

[Noyac]

Looks like Balco is still in business.

 

[jetproppilot]

Looks like Balco is still in business.

Nahhh, Noy, if Balco and I were hangin' out I'd be sportin' about 280 lb instead of 208.....

 

[cfdavid]

since we're sendin pics.......

i've been workin out though......

 

[dhb]

so do i

 

[Painter1]

That first 5 years weed out those with personality disorders, bad work habits, bad skills, etc, etc.....

QUOTE]

does that include narcissictic personality disorder? because you've done a dandy-of-a-job riding low on that radar screen.

 

[jetproppilot]

since we're sendin pics.......

i've been workin out though......

HAHAHAHAHHAHAHAHAHAHAHHAHAHAHHAHAHAHHAHAHAHAHAHHAHAHAHAH

 

[ckyuen]

JWK sure medicare doesn't pay for cosmetic plastic surgery, but it does pay you guys based on units. and I believe you guys get like 6 or 7 units for a cataract, it takes me a very short period of time to do that you guys have no post op 90 rule or visits, at 60.00 a unit you would be getting more than the surgeon for the procedure, when I administer the anesthesic if a retrobulbar is needed, but 95% of the time it's just topical eye drops. So are you seriously saying you can compare that to what the surgeon receives. remember rvus are determined in part by practice expenses, when i operate I still pay about 200.00 an hour for my office expenses. so at 60.00 a unit and with 10 cataracts in a half day, you are looking at about 4200.00 for four or five hours of work. I'm sure medicare doesnt pay that much, and if it was that much for my private pay patient's that would be too high. If you have about a 20% overhead, then I would end up with less than you, and I would be the one doing the surgery and providing 3 months of post op for free. I know my anesthesiologist would be happy to do a cataract for 200.00 cash pay for me b/c at his 300.00 an hour charge, it would be much higher than his hourly rate. Medicare by the way does pay for medically necessary blepharoplasties which I do all the time, and the reimbursement for those sucks for you and me.

 

[timtye78]

thanks for the stimulating responses. Unverified and off the record responses-that what I love and hate about SDN. lol

 

[UTSouthwestern]

JWK sure medicare doesn't pay for cosmetic plastic surgery, but it does pay you guys based on units. and I believe you guys get like 6 or 7 units for a cataract, it takes me a very short period of time to do that you guys have no post op 90 rule or visits, at 60.00 a unit you would be getting more than the surgeon for the procedure, when I administer the anesthesic if a retrobulbar is needed, but 95% of the time it's just topical eye drops. So are you seriously saying you can compare that to what the surgeon receives. remember rvus are determined in part by practice expenses, when i operate I still pay about 200.00 an hour for my office expenses. so at 60.00 a unit and with 10 cataracts in a half day, you are looking at about 4200.00 for four or five hours of work. I'm sure medicare doesnt pay that much, and if it was that much for my private pay patient's that would be too high. If you have about a 20% overhead, then I would end up with less than you, and I would be the one doing the surgery and providing 3 months of post op for free. I know my anesthesiologist would be happy to do a cataract for 200.00 cash pay for me b/c at his 300.00 an hour charge, it would be much higher than his hourly rate. Medicare by the way does pay for medically necessary blepharoplasties which I do all the time, and the reimbursement for those sucks for you and me.

The vast majority of cataract patients I have seen posted at the various hospitals I work at are medicare patients. Let's say that you get 10 patients in five hours, 6 base points, 2 points for time, likely one point for ASA 3 status and that comes out to 9 points per patient. 90 points for the day, but at medicare rates of $11-$15/point depending on your location. That's $990 - $1350 for that five hour day or $195 - $270/hour. Not a great day.