Pain pay sucks

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I'm in California working my tail off and I have several friends in real estate making 3x what I make and a few CRNAS making 2x what I make. I never thought working to become a specialized physician would end up being such a slap in the face. And don't get me started on the difference between my patients vs the people looking to buy a house. FML. CRNA I know is working on her NP so she can see pain patients independently, own her clinic and do fluoroscopically guided injections; ins pays her the same as physician rate.

I'm outta here
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I'm working for a multi physician private pain practice, seeing 35-40 puts per day, of which 15 are injections
 
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That is really busy. thought about joining Arizona Pain? You could handle the volume they expect
 
SpineBound said:
I'm in California working my tail off and I have several friends in real estate making 3x what I make and a few CRNAS making 2x what I make. I never thought working to become a specialized physician would end up being such a slap in the face. And don't get me started on the difference between my patients vs the people looking to buy a house. FML. CRNA I know is working on her NP so she can see pain patients independently, own her clinic and do fluoroscopically guided injections; ins pays her the same as physician rate.

I'm outta here
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Wow, that sucks! Obviously I'm not privy to how finances are structured at your practice but I suspect a very sketchy compensation structure, with some permutation of "senior partners" or practice owners making a fortune off you, or a really crappy collections and billing system.

Seeing that number of patients a day and performing that many procedures weekly should generate a ton of revenue for the practice, especially if the practice owns a lab and an asc. With that volume, assuming that your billing folks are doing a solid job, you should be earning well above $450,000/yr.

As for the CRNA, I wouldn't worry about it. Clearly she's a greedy idiot who thinks too highly of herself. Pain medicine requires an extraordinarily broad knowledge base and skill set to do it well. CRNAs don't have either. Jesus, even after completing medical school, internship, residency, and a fellowship, I still find it very challenging.

Psychiatry, physical medicine and rehabilitation, neurology, radiology, anesthesiology, surgery, and rheumatology--pain medicine is a unique blend of ALL of these fields. Only physicians get training in all of these areas. Plain and simple. The CRNA you referenced is a greedy individual who truly doesn't care about patients. Would you send one of your family members to a CRNA practicing pain independently? Not a chance in hell. Any referring doc who cares about his/her patients will feel the same way.

Also, a career in medicine isn't the best way to become wealthy. There are plenty of easier paths out there, including real estate, but I would argue we have a very meaningful career, far more than the vast majority of career paths out there.

One final thought: if you're that upset about your financial situation, the solution is pretty simple. Get the hell out of there. I know of TONS of jobs in the Midwest and South that pay extremely well.
 
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Yeah this do not sound like a good set up. You should look for something else or renegotiate your contract.

On a similar note I recently interviewed at a job in a desirable geographic location with an ortho group. 2 other full time interventionalists. Both with access to office based c arm and surgical center. Shares in surgical center and both are partners in the group. They are looking to bring on another interventionalist to man two new prospective offices with unknown variables and being a new presence in that market. The new guy would have no access to in office c arm and would have to do everything is asc. Base salary 160k for two years with 25% production over twice base. Partnership possible after three years. They seem to think it's very reasonable. I think it's pretty low esp bc of the lack of access to office c arm. They site decreased reimbursement for procedures for low base salary. Anyway just wondering what people thought about it..
 
I guess I'm missing something here.....if the crna is making twice what you do, can't you go take their job? If I'm paying a crna "x" amount of dollars and a physician shows up and says they'll do it for the same money...the physician is hired.

Or start the same clinic the NP was going to do if it's more profitable
 
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Yes, I am doing maybe 60% of what he is doing and I am just over the median RVU target for anesthesia-pain per mgma.
 
Try not to compare your career to that of non-medical friends who are doing better. The grass always looks greener. In the final analysis, I don't think there's anything I could be doing that is as satisfying, flexible in lifestyle, and still pays reasonably well for all the investment of time and money.

C'mon, real estate? Sales? Yes, the money would be nice, but the big dollars don't flow to everyone who gets into that game. As a guilty pleasure when I'm zonked I like watching that million dollar listing show. How many of those guys doing the big deals didn't get where they are through connections unavailable to most people. As for job satisfaction, I doubt you ever feel that sense of satisfaction having diagnosed something unusual and truly helping someone. Hell, I get that on a daily basis.

When I'm done with work at 5:30 pm, I'm really done and go home to the family. When I'm on vacation, which is often, I'm really off and not having to respond to emails or worry about deals or the state of financial markets, or that I'm losing business to the competition.

One buddy of mine, who trained in anesthesia, tried out real estate development for two years, more or less full time while doing some locums. He ended up deciding it wasn't worth it. This is a guy who talks business non-stop and probably should never have gone into medicine. After residency he went into business with a few partners who had experience doing high level real estate development trying to make a go of it on a smaller scale. In two years he made about $50k in profit, but to make that he ended up taking on enormous financial risk. So he went back to anesthesia.

My wife's cousin manages his own hedge fund. He makes millions of dollars per year, and lives in a $7M apartment on the upper east side of NY. That business didn't just fall into his lap. He started at a top business school, worked for B of A for many years working on mortgage bonds, and was eventually making the really big dollars. He married the daughter of one of the billionaire captains of industry (I believe Obama attended his wedding), and working that connection had no problem assembling a panel of investors for his hedge fund venture, which has been very successful. Is he happy?? Not from my point of view. He seems freakin' miserable, and is a total miser unable to enjoy the wealth he is creating for himself.

Ever read the message boards where "biglaw" lawyers and wannabes chat? I wouldn't want that life.

Be happy you're a doc, and find a better employment situation. Preferably one where you have some ownership.
 
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"I would not chase the moving target of pure ROI (after all, there is always a more speculative vehicle with potential higher gains), but choose the vehicles that offers the greatest ROI with the least insomnia. More cash with constant sweat in the palms is hereby defined as a poor “investment.”
 
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SpineBound said:
I'm working for a multi physician private pain practice, seeing 35-40 puts per day, of which 15 are injections
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California has, in general, poor insurance contracts compared to other states. Managed Medi-Cal rolls have swelled, ASCs have been cut down, and hospital consolidation continues to take more and more patients out of the available pool. Market saturation cuts down on the procedure volume, as does being in a single-specialty group with other physicians looking for the same procedures.

Need to diversify the services. Just seeing whatever patients are referred to the group and doing some procedures is not going to do it.
 
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I hear this lament everytime the economy is on an upswing. Ask your real estate friends how they did in 2008-10. Ask the hedge fund guys. Ask your friends in fashion.

You should consistently make $500k (adjusted for inflation) for the next 20yrs. Yes, they will cut ur reimbursement, but u will figure out ancillary revenue streams, or alternate payer structures (comp, PI, concierge medicine, etc) to keep u flush.

No one ever promised that you'd get rich as a doc. Comfortable? Sure. "Fu¢k u money"? Maybe. Private jet money? Probably not.

Also, to be clear, your comparison isn't fair. You are an average pain doc. You are comparing yourself to the top 0.1% of real estate and finance guys.
 
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So let me get this straight, you know a few CRNAs making 2x what you do. Upper limit of CRNA might be 300-325k. So you're making 150k? I'm not trying to be mean but were you drunk when you took this job?
 
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Dr. Ice said:
Yeah this do not sound like a good set up. You should look for something else or renegotiate your contract.

On a similar note I recently interviewed at a job in a desirable geographic location with an ortho group. 2 other full time interventionalists. Both with access to office based c arm and surgical center. Shares in surgical center and both are partners in the group. They are looking to bring on another interventionalist to man two new prospective offices with unknown variables and being a new presence in that market. The new guy would have no access to in office c arm and would have to do everything is asc. Base salary 160k for two years with 25% production over twice base. Partnership possible after three years. They seem to think it's very reasonable. I think it's pretty low esp bc of the lack of access to office c arm. They site decreased reimbursement for procedures for low base salary. Anyway just wondering what people thought about it..
Click to expand...
Move on. Run... don't walk and don't negotiate.
 
SpineBound said:
I'm in California working my tail off and I have several friends in real estate making 3x what I make and a few CRNAS making 2x what I make. I never thought working to become a specialized physician would end up being such a slap in the face. And don't get me started on the difference between my patients vs the people looking to buy a house. FML. CRNA I know is working on her NP so she can see pain patients independently, own her clinic and do fluoroscopically guided injections; ins pays her the same as physician rate.

I'm outta here
Click to expand...
Get the heck out of Cali. Maybe retire there after they bankrupt the state and nurses run health care.
 
That sounds like a pretty terrible situation but I don't think the location can be totally blamed. Sounds like the practice is taking advantage of you. See what else is available in your area if you are committed to the west coast life.
 
EtherBunny said:
As for the CRNA, I wouldn't worry about it. Clearly she's a greedy idiot who thinks too highly of herself. Pain medicine requires an extraordinarily broad knowledge base and skill set to do it well. CRNAs don't have either. Jesus, even after completing medical school, internship, residency, and a fellowship, I still find it very challenging.
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She'll do well. Everything else being equal, pain management income is inverse to skill. If you correctly diagnose pseudosciatica, do an SI injection, and get the patient better you're done. The fumblebutt who treats the asymptomatic mild HNP on the MRI with ESI X 3 and then finally stumbles onto the SI joint gets 3 ESI fees and an SI joint fee.
 
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Yo GabbaPentin said:
Move on. Run... don't walk and don't negotiate.
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They are telling me they are collecting between 820-900k/year..but they also have access to in office c arm and are in established offices. You're right.. I'm running..like Forrest gump
 
Dr. Ice said:
On a similar note I recently interviewed at a job in a desirable geographic location with an ortho group. 2 other full time interventionalists. Both with access to office based c arm and surgical center. Shares in surgical center and both are partners in the group. They are looking to bring on another interventionalist to man two new prospective offices with unknown variables and being a new presence in that market. The new guy would have no access to in office c arm and would have to do everything is asc. Base salary 160k for two years with 25% production over twice base. Partnership possible after three years. They seem to think it's very reasonable. I think it's pretty low esp bc of the lack of access to office c arm. They site decreased reimbursement for procedures for low base salary. Anyway just wondering what people thought about it..
Click to expand...

There is the reason for the low offer on the base. They're worried about the new offices being slow, or having bad referrals with low procedure volume, or what have you.

Satellite locations fail all the time in competitive markets.

Maybe worth consideration if you really want to be in this area, believe in your ability to build up these new locations (with a good payor mix), and feel good about a potential for partnership.
 
Update: CRNAs in the area do anesthesia for pain cases as out of network providers and are making a killing, 500-1M per year. Being California I cannot be employed by hospitals. Is there a way I could do epidurals for people on an out of network basis? How do the CRNAs get away with this? They are making more than me for my injections and I'm paying overhead! I think I need a coach.
 
SpineBound said:
Update: CRNAs in the area do anesthesia for pain cases as out of network providers and are making a killing, 500-1M per year. Being California I cannot be employed by hospitals. Is there a way I could do epidurals for people on an out of network basis? How do the CRNAs get away with this? They are making more than me for my injections and I'm paying overhead! I think I need a coach.
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All about marketing. I knew of a NP in Florida that had a private jet. He could sell anything -and did.
 
SpineBound said:
Update: CRNAs in the area do anesthesia for pain cases as out of network providers and are making a killing, 500-1M per year. Being California I cannot be employed by hospitals. Is there a way I could do epidurals for people on an out of network basis? How do the CRNAs get away with this? They are making more than me for my injections and I'm paying overhead! I think I need a coach.
Click to expand...

what do you mean you cant be employed by hospitals?
 
SpineBound said:
Update: CRNAs in the area do anesthesia for pain cases as out of network providers and are making a killing, 500-1M per year. Being California I cannot be employed by hospitals. Is there a way I could do epidurals for people on an out of network basis? How do the CRNAs get away with this? They are making more than me for my injections and I'm paying overhead! I think I need a coach.
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Forgive me for not understanding. But how can a CRNA make more than you for injections?
 
A Witty Fool said:
Forgive me for not understanding. But how can a CRNA make more than you for injections?
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I'm doing the injection, she's doing the anesthesia. I'm in network and paid something around $85-100 for an epidural in ASC. She is out of network and can charge whatever she wants because she is not under contract- and is getting paid.

@Jcm800 Hospitals cannot employ physicians in California. State law.
 
As bad as the practice environment is in CA, it does have opportunity for practice innovation not available/feasible elsewhere.
 
SpineBound said:
I'm doing the injection, she's doing the anesthesia. I'm in network and paid something around $85-100 for an epidural in ASC. She is out of network and can charge whatever she wants because she is not under contract- and is getting paid.

@Jcm800 Hospitals cannot employ physicians in California. State law.
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I don't want to rip on you here, but pain docs don't make money doing procedures in an ASC in ANY STATE, unless you own a decent chunk of the ASC (20%). If you continue your described practice pattern of seeing 35 pts a day, but doing them all in an ASC, which you don't have a big share in, then yes you'll always make chump change, no matter what state you practice in.

Honest pain docs can make money with procedures one of three ways.
1-do procedures in office, just rent a c-arm and go. You'll make a lot more $ because you get paid more per procedure in office and you can be more efficient due to reduced turnover time.
2- do procedures in ASC that you have a big share in (20% or more ownership of ASC)
3- work for hospital (yes I know not in CA), and you get a very generous base salary/bonus from the hospital, because the hospital make tons of $ from facility fees, and they know you could start doing in office procedures across the street if you want to.
 
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Disciple said:
As bad as the practice environment is in CA, it does have opportunity for practice innovation not available/feasible elsewhere.
Click to expand...

Can you expound on that? I want to innovate.........

I do plan to increase my % of peripheral joint/tendon patients in CA as there are more patients in CA who are willing to pay cash for PRP/stem cell treatments.
 
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https://projects.propublica.org/treatment/states/CA/specialties/207?by=desc&sort=money_paid

fyi, top interventional pain physicians in California that billed Medicare. 16 billed over $340K to Medicare alone. (yes, i know, data is not complete and does not represent how much someone makes - bear with me, im using it to suggest a course of action)

that is a lot fewer than Texas, where 43 billed that many, or Florida, where 60 billed over that much.

on the other hand, California is a lot better than than NY, where only 7 billed that much, or 8 in NC, or 2 total in Penn.



so long story short.... move to Tx or Fla....
 
Ducttape said:
https://projects.propublica.org/treatment/states/CA/specialties/207?by=desc&sort=money_paid

fyi, top interventional pain physicians in California that billed Medicare. 16 billed over $340K to Medicare alone. (yes, i know, data is not complete and does not represent how much someone makes - bear with me, im using it to suggest a course of action)

that is a lot fewer than Texas, where 43 billed that many, or Florida, where 60 billed over that much.

on the other hand, California is a lot better than than NY, where only 7 billed that much, or 8 in NC, or 2 total in Penn.

so long story short.... move to Tx or Fla....
Click to expand...
I believe this is just Trad Medicare. My state is huge on Medicare Advantage and all the docs have ridiculously low Medicare numbers. I remember FL was the opposite. My only point is there is more to these numbers...
 
Ducttape said:
https://projects.propublica.org/treatment/states/CA/specialties/207?by=desc&sort=money_paid
so long story short.... move to Tx or Fla....
Click to expand...

Some truth to that from a financial perspective. I hear texas is overrun with pain docs because its a physician friendly state with tort reform etc, but a good place to practice if you can make it work against all the competition.

Florida is a different story, sure you get tropical beach weather, and no state income tax, but "pain physician" in florida is a dirty word, due to all the pill mills run by burnout PCPs, etc. Everyone is looking to sue someone in that state, and medicare pays better than commercial insurance in most areas, so yes docs get huge relative medicare numbers in FL, because thats where the money is in Florida.
 
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bedrock said:
Some truth to that from a financial perspective. I hear texas is overrun with pain docs because its a physician friendly state with tort reform etc, but a good place to practice if you can make it work against all the competition.
Florida is a different story, sure you get tropical beach weather, and no state income tax, but "pain physician" in florida is a dirty word, due to all the pill mills run by burnout PCPs, etc. Everyone is looking to sue someone in that state, and medicare pays better than commercial insurance in most areas, so yes docs get huge relative medicare numbers in FL, because thats where the money is in Florida.
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North Florida, pan handle, and West coast are OK. Southeast is where things get seedy. Huge population of NY PI lawyers desperate to make a buck so they can buy a pink house. Lots of ex-cons hiring burnout Craigslist docs to operate in the shadows. You can totally operate a great business but you have to be okay with this going on in the background. OTOH the lifestyle and value for your money in South Florida is incredible. Where else can you go to your back yard, hop in your boat, open the throttle and cruise to the Bahamas under the sunset?
 
hyperalgesia said:
North Florida, pan handle, and West coast are OK. Southeast is where things get seedy. Huge population of NY PI lawyers desperate to make a buck so they can buy a pink house. Lots of ex-cons hiring burnout Craigslist docs to operate in the shadows. You can totally operate a great business but you have to be okay with this going on in the background. OTOH the lifestyle and value for your money in South Florida is incredible. Where else can you go to your back yard, hop in your boat, open the throttle and cruise to the Bahamas under the sunset?
Click to expand...

Thank you for your additional insight on the differences of practicing in other areas of Florida. I'll keep it in mind if LA doesn't work out.

I love to sail and the idea of just cruising down to the Caribbean for a 4 day weekend sounds incredible!
 
Dr. Ice said:
Yeah this do not sound like a good set up. You should look for something else or renegotiate your contract.

On a similar note I recently interviewed at a job in a desirable geographic location with an ortho group. 2 other full time interventionalists. Both with access to office based c arm and surgical center. Shares in surgical center and both are partners in the group. They are looking to bring on another interventionalist to man two new prospective offices with unknown variables and being a new presence in that market. The new guy would have no access to in office c arm and would have to do everything is asc. Base salary 160k for two years with 25% production over twice base. Partnership possible after three years. They seem to think it's very reasonable. I think it's pretty low esp bc of the lack of access to office c arm. They site decreased reimbursement for procedures for low base salary. Anyway just wondering what people thought about it..
Click to expand...

I would pass on that offer if you have other options. I am GI but my wife is Pain-Anesthesia. We are in a geographically desirable metropolitan area so average starting pay is lower compared to Midwest and South. Most of the starting base in our area is in the $225-250K range and that includes expansion. The big mills start off in the high $200K. She ultimately signed with a group of three interventionalist (all partners). She gets mid $200K. She uses their ASC for fluoroscopic procedures. She is in a satellite location 50% of the time in an attempt to expand. She does a lot of ultrasound based procedures so does a lot in the office. She has potential partnership track after 2 years. She keeps 40% production over base.

It sounds like a crummy deal; $160K base and 25% of production over base with minimal ancillary support. You'd have to hustle to get patients in an office that is probably lacking. Too many variables unknown. If business is not lucrative for them, they'd let you go after your contract and you'd have nothing to show for it.
 
jabreal00 said:
I would pass on that offer if you have other options. I am GI but my wife is Pain-Anesthesia. We are in a geographically desirable metropolitan area so average starting pay is lower compared to Midwest and South. Most of the starting base in our area is in the $225-250K range and that includes expansion. The big mills start off in the high $200K. She ultimately signed with a group of three interventionalist (all partners). She gets mid $200K. She uses their ASC for fluoroscopic procedures. She is in a satellite location 50% of the time in an attempt to expand. She does a lot of ultrasound based procedures so does a lot in the office. She has potential partnership track after 2 years. She keeps 40% production over base.

It sounds like a crummy deal; $160K base and 25% of production over base with minimal ancillary support. You'd have to hustle to get patients in an office that is probably lacking. Too many variables unknown. If business is not lucrative for them, they'd let you go after your contract and you'd have nothing to show for it.
Click to expand...

How is her production determined, RVUs or straight dollars?
 
SpineBound said:
@Jcm800 Hospitals cannot employ physicians in California. State law.
Click to expand...

The way they (the big hospital systems at least) get around that is by creating a medical foundation.

E.g. Doctors at Kaiser work for "The Permanente Medical Group"
 
bedrock said:
Can you expound on that? I want to innovate.........

I do plan to increase my % of peripheral joint/tendon patients in CA as there are more patients in CA who are willing to pay cash for PRP/stem cell treatments.
Click to expand...

Yes, that's on the right track. A lot of people who move to CA do so specifically to lead an active lifestyle. They have interest in services that patients in other regions of the country generally don't. Combined with rising deductibles, it can facilitate a cash based model of primarily younger healthy patients. Theoretically speaking, of course.

There are also more opportunities for innovative models of corporate medical practice. Not the Walmarts, Safeways, etc., but CA is home to Google, Facebook, etc.
Opportunities might be limited to SoCal and Bay Area.

I'm starting to think more and more that the ideal Pain/PMR musculoskeletal practice may be the positions that some primary care Sports Med docs have with Ortho groups. With a smattering of spine work, work comp and PI to replace the primary care component.

And minus the substantial overhead/cut the group takes :laugh:
 
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what is the group's opinion about being the pain guy for an orthopedic group? Any experiences with orthopedic group partnerships?

I'm in talks with a group in the area and although they seem very nice and offered buy into partnership after 1 year (they own the building, equipment). However, details for possible ASC buy in was not given, was told "it was separate".
 
Separate buy-in to ASC is the norm.

The trade off in joining an Ortho group is generally the higher overhead. You may be handed a lot of procedures, but could be under immense pressure to do high volume because of this.

I would also make sure there are no misunderstandings about the job description. Some Ortho groups are focused on surgical patients only, and will want you to do primarily injections and/or EMGs.

Other groups may be "entrepreneurial" and want you to do a lot of opioid management, for purposes of urine screens, med dispensing, ongoing chiropractic care, etc.
 
All I ever get from ortho joint guys are med dumps. Botched knees started on percocet and dumped on me. Or 20 year olds with no pathology started on percocet and dumped on me. Ortho spine is a different story.

No direct experience working with or for ortho, but my experience is that they think pain = opioid management. When the patient talks about any pain not related to their joint of choice, they hear only the Charlie Brown teacher voice.
 
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