Question for graduating seniors

[Rehab_dr]

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Wondering what kind of offers you all are getting?

I am rather confused as to what realistically each bed generates in term of income for hospitals. I hear at one end - each rehab admission is between 20-40k, and recently saw a job saying each bed generates 6k, so they are calculating salary as 15 beds X6 k = 150k which makes no sense to me. Clearly there are more than 15 patients for the entire year. If each bed ONLY generated 6k throughout the year, that would be shocking. I have heard that many/most rehab hospitals make a tremendous amount of money from inpt. rehab.

So I am confused as to certain salaries posted. Anyone more knowledgeable care to comment?

 

[RangerBob]

Most hospitals do make a lot of money off rehab, though academic centers often lose money (dispo issues, more medicaid patients, etc.). But having a patient with dispo problems on rehab is still cheaper for the hospital than keeping them on the acute unit, so that's not the whole story.

I've always heard 10K thrown around--for each bed filled for the year you can expect 10k towards your salary. I have no idea how much each bed actually generates. So if you have a 15 bed unit and keep the unit filled for the year, your salary would be roughly 150k. 20 bed unit you could expect closer to 200k. But I knew a rehab doc in a slightly more rural area with a 15 bed unit (not always filled) and two half days of clinic and he made over $250k, so obviously there's a lot of variability in salary. Shop around a bit and see what other hospitals offer.

 

[PMR2008]

Or better yet don't work for a hospital. Strongly consider subacute or HealthSouth if you want to work in an inpatient rehab like setting and make 300K+.

 

[RUOkie]

Most hospitals do make a lot of money off rehab, though academic centers often lose money (dispo issues, more medicaid patients, etc.). But having a patient with dispo problems on rehab is still cheaper for the hospital than keeping them on the acute unit, so that's not the whole story.

I've always heard 10K thrown around--for each bed filled for the year you can expect 10k towards your salary. I have no idea how much each bed actually generates. So if you have a 15 bed unit and keep the unit filled for the year, your salary would be roughly 150k. 20 bed unit you could expect closer to 200k. But I knew a rehab doc in a slightly more rural area with a 15 bed unit (not always filled) and two half days of clinic and he made over $250k, so obviously there's a lot of variability in salary. Shop around a bit and see what other hospitals offer.

Made being past tense.

When you see ads for investment companies there is always a disclosure past performance does not guarantee future returns

this needs to be taken into account in today's healthcare environment. Salaries are going down for all physicians. SOME rural areas give large initial incomes to doctors because they want to control them. Then after 2-3 yrs markedly lower the salary since the doc was not making their nut. If a company/hospital gives you an offer that is too good to be true, it usually is.

 

[j4pac]

Made being past tense.

When you see ads for investment companies there is always a disclosure past performance does not guarantee future returns

this needs to be taken into account in today's healthcare environment. Salaries are going down for all physicians. SOME rural areas give large initial incomes to doctors because they want to control them. Then after 2-3 yrs markedly lower the salary since the doc was not making their nut. If a company/hospital gives you an offer that is too good to be true, it usually is.

How are salaries going down while demand is going up? "I'm not a very smart man"...but my high school economics teach taught me that prices rise when demand rises.

Does anyone have a good answer to this?

 

[DOctorJay]

health care does not follow typical economics. our prices are artificially set and continue to decline whereas overhead continues to rise.

 

[Rehab_dr]

This doesn't quite make sense to me. I would imagine that each bed makes a lot more than 10k per YEAR. If that's all they make then that's pretty low. My understanding is that each admission makes between 10-20k - again per admission. So if you have say 15 patients per month, at roughly 10k per admission, that should be 150k per month for example, at 1.8 million in a year - overhead, let's say 50% for a net profit of say 900k. Am I grossly wrong? A salary of 150k is offensively low I'm not sure why anyone would work for that - not even primary care docs make that these days. What happens with all the money generated? Doesn't make sense to me honestly.

Most hospitals do make a lot of money off rehab, though academic centers often lose money (dispo issues, more medicaid patients, etc.). But having a patient with dispo problems on rehab is still cheaper for the hospital than keeping them on the acute unit, so that's not the whole story.

I've always heard 10K thrown around--for each bed filled for the year you can expect 10k towards your salary. I have no idea how much each bed actually generates. So if you have a 15 bed unit and keep the unit filled for the year, your salary would be roughly 150k. 20 bed unit you could expect closer to 200k. But I knew a rehab doc in a slightly more rural area with a 15 bed unit (not always filled) and two half days of clinic and he made over $250k, so obviously there's a lot of variability in salary. Shop around a bit and see what other hospitals offer.

 

[Rehab_dr]

Or better yet don't work for a hospital. Strongly consider subacute or HealthSouth if you want to work in an inpatient rehab like setting and make 300K+.

How does healthsouth work?

 

[Baritonebass]

This doesn't quite make sense to me. I would imagine that each bed makes a lot more than 10k per YEAR. If that's all they make then that's pretty low. My understanding is that each admission makes between 10-20k - again per admission. So if you have say 15 patients per month, at roughly 10k per admission, that should be 150k per month for example, at 1.8 million in a year - overhead, let's say 50% for a net profit of say 900k. Am I grossly wrong? A salary of 150k is offensively low I'm not sure why anyone would work for that - not even primary care docs make that these days. What happens with all the money generated? Doesn't make sense to me honestly.

So With billing there are professional fees(doctor) and facility fee(hospitals) the 10k is what you make. the hospital get a fee for nursing, therapist and other services they pay the other staff and keep a profit. If they are incline they may give you a stipend as director. So the total bill for an admission is not the physicians take home. Your take home is you admission, discharge and daily notes minus your overhead. Overhead could be departmental tax(academics) or NP in private practice. I've met heathsouth doc who make mad money but the worked for it... Seeing 20 plus patients plus outpatient practice

 

[Rehab_dr]

Well if you work for a hospital, you don't pay "overhead" - the hospital pays that when you are a hospital employee and you get x salary +/- rvu/bonus. If you are a contractor, then you get to keep the billings/collection - overheard, with no specific set base salary - that's sort of my understanding of how Health south works that's why I was asking. Some people have stated that there are people who work for HS who make 500/600K + and of course they are not sitting at their desk just playing bingo - of course they are working hard. Seeing 20 patients a day is not that much. As a resident, I'm handling 12-14 on a daily basis so as an attending I doubt it would be that difficult to handle that many. That's what a hospitalist/primary care doc does and rehab pts are much more stable in general.

So With billing there are professional fees(doctor) and facility fee(hospitals) the 10k is what you make. the hospital get a fee for nursing, therapist and other services they pay the other staff and keep a profit. If they are incline they may give you a stipend as director. So the total bill for an admission is not the physicians take home. Your take home is you admission, discharge and daily notes minus your overhead. Overhead could be departmental tax(academics) or NP in private practice. I've met heathsouth doc who make mad money but the worked for it... Seeing 20 plus patients plus outpatient practice

 

[Baritonebass]

Depends NP/PA can be overhead....they generally work for you or your group. But if your do it all yourself there is no overhead. I knew I guy who saw 40 patient conferences 10 per day mon-Thursday. Some use NP/Pa like a resident so they can leave and do other things. Also mid level can assist with note prep. Though 3 notes a week plus conference must be MD

 

[Rehab_dr]

Depends NP/PA can be overhead....they generally work for you or your group. But if your do it all yourself there is no overhead. I knew I guy who saw 40 patient conferences 10 per day mon-Thursday. Some use NP/Pa like a resident so they can leave and do other things. Also mid level can assist with note prep. Though 3 notes a week plus conference must be MD

Not sure what you mean by 40 patient conferences? 40 patients? I think it's rare for one facility to have 40 patients with just 1 doc, I guess doable. Obviously if you are seeing 40 inpts. and have an NP and then have clinic or something like that then you should be doing well.

 

[PMR2008]

I have 40+ patients in my subacute that I cover. It is run like an inpatient unit with high intensity of rehab, team conferences and relatively quick discharges mostly to home. My PA's help me cover the subacute while I cover the clinic. I have scribes who also help with notes etc and I am an independent contractor.
I have a few friends who work at Health South and they make 500K+ but the stress level and burn out is high. Technically there is no overhead at HS and you keep what you bill. You just have a higher acuity of patients and also have to be on call vs subacute. In the subacute setting using a similar model you can make 400K+.

 

[Rehab_dr]

I have 40+ patients in my subacute that I cover. It is run like an inpatient unit with high intensity of rehab, team conferences and relatively quick discharges mostly to home. My PA's help me cover the subacute while I cover the clinic. I have scribes who also help with notes etc and I am an independent contractor.
I have a few friends who work at Health South and they make 500K+ but the stress level and burn out is high. Technically there is no overhead at HS and you keep what you bill. You just have a higher acuity of patients and also have to be on call vs subacute. In the subacute setting using a similar model you can make 400K+.

You seem to know your stuff well and seem to run an efficient system. As the time gets closer to when I finish training, I'll probably PM you.

 

[j4pac]

Now that we got the "plenty of money" part figured out...

How do you get the "and relaxation" job? You know...the job that prevents you from buying the mansion and newest sports car...but allows you to enjoy life while giving lots of individual care (in a non-assembly line fashion) to patients? Academics? Private practice?

 

[Rehab_dr]

Now that we got the "plenty of money" part figured out...

How do you get the "and relaxation" job? You know...the job that prevents you from buying the mansion and newest sports car...but allows you to enjoy life while giving lots of individual care (in a non-assembly line fashion) to patients? Academics? Private practice?

I think outpatient fits that description. Outpatient particularly private practice allows you to have a controlled schedule and decent money, free weekends.

 

[RUOkie]

How are salaries going down while demand is going up? "I'm not a very smart man"...but my high school economics teach taught me that prices rise when demand rises.

Does anyone have a good answer to this?

The physician reimbursement is not directly tied to hospital collections. The Medical Director is paid on an hourly rate for administrative work plus they can bill for the "doctor" work that they do. That is paid by fee schedule set by Medicare and negotiated contracts with private health insurance (usually a % of MCR or on RVU). Those numbers determine what the doctor gets paid.
Reimbursement is going down because of two reasons:

1. The MCR fee schedule has been static for years, and some went down. EMG reimbursement went down between 40-60% in 2013 because CMS changed the codes and assigned much lower RVU work to the new codes. It is naive to think that our reimbursement from MCR is going to increase.

And 2. The reimbursement for Medical Directorships has gone down tremendously over the past 20 yrs (but seems to have leveled out of late). While there is a paucity of inpatient PM&R docs, thereby creating demand, there are many internists, neurologists, and some ortho docs who are taking on Medical Directorships of IRFs, especially in community hospitals. There are a few for profit companies (RehabCare, for example) that contract at community hospitals that don't particularly like PM&R docs to be their medical directors, since we tend to disagree with the administration on things like length of stay and medical appropriateness.

Also, while hospitals can bring in a little "blue sky" (how much money the doctor makes for the hospital) in determining physician reimbursement for employed physicians, if they build in too much, it could look like an "Undue Inducement" for ordering procedures, tests, etc and thereby subject the hospital to an OIG investigation.

 

[j4pac]

The physician reimbursement is not directly tied to hospital collections. The Medical Director is paid on an hourly rate for administrative work plus they can bill for the "doctor" work that they do. That is paid by fee schedule set by Medicare and negotiated contracts with private health insurance (usually a % of MCR or on RVU). Those numbers determine what the doctor gets paid.
Reimbursement is going down because of two reasons:

1. The MCR fee schedule has been static for years, and some went down. EMG reimbursement went down between 40-60% in 2013 because CMS changed the codes and assigned much lower RVU work to the new codes. It is naive to think that our reimbursement from MCR is going to increase.

And 2. The reimbursement for Medical Directorships has gone down tremendously over the past 20 yrs (but seems to have leveled out of late). While there is a paucity of inpatient PM&R docs, thereby creating demand, there are many internists, neurologists, and some ortho docs who are taking on Medical Directorships of IRFs, especially in community hospitals. There are a few for profit companies (RehabCare, for example) that contract at community hospitals that don't particularly like PM&R docs to be their medical directors, since we tend to disagree with the administration on things like length of stay and medical appropriateness.

Also, while hospitals can bring in a little "blue sky" (how much money the doctor makes for the hospital) in determining physician reimbursement for employed physicians, if they build in too much, it could look like an "Undue Inducement" for ordering procedures, tests, etc and thereby subject the hospital to an OIG investigation.

Considering that physicians are an essential part of the equation...what could physicians do to take back the power? I know that it is pie in the sky thinking but it seems that many are making money on the backs of physicians.

 

[RUOkie]

Considering that physicians are an essential part of the equation...what could physicians do to take back the power? I know that it is pie in the sky thinking but it seems that many are making money on the backs of physicians.

Get together, build your own hospitals and sell your private practices to the hospital entity. Then you become your own employee. That also removes the penalty that CMS currently puts on physician owned hospitals.

Repeal Stark in its entirety.

None of those things are going to happen, because the general populace believes that all doctors are rich. We have absolutely no power in Washington, because the most recognised lobbyist organisation (the AMA) has already sold its soul to CMS. That is why less than 50% of docs now belong to the AMA.

 

[RangerBob]

Now that we got the "plenty of money" part figured out...

How do you get the "and relaxation" job? You know...the job that prevents you from buying the mansion and newest sports car...but allows you to enjoy life while giving lots of individual care (in a non-assembly line fashion) to patients? Academics? Private practice?

Work at the VA--I've rotated through plenty and they're generally the happiest and most laid back attendings.

I actually have found inpatient physiatrists tend to generally be more relaxed than outpatient--they get more control over their daily schedule. On outpatient you're at the whim of whatever your schedule is for the day, and while you might get a no-show, you never know when that will happen. On inpatient, you get your random emergencies and you have a few scheduled things (team meetings once per week, etc.), but you can decide to come in early and spend a lot of time rounding/chatting with your patients, or take a coffee break whenever you want, etc. Sure there's call, but it's becoming more common for hospitalists to cover nights, and avoid places that schedule you for excessive call. If you're part of a large group (academic hospitals and VA's definitely fit the bill), then your call is pretty infrequent.

But from all the community, academic, and VA docs I've worked with, none worked as lucrative/ridiculous of a schedule as above. But none made 400K. One made ~300k (salaried) as I mentioned above, and he had a really nice gig going. 15 beds, 2 half days of clinic, medical director. But I think the above poster points out that if you're willing to work hard and work smart, you can earn a nice income in PM&R.

 

[j4pac]

Get together, build your own hospitals and sell your private practices to the hospital entity. Then you become your own employee. That also removes the penalty that CMS currently puts on physician owned hospitals.

Repeal Stark in its entirety.

None of those things are going to happen, because the general populace believes that all doctors are rich. We have absolutely no power in Washington, because the most recognised lobbyist organisation (the AMA) has already sold its soul to CMS. That is why less than 50% of docs now belong to the AMA.

Perhaps bringing the AMA to its knees is step 1.

I think that there is lots of learned helplessness on the part of physicians (and providers in general). We have power because we have a highly sought after skill...what we don't have is solidarity.