Rheumatology job prospects

[bronx43]

Are injections or ultrasound efficient for increasing RVUs or are you better off just seeing more patients?

It depends on your workflow and support staff. If your staff can set up the injection supplies for you, then it's quick enough to add value. If not, then it may be a wash from a time perspective, but that also depends on your overall clinic volume. If you're just cramming fibro/OA/fatigue onto your schedule, then you will be full all the time. If you're discerning about what diseases you see, then it's actually quite hard to fill up in a metro area. In that case, then the decision isn't "should I just see one more patient instead of doing this injection."

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[dozitgetchahi]

I am a practicing rheumatologist who has been out of fellowship for 3 years. I recently just switched jobs and moved states. Since graduating, I have worked initially in a health system and now in private practice.

I will say that I’m not sure what some other posters are talking about with regards to demand for rheumatologists right now. My experience is that rheumatology demand is EXTREMELY robust at the moment. When I began looking for jobs earlier this year, I was absolutely inundated with recruiters calling and emailing and texting etc. It was off the hook. I had far more institutions interested in interviewing me than I could possibly keep up with. Granted, I was *not* specifically looking in the Great Big Cities that Doctors Usually Love (you know what these are), but rest assured that I saw plenty of job opportunities come through email etc in these locations as well.

Also, I secured a partnership track job with a starting salary of $300k with $25k signon bonus, $10k moving alllowance, $100k loan repayment - and the income potential is very good going forward. There are lots and lots of rheumatology patients out there, and waiting times for rheum consults in most of the country are >3 months (often >6 months). And I don’t see fibro/OA/whatever either. These are bona fide rheum patients. This job is in the South, where the incomes are generally higher even if you’re looking at the big southern cities (Atlanta, Nashville, etc). And these cities have become very trendy and hip as well…people are flocking to Nashville right now.

In short, my experience in rheumatology has been drastically different from those of other posters here. There is life in America outside of the tri-state area, Chicago and Southern California - and I suggest docs take a look at that. Rheumatology is awesome right now, and I have zero regrets with choosing it. Feel free to ask me questions.

 

[bronx43]

I am a practicing rheumatologist who has been out of fellowship for 3 years. I recently just switched jobs and moved states. Since graduating, I have worked initially in a health system and now in private practice.

I will say that I’m not sure what some other posters are talking about with regards to demand for rheumatologists right now. My experience is that rheumatology demand is EXTREMELY robust at the moment. When I began looking for jobs earlier this year, I was absolutely inundated with recruiters calling and emailing and texting etc. It was off the hook. I had far more institutions interested in interviewing me than I could possibly keep up with. Granted, I was *not* specifically looking in the Great Big Cities that Doctors Usually Love (you know what these are), but rest assured that I saw plenty of job opportunities come through email etc in these locations as well.

Also, I secured a partnership track job with a starting salary of $300k with $25k signon bonus, $10k moving alllowance, $100k loan repayment - and the income potential is very good going forward. There are lots and lots of rheumatology patients out there, and waiting times for rheum consults in most of the country are >3 months (often >6 months). And I don’t see fibro/OA/whatever either. These are bona fide rheum patients. This job is in the South, where the incomes are generally higher even if you’re looking at the big southern cities (Atlanta, Nashville, etc). And these cities have become very trendy and hip as well…people are flocking to Nashville right now.

In short, my experience in rheumatology has been drastically different from those of other posters here. There is life in America outside of the tri-state area, Chicago and Southern California - and I suggest docs take a look at that. Rheumatology is awesome right now, and I have zero regrets with choosing it. Feel free to ask me questions.

Glad to hear about your job. Is the partnership job with a private group? If so, is it billing minus overhead in terms of compensation model?

 

[dozitgetchahi]

Glad to hear about your job. Is the partnership job with a private group? If so, is it billing minus overhead in terms of compensation model?

Midsized multispecialty private group, yes. Compensation is billing minus overhead PLUS ancillaries (labs, imaging, and most importantly infusion revenue as well as profit sharing within the group) which can dramatically improve your compensation.

There is a popular view that rheumatology isn’t paid all that well compared to some specialties. This may be true in the case of academic rheumatology or employed rheumatology within a health system - but private practice is another ball game altogether. What I learned on the interview trail is that midsized/large multispecialty private groups can be something of a gold mine for rheumatologists - as in >$450k/year and the extra money is made in ancillaries and infusions. You don’t have to kill yourself seeing a bazillion patients a day, either. I met at least a dozen rheumatologists across 5 different states who were seeing a very reasonable number of pts per day (15-18 or so), working 8-5pm…and each of these docs made $450k+. One was making about $800k. We rheumatologists have huge “downstreams” relative to most IM subspecialties- ie, we order lots of expensive labs and imaging and drugs - and when you work for a hospital system they’re eating all the profit on that stuff and giving none of it back to you. (For instance, one year at my previous hospital system job my downstream was something like $3.5 million - massive for a non-surgeon - and yet my salary was something like $250k). This is not the case in private practice, where if you are in a good practice with low overhead and good ancillary capabilities, as a partner you actually get a significant slice of this back. I interviewed at one practice where one of the partners broke all this down for me with their accountant…Towards the end of the interview, he took me aside and said “look, even if you don’t take a job with us, you should definitely make sure you sign with a private practice or even go out and hang a shingle yourself. There’s no benefit to being employed by a hospital system if you’re a rheumatologist. You don’t need them, but they’d sure as hell love to eat your downstream.” And it’s all true. I don’t round in the hospital and I’m never on call. So wtf bother dealing with a hospital system? I know for a fact that when I left my last job it hurt the hospital financially - I have friends still there who talk about how much the execs are grumbling about it. They haven’t found another rheumatologist to replace me yet.

My current job is awesome for a variety of reasons - but the first of which is that you become a full partner in the practice after just 1 year, the buy in is minimal (something like $10k), and once you’re a partner you get a cut of the profit sharing too. The practice cleared something like $23 million in profits last year - and this will be split in some fashion among 58 physicians. Not a bad little bonus.

A few other observations/opinions from my time in rheumatology so far:

- “Fakedemia” rheumatology jobs are complete garbage. I actually think academic medicine just sucks in general unless you really have a raw passion for teaching and especially research - and keep in mind that you can do plenty of teaching outside of academia as an associate professor or adjunct etc - but fakedemia is just pure ****. Work like it’s a hospital system but get paid trash salaries like it’s academia (all while you put up with much of the same silly political horse**** and pressure to do research and teaching and more and more that goes on in an academic department, to boot)? It’s definitely a no from me, dog. Who wants these jobs, anyway? And why are people taking them?

- Go private practice. You’ll have control over your life and you’ll get paid better too.

- I don’t regret rheumatology at all. I’m never on call (hell, I don’t even have a pager), i think the work is really interesting, I work 4.5 days a week and I make $300k. Next year I’ll probably pull $400k+. I have a scribe, too, so I don’t have to do the drudgework data entry EMR clerk thing. I don’t see what there is to complain about here? Hell, I’ll see all the fibro you want for $250k+ and a 4-4.5 day work week with zero call. Sounds great to me.

 

[bronx43]

Midsized multispecialty private group, yes. Compensation is billing minus overhead PLUS ancillaries (labs, imaging, and most importantly infusion revenue as well as profit sharing within the group) which can dramatically improve your compensation.

There is a popular view that rheumatology isn’t paid all that well compared to some specialties. This may be true in the case of academic rheumatology or employed rheumatology within a health system - but private practice is another ball game altogether. What I learned on the interview trail is that midsized/large multispecialty private groups can be something of a gold mine for rheumatologists - as in >$450k/year and the extra money is made in ancillaries and infusions. You don’t have to kill yourself seeing a bazillion patients a day, either. I met at least a dozen rheumatologists across 5 different states who were seeing a very reasonable number of pts per day (15-18 or so), working 8-5pm…and each of these docs made $450k+. One was making about $800k. We rheumatologists have huge “downstreams” relative to most IM subspecialties- ie, we order lots of expensive labs and imaging and drugs - and when you work for a hospital system they’re eating all the profit on that stuff and giving none of it back to you. (For instance, one year at my previous hospital system job my downstream was something like $3.5 million - massive for a non-surgeon - and yet my salary was something like $250k). This is not the case in private practice, where if you are in a good practice with low overhead and good ancillary capabilities, as a partner you actually get a significant slice of this back. I interviewed at one practice where one of the partners broke all this down for me with their accountant…Towards the end of the interview, he took me aside and said “look, even if you don’t take a job with us, you should definitely make sure you sign with a private practice or even go out and hang a shingle yourself. There’s no benefit to being employed by a hospital system if you’re a rheumatologist. You don’t need them, but they’d sure as hell love to eat your downstream.” And it’s all true. I don’t round in the hospital and I’m never on call. So wtf bother dealing with a hospital system? I know for a fact that when I left my last job it hurt the hospital financially - I have friends still there who talk about how much the execs are grumbling about it. They haven’t found another rheumatologist to replace me yet.

My current job is awesome for a variety of reasons - but the first of which is that you become a full partner in the practice after just 1 year, the buy in is minimal (something like $10k), and once you’re a partner you get a cut of the profit sharing too. The practice cleared something like $23 million in profits last year - and this will be split in some fashion among 58 physicians. Not a bad little bonus.

A few other observations/opinions from my time in rheumatology so far:

- “Fakedemia” rheumatology jobs are complete garbage. I actually think academic medicine just sucks in general unless you really have a raw passion for teaching and especially research - and keep in mind that you can do plenty of teaching outside of academia as an associate professor or adjunct etc - but fakedemia is just pure ****. Work like it’s a hospital system but get paid trash salaries like it’s academia (all while you put up with much of the same silly political horse**** and pressure to do research and teaching and more and more that goes on in an academic department, to boot)? It’s definitely a no from me, dog. Who wants these jobs, anyway? And why are people taking them?

- Go private practice. You’ll have control over your life and you’ll get paid better too.

- I don’t regret rheumatology at all. I’m never on call (hell, I don’t even have a pager), i think the work is really interesting, I work 4.5 days a week and I make $300k. Next year I’ll probably pull $400k+. I have a scribe, too, so I don’t have to do the drudgework data entry EMR clerk thing. I don’t see what there is to complain about here? Hell, I’ll see all the fibro you want for $250k+ and a 4-4.5 day work week with zero call. Sounds great to me.

Couldn't agree more. Take it from someone who is about to leave fakedemia - don't join. Unless you can't see yourself doing anything but research AND have a NIH grant, then it's a complete scam. Even for people that like research and want to try their hand in it, don't do it. Because, the chance of you succeeding and getting a K or R01 grant approaches zero. And if you're not bringing in research dollars, then you're basically a beast of burden for the higher ups. The whole system is designed to enrich the established faculty members/administrators at the expense of the younger faculty.

There's honestly no viable job outside of private these days. I think true private practice is still viable as long as the infusion money keeps flowing. However, one thing that I've mentioned before is that infusions are more difficult to get due to the plethora of SC and oral therapies. Furthermore, a lot of Medicare Advantage plans simply won't cover the whole cost of the drug, so the co-insurance falls on the shoulder of patients, most of whom can't afford it. When I was in a purely private group (billing minus overhead), I was struggling to get infusions and ultimately couldn't make enough to justify the cost structure.

I've found that you really need 50-100 infusion patients to make it worth it, otherwise the high overhead you're paying may not make it all that profitable. Also, you need an MRI to really generate high ancillary revenue, which also eats significantly into the group overhead. Labs can be a money maker, but you need really high volume or else it's more or less a wash. Return rheum patients don't typically generate high ancillaries without infusions. Xrays are generally a money sink. We didn't have PT so that didn't really factor in. However, the complete autonomy is a significant upside - I would probably give up a chunk of cash for it.

 

[dozitgetchahi]

Couldn't agree more. Take it from someone who is about to leave fakedemia - don't join. Unless you can't see yourself doing anything but research AND have a NIH grant, then it's a complete scam. Even for people that like research and want to try their hand in it, don't do it. Because, the chance of you succeeding and getting a K or R01 grant approaches zero. And if you're not bringing in research dollars, then you're basically a beast of burden for the higher ups. The whole system is designed to enrich the established faculty members/administrators at the expense of the younger faculty.

There's honestly no viable job outside of private these days. I think true private practice is still viable as long as the infusion money keeps flowing. However, one thing that I've mentioned before is that infusions are more difficult to get due to the plethora of SC and oral therapies. Furthermore, a lot of Medicare Advantage plans simply won't cover the whole cost of the drug, so the co-insurance falls on the shoulder of patients, most of whom can't afford it. When I was in a purely private group (billing minus overhead), I was struggling to get infusions and ultimately couldn't make enough to justify the cost structure.

I've found that you really need 50-100 infusion patients to make it worth it, otherwise the high overhead you're paying may not make it all that profitable. Also, you need an MRI to really generate high ancillary revenue, which also eats significantly into the group overhead. Labs can be a money maker, but you need really high volume or else it's more or less a wash. Return rheum patients don't typically generate high ancillaries without infusions. Xrays are generally a money sink. We didn't have PT so that didn't really factor in. However, the complete autonomy is a significant upside - I would probably give up a chunk of cash for it.

Yeah academia is just rough. I see so many young and impressionable docs dive into it fresh out of training only to wash out after 5-10 years when they realize it totally sucks. When I was in fellowship, there was a young doc who had some really serious research experience who was being used as one of those “beast of burden” docs by the department because he wasn’t bringing in big grants etc…he wanted to be teaching and doing research but instead he was saddled with a loaded schedule with huge numbers of pts (and little time for much else). He was one of the biggest RVU generators in the department, but he wasn’t getting paid like it…I rounded in the hospital a couple of times with the dude and he was burned out, depressed and so pissed off at the dept admin all the time. He left for a different program around the same time I graduated fellowship. Not worth it. I realize we need some academic docs to teach and move the needle forward in terms of research, but my experience is that the number of young (and often misguided, sadly) docs who are interested in diving into the medical educational industrial complex far outnumber the people who actually need to be there - and the institutions know this and feed off their enthusiasm and cluelessness to extract as much effort and value as possible before they burn out and bail out. My fellowship department was an understaffed burnout zone despite being at a “prestigious” institution with enough $$$ to hire adequate staff to make everyone’s lives easier…instead I saw nonsense like attending docs wasting huge amounts of time scheduling their own patients and chasing down schedulers to do their damn jobs and actually schedule studies that were ordered etc. Even the attendings seemed to be doing the scut work that typically gets dumped on trainees (and don’t worry, we did plenty of it too)…just ridiculous. If this type of **** happened for even one day at the hospital system I worked at - never mind the private practice I’m at now - there would probably be a mutiny with hoards of angry docs banging on the doors of admin until things got fixed asap. At this institution, it’s like all the staff physicians were so downtrodden that they just went along with the crappy leadership and thought that’s how the world worked. Stockholm syndrome, or something. Really weird. The ones who came to their senses and realized the rest of the world wasn’t like this quickly exited. But I digress.

With regards to the rest…I think private practice success has a lot to do with overhead. The bigger the group, the less the overhead tends to be as it’s split between more docs. We have MRI machines and we are starting PT, so that may be helpful too. There are also several factors that come into play with infusion revenue, including whether or not your institution can get things like 340b pricing for infusion drugs…that ratchets down the cost considerably, improving the profit margins big time. I love the autonomy too - at my last job, my hospital admin was always up my ass about the stupidest things and chose to have big ongoing debates with me over little things like whether clinic started at 8 or 9 am (I had verbally agreed to 9 when the contract was signed, and then after I started they pressured me to move back to 8:30 and then 8 even though that made it hard for me as a single dad to put my kids on the bus etc)…just endless stupid bull**** that all but drove me nuts by the time I was done there. Here, I set the start time and the end time and I have final say over all sorts of other things. Dr wants this done a certain way? That’s it, no debates. It’s wonderful.

 

[bronx43]

Yeah academia is just rough. I see so many young and impressionable docs dive into it fresh out of training only to wash out after 5-10 years when they realize it totally sucks. When I was in fellowship, there was a young doc who had some really serious research experience who was being used as one of those “beast of burden” docs by the department because he wasn’t bringing in big grants etc…he wanted to be teaching and doing research but instead he was saddled with a loaded schedule with huge numbers of pts (and little time for much else). He was one of the biggest RVU generators in the department, but he wasn’t getting paid like it…I rounded in the hospital a couple of times with the dude and he was burned out, depressed and so pissed off at the dept admin all the time. He left for a different program around the same time I graduated fellowship. Not worth it. I realize we need some academic docs to teach and move the needle forward in terms of research, but my experience is that the number of young (and often misguided, sadly) docs who are interested in diving into the medical educational industrial complex far outnumber the people who actually need to be there - and the institutions know this and feed off their enthusiasm and cluelessness to extract as much effort and value as possible before they burn out and bail out. My fellowship department was an understaffed burnout zone despite being at a “prestigious” institution with enough $$$ to hire adequate staff to make everyone’s lives easier…instead I saw nonsense like attending docs wasting huge amounts of time scheduling their own patients and chasing down schedulers to do their damn jobs and actually schedule studies that were ordered etc. Even the attendings seemed to be doing the scut work that typically gets dumped on trainees (and don’t worry, we did plenty of it too)…just ridiculous. If this type of **** happened for even one day at the hospital system I worked at - never mind the private practice I’m at now - there would probably be a mutiny with hoards of angry docs banging on the doors of admin until things got fixed asap. At this institution, it’s like all the staff physicians were so downtrodden that they just went along with the crappy leadership and thought that’s how the world worked. Stockholm syndrome, or something. Really weird. The ones who came to their senses and realized the rest of the world wasn’t like this quickly exited. But I digress.

With regards to the rest…I think private practice success has a lot to do with overhead. The bigger the group, the less the overhead tends to be as it’s split between more docs. We have MRI machines and we are starting PT, so that may be helpful too. There are also several factors that come into play with infusion revenue, including whether or not your institution can get things like 340b pricing for infusion drugs…that ratchets down the cost considerably, improving the profit margins big time. I love the autonomy too - at my last job, my hospital admin was always up my ass about the stupidest things and chose to have big ongoing debates with me over little things like whether clinic started at 8 or 9 am (I had verbally agreed to 9 when the contract was signed, and then after I started they pressured me to move back to 8:30 and then 8 even though that made it hard for me as a single dad to put my kids on the bus etc)…just endless stupid bull**** that all but drove me nuts by the time I was done there. Here, I set the start time and the end time and I have final say over all sorts of other things. Dr wants this done a certain way? That’s it, no debates. It’s wonderful.

I have also seen people get chewed and spat out by fakedemia. And you can't get that money and time back. Graduating fellows need to read this, and avoid stepping into that trap at all cost. Having no autonomy and doing private practice volume for s*** pay is NOT sustainable.

I can't even imagine doing fakedemia in a tier 1 city (where many of these institutions are). Brb seeing 20 pts per day while making $150k as a "clinical instructor" or "assistant professor." Buying property is a pipe dream. Even rent will eat 1/2-1/3rd of your monthly income. With the way inflation is going, budgeting and clipping coupons isn't that far off the horizon. No joke... anyone can do the math.

 

[dozitgetchahi]

I have also seen people get chewed and spat out by fakedemia. And you can't get that money and time back. Graduating fellows need to read this, and avoid stepping into that trap at all cost. Having no autonomy and doing private practice volume for s*** pay is NOT sustainable.

I can't even imagine doing fakedemia in a tier 1 city (where many of these institutions are). Brb seeing 20 pts per day while making $150k as a "clinical instructor" or "assistant professor." Buying property is a pipe dream. Even rent will eat 1/2-1/3rd of your monthly income. With the way inflation is going, budgeting and clipping coupons isn't that far off the horizon. No joke... anyone can do the math.

Agree on the salaries. When I was signing the offer for my first job at the end of fellowship, I was starting at $250k in a hospital system…one of my co fellows was starting at $125k in one of those “instructor” positions at a Big Name Academic program. She was astounded to hear what I’d be making out in the community. Her mantra throughout fellowship was that “rheumatologists make crap [money]”…but as we’ve seen that’s not really an accurate statement. *Academic* rheumatologists “make crap”. She (being a bit of a workaholic) was also “thrilled” to hear that they were having her start off doing a whole bunch of teaching and administrative stuff, including editing the fellowship curriculum etc…she thought it was really cool and sexy that they were “allowing her” to start off doing this. I was like, dude…they’re going to work the daylights out of you while they pay you peanuts, doing the administrative garbage that no senior person in the department wants to be doing (ever notice that the “directors” of super specialized clinics and programs in academia are almost invariably young docs? They give important sounding titles to young docs who go gaga for this stuff…but do those docs realize that this is going to be a ton of work, they’re generally not getting compensated for any of it, and none of the senior people in the dept wanted to be doing it - so it came to them…?) And this was in an expensive city, too. Good luck.

The problem is that for so much of our lives, docs chase “prestige” and maximum academic performance…and then we all get to the end of training. Academia is all about producing more academics to keep the Ponzi scheme going, more or less. Most docs at the end of training have no idea what life is like for a non academic doc, and how that life may be different/better. So a lot of docs who never looked outside of academia just sort of keep swimming up the academic stream, like salmon going back to spawn…gotta chase that academic carrot. At some point, many of them come to their senses and they realize that being underpaid and overworked really blows…this seems to come at the 5-10 year mark. A lot of the ones who stay for a lifetime, IMHO, are rich kids who came in with low debt or are folks with wealthy spouses whose income allows them to “indulge” in academia while still living the kind of lifestyle you might expect from being a physician. Everyone else sees that it sucks, and gets the hell out. At some point in this medical life, it has to actually become a “life” with proper pay and work life balance and a sustainable lifestyle etc…all things that I didn’t see going on in my fellowship department. There were a number of people who were basically “married to their jobs”, or who seemed to have forgone having children to be able to maximize their time working to keep grinding out one more paper a year or whatever. Just crazy. I wouldn’t call most of these people “happy”, either - just deluded into the idea that working their ass off for an academic system that didn’t give two ****s about their well being was somehow going to bring a sense of fulfillment or joy. When they realize that it doesn’t, there’s often a reckoning. Some leave medicine altogether.

Physicians are sometimes really stupid about some things. I’m glad you saw the forest for the trees and got out. Most academics I know are doing at least double the amount of work I do for 50% less pay.

 

[drk310]

Yeah academia is just rough. I see so many young and impressionable docs dive into it fresh out of training only to wash out after 5-10 years when they realize it totally sucks. When I was in fellowship, there was a young doc who had some really serious research experience who was being used as one of those “beast of burden” docs by the department because he wasn’t bringing in big grants etc…he wanted to be teaching and doing research but instead he was saddled with a loaded schedule with huge numbers of pts (and little time for much else). He was one of the biggest RVU generators in the department, but he wasn’t getting paid like it…I rounded in the hospital a couple of times with the dude and he was burned out, depressed and so pissed off at the dept admin all the time. He left for a different program around the same time I graduated fellowship. Not worth it. I realize we need some academic docs to teach and move the needle forward in terms of research, but my experience is that the number of young (and often misguided, sadly) docs who are interested in diving into the medical educational industrial complex far outnumber the people who actually need to be there - and the institutions know this and feed off their enthusiasm and cluelessness to extract as much effort and value as possible before they burn out and bail out. My fellowship department was an understaffed burnout zone despite being at a “prestigious” institution with enough $$$ to hire adequate staff to make everyone’s lives easier…instead I saw nonsense like attending docs wasting huge amounts of time scheduling their own patients and chasing down schedulers to do their damn jobs and actually schedule studies that were ordered etc. Even the attendings seemed to be doing the scut work that typically gets dumped on trainees (and don’t worry, we did plenty of it too)…just ridiculous. If this type of **** happened for even one day at the hospital system I worked at - never mind the private practice I’m at now - there would probably be a mutiny with hoards of angry docs banging on the doors of admin until things got fixed asap. At this institution, it’s like all the staff physicians were so downtrodden that they just went along with the crappy leadership and thought that’s how the world worked. Stockholm syndrome, or something. Really weird. The ones who came to their senses and realized the rest of the world wasn’t like this quickly exited. But I digress.

With regards to the rest…I think private practice success has a lot to do with overhead. The bigger the group, the less the overhead tends to be as it’s split between more docs. We have MRI machines and we are starting PT, so that may be helpful too. There are also several factors that come into play with infusion revenue, including whether or not your institution can get things like 340b pricing for infusion drugs…that ratchets down the cost considerably, improving the profit margins big time. I love the autonomy too - at my last job, my hospital admin was always up my ass about the stupidest things and chose to have big ongoing debates with me over little things like whether clinic started at 8 or 9 am (I had verbally agreed to 9 when the contract was signed, and then after I started they pressured me to move back to 8:30 and then 8 even though that made it hard for me as a single dad to put my kids on the bus etc)…just endless stupid bull**** that all but drove me nuts by the time I was done there. Here, I set the start time and the end time and I have final say over all sorts of other things. Dr wants this done a certain way? That’s it, no debates. It’s wonderful.

340b pricing for infusion drugs only applies to large hospital settings where you would need to be an employee and that would take away the autonomy part...are there any people who have been able to access 340b discounts in underserved areas without being an employee for a large healthcare system? I've not heard of private practice single or multispecialty groups with access to this.

 

[bronx43]

340b pricing for infusion drugs only applies to large hospital settings where you would need to be an employee and that would take away the autonomy part...are there any people who have been able to access 340b discounts in underserved areas without being an employee for a large healthcare system? I've not heard of private practice single or multispecialty groups with access to this.

I don't think my old private practice had 340b pricing, but we did have a substantial discount from bulk purchases given the size of the multispecialty group. I don't know the margins on drugs purchased through 340b, but our margins were relatively healthy. For certain drugs, it was easily 15-20%.

 

[dozitgetchahi]

340b pricing for infusion drugs only applies to large hospital settings where you would need to be an employee and that would take away the autonomy part...are there any people who have been able to access 340b discounts in underserved areas without being an employee for a large healthcare system? I've not heard of private practice single or multispecialty groups with access to this.

I encountered a large multispecialty private practice in Ohio that claimed to have gotten 340b pricing. Not sure how they did it (or if they were telling the truth), but that’s what they said to me at the interview. I’m not necessarily an expert on the subject, but 340b pricing doesn’t really have much to do with the size of the health system - it does have to do with whether the system is handling underserved populations, either rurally or in an urban environment. Most 340b institutions are actually tiny rural critical access hospitals with 40 beds etc, not huge health systems.

 

[Renal_Prometheus]

This thread is interesting. Maybe I should make a thread on neph job prospects.

 

[TaroBubbleTea]

This thread is interesting. Maybe I should make a thread on neph job prospects.

Lol so meta

 

[bronx43]

Another point I have to make about fakedemic rheumatology is this - most of these BS gigs give you very limited time with the fellows. I'm talking like 1 half day of clinic per week (or time equivalent) if you're lucky. This means that the vast majority of your job will be you slaving away in clinic just like you would be doing in private practice. You'll be seeing the patient, writing the note, refilling meds, and answering patient calls/mychart.

Contrast that to the ICU docs or cardiologists. At my shop, the cardiologists NEVER do inpatient service that isn't completely covered by residents and fellows. These trainees also are first call overnight. The attendings are also never called unless there's some crazy emergency. They get to sleep through the night, unlike their private practice counterparts. Therefore, it makes a lot more sense for them to take academic jobs and endure the paycut. However, it makes absolutely ZERO sense for an outpatient specialist to do the same - we simply pay the academic tax for no representation.

 

[Renal_Prometheus]

Another point I have to make about fakedemic rheumatology is this - most of these BS gigs give you very limited time with the fellows. I'm talking like 1 half day of clinic per week (or time equivalent) if you're lucky. This means that the vast majority of your job will be you slaving away in clinic just like you would be doing in private practice. You'll be seeing the patient, writing the note, refilling meds, and answering patient calls/mychart.

Contrast that to the ICU docs or cardiologists. At my shop, the cardiologists NEVER do inpatient service that isn't completely covered by residents and fellows. These trainees also are first call overnight. The attendings are also never called unless there's some crazy emergency. They get to sleep through the night, unlike their private practice counterparts. Therefore, it makes a lot more sense for them to take academic jobs and endure the paycut. However, it makes absolutely ZERO sense for an outpatient specialist to do the same - we simply pay the academic tax for no representation.

This is why so many nephrologists choose academics. Have the fellows take their night calls so they can sleep through the night. It makes sense in nephrology because private practice is hardcore and you are not making that much money(compared to cards or GI). So you end up getting a lot of these guys living off the back of fellows and lying grotesquely about the actual state of nephrology to trap a warm body. I know because I was a victim of these lies.

 

[dozitgetchahi]

Another point I have to make about fakedemic rheumatology is this - most of these BS gigs give you very limited time with the fellows. I'm talking like 1 half day of clinic per week (or time equivalent) if you're lucky. This means that the vast majority of your job will be you slaving away in clinic just like you would be doing in private practice. You'll be seeing the patient, writing the note, refilling meds, and answering patient calls/mychart.

Contrast that to the ICU docs or cardiologists. At my shop, the cardiologists NEVER do inpatient service that isn't completely covered by residents and fellows. These trainees also are first call overnight. The attendings are also never called unless there's some crazy emergency. They get to sleep through the night, unlike their private practice counterparts. Therefore, it makes a lot more sense for them to take academic jobs and endure the paycut. However, it makes absolutely ZERO sense for an outpatient specialist to do the same - we simply pay the academic tax for no representation.

Completely agree.

The fakedemia jobs seem to combine all the disadvantages of academic medicine (low pay, huge additional work burden, relatively little chance for advancement, etc) with a minimal amount of the “good stuff” some people pursue in academia (trainee teaching, research). The overworked young attending I spoke of above really, really wanted to work with fellows - he was really passionate about teaching trainees. But he was spending perhaps a day every other week with fellows on average. The rest of the time he was seeing private practice pt volumes with probably 2/3 of the pay he’d be getting if he saw them in private practice.

I had phone interviews with a couple of fakedemia jobs which told me “we work in academia, but we don’t get paid like it!” In reality, these docs were still being underpaid - just not to the hideous level that the “true academic” docs were. Getting 1/3 less pay rather than 1/2 less pay vs private practice isn’t some sort of massive victory, especially since you have a lot more BS to put up with in academia.

Another thing to note is that the “fakedemia” docs often get looked down on by other “academic” docs in their depts. I am still friends with a “fakedemic” in my dept who retired the year I graduated. He described sitting in faculty meetings where dept chairs called him a “clinical drone”…as if he was much less worthy than the “true academics” etc. So in fakedemia, you do private practice volumes for trash pay and your colleagues look at you like you’re a joke while you have a huge burden of teaching and clinical research to try to do. Not sure where the “plus” is there.

 

[bronx43]

Completely agree.

The fakedemia jobs seem to combine all the disadvantages of academic medicine (low pay, huge additional work burden, relatively little chance for advancement, etc) with a minimal amount of the “good stuff” some people pursue in academia (trainee teaching, research). The overworked young attending I spoke of above really, really wanted to work with fellows - he was really passionate about teaching trainees. But he was spending perhaps a day every other week with fellows on average. The rest of the time he was seeing private practice pt volumes with probably 2/3 of the pay he’d be getting if he saw them in private practice.

I had phone interviews with a couple of fakedemia jobs which told me “we work in academia, but we don’t get paid like it!” In reality, these docs were still being underpaid - just not to the hideous level that the “true academic” docs were. Getting 1/3 less pay rather than 1/2 less pay vs private practice isn’t some sort of massive victory, especially since you have a lot more BS to put up with in academia.

Another thing to note is that the “fakedemia” docs often get looked down on by other “academic” docs in their depts. I am still friends with a “fakedemic” in my dept who retired the year I graduated. He described sitting in faculty meetings where dept chairs called him a “clinical drone”…as if he was much less worthy than the “true academics” etc. So in fakedemia, you do private practice volumes for trash pay and your colleagues look at you like you’re a joke while you have a huge burden of teaching and clinical research to try to do. Not sure where the “plus” is there.

Do you mind me asking how much those semi-fakedemic jobs were paying?

In terms of fakedemia, there's the LOW paying ones where the "clinical instructors" make like 140k. I pity those who get sucked into these scams. It's usually the top 20 institutions that get to swindle their docs this badly. I bet the division chairs there are just ROFL in their head every time they snag someone with their offer. Out of every 10 junior faculty that join, only one has a shot at actually making it big and getting a grant. The other 9 are just there to stroke their egos for garbage pay.

The next tier up are the non-ivory tower institutions that still think they're hot stuff... they at least give you the "assistant professor" title, and pay 170-180k. But often times, these are even crappier jobs than the ones above, because they want the full clinical productivity.

Next up are the middling centers that had the "lightbulb moment" and are paying their docs 200-220k (still too low but at least palatable).

All three are a ripoff, but I can at least understand if someone took #3 IF the work is less. If the workload isn't less, then it's a loss all around.

 

[dozitgetchahi]

Do you mind me asking how much those semi-fakedemic jobs were paying?

In terms of fakedemia, there's the LOW paying ones where the "clinical instructors" make like 140k. I pity those who get sucked into these scams. It's usually the top 20 institutions that get to swindle their docs this badly. I bet the division chairs there are just ROFL in their head every time they snag someone with their offer. Out of every 10 junior faculty that join, only one has a shot at actually making it big and getting a grant. The other 9 are just there to stroke their egos for garbage pay.

The next tier up are the non-ivory tower institutions that still think they're hot stuff... they at least give you the "assistant professor" title, and pay 170-180k. But often times, these are even crappier jobs than the ones above, because they want the full clinical productivity.

Next up are the middling centers that had the "lightbulb moment" and are paying their docs 200-220k (still too low but at least palatable).

All three are a ripoff, but I can at least understand if someone took #3 IF the work is less. If the workload isn't less, then it's a loss all around.

The semi-fakedemic jobs were making that exact range you mentioned- like $200-225k. One of these programs had aspirations of starting their own rheumatology fellowship (they had an IM residency, but not a fellowship) and apparently saw me as becoming part of the “core faculty” that applied for and got the fellowship running within the next few years. I noped out of that real quick, as I have heard that starting a fellowship takes an enormous amount of faculty time and effort and they certainly weren’t going to be paying me extra for any of that.

My own fellowship dept pays new rheums $200k, but the clinical work is definitely NOT less than private practice by any means and they expect you to keep a full slate of teaching and clinical research (read: not grant funded, meaning it’s unpaid and all done on your own personal time) going. So no. Plus the atmosphere in that department is heavily “politicized” and honestly resembled some sort of “Game of Thrones” situation with different factions fighting each other over resources etc. As the young attending I mentioned said before…the newly hired docs don’t tend to fit well into any of the factions, and if you’re not part of any of them you’re basically hung out to dry.

I mentioned that I had a co-fellow starting at $125k as a “clinical instructor” at a Big Name Academic program we all would recognize…the sad/ridiculous part of this was that this co-fellow had close ties to the faculty at this place from past training, knew them very well, and they had been grooming this fellow to come back to them as faculty…and yet still they delivered one of the worst deals I’ve ever heard of for a new academic rheumatologist. And this co-fellow snapped up the deal like it was going to run away if they didn’t jump on it. No negotiation whatsoever - well, except to add a provision that this fellow would be allowed to moonlight on the general wards for extra money because the pay was such ****. Let that sink in for a second, and remember that this was also a job with massive teaching and research obligations…and possibly moonlighting as well. SMH.

Periodically I look at academia and wonder if it’s not so bad - and I do like teaching a lot, so maybe I should try it sometime? But then I am reminded of these stories, get nauseous and remember why I’m way happier doing what I’m doing now.

 

[dozitgetchahi]

This is why so many nephrologists choose academics. Have the fellows take their night calls so they can sleep through the night. It makes sense in nephrology because private practice is hardcore and you are not making that much money(compared to cards or GI). So you end up getting a lot of these guys living off the back of fellows and lying grotesquely about the actual state of nephrology to trap a warm body. I know because I was a victim of these lies.

See, rheum is the exact opposite - mostly because we don’t really deal with “rheumatologic emergencies” outside of tertiary care and many of us are purely outpatient. Big vasculitis disasters, Raynauds with digital ischemia, etc etc often times just get shipped to tertiary care because small local hospitals can’t do plasmapheresis or iloprost drips etc. There is also no real “advantage” to having large numbers of fellows etc see clinic patients with you - the process of staffing the patients is usually way slower than just seeing the pts yourself (although in at least some programs, the attendings are trying to see their own slate of clinic pts while trying to weave in staffing the fellows’ pts - which is exhausting and idiotic for fellow and attending alike, and sometimes resulted in a logjam of fellows waiting to staff outside the exam room of one attending who took forever with patients, leading to massive clinic slowdowns whenever they were staffing). So there is no point.

Academic attendings frankly get paid trash, but some seem to put up with the crappy pay and ****ty hours out of a sincere desire to teach and/or do research (and I get it - I like teaching a lot and I thought hard about continuing in academia for that reason). However, I ultimately realized that I like things like sleep, personal well-being and health, family well-being, paying my debt, and overall enjoying my life and hobbies and free time with my family a lot more than teaching and/or trying to act like I’m the next William Osler at some big academic department somewhere. Your mileage may vary. Hats off to the folks that do it - although I agree that a lot of the “appeal” of academia seems to be ego stroking and/or boasting that you work at some Big Academic Institution somewhere. People outside of those Big Academic Institutions don’t usually realize how much working at one can suck.

 

[Renal_Prometheus]

See, rheum is the exact opposite - mostly because we don’t really deal with “rheumatologic emergencies” outside of tertiary care and many of us are purely outpatient. Big vasculitis disasters, Raynauds with digital ischemia, etc etc often times just get shipped to tertiary care because small local hospitals can’t do plasmapheresis or iloprost drips etc. There is also no real “advantage” to having large numbers of fellows etc see clinic patients with you - the process of staffing the patients is usually way slower than just seeing the pts yourself (although in at least some programs, the attendings are trying to see their own slate of clinic pts while trying to weave in staffing the fellows’ pts - which is exhausting and idiotic for fellow and attending alike, and sometimes resulted in a logjam of fellows waiting to staff outside the exam room of one attending who took forever with patients, leading to massive clinic slowdowns whenever they were staffing). So there is no point. Academic attendings frankly get paid trash, but some seem to put up with the crappy pay out of a sincere desire to teach and/or do research (and I get it - I like teaching a lot and I thought hard about continuing in academia for that reason). However, I ultimately realized that I like things like sleep, personal well-being and health, family well-being, paying my debt, and overall enjoying my life and hobbies and free time with my family a lot more than teaching and/or trying to act like I’m the next William Osler at some big academic department somewhere. Your mileage may vary. Hats off to the folks that do it - although I agree that a lot of the “appeal” of academia seems to be ego stroking and/or boasting that you work at some Big Academic Institution somewhere. People outside of those Big Academic Institutions don’t usually realize how much working at one can suck.

At least in Rheum, lifestyle is good, and you guys appear to keep a good quota on number of fellowship positions. In nephrology, it's the opposite. The market doesn't need this many grads but fellowships are incentives to increase number of positions(they eventually fill in the scramble) because that's less work for the attendings and more bodies to write dialysis orders. The acuity of the consults along with bad lifestyle(night consults for emergent dialysis and hyponatremia cases) make fellowship take anybody with heart beat for the scut work. The grads come out into a very bad job market and where they have no negotiating power and many get abused by exploitative practices, simply because they have no better options. Going back to hospitalist work is common outcome. It's been a vicious cycle downward for many years now, as everyone on SDN surely knows.

 

[danchiao]

is rheumatology considered as higher income specialty compared to endocrine if both work in private practice?

 

[dozitgetchahi]

is rheumatology considered as higher income specialty compared to endocrine if both work in private practice?

In a word, yes. Especially in private practice.

 

[danchiao]

In a word, yes. Especially in private practice.

Is it due to higher wrvu? I understand in rural area people can still open their own infusion center, however i dont think thats the case in urban area.

 

[dozitgetchahi]

Is it due to higher wrvu? I understand in rural area people can still open their own infusion center, however i dont think thats the case in urban area.

It’s partially from somewhat higher wRVUs (endo doesn’t do a lot of procedures, but then again we don’t either compared to GI or CCM etc), and partially from the infusion phenomenon. But the infusion bit only applies to private practice, because in hospital systems you’re basically never going to be given a cut of the infusion profits. They’re going to keep all that to themselves. Still, in suburbia outside of the saturated Big Cities Doctors Love, you’ll be able to make a solid $275k+ year in/year out working 4-4.5 days a week with no call and no consult work for a hospital system as a rheumatologist - which is more than what most endos make iirc. And this can get MUCH better in a good private practice with low overhead where you have a successful infusion operation - think like $400k+. When you see us bitching up above about “trash pay” in rheumatology, that’s an issue limited mostly to academia (especially “prestige academia” in big cities). I’m quite satisfied with my compensation in private practice rheumatology in the semi-rural South right now (I’m already making about 1/5 more than I did in the suburban Midwest, and poised to jump substantially next year), and I definitely do better than the endocrinologist in the group.

 

[bronx43]

It’s partially from somewhat higher wRVUs (endo doesn’t do a lot of procedures, but then again we don’t either compared to GI or CCM etc), and partially from the infusion phenomenon. But the infusion bit only applies to private practice, because in hospital systems you’re basically never going to be given a cut of the infusion profits. They’re going to keep all that to themselves. Still, in suburbia outside of the saturated Big Cities Doctors Love, you’ll be able to make a solid $275k+ year in/year out working 4-4.5 days a week with no call and no consult work for a hospital system as a rheumatologist - which is more than what most endos make iirc. And this can get MUCH better in a good private practice with low overhead where you have a successful infusion operation - think like $400k+. When you see us bitching up above about “trash pay” in rheumatology, that’s an issue limited mostly to academia (especially “prestige academia” in big cities). I’m quite satisfied with my compensation in private practice rheumatology in the semi-rural South right now (I’m already making about 1/5 more than I did in the suburban Midwest, and poised to jump substantially next year), and I definitely do better than the endocrinologist in the group.

Agreed. Though I have to say that even though hospital systems aren't going to directly give you infusion profits, they definitely look at your downstream revenue which includes infusion revenue. When you renegotiate your compensation per wRVU, you would have more leverage if you're heavy on infusions. This is why I have seen some established hospital employed rheums get 90+ percentile comp per wRVU, while others are significantly lower (comparable locations).

Another phenomenon that's somewhat unique to rheumatology is that our MGMA compensation data is very much right skewed. The bottom 90% make comparable to other nonprocedural specialties, while the top 10% make derm/urology/optho money.

From the 2020 MGMA, the median compensation for rheum was 261k, while the 90th percentile was 669k. Compare that to hospital medicine, where the median is 283k and 90th percentile is 373k. 90th percentile for radiology, optho, derm, and urology were 587k, 622k, 679k, and 680k respectively. This is consistent with what I have seen in the community, due to infusion profits. Our local private group partners easily clear 500k+, and some are much higher. The main problem is that the infusion revenue has slowed tremendously for new grads, since there are so many injectables out, not to mention insurances not covering in office infusions. Most of the high earners got in before these changes.

 

[danchiao]

Agreed. Though I have to say that even though hospital systems aren't going to directly give you infusion profits, they definitely look at your downstream revenue which includes infusion revenue. When you renegotiate your compensation per wRVU, you would have more leverage if you're heavy on infusions. This is why I have seen some established hospital employed rheums get 90+ percentile comp per wRVU, while others are significantly lower (comparable locations).

Another phenomenon that's somewhat unique to rheumatology is that our MGMA compensation data is very much right skewed. The bottom 90% make comparable to other nonprocedural specialties, while the top 10% make derm/urology/optho money.

From the 2020 MGMA, the median compensation for rheum was 261k, while the 90th percentile was 669k. Compare that to hospital medicine, where the median is 283k and 90th percentile is 373k. 90th percentile for radiology, optho, derm, and urology were 587k, 622k, 679k, and 680k respectively. This is consistent with what I have seen in the community, due to infusion profits. Our local private group partners easily clear 500k+, and some are much higher. The main problem is that the infusion revenue has slowed tremendously for new grads, since there are so many injectables out, not to mention insurances not covering in office infusions. Most of the high earners got in before these changes.

So does it mean for the next couple years the income of all rheum would be lower due to lower infusion revenue and less insurance covering in office infusions? Or this phenomena is only for new grads?

 

[bronx43]

So does it mean for the next couple years the income of all rheum would be lower due to lower infusion revenue and less insurance covering in office infusions? Or this phenomena is only for new grads?

I doubt we will see big changes in the next few years. Over the long run, older infusion patients will not get replaced with younger infusion patients, so that will affect the profitability of the private practices. I suspect that the top 10% won't be making this kind of massive income. I doubt much changes for the bottom 90%.

With that said, who knows? If a new, effective drug comes out only in infusion form, then the game is still on. For instance, this year anifrolumab just got approved for SLE. It's so far only infusion. If it's effective as an anti-IFN, then I can totally see private practice docs jumping on this band wagon and giving it to all their "SLE" patients (pos ANA, rash, fatigue, joint pain). And to be honest, looking at the physiologic effects of type 1 inferferons, I wouldn't be surprised if A LOT of patients feel better with blockade. Compare this to our last SLE drug (belimumab), which worked on B cell survival, I suspect anifrolumab will have far wider adoption.

 

[danchiao]

Agreed. Though I have to say that even though hospital systems aren't going to directly give you infusion profits, they definitely look at your downstream revenue which includes infusion revenue. When you renegotiate your compensation per wRVU, you would have more leverage if you're heavy on infusions. This is why I have seen some established hospital employed rheums get 90+ percentile comp per wRVU, while others are significantly lower (comparable locations).

Another phenomenon that's somewhat unique to rheumatology is that our MGMA compensation data is very much right skewed. The bottom 90% make comparable to other nonprocedural specialties, while the top 10% make derm/urology/optho money.

From the 2020 MGMA, the median compensation for rheum was 261k, while the 90th percentile was 669k. Compare that to hospital medicine, where the median is 283k and 90th percentile is 373k. 90th percentile for radiology, optho, derm, and urology were 587k, 622k, 679k, and 680k respectively. This is consistent with what I have seen in the community, due to infusion profits. Our local private group partners easily clear 500k+, and some are much higher. The main problem is that the infusion revenue has slowed tremendously for new grads, since there are so many injectables out, not to mention insurances not covering in office infusions. Most of the high earners got in before these changes.

it is very interesting to see the distribution of MGMA 2020; and you cited the compensation from eastern America, which showed very skewed distribution (std deviation $180k) compared to other sites (ie. midwest = $114k, southern = $115k, western = $103k). However when I compared the income of endo vs rheum (median, not comparing the mean since low number of samples and very skewed distribution especially in eastern; and i think i am an average worker not a 90th %tile ), this is what I got from MGMA 2020:
1. Eastern = Endo ($241k) Rheum ($261k)
2. Midwest = Endo ($270k) Rheum ($263k)
3. Southern = Endo ($272k) Rheum ($277k)
4. Western = Endo ($263k) Rheum ($273k).
So clearly rheum salary is higher in eastern, southern, and western America but by only $5k-20k. I don't know if i am interpreting these data correctly though.

 

[bronx43]

it is very interesting to see the distribution of MGMA 2020; and you cited the compensation from eastern America, which showed very skewed distribution (std deviation $180k) compared to other sites (ie. midwest = $114k, southern = $115k, western = $103k). However when I compared the income of endo vs rheum (median, not comparing the mean since low number of samples and very skewed distribution especially in eastern; and i think i am an average worker not a 90th %tile ), this is what I got from MGMA 2020:
1. Eastern = Endo ($241k) Rheum ($261k)
2. Midwest = Endo ($270k) Rheum ($263k)
3. Southern = Endo ($272k) Rheum ($277k)
4. Western = Endo ($263k) Rheum ($273k).
So clearly rheum salary is higher in eastern, southern, and western America but by only $5k-20k. I don't know if i am interpreting these data correctly though.

You’re right. I wouldn’t say that most rheum out-earns most endocrine by a large margin. The vast majority of both specialties is hospital employed and are non procedural so the compensation and the comp per rvu are somewhat similar. Contrast this to heme onc, who often are offered doubled the comp per rvu rheums get.

Your being an average worker isn’t necessarily something that will prevent you from being top 10% earner. In rheumatology, it’s all about infusions for the top earners. Not many employed rheumatologists will be top 10% unless you literally see 30/day. However, if you find the right group and somehow amass a large cohort of infusion patients then you can make $500k+ while seeing 15-20/day or even less.

 

[dozitgetchahi]

You’re right. I wouldn’t say that most rheum out-earns most endocrine by a large margin. The vast majority of both specialties is hospital employed and are non procedural so the compensation and the comp per rvu are somewhat similar. Contrast this to heme onc, who often are offered doubled the comp per rvu rheums get.

Your being an average worker isn’t necessarily something that will prevent you from being top 10% earner. In rheumatology, it’s all about infusions for the top earners. Not many employed rheumatologists will be top 10% unless you literally see 30/day. However, if you find the right group and somehow amass a large cohort of infusion patients then you can make $500k+ while seeing 15-20/day or even less.

Only thing I would add is that a few rheumatologists seem to have optimized the procedural end of the specialty for maximum $$$. Every now and then you’ll find a rheumatologist who basically functions like a sports medicine doctor - doing a buttload of injections and other procedures, and making some good coin doing so. But these folks certainly aren’t the core of the specialty, and most rheumatologists don’t actually like doing that stuff very much (I know I don’t).

 

[dozitgetchahi]

it is very interesting to see the distribution of MGMA 2020; and you cited the compensation from eastern America, which showed very skewed distribution (std deviation $180k) compared to other sites (ie. midwest = $114k, southern = $115k, western = $103k). However when I compared the income of endo vs rheum (median, not comparing the mean since low number of samples and very skewed distribution especially in eastern; and i think i am an average worker not a 90th %tile ), this is what I got from MGMA 2020:
1. Eastern = Endo ($241k) Rheum ($261k)
2. Midwest = Endo ($270k) Rheum ($263k)
3. Southern = Endo ($272k) Rheum ($277k)
4. Western = Endo ($263k) Rheum ($273k).
So clearly rheum salary is higher in eastern, southern, and western America but by only $5k-20k. I don't know if i am interpreting these data correctly though.

I’ll also add here that location makes a huge difference in living expenses…you can live like a damn king in the south on $277k a year. I’m pulling $300k on an initial salary guarantee, and in this county (semi rural South) that’s like 6x the local median income. You can buy a very respectable house here for $175k. I just bought an acre of land for $7k. It’s 1% type income here. All this is certainly not the case in the Northeast, for instance (that acre of land would probably be $200k, a decent house is like $400k+, median incomes in a lot of spots are well north of $100k, etc).

 

[bronx43]

I’ll also add here that location makes a huge difference in living expenses…you can live like a damn king in the south on $277k a year. I’m pulling $300k on an initial salary guarantee, and in this county (semi rural South) that’s like 6x the local median income. You can buy a very respectable house here for $175k. I just bought an acre of land for $7k. It’s 1% type income here. All this is certainly not the case in the Northeast, for instance (that acre of land would probably be $200k, a decent house is like $400k+, median incomes in a lot of spots are well north of $100k, etc).

Where I am (not even a tier 1 metro), a decent house is $600k+. 1 acre would run you 300k easy. And the fakedemic salaries are like 180k. Not sure why anyone works here…

 

[sloh]

Only thing I would add is that a few rheumatologists seem to have optimized the procedural end of the specialty for maximum $$$. Every now and then you’ll find a rheumatologist who basically functions like a sports medicine doctor - doing a buttload of injections and other procedures, and making some good coin doing so. But these folks certainly aren’t the core of the specialty, and most rheumatologists don’t actually like doing that stuff very much (I know I don’t).

What are they injecting and what specific procedures? I’m PM&R and ultrasound procedures reimburse poorly.

 

[Renal_Prometheus]

What are they injecting and what specific procedures? I’m PM&R and ultrasound procedures reimburse poorly.

botox

 

[dozitgetchahi]

What are they injecting and what specific procedures? I’m PM&R and ultrasound procedures reimburse poorly.

Who knows. I’m not that familiar with these rheumatologists (and I don’t think they do *that* well, especially compared to the infusion focused folks), which probably explains why there’s not that many of them around. Also, I have no huge desire to do the massive amount of procedures that some of these people seem to be doing. In fellowship, there was one attending who had 1-2 days of clinic each week where he did bazillions of joint injections…it wasn’t clear if he just really enjoyed doing those procedures or if he was making money off it, but like I said here and there there are rheumatologists who seem to be doing that stuff. Personally, I’d be happy to send a lot of it to sports medicine or PMR.

 

[sloh]

Who knows. I’m not that familiar with these rheumatologists (and I don’t think they do *that* well, especially compared to the infusion focused folks), which probably explains why there’s not that many of them around. Also, I have no huge desire to do the massive amount of procedures that some of these people seem to be doing. In fellowship, there was one attending who had 1-2 days of clinic each week where he did bazillions of joint injections…it wasn’t clear if he just really enjoyed doing those procedures or if he was making money off it, but like I said here and there there are rheumatologists who seem to be doing that stuff. Personally, I’d be happy to send a lot of it to sports medicine or PMR.

Yeah I figured they don’t do as well as infusion focused rheumatologists. I practiced outpatient for about 1 year and ultrasound procedures (usually corticosteroids) really aren’t worth the time from a financial perspective. Can’t imagine a rheumatologist is doing PRP/stem cells either—a completely different topic but this is grifting.

 

[dozitgetchahi]

Yeah I figured they don’t do as well as infusion focused rheumatologists. I practiced outpatient for about 1 year and ultrasound procedures (usually corticosteroids) really aren’t worth the time from a financial perspective. Can’t imagine a rheumatologist is doing PRP/stem cells either—a completely different topic but this is grifting.

Yeah I figured they don’t do as well as infusion focused rheumatologists. I practiced outpatient for about 1 year and ultrasound procedures (usually corticosteroids) really aren’t worth the time from a financial perspective. Can’t imagine a rheumatologist is doing PRP/stem cells either—a completely different topic but this is grifting.

Yeah I haven’t heard of rheumatologists doing that stuff (PRP etc). We tend to be evidence based and more skeptical of that kind of stuff unless it’s being done in the context of a clinical trial or something.

As far as most procedures go, I actually go out of my way to avoid them at this point. As was discussed above, unless you have a really streamlined operation where staff can quickly prep your procedure and you just drop in and get it done (and I haven’t), it tends to be a big waste of time and not worth the time or the effort vs just being able to see more pts.

 

[sloh]

Yeah I haven’t heard of rheumatologists doing that stuff (PRP etc). We tend to be evidence based and more skeptical of that kind of stuff unless it’s being done in the context of a clinical trial or something.

As far as most procedures go, I actually go out of my way to avoid them at this point. As was discussed above, unless you have a really streamlined operation where staff can quickly prep your procedure and you just drop in and get it done (and I haven’t), it tends to be a big waste of time and not worth the time or the effort vs just being able to see more pts.

Good on you guys. It's a huge racket in my specialty, and very sad.

 

[dozitgetchahi]

You’re right. I wouldn’t say that most rheum out-earns most endocrine by a large margin. The vast majority of both specialties is hospital employed and are non procedural so the compensation and the comp per rvu are somewhat similar. Contrast this to heme onc, who often are offered doubled the comp per rvu rheums get.

Your being an average worker isn’t necessarily something that will prevent you from being top 10% earner. In rheumatology, it’s all about infusions for the top earners. Not many employed rheumatologists will be top 10% unless you literally see 30/day. However, if you find the right group and somehow amass a large cohort of infusion patients then you can make $500k+ while seeing 15-20/day or even less.

I’ll add that out here in the community, you can unfortunately find a fair few rheums who are trying to do that “30 pts/day” thing. There were rheumatologists doing this at the practice across town in the Midwest at my old job, and there are docs in some nearby towns doing this here too. And the pts hate it. In both cases, I saw a huge number of pts who were bailing out of those practices because “the doctor spends 3 minutes with me in the room - I counted it on my watch” or “my doc never takes his hand off the doorknob during my visits…he never touches me either”. Needless to say, the quality of care given by these rheums is questionable at best…and even if for some reason you were OK giving ****ty care in exchange for making bank (and you shouldn’t be), seeing that many rheumatology pts daily sounds absolutely exhausting. So nobody should go into rheum thinking they’re going to become some sort of rheumatology baller just by packing in as many pts as possible. You will be miserable, your patients will be miserable, and everyone will know that you’re giving out garbage quality care. You won’t be fooling anyone.

In every specialty, there’s a point after which appointments become too short for you to possibly be an effective physician…and you reach this threshold pretty quickly in rheumatology because of the pt complexity. I don’t personally go any shorter than 15 minutes of scheduled time for f/u appts, although (very) occasionally you will encounter a simple gout or osteoporosis etc pt who can be seen faster than that. New pts get at least 40 minutes, sometimes more if complex.

 

[drk310]

https://cdn.fs.pathlms.com/QmiXoGmKR56H0dgslPYu?cache=true&_ga=2.166647806.1736832139.1638380617-774420141.1636487816

Curious if any rheum docs have seen this new model of reimbursement for infusions for patients requiring treatment through their pharmaceutical benefits.

Thoughts on how it changes the practice for those who are infusion heavy?

 

[bronx43]

https://cdn.fs.pathlms.com/QmiXoGmKR56H0dgslPYu?cache=true&_ga=2.166647806.1736832139.1638380617-774420141.1636487816

Curious if any rheum docs have seen this new model of reimbursement for infusions for patients requiring treatment through their pharmaceutical benefits.

Thoughts on how it changes the practice for those who are infusion heavy?

Interesting. So, PBMs now want infusions to go through them for claims, as opposed to the medical benefits side. It doesn't say that practices can't buy through a third party distributor. I suspect this is mostly insurers wanting to offload resource utilization to PBMs, while PBMs can be the bad guy to not cover drugs, or forcefully change patients to biosimilars. The fact that third party drug purchases aren't part of this arrangement means that PBMs' role here is solely as the enforcer and the gatekeeper of infusion $ outflows.

Big health systems are now starting to wake up to the massive profits to be made in the outpatient specialty drug market by attempting to cut out the middle man. If you have a big enough group of prescribers, you can set up a centralized "pharmacy" to essentially act as a PBM.

Ultimately, this is likely bad for rheumatologists. Whenever PBMs are involved, it's usually bad. I expect reimbursement for infusions to drop compared to going through medical benefits. I also expect more frequent changing of "coverage" which increases the risk of non-payment for services/drugs administered.

 

[drk310]

Interesting. So, PBMs now want infusions to go through them for claims, as opposed to the medical benefits side. It doesn't say that practices can't buy through a third party distributor. I suspect this is mostly insurers wanting to offload resource utilization to PBMs, while PBMs can be the bad guy to not cover drugs, or forcefully change patients to biosimilars. The fact that third party drug purchases aren't part of this arrangement means that PBMs' role here is solely as the enforcer and the gatekeeper of infusion $ outflows.

Big health systems are now starting to wake up to the massive profits to be made in the outpatient specialty drug market by attempting to cut out the middle man. If you have a big enough group of prescribers, you can set up a centralized "pharmacy" to essentially act as a PBM.

Ultimately, this is likely bad for rheumatologists. Whenever PBMs are involved, it's usually bad. I expect reimbursement for infusions to drop compared to going through medical benefits. I also expect more frequent changing of "coverage" which increases the risk of non-payment for services/drugs administered.

The practices are supposed to buy their own drug and submit billing to optum Rx. Optum Rx in turn will reimburse based on AWP and will give flat payments for administration and handling of the drug. So essentially they get rid of white bagging medication by shipping out the drug from specialty pharmacy. Maybe it reduces the overhead and they shift the burden of the cost of purchasing and handling of the meds to the providers to deal with it. In addition, all rebates earned on drug purchases have to be given back to the PBM per this contract. The only thing that remains unclear to me is if the drug reimbursement from the PBM is given with some margin of profit or not. If not, this seems like a total shaft for providers. I don't know if it justifies the cost and headache of operating an infusion center if this is the future.

 

[bronx43]

The practices are supposed to buy their own drug and submit billing to optum Rx. Optum Rx in turn will reimburse based on AWP and will give flat payments for administration and handling of the drug. So essentially they get rid of white bagging medication by shipping out the drug from specialty pharmacy. Maybe it reduces the overhead and they shift the burden of the cost of purchasing and handling of the meds to the providers to deal with it. In addition, all rebates earned on drug purchases have to be given back to the PBM per this contract. The only thing that remains unclear to me is if the drug reimbursement from the PBM is given with some margin of profit or not. If not, this seems like a total shaft for providers. I don't know if it justifies the cost and headache of operating an infusion center if this is the future.

Even if there’s a margin of profit I would bet money it’s low and will become lower with time. I always thought CMS would be the ones to end infusion profits but this is far far worse…

 

[dozitgetchahi]

There’s a lot I still need to learn with this infusion stuff…does anyone know of good books or other resources I can read to get a handle on how all this works?

 

[drk310]

There’s a lot I still need to learn with this infusion stuff…does anyone know of good books or other resources I can read to get a handle on how all this works?

currently have my own infusion center....there is no good manual I could find and I searched far and wide. Try contacting someone at CRSO and see if they can help though they would be my first step. I just outsourced the management of mine...margins suffer but then again the headache involved in trying to chase after payments is not worth doing everything on your own. Another rheumatologist in my area started an infusion center and tried to manage it by himself and lost 10 grand on rituximab in his first few months and immediately shut it down. It's possible to do it on your own, but the amount of admin you'll need to hire will be costly. It's not something that can be left to autopilot.

 

[bronx43]

currently have my own infusion center....there is no good manual I could find and I searched far and wide. Try contacting someone at CRSO and see if they can help though they would be my first step. I just outsourced the management of mine...margins suffer but then again the headache involved in trying to chase after payments is not worth doing everything on your own. Another rheumatologist in my area started an infusion center and tried to manage it by himself and lost 10 grand on rituximab in his first few months and immediately shut it down. It's possible to do it on your own, but the amount of admin you'll need to hire will be costly. It's not something that can be left to autopilot.

Are you in a single specialty or multispecialty? Are you finding difficulty having infusions be covered with Medicare Advantage (with high co-insurance)?

 

[drk310]

Are you in a single specialty or multispecialty? Are you finding difficulty having infusions be covered with Medicare Advantage (with high co-insurance)?

solo practice. Advantage plans make it difficult as patients in underserved areas cannot afford the treatments as the costs get pushed onto the patients and these MA plans get creative in avoiding their share of the cost to begin with. I've seen HMO groups get creative to avoid payment for treatment in general.

For those who have a PPO under managed care that is also problematic as they are all specialty pharmacy supplied meds meaning the infusion center only gets paid for admin of drug which doesn't justify the cost of keeping an infusion center open.

You are right that the future is not looking good for maintaining an infusion center in a private practice. You either need volume with multiple physicians or have some sort of revenue share with a hospital by being an employee since healthcare systems get paid a lot more per infusion.

 

[bronx43]

solo practice. Advantage plans make it difficult as patients in underserved areas cannot afford the treatments as the costs get pushed onto the patients and these MA plans get creative in avoiding their share of the cost to begin with. I've seen HMO groups get creative to avoid payment for treatment in general.

For those who have a PPO under managed care that is also problematic as they are all specialty pharmacy supplied meds meaning the infusion center only gets paid for admin of drug which doesn't justify the cost of keeping an infusion center open.

You are right that the future is not looking good for maintaining an infusion center in a private practice. You either need volume with multiple physicians or have some sort of revenue share with a hospital by being an employee since healthcare systems get paid a lot more per infusion.

Totally agreed about MA plans. The only practices that can sustain itself on infusions are the ones who have collected a large cohort of patients that have Medicare with supplemental coverage. This means that only older docs who got in at the right time would have this arrangement. New docs coming in are stuck with the MA and privately insured folks.

Honestly, I think outpatient docs (not just rheum) have to shift our way of thinking entirely - and not just regarding infusions. Labor costs are now so high that paying a small army of employees to run a high volume practice doesn't make much financial sense. CMS increasing E&M reimbursement has opened up new possibilities. Cognitive outpatient docs should be seeing far fewer patients (also can bill high level based on time while increasing patient satisfaction) but also run a VERY LEAN business. Several docs need to share as few employees as possible and do everything else themselves. If it comes down to it, seeing 8-10 per day and doing your own scheduling, rooming, and maybe even billing should be the business model. Your few shared employees can help with billing and obtaining records and other office tasks. Commercial real estate is also cheaper now than ever which cuts down overhead significantly. You can get a workable EMR for $150/month.

Using this model, I would also consider narrowing down the number of payers. Heck, you can probably fill a small practice with only Medicare. There would be no hassle of negotiating with private payers or having your AR be backed up for months. Medicare is much more straight forward and timely with their reimbursement. Non-medicare can pay cash at the door, which honestly I think people don't have a problem with these days due to ridiculously high deductibles anyways. If you truly spend a lot of time with fewer patients, then word of mouth gets out quick and I would be surprised if cash paying patients don't line up outside your door. Ultimately, as business conditions change, docs need to evolve with it.

 

[drk310]

Totally agreed about MA plans. The only practices that can sustain itself on infusions are the ones who have collected a large cohort of patients that have Medicare with supplemental coverage. This means that only older docs who got in at the right time would have this arrangement. New docs coming in are stuck with the MA and privately insured folks.

Honestly, I think outpatient docs (not just rheum) have to shift our way of thinking entirely - and not just regarding infusions. Labor costs are now so high that paying a small army of employees to run a high volume practice doesn't make much financial sense. CMS increasing E&M reimbursement has opened up new possibilities. Cognitive outpatient docs should be seeing far fewer patients (also can bill high level based on time while increasing patient satisfaction) but also run a VERY LEAN business. Several docs need to share as few employees as possible and do everything else themselves. If it comes down to it, seeing 8-10 per day and doing your own scheduling, rooming, and maybe even billing should be the business model. Your few shared employees can help with billing and obtaining records and other office tasks. Commercial real estate is also cheaper now than ever which cuts down overhead significantly. You can get a workable EMR for $150/month.

Using this model, I would also consider narrowing down the number of payers. Heck, you can probably fill a small practice with only Medicare. There would be no hassle of negotiating with private payers or having your AR be backed up for months. Medicare is much more straight forward and timely with their reimbursement. Non-medicare can pay cash at the door, which honestly I think people don't have a problem with these days due to ridiculously high deductibles anyways. If you truly spend a lot of time with fewer patients, then word of mouth gets out quick and I would be surprised if cash paying patients don't line up outside your door. Ultimately, as business conditions change, docs need to evolve with it.

I agree with the strategy of consolidating and having multiple docs work together to reduce average overhead per doctor. I would LOVE seeing 8-10 per day -- that would mean fewer phone calls, fewer follow up calls, fewer administrative tasks to follow up on in general, etc...But the increase in medicare pay in 2021 is now going down again for 2022 isn't it? If you count medicare sequestration which is back in play next year, we're looking at a 10% pay cut for medicare patients in 2022. The bump in pay for cognitive specialties is a wash in 2022 onwards if all those medicare cuts go through if you're designing a clinic with predominantly medicare patients.

agree with the time based billing though, that part should work in our favor unless you're running a high volume clinic in an underserved area.

As for the EMR costs -- while there are cheaper options, a complete system with billing software and appt reminders, electronic med refills, and other features built in will eventually drive it up to 500+/month. I've tried looking into buying these features separately but at the end of the day it wound up coming to the same amount.

I think an alternative practice structure that may also work is consolidate with multiple other rheum docs, negotiate better reimbursement rates directly with HMO and PPO groups or drop their contracts if they don't comply. But your approach mentioned above is great for autonomy and quality of life. When you join forces with others there is invariably more headache and politics involved.

I spoke with a very successful rheumatologist who grew his practice into a large group of single specialty docs. Between all the overhead, administrative burden, and additional volume to deal with, he said it may not have been worth it as he wasn't even making that much more than he used to make running in own lean solo practice. So I see the value in what you're suggesting too.

 

[bronx43]

I agree with the strategy of consolidating and having multiple docs work together to reduce average overhead per doctor. I would LOVE seeing 8-10 per day -- that would mean fewer phone calls, fewer follow up calls, fewer administrative tasks to follow up on in general, etc...But the increase in medicare pay in 2021 is now going down again for 2022 isn't it? If you count medicare sequestration which is back in play next year, we're looking at a 10% pay cut for medicare patients in 2022. The bump in pay for cognitive specialties is a wash in 2022 onwards if all those medicare cuts go through if you're designing a clinic with predominantly medicare patients.

agree with the time based billing though, that part should work in our favor unless you're running a high volume clinic in an underserved area.

As for the EMR costs -- while there are cheaper options, a complete system with billing software and appt reminders, electronic med refills, and other features built in will eventually drive it up to 500+/month. I've tried looking into buying these features separately but at the end of the day it wound up coming to the same amount.

I think an alternative practice structure that may also work is consolidate with multiple other rheum docs, negotiate better reimbursement rates directly with HMO and PPO groups or drop their contracts if they don't comply. But your approach mentioned above is great for autonomy and quality of life. When you join forces with others there is invariably more headache and politics involved.

I spoke with a very successful rheumatologist who grew his practice into a large group of single specialty docs. Between all the overhead, administrative burden, and additional volume to deal with, he said it may not have been worth it as he wasn't even making that much more than he used to make running in own lean solo practice. So I see the value in what you're suggesting too.

I believe the proposed cuts to Medicare were voted down by Congress. It's "possible" that it may drop some time in the future, but I think the likelihood is rather low. CMS loves to act like they're going to do heavy cuts across the board, but it's politically difficult. They usually opt for rearranging reimbursement rather than true cuts that would affect all specialties.