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wrong again
"The map is not the territory."
wrong again
I use the free cafeteria - at least $10-15 a day, so I guess that accounts for a raiseNo answers yet, but I get a doc lounge and free cafeteria food at my hospital. (never used the free cafeteria privileges).View attachment 358235
I have been around just over 18k the past few years. And I have a side job. 💪
I foresee you showing up at 5 after a long clinic day, and the admin handing these out with a fake smile gives the last one to the nurse in line in front of you.No answers yet, but I get a doc lounge and free cafeteria food at my hospital. (never used the free cafeteria privileges).View attachment 358235
I foresee you showing up at 5 after a long clinic day, and the admin handing these out with a fake smile gives the last one to the nurse in line in front of you.
Most HOPD docs are getting at least $750K.
If so, sign me up. But Most HOPD Docs are getting 350k average with guaranteed income. I'm noticing more and more are hovering above and below 300, with $250-280k in desirable cities. These are very raw deals.
Also, I love how everyone dangles the "you make X amount if you hit 10,000 wRVUs or bring in $2 Million in collections!" Okay buddy, these are insanely rare numbers but I guess you have to give some ridiculous goal for me to work like a hamster until I'm sent off to the glue factory. Most commonly new fellows fall for it. I can attest, as I was one of those. "Wow, I can definitely hit this!" Nope, it's very hard to, and even if you do, you'll be exhausted and burn out, and it depends on the system or practice to be a well oiled factory machine.
HOPD Gig - Become a Provider, guaranteed income for 1-2 years, afterward highly dependent on production which makes it risky.
Self Employed Gig - Be an entrepreneur Doctor. No guaranteed income, but you have autonomy, independence, and the same risk with production as HOPD gig, except you're forking over your money to make this practice. But that also means you'll take home the lion's share.
Everyone's different, not saying one is better than the other for everyone. For me, self employed > employed any day of the week, even in a desirable city.
For those of us with collections-based bonus structures, what would you say is a reasonable collections $ amount in the first couple years of practice? Moderately busy but not insane.If so, sign me up. But Most HOPD Docs are getting 350k average with guaranteed income. I'm noticing more and more are hovering above and below 300, with $250-280k in desirable cities. These are very raw deals.
Also, I love how everyone dangles the "you make X amount if you hit 10,000 wRVUs or bring in $2 Million in collections!" Okay buddy, these are insanely rare numbers but I guess you have to give some ridiculous goal for me to work like a hamster until I'm sent off to the glue factory. Most commonly new fellows fall for it. I can attest, as I was one of those. "Wow, I can definitely hit this!" Nope, it's very hard to, and even if you do, you'll be exhausted and burn out, and it depends on the system or practice to be a well oiled factory machine.
HOPD Gig - Become a Provider, guaranteed income for 1-2 years, afterward highly dependent on production which makes it risky.
Self Employed Gig - Be an entrepreneur Doctor. No guaranteed income, but you have autonomy, independence, and the same risk with production as HOPD gig, except you're forking over your money to make this practice. But that also means you'll take home the lion's share.
Everyone's different, not saying one is better than the other for everyone. For me, self employed > employed any day of the week, even in a desirable city.
Hard to answer that as the comp formula can be all over the map. Depends on your base salary and how your payment relative to collections is structured. What’s your site of service? Are you office or asc? If asc, what percent of pro fees are you getting? Are you working towards some kind of buy in? If the practice has good contracts, they may low ball everything and keep more cash and have you work like a donkey having you think you are doing well. I’ve seen production bonuses range anywhere from 30-50% based on a multiplier of your base salary. I’ve also seen eat what you kill models with very low base salary and 50/50 split incentivizing more production as you are paid after your direct employed expenses are covered.For those of us with collections-based bonus structures, what would you say is a reasonable collections $ amount in the first couple years of practice? Moderately busy but not insane.
Hard to answer that as the comp formula can be all over the map. Depends on your base salary and how your payment relative to collections is structured. What’s your site of service? Are you office or asc? If asc, what percent of pro fees are you getting? Are you working towards some kind of buy in? If the practice has good contracts, they may low ball everything and keep more cash and have you work like a donkey having you think you are doing well. I’ve seen production bonuses range anywhere from 30-50% based on a multiplier of your base salary. I’ve also seen eat what you kill models with very low base salary and 50/50 split incentivizing more production as you are paid after your direct employed expenses are covered.
So yeah hard to answer the question
I would think this is a great deal if in a desirable area. 375k base is solid for west/east coast. 500k is easy to get in clinic alone (assuming there is large volume of patients ready to be seen), even with just medicare rates. 50% collections is generous, esp with today's inflation costs.How is $375k plus 50% of collections over $500k? Office with a connected ASC. No professional fees, partner after 1 year can buy into ASC for FMV. This was the set up at another place I looked at that I ended up ruling out. The guy claimed they had huge collections but was kinda vague and sketchy, the day I was there visiting them it seemed like a really inefficient operation and they only did like 3-4 procedures in a 2-3 hour period.
edited: actually it was revenue, not collections. I'm sure that makes some sort of difference but idk
that's why it's a rat race to the bottom. get as much crappy contracts as you can and play the volume game while juggling patient satisfaction, pcp/surgeon satisfaction, personal satisfaction and safety. getting harder and harder.I would never discourage anyone from not opening their own practice but it really is a difficult environment. The big university hospital system bought up pretty much everything in my little town. They own nearly all of the PCPs and specialties and ancillaries. My PHO dissolved once they came in and I took a major cut in reimbursement. I can't negotiate this with the payers because it's a take it or leave it situation. The university hospital fee schedule, at least for an E and M, brings in 2-3 times what I'm reimbursed for the same code. I've seen the EOB for my kids' peds visits.
The big guys put little guys like me out of business, monopolize the area, and rates go up for everyone. They market to me to make sure they capture my referrals while at the same time pressuring their docs to keep things in-house. I think this is the same story throughout the country.
I still want my independence so I wouldn't trade it but I'm glad I'm close to retirement. If I hadn't been established in the area prior to the big system moving in things would be more difficult.
I would never discourage anyone from not opening their own practice but it really is a difficult environment. The big university hospital system bought up pretty much everything in my little town. They own nearly all of the PCPs and specialties and ancillaries. My PHO dissolved once they came in and I took a major cut in reimbursement. I can't negotiate this with the payers because it's a take it or leave it situation. The university hospital fee schedule, at least for an E and M, brings in 2-3 times what I'm reimbursed for the same code. I've seen the EOB for my kids' peds visits.
The big guys put little guys like me out of business, monopolize the area, and rates go up for everyone. They market to me to make sure they capture my referrals while at the same time pressuring their docs to keep things in-house. I think this is the same story throughout the country.
I still want my independence so I wouldn't trade it but I'm glad I'm close to retirement. If I hadn't been established in the area prior to the big system moving in things would be more difficult.
or just do PI/deposition/work comp and make bankthat's why it's a rat race to the bottom. get as much crappy contracts as you can and play the volume game while juggling patient satisfaction, pcp/surgeon satisfaction, personal satisfaction and safety. getting harder and harder.
whoever has their cash game or OON set up is living it good but not sure how that'll last either
I hate sounding negative but I think this is right, unfortunately. At least when Walmart comes into a town they put smaller guys out of business by offering a more efficient business operation resulting in less expensive products. With healthcare, it seems like it's the opposite.that's why it's a rat race to the bottom. get as much crappy contracts as you can and play the volume game while juggling patient satisfaction, pcp/surgeon satisfaction, personal satisfaction and safety. getting harder and harder.
whoever has their cash game or OON set up is living it good but not sure how that'll last either
Do you think different politicians would have a different impact? I bet the system is so pressured by these big guys that it doesn't really matter who's in charge anymore at this point.That's why I tell new grads and fellows that elections have consequences. No one believed me during the Obama years, but it turned out that I was right.
Healthcare Reform Creates Provider Monopolies | The Lund Report
www.thelundreport.org
I hate sounding negative but I think this is right, unfortunately. At least when Walmart comes into a town they put smaller guys out of business by offering a more efficient business operation resulting in less expensive products. With healthcare, it seems like it's the opposite.
Do you think different politicians would have a different impact? I bet the system is so pressured by these big guys that it doesn't really matter who's in charge anymore at this point.
I think as a PCP it would be reasonable to start your own practice since supply/demand is in your favor but as a specialist who depends on referrals, it's a different story.
Really? You think the goal is to create an inefficient system?I do. I think Obama and Hillary wanted to make going to see the doctor like going to the post office.
I’m not sure we can “afford” anything at this point. How big is the federal deficit now? All we do is borrow money and then increase taxes to pay for all these frivolous spending packagesReally? You think the goal is to create an inefficient system?
I think the goal was to move towards universal healthcare. I don't think they did it how they would like to, but how they could. They really wanted a Medicare for all system. You don't have to agree with the goal (universal healthcare) but should be more honest about their motives.
I disagree with how it was done. I disagree with the idea the health care is a "right". I agree with the idea that we are a wealthy nation and can afford to do universal healthcare.
Obama went on the record opposing physician-owned hospitals and doctors getting any of the sweet sucres of the SOS.Really? You think the goal is to create an inefficient system?
I think the goal was to move towards universal healthcare. I don't think they did it how they would like to, but how they could. They really wanted a Medicare for all system. You don't have to agree with the goal (universal healthcare) but should be more honest about their motives.
I disagree with how it was done. I disagree with the idea the health care is a "right". I agree with the idea that we are a wealthy nation and can afford to do universal healthcare.
Moving the goalposts..... againObama went on the record opposing physician-owned hospitals and doctors getting any of the sweet sucres of the SOS.
Obama Hates Doctors, and Medicare Patients Too
As if we need more evidence that President Obama and Congress despise doctors and the current medical care system in America. The July issu...www.blog.greatzs.com
Private practice is dead/dying. It’s just the reality and bitter pill to swallow. Some large corporate private practices will survive for a short while but their ultimate goal once those that make the decisions within them, will be to sell sell and screw all the still practicing docs within the entity. The decision makers will leave having made enough for their grandchildren while the rest are stuck running the hamster wheel being whipped by whatever hopd/private equity master is in charge at the time.
It's true...It more or less requires being a Rennaissance Physician, putting in time and energy, and relentless focus on excellence to stay competitive.
Why and how to open a private practice with Marie Brown, MD
AMA's Moving Medicine series features physician voices and achievements. Learn more in this discussion on how to open a private practice.www.ama-assn.org
It's true...
or you can look at your $500K in student debt and take the job that pays double for half the work. It's a no-brainer for a new grad.
Private practice is dead/dying. It’s just the reality and bitter pill to swallow. Some large corporate private practices will survive for a short while but their ultimate goal once those that make the decisions within them, will be to sell sell and screw all the still practicing docs within the entity. The decision makers will leave having made enough for their grandchildren while the rest are stuck running the hamster wheel being whipped by whatever hopd/private equity master is in charge at the time.
yet....Obama went on the record opposing physician-owned hospitals and doctors getting any of the sweet sucres of the SOS.
Obama Hates Doctors, and Medicare Patients Too
As if we need more evidence that President Obama and Congress despise doctors and the current medical care system in America. The July issu...www.blog.greatzs.com
Private practice is dead/dying. It’s just the reality and bitter pill to swallow. Some large corporate private practices will survive for a short while but their ultimate goal once those that make the decisions within them, will be to sell sell and screw all the still practicing docs within the entity. The decision makers will leave having made enough for their grandchildren while the rest are stuck running the hamster wheel being whipped by whatever hopd/private equity master is in charge at the time.
It's true...
or you can look at your $500K in student debt and take the job that pays double for half the work. It's a no-brainer for a new grad.
I think all of these posts are correct. Why would anyone want to start a PP with all of its inherent risks when the hospital will probably pay more? I would be more accepting of this scenario if it didn't drive prices up but from what I'm seeing it is.Exactly this. I had close to 400k in debt when I finished fellowship, took the higher paying job. No way im taking out a loan to start my own practice. This is the case for every new grad nowadays and the cost of tuition gets worse every year. Only way to do it is work full time in your primary specialty and start a practice on the side and hope it grows.
I agree with everything you're saying but why would #2 make trouble for private practice? I think that would lower the supply of docs making it more attractive to start a practice.Private Practice is in deep trouble due to:
1) Increasing overhead with massive inflation with supply costs/labor costs
2) Overabundance of older retiring doctors not being replaced by younger doctors
3) Higher starting salaries with hospital based employment
4) Peak Salaries in private practice isnt really higher anymore (probably lower) then an efficiently run hospital based practice
The biggest issue seems to be $/wRVU variances in Hospital Employment and potential efficiency of the practice.
But the same issues present in private practice as well in terms of insurance contracts and efficiency/business sense of the people running the private practice.
It more or less requires being a Rennaissance Physician, putting in time and energy, and relentless focus on excellence to stay competitive.
Why and how to open a private practice with Marie Brown, MD
AMA's Moving Medicine series features physician voices and achievements. Learn more in this discussion on how to open a private practice.www.ama-assn.org
codespeak: i need to offer cash-only procedures which border on the realm of selling snake oil so that i can survive in PP
how much do you value your independence? enough to compromise your morals and ethics? that is becoming what it takes to compete in private practice these days, unfortunately.
How come being a facility fee ***** is more moral? No one becomes a doctor just to juice the vig on the SOS.
nobody wants to be someone else's bitch (although in your mind ANYONE who is employed is inferior and wrong).
but, doing an ESI for a HNP is more moral than charging 5K for stem cells. sorry.
again, changing the narrative.Do you know how much hospitals charge for aspiration for BMAC? It's jaw-dropping...same service, two different sites of service, orders of magnitude difference. You can't defend that.
Bone marrow biopsy and aspiration: a departmental financial comparison in a rural hospital
The purpose of this study was to compare the charges and payments associated with bone marrow aspiration and biopsies performed by hematology/oncology specialists versus interventional radiology specialists at Bassett Medical Center located in a rural ...www.ncbi.nlm.nih.gov
"We compared the health care related costs of a relatively common procedure when performed by HO versus IR. Although sample adequacy was the same, median charges and payments were significantly higher when the procedure was performed by IR specialists compared to in office procedures performed by HO specialists."
One patient showed me her EOB for a local health system: $15K....and they were still claiming that's a BARGAIN.
Regenerative Medicine
Regenerative medicine is a non-surgical and natural treatment to stimulate and enhance healing of injuries, osteoarthritis and degenerative disease using platelet rich plasma or stem cell therapy.www.swedish.org
View attachment 358329
PRP & Stem Cell Therapy
Stem cell therapies are experimental therapies that can treat arthritis, back pain, or chronic tendon pain. Call us to learn more and schedule an appointment.healthcare.utah.edu
BMAC Injections: Bone Marrow Treatment | Cromwell Hospital
Discover the benefits of BMAC (bone marrow aspirate concentrate) injections at Cromwell Hospital London. Learn how this innovative treatment can help you.www.cromwellhospital.com
View attachment 358330
if you want to critique the system, go ahead, but please stop insulting your colleagues.
doctors who decide to work for a system are not facility fee ******. they are doctors who want to do what they feel is their life calling - taking care of patients.
you are right, noone becomes a doctor to juice the vig.
in a similar thought process, one could argue that private practice docs are cash ****** who sacrifice their souls and practice for bucks. that is also not a fair assessment.
if you want to critique the system, go ahead, but please stop insulting your colleagues.
doctors who decide to work for a system are not facility fee ******. they are doctors who want to do what they feel is their life calling - taking care of patients.
you are right, noone becomes a doctor to juice the vig.
in a similar thought process, one could argue that private practice docs are cash ****** who sacrifice their souls and practice for bucks. that is also not a fair assessment.
but you kinda are a bean counter. You act as your own scribe I assume and do all of your own billing by entering the appropriate E/M codes and CPT codes before closing every encounter. Yes you are a well educated bean counterone thing it takes to succeed in PP ithat is not mentioned is the undeterred focus in medicine as a business, rather than as a calling. i for one didnt go in to medicine to be a bean counter. if i had wanted to do that, i would have studied healthcare administration...
yet....
more people are covered by insurance than ever before.
2021-12-30 15:27 | Archive of HHS.gov
www.hhs.gov
and medical bankruptcies are down (at least as far as we are aware prior to COVID)
Healthcare bankruptcies at all-time low, new report finds
Bankruptcies in the healthcare industry are at their lowest since 2010, according to a new report. | The second quarter of this year was the lowest the Health Care Services Distress Research Index had ever recorded, according to a new report.www.fiercehealthcare.com
and most people like the ACA.
5 Charts About Public Opinion on the Affordable Care Act | KFF
This compiles key polling data examining the favorability of the Affordable Care Act and its provisions, including protections for people with pre-existing conditions and the impact of the law on families.www.kff.org
i can understand as a businessman first and foremost someone would despise the ACA.
but i went to med school to learn how to take care of people and try to get them healthier. guess that was the wrong choice...
I agree with everything you're saying but why would #2 make trouble for private practice? I think that would lower the supply of docs making it more attractive to start a practice.
Some private practices have "locked in" long term leases that need to be covered in a "catchment" area. These leases are a poison pill since the previous older doctors often locked them into higher cost contracts that increase with inflation over 5+ year contracts. Also, closing these more expensive leases would be a loss of equipment etc.
Therefore, it becomes a higher cost of running the practice over a smaller number of doctors. Many of these practices are setup as expensive high volume "mills" that require higher reimbursement to manage the costs. With less doctors, the overhead per doctor is far higher.
When you add in large reimbursement cuts for practices that are dependent on higher volumes.
A) RF and MBBs: three levels to two levels. Was the practice dependent on doing mostly 3 level RF/Facets rather then 2? This is a 33% cut in reimbursement then.
B) Epidurals limited to 4 per year with yearly reevaluation by PCP who isnt at their primary practice. Many of their inherited patients are "legacy" patients who got a stead 6 epidurals per year to keep the reimbursement flowing in many regions (1/3 cut in number of epidurals per year minimum)
C) Cant charge for sedation that brought in former revenue
D) Cant do multiple procedures at a time anymore.
E) Increased burdensome PA
F) Modifier 25 is harder to get reimbursed.
This is without counting the 2023 reimbursement cuts on the horizon.
Any physician evaluating private practices that are "established" must look at:
1) Are there an overabundance of older doctors close to retirement age? Is the practice losing or gaining doctors over last few years? A new physician is often paid far lower for the first 3 years before "making partner" in the HOPES of making bank as a partner compared to hospital employment. This was true in the past but is far less likely now. If you walk into one of these practices, you will make less starting, take far longer to "partner" and have a far lower ceiling as a "partner" with far more business responsibility. They will use older salary figures to keep you enticed without mentioning the shifts over the last few years.
2) Cost structure of rentals/staff/supplies: What % of revenue is this? How is it increasing relative to revenue since COVID? High overhead cost practices with increasing costs of labor/supplies (>20% increase over last 2 years minimum) that were dependent on high reimbursement rates of the past that were run as "mills" will not be a good bet going forward.
3) Reimbursement: How dependent in the practice on higher collections/patient? How were margins affected by reimbursement cuts in 2021 (look at 2022 reimbursement figures compared to 2019).
If trending badly, even if its an "established" practice, there is no point in joining. Hospital based practices are far better at that point.
The best part of working for the hospital is joining a physician union! I'm hearing really good things about it.
Oregon Physicians File to Join Union
A physician involved in the move to seek union representation says the main reason for the effort is to gain influence on administrative decision-making.www.healthleadersmedia.com
View attachment 358390
You're acting like physicians who own these private practices are any less ruthless or more caring about future physician employees then some administrative MBA or private equity shareholder.
I think you'd be surprised to find that many of these physicians are just buying their time to retirement after making the money during the "heyday" of medicine, often are very egotistical in irrational manners with pissing contests when a younger doc outshines them, don't have much business sense since they didn't have to during good times, etc. These doctors are often working because they didn't save enough and/or living a lifestyle they can't afford. They are often miserable and bitter towards newcomer physicians looking at them as a way to just pay overhead or sucker into a PE deal to sell the practice that would have no value without younger docs in a pyramid scheme.
They often dangle higher "partner" salaries that existed years ago to sucker them into lower paying positions for years. I can assure you they have no concern long term for newer physician's well being or the well being of the overall practice once they leave.
Its often far worse to work under this structure under the conditions mentioned in my previous post rather then some hospital MBA that is focused on making the hospital money but willing to pay a far higher starting salary with likely the same if not better ceiling if run efficiently. In many ways, the hospital MBA is far more reasonable and easy to work with.
We all know the negatives of working for a hospital system or PE group but underestimate the negatives of the current private practice job market.
How To Discourage a Doctor
By RICHARD GUNDERMAN, MD Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily. Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves...thehealthcareblog.com
I would agree the delta between a hospital employed pain physician and new pain physician starting out as associate in a private group is likely in the favor of the former.
In addition I agree the days of a purely pain practice are not once they used to be in terms of autonomy and financial security.
I’ve seen the private pain guys get squeezed beyond belief. Some of them have closed shop in the last 12-18 months. As others have alluded to the cost of labor have increased and reimbursements have declined. I’ve also seen some buy too big of an ASC. Alas, they don’t have enough cases yet need to pay rent on it. It’s just not feasible for them.
I’d propose alternatives such as joing an orthopedic group, pairing with a surgeon, working on pain part time are all viable solutions. Sure the payout may not be as great but I’ve seen some sweet *rare* deals out that make sense. Again there are more “ok” deals for hospitals available than the sweet ones alluded to earlier.
At the end of the day it is still a business. If we can stop trading time for money then we will be able leverage up returns. Getting a cut of PT and imaging, getting ownership in an ASC, sprinkling in some well reasoned and researched procedures for cash, hiring a PA etc are all ways.