Salary structure question

[drusso]

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wrong again

"The map is not the territory."

 

[lobelsteve]

No answers yet, but I get a doc lounge and free cafeteria food at my hospital. (never used the free cafeteria privileges).

 

[buddababa]

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 use the free cafeteria - at least $10-15 a day, so I guess that accounts for a raise

 

[cowboydoc]

I have been around just over 18k the past few years. And I have a side job. 💪

 

[RoloTomassi]

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.

 

[lobelsteve]

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.

I am in docs lounge getting deluxe mixed nuts, Oui yogurt, and fresh hummus nad veggies.

 

[DrSpine]

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.

 

[Brown Striker]

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.

Generating wRVUs is highly dependent on the system. You can generate 12K+ wRVUs working 4 days a week if you have an efficient procedure suite.

That is why the 70+/wRVU discussion is irrelevant if you cant get a higher wRVU number.

If you are at 62/wRVU but have a system that can generate 12k+ RVUs vs system that offers 70+/wRVU but you cant be efficient? I think thats the biggest risk.

How many HOPD jobs have 12K+ wRVU generation at 75/wRVU? That is the real question.

 

[MitchLevi]

The single most important part of being a successful pain physician is your staff. They turn over procedure rooms, answer calls, send in Rx, schedule procedures, etc.

If you have high turnover you'll never hit lofty RVU goals.

You can't do everything, and in fact you can only do a few things efficiently.

Hospitals may offer you insane packages but what happens if they give you one MA and she gets pregnant? One MA and he gets migraines a few times per week?

There are a million things to consider.

PP is what I do...Can't imagine hospital.

 

[BobBarker]

I have one MA. It doesn’t really matter if you aren’t doing fluoro procedures in clinic.

 

[glapapa]

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.

 

[clubdeac]

cuts be a comin

 

[Dr. Ice]

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

 

[mdo1738]

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

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

 

[GoBeers]

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

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.

 

[Pain Applicant1]

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.

 

[GoBeers]

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.

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

 

[drusso]

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.

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

 

[buddababa]

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

or just do PI/deposition/work comp and make bank

 

[Pain Applicant1]

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

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 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

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.

 

[drusso]

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.

I do. I think Obama and Hillary wanted to make going to see the doctor like going to the post office.

 

[mid|ine]

I do. I think Obama and Hillary wanted to make going to see the doctor like going to the post office.

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.

 

[clubdeac]

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.

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 packages

 

[drusso]

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.

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

 

[SSdoc33]

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

Moving the goalposts..... again

 

[Dr. Ice]

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.

 

[drusso]

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 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

 

[Ferrismonk]

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.

 

[Tramadeezy]

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.

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.

 

[Brown Striker]

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.

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.

 

[Ducttape]

one 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...

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

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

A look at public opinion about the ACA 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...

 

[Pain Applicant1]

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.

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 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.

There are also other issues to contend with. MIPS, Board certification maintenance, contract reviews, licensing requirements, etc. It can become too much for a solo guy after a while.

PP does look like it's becoming extinct but everything always shifts and cycles so who really knows what the future holds.

 

[Pain Applicant1]

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.

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.

 

[SSdoc33]

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.

 

[drusso]

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.

 

[SSdoc33]

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.

 

[drusso]

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.

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 - PMC

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 ...

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

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

Bone marrow aspirate concentrate (BMAC) injections

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

 

[SSdoc33]

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 - PMC

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 ...

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

Bone marrow aspirate concentrate (BMAC) injections

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

again, changing the narrative.

looks, i have said before and ill say again that the SOS (d) is too high.

 

[Ducttape]

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.

 

[drusso]

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 cared about cost, you'd offer your services in the lowest cost venue.

 

[drusso]

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.

BTW, I'm not insulted by $2K 60 min CESIs in the HOPD while nibbling on RVU biscuits. To me, it's Shangri-la. Just own it.

 

[clubdeac]

one 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

A look at public opinion about the ACA 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...

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 counter

 

[DrMDAware]

Nice. What’s a typical amount of cases for a day of advanced procedures? What about for minor ones?

Your staff must be well trained.

 

[Brown Striker]

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.

 

[drusso]

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

 

[Brown Striker]

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 the 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.

 

[drusso]

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

 

[Brown Striker]

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

Nothing to disagree with in that article about the potential negatives with hospital employment. This has been discussed with vigor for years and is well documented. The reality is there is no real "security" in medicine in general since any situation can change with time unlike in the past.

This article is from 2014 when private practices were less affected by huge labor cost increases, supply cost increases, rent increases, etc with less reimbursement declines.

The negatives for private practice have increased exponentially since COVID with plenty of sociopathy by "partner" physicians more then willing to sell out the younger newer doctors while dangling former higher partner salaries from years ago as the "carrot".

You must be cautious with due diligence in all these situations considering the changing economic environment and don't just assume being a potential partner in a private practice is worth the squeeze these days compared to hospital employment without very specific conditions.

The days of just walking into some private practice for 20+ years as a "partner" that just does a few years of working below the market rate to "pay your dues" is far less likely now and comes with large financial risks for the younger doctor.

 

[DrMDAware]

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.

 

[Brown Striker]

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.

Oh I forgot: Medicare has limited the number of "transforaminal" epidurals to 1 per level on average (not 2 on everyone or bilateral on everyone like the mills did in the past as well to keep revenue up). This is another 30% or so cut on average for reimbursement since 2021.

Let me go into the economics of HOPD employment vs "Private Practice" now from a salary perspective:

1) HOPD starts physician at 450-500K for first 2-3 years. Private Practice has "3 year partnership" starting the physician at 250-300K or so per year. (Gradient: 500k-275K *3= 675K). So you are essentially starting 700K in the red just signing with the private practice.

Good luck partnering in an increasingly costly "mill" practice that is losing docs considering your share of the overhead you need to "payback" is astronomical. Its even worse if the practice wants you to "indemnify" them for the money before partnership. Could take 4+ years to partner at lower salaries at that point or never partner. This is if the practice survives in the interim or isn't attempted to be sold to PE.

2) Depending on $/RVU structure and efficiency of HOPD vs Private Practice "ceiling" 3 years later is TRICKY. However, with the increases costs and declining reimbursements for PPs, its likely maximum for both is realistically at 800K to 900K. I think its a wash at best.

HOPD can realistically obtain 14k/RVU in an "efficient" practice pretty easily after a few years (depending on location, etc) and even at 62/RVU, its a little under 900K. You would need to work equally hard at a private practice to obtain those numbers in an inflationary environment with increasing costs and decreasing reimbursement. The risk difference is enormous.

3) How much is extra time worth that will be required from "partners" for administrative tasks?

4) Ancillaries of Private Practice: PT is not profitable anymore and can actually be costing the practice money in rent, UDS profit is marginal, etc. I dont really see much opportunity here anymore.

Im really not seeing the advantages of PP at this point if you properly vet a hospital based job or even private equity job. Dr Russo might have a better argument?

Also, remember, you can NEGOTIATE a better deal with a PE group if you join it as an outside physician rather then get taken over as a "non partner" in a private practice. Non partners are not going to do well in a PE deal and have worked for less for nothing.

Most PE deals target practices that are growing with a few "super partners" who get all the money.