State of anesthesiology

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AKMD_1984

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pubs.asahq.org

The Current and Future State of Anesthesiology: Good, Bad,... : ASA Monitor

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pubs.asahq.org pubs.asahq.org

great summary of current challenges. Explains why anesthesiologists are flocking to locums/prn/independent setups or atleast incorporating that in their practices.

We all know the issues

What’s the solution?

Direct hospital employment?

What needs to happen to stop the hemorrhage?
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I came across this article because I was trying to understand and look at “downstream revenue” specifically to anesthesiology services.

For orthopedic - it’s around 3million per year per surgeon - average. That seems low to me.

But let’s go with that figure. Can’t perform surgery without anesthesia. In fact can’t even book cases without reliable anesthesia services. Not even talking about quality of care with regional anesthesia - not everyone anesthesiologist is good at these.

We need a study to look at loss of downstream revenue when anesthesiologist is not reliably available.

It needs to be a part of contract negotiations. Too much emphasis is on payor mix, hours, call etc. it makes it easy for the hospital.

Don’t know how we can study this?
 
Honesty and I read the entire article. I could have cut it down to a few sentences

1. Hospitals administrators are dumb thinking catering for surgeons and procedurists after 5pm and weekends cases is cost effective (it’s not). The threat of the surgeon moving their cases to another hospital system is real but who cares. Unless that surgeon guarantees that hospital at least 3 days full of cases. They aren’t bringing any real consistent revenue you in.

So let the surgeons walk to the competing hospital.

Reward the surgeons who bring consistent cases to your hospital.

It’s very simple

We have these gen surgeons (big surgery group). They bitch and complain their cases aren’t on time. 12/1pm starts when they operate at their surgery center first.

Fine. Go to the competing hospital. Do your inpatient cases there. No one cares. Or move your cases to the main OR and we will give you the 7/730am starts. Nope. It’s easier for them and more profitable to keep the profits to themselves at their outpatient surgery center.
 
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from the gist of the article, it seems that payor mix will worsen as the population ages (ie the proportion of Medicare will be higher).

That’s logical.

At the same time, facility fees for hospitals are rising.

Essentially there is a transfer of revenue from physicians to the hospital.

Hospital revenue is predicated upon completion of service (anesthesia/ surgeon).

-Who’s going to pay for anesthesiologists time on call - already shortages of plus desire for no-call/ no weekends gigs; like ASCs and daytime. Eventually the hospital will. They don’t have a choice.

No way an anesthesia group can be profitable unless you’re a boutique practice etc as the article suggests.

- maybe direct hospital employment isn’t bad after all

Atleast there is stability?
 
neutro said:
from the gist of the article, it seems that payor mix will worsen as the population ages (ie the proportion of Medicare will be higher).

That’s logical.

At the same time, facility fees for hospitals are rising.

Essentially there is a transfer of revenue from physicians to the hospital.

Hospital revenue is predicated upon completion of service (anesthesia/ surgeon).

-Who’s going to pay for anesthesiologists time on call - already shortages of plus desire for no-call/ no weekends gigs; like ASCs and daytime. Eventually the hospital will. They don’t have a choice.

No way an anesthesia group can be profitable unless you’re a boutique practice etc as the article suggests.

- maybe direct hospital employment isn’t bad after all

Atleast there is stability?
Click to expand...
Payor mix will inevitably worsen for a number of reasons; aging population and hospitals building towards service lines that bring in good revenue to them but are not typically high anesthesia reimbursement or time efficient for anesthesia (Cardiac, EP, spine, etc), and outpatient private payors cases being diverted to surgery centers.

So hospital work is fruitless. It’s low paying and high resource/time intensive.

Anesthesia groups will die without a few things;

1.) outpatient/surgery center work subsidizing your hospital work

2.) a stipend to cover the delta between staff/partner income expectation and payor mix or avg $/unit as well as call requirement that costs the most to staff but brings in the least.

So, the choices are; heavily subsidize your hospital work with surgery center work, get a large stipend, or go hospital employed. Unless there’s a paradigm shift.

Alternatively, and I think this is the answer for long term sustainability; argue that all of these surgical services are service lines and they require anesthesia. Want a trauma service so your entire hospital can bill at a higher rate? Cut in anesthesia or you can’t do it. Want a TAVR and other structural heart programs (Watchman etc)? Guess what? You need anesthesia, pay us. You want to recruit a handful of spine surgeons to do 2-3 big spines/day which pay us garbage but bring in $$$ in device/hardware/facility fees? You need us. We have leverage, they can’t create or deliver on any of these service lines without us. And, this is the dirty secret, they don’t understand anesthesia finances/reimbursement, and it would be more expensive for them to employ us on a per doc/CRNA basis than if they simply provided the delta.
 
[QUOTE="Robotic Wis-Hipple, post: And, this is the dirty secret, they don’t understand anesthesia finances/reimbursement, and it would be more expensive for them to employ us on a per doc/CRNA basis than if they simply provided the delta.[/QUOTE]

But when the Hospital CEO makes the wrong decision and causes chaos in anesthesia services at the hospital and/or massively increased costs to the hospital , no one cares and there is no consequence to the CEO.

Taking call nowadays makes less sense than ever. You can make about the same being per diem with no call. We need some people to take call and do those nonprofitable cases for the sake of the community. But we don’t need every little hospital open all night with a skeleton crew available for an appy.

Especially around me near NYC with so many competing systems, if the public wants a chance at any sort of efficiency these different systems need to start working together to minimize docs needed on call. Instead we are building EP suites in every one of them
 
There are 2 completing dynamics. There’s a shortage of us, but many healthcare systems are hemorrhaging money. Depending on which dynamic is winning at the time determines our pay.

There's a constant cycle of provider (MD, midlevel, RN) getting paid below market, providers leaving, pay increased above market directly or indirectly through travelers. Until someone leaves nothing changes. It's unstable, but often instability leads to opportunity.

Even at very high hourly rates our pay doesn't come close to the cost of shutting down services. If you're providing great service it won't be appreciated until its gone. If you're the key to a health system providing services that they currently can't they will roll out the red carpet.

A strong group asks for their compensation to be increased 10% to keep up with market conditions. Administrator: no way, there's no money for that, loyalty, greedy doctors... Group dissolves. Hospital can't run ORs. Locums company offers coverage at double what the group charged. Administrator: no problem, when can they start?

I'm thankful to be in high demand. I do wish the average administer had more foresight.
 
Hoya11 said:
[QUOTE="Robotic Wis-Hipple, post: And, this is the dirty secret, they don’t understand anesthesia finances/reimbursement, and it would be more expensive for them to employ us on a per doc/CRNA basis than if they simply provided the delta.
Click to expand...

But when the Hospital CEO makes the wrong decision and causes chaos in anesthesia services at the hospital and/or massively increased costs to the hospital , no one cares and there is no consequence to the CEO.

Taking call nowadays makes less sense than ever. You can make about the same being per diem with no call. We need some people to take call and do those nonprofitable cases for the sake of the community. But we don’t need every little hospital open all night with a skeleton crew available for an appy.

Especially around me near NYC with so many competing systems, if the public wants a chance at any sort of efficiency these different systems need to start working together to minimize docs needed on call. Instead we are building EP suites in every one of them
[/QUOTE]

Agree 100%. I’m no MBA but part of the problem it seems is the way these business dinguses are running hospitals for their motivations.

Every hospital, even different hospitals in the same “system” compete with each other. The business folks want their hospital to be more profitable or more efficient than their in-system colleagues’ hospital. Every department, division, or business entity has to show black in the books so they make insane cuts in areas that make little sense just so they can say each one is in the black. Decisions like cutting anesthesia techs or surgical services and asking offsite RNs to restock the anesthesia equipment or clean their own labs etc. Then they still want the same turnover times and don’t understand why that could be a downstream effect.

The business folks are a huge part of the problem, the admin bloat is at a breaking point. Each hospital is overrun with administrators making decisions that are short term budget positive so they can add a buzzword heavy bullet point on their CV and move up in the chain at another hospital. They’re cannibalizing and skeletonizing the hospitals for personal gain leaving understaffed, wrecked culture husks of their prior glory behind. And this takes years to recoup, not that the administrators that did it would know, as they’re at their next hospital making similar decisions that got them promoted.
 
This logic doesn't pan out for other specialties. Yes they can't do the procedure without the anesthetic but the surgeon doesn't get to do the procedure unless the patient is referred by the PCP/specialist who found the problem yet there are strict laws preventing kickbacks to reward the providers who do that work so they are stuck on their RVUs only. The surgeon gets all the credit and the entire team of other providers (from the PCP to the radiologist, pathologist, anesthesiologist) are just SOL under the Stark rules where the only credit they get are for wRVUs. Hospitals of course can circumvent this by moving money around when needed to recruit but then point right back at those rules to keep pay low and protect their margins because rules don't really apply to them.

The entire system needs to collapse and de-emphasize our obsession with surgery. Surgical subspecialists shouldn't be the only reason a hospital can operate in the green. The fact that so many healthcare facilities nearly imploded during COVID when they were full of sick people because taking care of sick people apparently doesn't generate revenue is emblematic of how ****ed our entire healthcare system is but instead of taking that warning shot we just keep going business as usual until the next crisis.
 
chessknt said:
This logic doesn't pan out for other specialties. Yes they can't do the procedure without the anesthetic but the surgeon doesn't get to do the procedure unless the patient is referred by the PCP/specialist who found the problem yet there are strict laws preventing kickbacks to reward the providers who do that work so they are stuck on their RVUs only. The surgeon gets all the credit and the entire team of other providers (from the PCP to the radiologist, pathologist, anesthesiologist) are just SOL under the Stark rules where the only credit they get are for wRVUs. Hospitals of course can circumvent this by moving money around when needed to recruit but then point right back at those rules to keep pay low and protect their margins because rules don't really apply to them.

The entire system needs to collapse and de-emphasize our obsession with surgery. Surgical subspecialists shouldn't be the only reason a hospital can operate in the green. The fact that so many healthcare facilities nearly imploded during COVID when they were full of sick people because taking care of sick people apparently doesn't generate revenue is emblematic of how ****ed our entire healthcare system is but instead of taking that warning shot we just keep going business as usual until the next crisis.
Click to expand...

If the administrative burden were lower, would hospitals be able to keep the lights on with medical care?
They’d like us to shuffle money from one specialty to another when we should really cut administration.
 
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triggermaster said:
If the administrative burden were lower, would hospitals be able to keep the lights on with medical care?
They’d like us to shuffle money from one specialty to another when we should really cut administration.
Click to expand...
I have yet to see a locums administrator so my guess is that the supply must be adequate...
 
Hospital CEOs respond to "market conditions". They will KNOW market conditions (i.e. anesthesia salaries) and revolve around them. Quality of care really has no impact on them, as they are not trained to understand or care or receive a benefit from it. SO: learn the business side of the whole mess. The guy who has all the power in a negotiation is the guy who says, "No". Read that book. Take a negotiation course. Before he was a partisan politician EVERY LAST BUSINESS SCHOOL AND PERSON considered "The Art of the Deal" by Donald Trump a must read.
 
JStarMD said:
Hospital CEOs respond to "market conditions". They will KNOW market conditions (i.e. anesthesia salaries) and revolve around them. Quality of care really has no impact on them, as they are not trained to understand or care or receive a benefit from it. SO: learn the business side of the whole mess. The guy who has all the power in a negotiation is the guy who says, "No". Read that book. Take a negotiation course. Before he was a partisan politician EVERY LAST BUSINESS SCHOOL AND PERSON considered "The Art of the Deal" by Donald Trump a must read.
Click to expand...
You can only say no if you have options and alternatives.
Hard to do as an anesthesiologist, unless you set up multiple gigs/ contract with groups.
 
AKMD_1984 said:
You can only say no if you have options and alternatives.
Hard to do as an anesthesiologist, unless you set up multiple gigs/ contract with groups.
Click to expand...
Biggest negotiation chip isn’t another job, it’s enough money to retire. Not retire in excess, but have an acceptable lifestyle for the rest of your life. It’s also the best protection against scope creep. Against disability. Against a down job market. Against a hypothetical horrendous national healthcare bill. Stack up ~3M and none of that matters much, it’s a wonderful feeling.
 
AKMD_1984 said:
You can only say no if you have options and alternatives.
Hard to do as an anesthesiologist, unless you set up multiple gigs/ contract with groups.
Click to expand...
Alternatives and options abound these days…. But depending on your locale, horrid non competes and local AMC monopolies it may mean moving. The good news is a moving stipend and signing bonus is standard now for a call taking fte.
Lots of other professions involve moving, switching jobs to get ahead, get promoted. Stats abound in other professions about money left on the table if you stay in the same job these days… it’s not like the old days where you stayed with a company your whole career for the pension - pension default happened too much.
The last data I saw was that anesthesiologists retirements out paced new grads by 1000 a year…. And that can’t account for those just pulling back and not taking call anymore, the mid career people like me that really just want to be one regular FTE (40-45h work week max like a regular person) or the new grads who have a great but novel outlook on work-life balance for youngsters.
 
NicholasPavona said:
The anesthesia job market is cooling off. Considerably. 🥶
Click to expand...
It’s definitely different than last winter.

It cycles through. Place told me they didn’t need me back in December just released about 40 different dates the next 2.5 months they needed coverage.

Prn w2 people get first dibs though. No biggie. So the existing staff get to make extra money. Which is the good way to get money to ur loyal staff
 
NicholasPavona said:
The anesthesia job market is cooling off. Considerably. 🥶
Click to expand...
Just curious what makes you say that? I think the market is changing - some places have realized they need to raise permanent salaries to get people so are less reliant on expensive locums. People have also joined the locums market in droves - I’d believe that the locums market is slowing in places but the permanent market seems strong. It’s also January - historically a slower time
 
I've been hearing from several people in academics that this year may have about the lowest numbers of applicants for fellowships. Has anyone else heard the same?
 
I have heard similar gossip about fellowship applications being down.
I think the market is shifting - some places are beginning to realize the “short term” locums fix is too costly… and it’s not that short term after all. Standard hospital employed packages seem to have improved.
 
amyl said:
I have heard similar gossip about fellowship applications being down.
I think the market is shifting - some places are beginning to realize the “short term” locums fix is too costly… and it’s not that short term after all. Standard hospital employed packages seem to have improved.
Click to expand...
Should have done this 2 years ago.

Pay people what is the market rate. I keep saying it’s close to 700k/10 weeks. And I’m right

But companies and amc and hospitals keep colluding to make it sound like 500k/8 weeks off plus some bs weekend incentive or extra pay package for another 50k is “market rate”

We all know the games.

I can guarantee places that use locums can get rid of most or all of their locums MDs with what I stated.

It’s far cheaper to pay regular staff an extra 100k than to use a locums doc

Crnas are similar. A couple of places I know have hired 5 full time crnas and another place hired 3 w2 crnas. The 1099 crnas are kinda of worried. But I think they are ok for now. As those places need 15 more full time crnas and the smaller place needs 3 more full time crnas. Because the compensation package with benefits and retirements match is close to 350k with 10-12 weeks off. Not much different than a 1099 crna making around 400k 1099 at $200/hr and 1099 has less job security
 
aneftp said:
Should have done this 2 years ago.

Pay people what is the market rate. I keep saying it’s close to 700k/10 weeks. And I’m right

But companies and amc and hospitals keep colluding to make it sound like 500k/8 weeks off plus some bs weekend incentive or extra pay package for another 50k is “market rate”

We all know the games.

I can guarantee places that use locums can get rid of most or all of their locums MDs with what I stated.

It’s far cheaper to pay regular staff an extra 100k than to use a locums doc

Crnas are similar. A couple of places I know have hired 5 full time crnas and another place hired 3 w2 crnas. The 1099 crnas are kinda of worried. But I think they are ok for now. As those places need 15 more full time crnas and the smaller place needs 3 more full time crnas. Because the compensation package with benefits and retirements match is close to 350k with 10-12 weeks off. Not much different than a 1099 crna making around 400k 1099 at $200/hr and 1099 has less job security
Click to expand...
I work 1099 at 2 to 3 places. When calculating benifits and vacation I am about the same as W2. I do this purposely...1099 allows me to sock away retirement, I have at least 3 jobs so no one can cripple me, and I am economical.
I am interested in the next 5 to 10 years in my home market.
 
crna2006 said:
I work 1099 at 2 to 3 places. When calculating benifits and vacation I am about the same as W2. I do this purposely...1099 allows me to sock away retirement, I have at least 3 jobs so no one can cripple me, and I am economical.
I am interested in the next 5 to 10 years in my home market.
Click to expand...
It’s just a simple fix for most employers

I hear the same excuses from administrators how to fix things. They claim if they give everyone pay raises. That 6 months -12 months down the road the employees will ask for more money.

Which probably is true. But it’s better than the cost of locums agencies.

Good for you for having 3 1099 gigs rotate.

And yes. Putting a ton of money away into retirement is key. It sucks when you work for amc where you can only put away 23k/30k if over age 50.

I’ve been putting away pretty much the max self employed sep/solo 401k plans most of my career except for two stints at state university places and those state universities places pretty much allowed the same or similar max retirement places as self employed

Obviously define benefits plans can sock away even more money than solo 401k/sep matches.
 
aneftp said:
It’s just a simple fix for most employers

I hear the same excuses from administrators how to fix things. They claim if they give everyone pay raises. That 6 months -12 months down the road the employees will ask for more money.

Which probably is true. But it’s better than the cost of locums agencies.

Good for you for having 3 1099 gigs rotate.

And yes. Putting a ton of money away into retirement is key. It sucks when you work for amc where you can only put away 23k/30k if over age 50.

I’ve been putting away pretty much the max self employed sep/solo 401k plans most of my career except for two stints at state university places and those state universities places pretty much allowed the same or similar max retirement places as self employed

Obviously define benefits plans can sock away even more money than solo 401k/sep matches.
Click to expand...
Lets see if it works
 
amyl said:
Just curious what makes you say that? I think the market is changing - some places have realized they need to raise permanent salaries to get people so are less reliant on expensive locums. People have also joined the locums market in droves - I’d believe that the locums market is slowing in places but the permanent market seems strong. It’s also January - historically a slower time
Click to expand...
Exactly.
 
aneftp said:
It’s just a simple fix for most employers

I hear the same excuses from administrators how to fix things. They claim if they give everyone pay raises. That 6 months -12 months down the road the employees will ask for more money.

Which probably is true. But it’s better than the cost of locums agencies.

Good for you for having 3 1099 gigs rotate.

And yes. Putting a ton of money away into retirement is key. It sucks when you work for amc where you can only put away 23k/30k if over age 50.

I’ve been putting away pretty much the max self employed sep/solo 401k plans most of my career except for two stints at state university places and those state universities places pretty much allowed the same or similar max retirement places as self employed

Obviously define benefits plans can sock away even more money than solo 401k/sep matches.
Click to expand...

That argument from administrators is just hilarious when you consider how often the upper level management in hospitals are getting salary bumps and increased benefits on a nearly yearly basis.

I've spoken to some surgeons in my hospital and a number of specialities haven't seen a raise since COVID 😳
 
aneftp said:
It’s just a simple fix for most employers

I hear the same excuses from administrators how to fix things. They claim if they give everyone pay raises. That 6 months -12 months down the road the employees will ask for more money.

Which probably is true. But it’s better than the cost of locums agencies.

Good for you for having 3 1099 gigs rotate.

And yes. Putting a ton of money away into retirement is key. It sucks when you work for amc where you can only put away 23k/30k if over age 50.

I’ve been putting away pretty much the max self employed sep/solo 401k plans most of my career except for two stints at state university places and those state universities places pretty much allowed the same or similar max retirement places as self employed

Obviously define benefits plans can sock away even more money than solo 401k/sep matches.
Click to expand...
Unless and until they start adding a COLA and % increase for inflation to keep it market on all anesthesia employment contract, I am not signing F/T.

I do not find it dignified to go back and forth with any employers on how much I should be paid when clearly the numbers are not market.

My last job I did that and all I got was a 25K raise after 7 month of back and forth. f**k that. Some weeks, I can make that in a week.

This is why locums is attractive - you don't like the rate? F**k off.

I am not trying to be greedy, but I didnt dedicate 13 years to be a fellowship trained physician with good profile and no poor outcomes for you to now tell me how much I should be paid, while your attorneys make $500/15 minutes signing off on emails.

Take it or leave it.

Unless and until the environment improves, I ain't signing.

Its not about loyalty. Its about mathetmatics and securing mine and my family's financial future.
 
AKMD_1984 said:
Unless and until they start adding a COLA and % increase for inflation to keep it market on all anesthesia employment contract, I am not signing F/T.

I do not find it dignified to go back and forth with any employers on how much I should be paid when clearly the numbers are not market.

My last job I did that and all I got was a 25K raise after 7 month of back and forth. f**k that. Some weeks, I can make that in a week.

This is why locums is attractive - you don't like the rate? F**k off.

I am not trying to be greedy, but I didnt dedicate 13 years to be a fellowship trained physician with good profile and no poor outcomes for you to now tell me how much I should be paid, while your attorneys make $500/15 minutes signing off on emails.

Take it or leave it.

Unless and until the environment improves, I ain't signing.

Its not about loyalty. Its about mathetmatics and securing mine and my family's financial future.
Click to expand...
This is unfortunately how a lot of mega corp America functions. Get hired at a good salary, get a few token raises for a few years but barely keep pace with inflation or fall behind, and then find a new job to get an actual decent (10%+) raise and repeat the process. As more doctors become employed by big health systems I expect this to be our fate as well. So make sure you don’t have to pay tail or have a big noncompete.
 
ambiturner said:
This is unfortunately how a lot of mega corp America functions. Get hired at a good salary, get a few token raises for a few years but barely keep pace with inflation or fall behind, and then find a new job to get an actual decent (10%+) raise and repeat the process. As more doctors become employed by big health systems I expect this to be our fate as well. So make sure you don’t have to pay tail or have a big noncompete.
Click to expand...

At some point all anesthesiologists and CRNAs will be employees of either a) a hospital system, b) a large insurance company, or c) a staffing company. The days of having a lucrative salary as a full fledged partner in a small local group is either at its end or close to it.
 
m
Sevo said:
At some point all anesthesiologists and CRNAs will be employees of either a) a hospital system, b) a large insurance company, or c) a staffing company. The days of having a lucrative salary as a full fledged partner in a small local group is either at its end or close to it.
Click to expand...
What do you consider a lucrative salary for a full fledged partner? Hours worked per week/weeks off

Back 20 years ago. Unequal partners the 3-4 main guys at the top got 1 million working 45 hours with 8 weeks off siphon off the employee docs (who worked 60 plus hrs for 250k-300k with 4 weeks paid off and non voting fake partners (they usually got around 600k-650k) who had same 8 weeks off

The truly equal partners practice made around 750k and took 6 weeks off and worked around 55 hours. These are 2000-2010 real numbers in many partners of the country. Employee docs made half

When you account for inflation and 2025. My estimate of a good fair partnership is that you make 750k with 40 hours and 10 weeks off. The docs who want to kick it to another level and average 60’plus hours and take 6 weeks off should all be hitting low 7 figures

The issue is anesthesia reimbursement no longer can support those numbers. And money needs to come from subsidies as we discussed.
 
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