PMR2008

PM&R
10+ Year Member
Aug 17, 2007
585
78
Status
Attending Physician
I get a number of PM's regarding subacute/SNF rehab. There are a lot of misconceptions regarding the role physiatrists have in this practice setting. Working in the subacute setting was highly discouraged by my program director during residency even though quite a few of our attending had subacute side gigs. Unfortunately even now most residents do not get exposure during training. I wanted to make myself available to hopefully answer any questions people might have.

  1. What is subacute/ SNF rehab?
    Over the past decade and more intensely over the past 7 years, there has been a steady decline of patients being approved for Inpatient Rehab Facility (IRF) stays by Medicare. Through payer regulatory changes and certain determinations, these patients who would have been approved for IRF stays are now being discharged to Skilled Nursing Facilities (SNF). As of 2014, there were 339,000 beneficiaries in IRF vs 1.7 million in SNFs. Rehabilitation in the SNF environment is rapidly emerging as the predominant level of post-acute rehabilitation care in the United States. More patients will receive their rehabilitation in a SNF today than in an IRF—and the trend is likely to continue! Physiatrists have worked in the subacute environment since the 80’s but our involvement in this level of care is now more important than ever.
  2. Why did you decide to work in this setting?
    I was fortunate enough to complete my residency at a hospital with an attached SNF unit. As residents, we rounded on patients and covered them during call. The hospital also had a dedicated subacute rotation where residents spent time with the Attending Physicians learning firsthand how to provide care for patients in this setting. Most of our teaching attendings balanced an acute, SNF, and outpatient practice. Initially my interests were aligned within sports medicine, however, I quickly realized that a more balanced practice going forward would be the best answer.
  3. How is it different from acute rehab and outpatient?
    In a subacute setting, I work as a consultant in a team model where a primary care physician and I co-manage patient care. The types of patients can vary depending on the facility but most often I provide rehab and pain management for patients undergoing therapy. Patient mix is approximately 30-40% orthopedic, 15-20% neuro and the rest are cancer and cardiopulmonary rehab patients. The vast majority of issues I am managing are ‘bread and butter’ rehab including spasticity, pain, bowel/bladder, neuropathy, and amputee care, etc. I will also occasionally perform bedside joint injections. The primary care physician manages all other medical issues and will take call.
  4. How often are the patients seen?
    As per the AAPM&R position statement on a physiatrist’s role in skilled nursing facility, “in the ideal situation, a physiatrist in a SNF setting will serve in a consulting or co-treating physician role and visit the patient two to three times a week depending on the needs of the patient” (June 2016). As the length of stays are declining, sometimes the frequency increases to 3 times a week with the goal of leading to greater functional gains by the patient and cost saving to the health care system.
  5. What is the typical work schedule?
    I work 4 days a week about 8 hours a day. In my capacity as a consultant, I do not work on weekends or take call. Typically, I am able to see approximately twenty follow-up and five new patients a day. I also have an outpatient sports/spine practice one day a week and a medical legal practice.
  6. How did you start your practice?
    I had the opportunity to start the practice myself but I was concerned with stability and future Medicare regulations. I ended up joining a company as an independent contractor. The company provides managerial services for my practice. Initially one of my main concerns was stability but given that my overhead is very low, I am able to take home most of what I earn and have tremendous flexibility to create a work-life balance. I have the ability to create my own schedule, as well as implement changes and improvements to my practice and routine as needed. This type of work can be done on a full-time basis or as an addition to your current form of practice.
  7. What is the future of SNF rehab and is this a practice setting you feel is sustainable into the near future?
    The medical landscape has changed drastically since I began practicing in the SNF rehab setting 7 years ago. The changes in effect have led to increased focus on providing quality care, reducing readmissions to the hospitals and reducing cost. Physiatrists are well positioned as the ideal specialists to facilitate these objectives by providing continuing care of the patients during various stages of recovery.
  8. Do you find the work rewarding? I am extremely fortunate to work in the SNF rehab space. I believe I make a difference in the lives of my patients every day. I have the opportunity to provide outcome-oriented care, lead a team, and assist with cost saving while continuing to strive for optimal patient care. I am able to set goals, which correspond with the patient and their family’s needs. My focus is on eliminating barriers that impede transition from facility to home or a more home-like environment. I am also able to practice general physiatry without the pressures that come along with being an employee in a large scale medical practice or hospital.
 

CoomassieBlue57

2+ Year Member
Oct 2, 2015
385
653
Status
Medical Student
What’s the potential pay range working four days a week plus your outpatient practice?
 
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PMR2008

PMR2008

PM&R
10+ Year Member
Aug 17, 2007
585
78
Status
Attending Physician
If working 4 days a week 300-350k. Depends on volume and location.
 
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exodian1

2+ Year Member
May 16, 2015
136
52
Status
Medical Student
Is that pay just from your SNF work or is that also including the sports and spine outpatient?
 

exodian1

2+ Year Member
May 16, 2015
136
52
Status
Medical Student
Just SNF. 6-8 hours of work a day, no call and no weekends.
Wow that's actually amazing pay for those hours. And you're able to do a day of sports and spine clinic on top of that to increase those earnings? Haven't heard much about people doing SNF consults, but that might be on my radar now. Thanks for the information!
 
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Sep 23, 2017
8
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Medical Student
Wow that's actually amazing pay for those hours. And you're able to do a day of sports and spine clinic on top of that to increase those earnings? Haven't heard much about people doing SNF consults, but that might be on my radar now. Thanks for the information!
Things move at a different speed and intensity at a SNF a lot of the time. You have to be okay with that which can be very frustrating to some people.
 
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PMR2008

PMR2008

PM&R
10+ Year Member
Aug 17, 2007
585
78
Status
Attending Physician
Things move at a different speed and intensity at a SNF a lot of the time. You have to be okay with that which can be very frustrating to some people.
Agree with you. But the practice is setup to suit your own style. It is not very organized and the nursing care in the SNF setting is subpar but the patients and the issues that you help them with are similar.
 
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castalmond

7+ Year Member
Jan 31, 2012
8
2
Status
Thanks for the post - I had a few questions:
What percentage of collections does the company take?
Do you use a template, scribe, or other program for documentation?
What level do you bill for each encounter, if you are seeing 25+ patients a day?
 
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PMR2008

PMR2008

PM&R
10+ Year Member
Aug 17, 2007
585
78
Status
Attending Physician
Percentage of collection is based on part-time/full-time, seniority, market, company etc. Can range from 60% to 75%.
Templates + scribe. Sometimes dragon dictation to supplement.
Level of encounter is based on what I am doing for the patient. If prescribing meds than moderate while routine visit would be a low. I am very involved with rehab and med management.
 

castalmond

7+ Year Member
Jan 31, 2012
8
2
Status
Interesting, thanks. Sounds like the SNF staffing company takes 25-40%, which sounds ridiculously high when considering there is no overhead besides billing...
 
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PMR2008

PMR2008

PM&R
10+ Year Member
Aug 17, 2007
585
78
Status
Attending Physician
Not true. The overhead includes credentialing, marketing, full time admin support(phone calls, faxes), compliance, templates, billing apps, online portals-webinars, education, ongoing physician support, practice expansion, assisting in hiring midlevels, billing etc
What percentage of your collection as a hospital employee do you get to keep? Also what do you think is the average overhead in an outpatient clinic?
I agree that is sounds like a lot but there is power in numbers. If you want I can elaborate further.
 

RangerBob

7+ Year Member
Sep 16, 2012
1,307
991
Status
Attending Physician
Not true. The overhead includes credentialing, marketing, full time admin support(phone calls, faxes), compliance, templates, billing apps, online portals-webinars, education, ongoing physician support, practice expansion, assisting in hiring midlevels, billing etc
What percentage of your collection as a hospital employee do you get to keep? Also what do you think is the average overhead in an outpatient clinic?
I agree that is sounds like a lot but there is power in numbers. If you want I can elaborate further.
Your lifestyle and salary both sound great (better than the majority of rehab physicians). But it does seem to me that your overhead High. My billers cut is 6%, and I am paid a director stipend. I pay my own malpractice insurance, but otherwise minimal overhead for me in an acute rehab unit.

Like I said, your lifestyle and salary are great. And maybe it’s a common thing for those doing consults at SNFs to have to give a big cut to the SNF facility. I don’t know much about SNF.

It’s great you started this thread-IPR is already losing so much interest (there are so many open positions, and even more filled positions are filled by non-PM&R), and my guess is interest in SNF is even lower. I think residents underestimate how nice of a life and income you can have by doing inpatient/SNF and how much they can make (and how much more you make when your not an employee)
 
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PMR2008

PMR2008

PM&R
10+ Year Member
Aug 17, 2007
585
78
Status
Attending Physician
Agree with a lot of the points you have made. I just had a conversation with a physician this morning from the east cost. He has practiced for 15+ years. Works in the inpatient rehab setting with a clinic. He told me his billing last year was 1.7, collection was 900k while his take home was 200k. He told me he has asked for a production based raise for years without luck. He is planning on doing subacute now. Also they hired 50 new admin over the past year while they lost 2 physiatrists and they have not filled the positions for 3 years.
One of the best comments this physician made to me was that one of the reasons he has burned out is that he is only taking home 25% of his collection.

I have friends of mine who have nice gigs doing inpatient rehab. They are 1099, get medical director stipends, cover medium sized units and have internal medicine coverage. They also cover SNF's with PA/NP's. With that kind of setup making 650k+ a year is not very difficult.

Regardless of the money and the financial freedom (better chance to retire early) it gets you, it is the patient care. There is a stigma out there specially from the academic physiatrists that subacute work is 'dirty' or 'subpar'. The patients and conditions I am treating in the subacute setting are the same I was treating as a resident 10 years ago. If I get to make money while providing the same care I don't have a problem with that.

The only reason for my original post was to raise awareness and to address the questions I am asked privately all the time. The interest in SNF work has increased dramatically over the past few years as the awareness has improved.