Surgeons vs anaesthetist fees=3 times the difference. wheres the business case then?

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ALTorGT

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hi all
heres an interesting articlle discussing the total costs of orthopaedic surgery in Aus. The surgeons fee on average is 3 times the cost of the anesthetist. Granted the surgeon has to pay a higher indemnity and also provide post op patient care and pay for rooms. But surely all of that is less than a 1/3rd of the difference. Doesnt this mean that the big bucks are still in surgery....1500 - 2500 for surgeon vs 500 - 700 for anaesthetist for a knee reconstruction op. And as you go further along in your career and are able to do more and more pvt work, your cost base should technically be a much smaller percentage of your total revenue right...a room + secretary = fixed cost?



The cost of surgery for sports injuries in Australia


Surgery for sports injuries in Australia is expensive by the standards of most consumer items, but on a world scale it is actually quite cheap (and good value). Unlike other consumer items, it is very difficult to make cost comparisons between surgeons and therefore most people make the decision on which surgeon to use based on quality rather than cost.

Approximate costs for surgery can be estimated in the table below. Every Australian has access to Medicare rebates for doctors' fees, but in being part of Medicare, Australians are not allowed to take out full insurance to cover all fees charged by surgeons and other doctors above the Medicare schedule amounts. Surgery in public hospitals is free for Australian citizens but choice of surgeon is not allowed and most surgery requires joining a lengthy waiting list. In recent years, 'no gaps' private health insurance products have been promoted and these are relevant for certain areas in Australia. Many orthopaedic surgeons in South Australia, for example, accept the rebates from 'no gaps' products and so a good surgeon in Adelaide may be found without out-of-pocket medical expenses. In New South Wales, where the cost of living is higher, but health insurance rebates are exactly the same, very few top orthopaedic surgeons agree to accept the 'No Gaps' products, meaning that patients will face 'gaps' even with full insurance.

Surgery in sports medicine can roughly be divided into day-case procedures (arthroscopes of most joints) where hospital fees are minimised and full admission procedures (including joint reconstructions) where hospital fees for the uninsured patient are much more expensive. An approximate guide to the costs is presented in the table below:


Arthroscope Reconstruction

Surgeon's fee:
approx $1000-$1800 approx $1500-2500

Surgeon's 'gap':
up to $1200 up to $1500

Anaesthetist's fee:
approx $400-600 approx $500-700

Anaesthetist's ‘gap’:
up to $300 up to $400

Assistant's fee:
approx $150-250 approx $200-400

Assistant's ‘gap’:
up to $200 up to $300

Other providers may be needed (e.g. X-ray, pathology)



Total medical fees:
up to $3000 up to $4000

Total medical ‘gaps’:
up to $2000 up to $3000

Theatre & hospital fees:
approx $1500-2000 approx $2500-5000

Total costs: $4000-$5000 $8000-9000


The above doctor fees are covered mainly by Medicare, but in most cases the 'gap' cannot be insured against, so this represents out of pocket expenses for the patient, even with private health insurance.

Hospital fees may be covered fully by private health insurance, but may be subject to excess payments or complete payment by the patient in the case of someone without private health insurance.

Therefore total cost for an arthroscopy procedure may be $4000-$5000, or for a reconstruction $8000-9000, with the patient subject to a percentage of these costs depending on insurance status.

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ALTorGT said:
hi all
heres an interesting articlle discussing the total costs of orthopaedic surgery in Aus. The surgeons fee on average is 3 times the cost of the anesthetist. Granted the surgeon has to pay a higher indemnity and also provide post op patient care and pay for rooms. But surely all of that is less than a 1/3rd of the difference. Doesnt this mean that the big bucks are still in surgery....1500 - 2500 for surgeon vs 500 - 700 for anaesthetist for a knee reconstruction op. And as you go further along in your career and are able to do more and more pvt work, your cost base should technically be a much smaller percentage of your total revenue right...a room + secretary = fixed cost?



The cost of surgery for sports injuries in Australia


Surgery for sports injuries in Australia is expensive by the standards of most consumer items, but on a world scale it is actually quite cheap (and good value). Unlike other consumer items, it is very difficult to make cost comparisons between surgeons and therefore most people make the decision on which surgeon to use based on quality rather than cost.

Approximate costs for surgery can be estimated in the table below. Every Australian has access to Medicare rebates for doctors' fees, but in being part of Medicare, Australians are not allowed to take out full insurance to cover all fees charged by surgeons and other doctors above the Medicare schedule amounts. Surgery in public hospitals is free for Australian citizens but choice of surgeon is not allowed and most surgery requires joining a lengthy waiting list. In recent years, 'no gaps' private health insurance products have been promoted and these are relevant for certain areas in Australia. Many orthopaedic surgeons in South Australia, for example, accept the rebates from 'no gaps' products and so a good surgeon in Adelaide may be found without out-of-pocket medical expenses. In New South Wales, where the cost of living is higher, but health insurance rebates are exactly the same, very few top orthopaedic surgeons agree to accept the 'No Gaps' products, meaning that patients will face 'gaps' even with full insurance.

Surgery in sports medicine can roughly be divided into day-case procedures (arthroscopes of most joints) where hospital fees are minimised and full admission procedures (including joint reconstructions) where hospital fees for the uninsured patient are much more expensive. An approximate guide to the costs is presented in the table below:


Arthroscope Reconstruction

Surgeon's fee:
approx $1000-$1800 approx $1500-2500

Surgeon's 'gap':
up to $1200 up to $1500

Anaesthetist's fee:
approx $400-600 approx $500-700

Anaesthetist's ‘gap’:
up to $300 up to $400

Assistant's fee:
approx $150-250 approx $200-400

Assistant's ‘gap’:
up to $200 up to $300

Other providers may be needed (e.g. X-ray, pathology)



Total medical fees:
up to $3000 up to $4000

Total medical ‘gaps’:
up to $2000 up to $3000

Theatre & hospital fees:
approx $1500-2000 approx $2500-5000

Total costs: $4000-$5000 $8000-9000


The above doctor fees are covered mainly by Medicare, but in most cases the 'gap' cannot be insured against, so this represents out of pocket expenses for the patient, even with private health insurance.

Hospital fees may be covered fully by private health insurance, but may be subject to excess payments or complete payment by the patient in the case of someone without private health insurance.

Therefore total cost for an arthroscopy procedure may be $4000-$5000, or for a reconstruction $8000-9000, with the patient subject to a percentage of these costs depending on insurance status.

Medicare reimbursement in the US is capitated..which means one lump sum for your work. Your numbers are accurate..an orthopedist gets $1500 for the surgery...but those 15 C notes also cover post op rounds while the pt is in the hospital post-op, and the subsequent outpatient office visits. So the 1500 is not just for the cuppla hours of surgery.

Orthopedist's have much higher overhead than anesthesia...they have to have an office for seeing patients, with secretaries/nurses/etc, and a billing area. I dont know what their overhead is, but I'd venture a guess at 30%...35%...

Anesthesiologists only need a billing office, and if you run your own efficiently you can approach 6-7% overhead. Or you can hire a billing service who typically charge 7-8% overhead. So you intelligently ask, "Why would you go through the trouble of doing the billing on your own to save 1-2%?"
Well, if your practice is doing 5-6 mil in annual revenue then you've saved a significant chunk of change.

Not trying to up-play anesthesia or downplay ortho- cause I'm not...ortho is a great field with high income potential.
Just trying to enlighten you on how to look at that $1500 surgeon's fee in a more realistic fashion.
 
jetproppilot said:
Medicare reimbursement in the US is capitated..which means one lump sum for your work. Your numbers are accurate..an orthopedist gets $1500 for the surgery...but those 15 C notes also cover post op rounds while the pt is in the hospital post-op, and the subsequent outpatient office visits. So the 1500 is not just for the cuppla hours of surgery.

Orthopedist's have much higher overhead than anesthesia...they have to have an office for seeing patients, with secretaries/nurses/etc, and a billing area. I dont know what their overhead is, but I'd venture a guess at 30%...35%...

Anesthesiologists only need a billing office, and if you run your own efficiently you can approach 6-7% overhead. Or you can hire a billing service who typically charge 7-8% overhead. So you intelligently ask, "Why would you go through the trouble of doing the billing on your own to save 1-2%?"
Well, if your practice is doing 5-6 mil in annual revenue then you've saved a significant chunk of change.

Not trying to up-play anesthesia or downplay ortho- cause I'm not...ortho is a great field with high income potential.
Just trying to enlighten you on how to look at that $1500 surgeon's fee in a more realistic fashion.

Ommitted from the above example that the $1500.00 was for a total knee replacement.
 
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look at reimbursement per hour worked to achieve that...
overhead for a good efficient office is about 40-45%, an average office 55% a poorly run or too quickly expanding office can be up to 80%...

an anesthesiologist has no overhead except for billing...
 
it looks like you have good grasp on the numbers

for example...lets say you have 3 knee reconstructions on 1 6 hour list
reasonable?

And lets say its your average 38 year old ortho whos been in practice for 3 years now...so he's no ruler of the roost who only does private work on gold card war veterans and charges 5000 per knee...

so three cases = 3*2100 = 6300

and the anesthetist gets 3* 700 = 2100

surgeons cost you say is 30% which gives him 4200 and anesthetist by contrast takes home 93% of what he makes = 1950

now lets extrapolate this into a week.....an anesthetist could probably do eight 6 hour lists a week = $16,000?

This is where I'm lost....how many such knee reconstruction lists could a surgeon do considering he needs time in clinic, post op and other B.S.

thanks.
 
ALTorGT said:
it looks like you have good grasp on the numbers

for example...lets say you have 3 knee reconstructions on 1 6 hour list
reasonable?

And lets say its your average 38 year old ortho whos been in practice for 3 years now...so he's no ruler of the roost who only does private work on gold card war veterans and charges 5000 per knee...

so three cases = 3*2100 = 6300

and the anesthetist gets 3* 700 = 2100

surgeons cost you say is 30% which gives him 4200 and anesthetist by contrast takes home 93% of what he makes = 1950

now lets extrapolate this into a week.....an anesthetist could probably do eight 6 hour lists a week = $16,000?

This is where I'm lost....how many such knee reconstruction lists could a surgeon do considering he needs time in clinic, post op and other B.S.

thanks.

An orthopedic surgeon in an efficient OR (flipping rooms) could do 3 knees in six hours...but that an extremely fast orthopedist in the best OR...so your example is like best case scenerio.
More realistic is 6-9 hour total time for 3 total knees.
Most knee replacements are medicare...so he can charge whatever he wants, but hes gonna collect 1500 bucks. I'd say the rare insurance total knee probably pays twice that, maybe a little more.

All your questions of extrapolating are good, and valid, but the money you make, no matter what specialty you are in, is VERY dependent on, probably in order of importance,
1)where you live
2)what your medicare ratio is...the lower the better if youre speaking from a monetary perspective
3)How capitated your insurance contracts are...typically the more competition you have, the higher the HMO penetrance...and the higher the chance of hospitals you are affiliated with striking deals with insurance companies...you can be a "provider" for the insurance company, which almost forces you to provide competetive rates...or risk losing business.
But say there is only one group in town...gives you more leverage, you can be a "non-provider", which means the insurance company has to pay you higher rates, since they'll pay you what you bill, within reason.
4)Surgical volume
5)OR efficiency

Notice I placed volume below a buncha factors. If you're in a premium position...say, for example, youre a group of ENTs in a midsize city...say, Mobile Alabama...and your group is the only one in town...you can target your practice to tonsillectomies, FESS's, PETs....most of these people will be kids and young people...youre the only group in town so you dont have to slash your billing since the insurance companies cant capitate you.
So you continue to charge, and more importantly, collect $2500 or so for a 30-45 minute case.
Practice in a busy city with alotta other groups competing with you, and your fee may have to be cut in half.
So WHAT you get paid per case is usually more important than how many cases you do...you can see in the above ENT dude, because he picked a premium location, will make equal money for half as much work...since he's making twice as much per case...or could make double the money for equal work. So reimbursement in medicine is analagous to the top three most important factors affecting real-estate prices...location, location, location.

A comfortably busy orthopedist does around 30 cases a month, total. Your example of 15 cases a week...never seen it. Not to say theres not ortho dudes doing that, but 25-40 cases a month for ortho is more realistic.

So getting back to your numbers example, its not really realistic to do that...to try and extrapolate what you'll make...until you decide where you are going to practice...then you can start looking at medicare ratio, how much competition you have in town, degree of HMO penetrance, and degree of insurance capitation.

The reason I say that is the annual salaries for EVERY specialty vary widely..you may make 500% more in a premium area than a poor chap in the worst scenerio.....
 
I understand what you say about picking location with less competition if you want to earn more per case. But assuming you're comparing apples with apples...i.e an orthopaedist and an anaesthetist in the same location, how does it work out.

Even if the orthopaedist manages only 30 cases per month in a given location, how much will an anesthetist working in the same location fare and how will the dynamics of their compensation work (comapring practicing costs of 30-35% that you quoted above vs 7% only for billing for anaesthetics etc....)





jetproppilot said:
An orthopedic surgeon in an efficient OR (flipping rooms) could do 3 knees in six hours...but that an extremely fast orthopedist in the best OR...so your example is like best case scenerio.
More realistic is 6-9 hour total time for 3 total knees.
Most knee replacements are medicare...so he can charge whatever he wants, but hes gonna collect 1500 bucks. I'd say the rare insurance total knee probably pays twice that, maybe a little more.

All your questions of extrapolating are good, and valid, but the money you make, no matter what specialty you are in, is VERY dependent on, probably in order of importance,
1)where you live
2)what your medicare ratio is...the lower the better if youre speaking from a monetary perspective
3)How capitated your insurance contracts are...typically the more competition you have, the higher the HMO penetrance...and the higher the chance of hospitals you are affiliated with striking deals with insurance companies...you can be a "provider" for the insurance company, which almost forces you to provide competetive rates...or risk losing business.
But say there is only one group in town...gives you more leverage, you can be a "non-provider", which means the insurance company has to pay you higher rates, since they'll pay you what you bill, within reason.
4)Surgical volume
5)OR efficiency

Notice I placed volume below a buncha factors. If you're in a premium position...say, for example, youre a group of ENTs in a midsize city...say, Mobile Alabama...and your group is the only one in town...you can target your practice to tonsillectomies, FESS's, PETs....most of these people will be kids and young people...youre the only group in town so you dont have to slash your billing since the insurance companies cant capitate you.
So you continue to charge, and more importantly, collect $2500 or so for a 30-45 minute case.
Practice in a busy city with alotta other groups competing with you, and your fee may have to be cut in half.
So WHAT you get paid per case is usually more important than how many cases you do...you can see in the above ENT dude, because he picked a premium location, will make equal money for half as much work...since he's making twice as much per case...or could make double the money for equal work. So reimbursement in medicine is analagous to the top three most important factors affecting real-estate prices...location, location, location.

A comfortably busy orthopedist does around 30 cases a month, total. Your example of 15 cases a week...never seen it. Not to say theres not ortho dudes doing that, but 25-40 cases a month for ortho is more realistic.

So getting back to your numbers example, its not really realistic to do that...to try and extrapolate what you'll make...until you decide where you are going to practice...then you can start looking at medicare ratio, how much competition you have in town, degree of HMO penetrance, and degree of insurance capitation.

The reason I say that is the annual salaries for EVERY specialty vary widely..you may make 500% more in a premium area than a poor chap in the worst scenerio.....
 
Hey all
2 Things

1. Im surprised that nobody has mentioned CRNA's. An anesthesiologist still makes $$ on the cases they do, even though the overhead is increased.

2. From my very limited exposure to surgery, it seems like most surgeons spend 2-3 days/wk operating, or maybe doing a majority in the morning, and then it's off to the office. You guys mentioned the fact that the surgeons reimbursement covers followup etc, but what about getting new patients for non-emergent cases? It doesn't seem like surgeons make too much $$ on new pt's after their office expenses are covered.
 
what all of you are forgetting is that procedures bring in the MONEY...

and an anesthesiologist can be in the OR 100% of the time... whereas a surgeon needs to be in the clinic no matter how many PAs he/she has at least 1-2 days/week....

so 5 days a week of money earning by the procedure compared to 3 days a week with the additional time spent pre-rounding, post-rounding, OR take-backs etc... evens the playing field to our advantage
 
Tenesma said:
what all of you are forgetting is that procedures bring in the MONEY...

and an anesthesiologist can be in the OR 100% of the time... whereas a surgeon needs to be in the clinic no matter how many PAs he/she has at least 1-2 days/week....

so 5 days a week of money earning by the procedure compared to 3 days a week with the additional time spent pre-rounding, post-rounding, OR take-backs etc... evens the playing field to our advantage

Today's work: Exploration of spinal fusion for possible infected hardware. 13 point start, A line, CVP, 13 points for time (two hours 6 minutes), private insurance. $1,200-$1,300. I should have billed for critical care setup afterward as well, but oh well.
 
do VATS cases all day... each one gets a thoracic epidural and an a-line --- the units add up quickly - especially if you have fast thoracic surgeons
 
Tenesma said:
do VATS cases all day... each one gets a thoracic epidural and an a-line --- the units add up quickly - especially if you have fast thoracic surgeons


vats dont get thoracic epidurals.. unless.. there is a great possiilty of Thoracotomy
 
sorry... i should have been more specific VATS lobectomies with mini-thoractomy incision
 
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