T+A reimbursement

[boondocksaint]

Hey everyone. Just a curious MSIV here. Does anyone know the average reimbursement for a tonsillectomy/adenoidectomy by private insurance versus medicare? And what percentage of that reimbursement would a typical doc be able to keep for themselves after overhead? I'm curious because I've seen some ENT's stop doing tonsillectomies due to "lower reimbursement" but then I've seen other's have an entire day devoted to like 12 of them. Anyone have any answers? Thanks.

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[LADoc00]

Hey everyone. Just a curious MSIV here. Does anyone know the average reimbursement for a tonsillectomy/adenoidectomy by private insurance versus medicare? And what percentage of that reimbursement would a typical doc be able to keep for themselves after overhead? I'm curious because I've seen some ENT's stop doing tonsillectomies due to "lower reimbursement" but then I've seen other's have an entire day devoted to like 12 of them. Anyone have any answers? Thanks.

A now retired ENT told me that he was paid less this year for T+As than he was in frickin 1972 when he was fresh out of training! And that is not even accounting for inflation!!!

 

[neutropeniaboy]

The Centers for Medicare and Medicaid list the facility fee for a T&A (CPT 42826) at $230 to $300, depending on region. The work RVU is 3.37; the nonfacility PE RVU is 3.04; and the facility PE RVU is 3.04.

BTW, the above for tubes (CPT 69436) is about $150 to $220.

When you think about it, that's not bad for 15 minutes of work. But, we should get more for the follow-up. I don't know what the global period is for either of these.

 

[GSresident]

A now retired ENT told me that he was paid less this year for T+As than he was in frickin 1972 when he was fresh out of training! And that is not even accounting for inflation!!!

Not a suprise at all. Just randomly I came across a fee schedule for various general surgery procedures in one county in Illinois from 1934. Back then a hernia repair paid around $350. Today you would be lucky to get that and I didn't adjust those numbers for inflation, those are 1934 dollars. I'll leave it to you to figure out what that would be worth today. Appendectomy paid around $700. You won't see $700 today for the same procedure.

Neutropeniaboy writes:

When you think about it, that's not bad for 15 minutes of work. But, we should get more for the follow-up. I don't know what the global period is for either of these.

It would be great if it was just 15 minutes of work. The fact is that the average ENT doc spent 13 years after highschool becoming an ENT doc. Have you called a plumber lately? Just before we sold our house a pipe started leaking where it was connected to a faucet. Whoever installed the faucet screwed it on too tight and the brass fitting cracked. The bill for the plumbers 30 minutes of work was about $250. How much does it cost to get brakes done on your car? I started doing my own car work because I have a VW jetta and the dealer wanted $550 to replace the rear brake pads and grind the rotors. He wanted an additional $220 to flush the brake lines. I told him to go fly a kite, bought the Bentley manual for VW service, a $20 rear brake calipur tool from metalnurds and a $30 power brake bleeder from parts4vw I was in business. I bought all new rotors and pads for $130 total. It took me 1 hour to change out the rear rotors and pads and bleed the brake lines. Total cost $180. Somehow a mechanic's time is worth $590 an hour but yours isn't? Give me a brake (parden the pun.)

Have you ever tried telling the mechanic that you are only going to pay 80% of his bill? Ever tried that with a plumber? Have you ever gone to the grocery store and bought $100 worth of groceries and just paid $80? I haven't, yet somehow I am expected to tolerate that treatment?

 

[boondocksaint]

I forgot about follow-up being included in the surgical fee. And even though the surgeon may make $400 for a tonsillectomy, if he/she is going to do them in 15min, they will require either the fastest turnover team in the country, or more than one room going at once. This adds up to overhead too if I'm not mistaken. So what's the ballpark "take-home" for a surgeon on that number? Like 50%? I've heard in ophtho their overhead is like 90%.

It sucks being a 4th year and still being on the ropes about what to do. I like a few subspecialities, and am trying to the find the one's that will lead to still-comfortable pay (250K/yr without having to bust out 70hr weeks as an attending) over the long-term with good job security. And that's hard! Primary care has the NP threat to their overall practice, and places would rather hire a PA for less than an MD as well. I see ED's in my area being staffed with increasing numbers of PAs, which in turns means less jobs for MD. Anesthesia has their CRNA threat (they have some battles over at their board about that). OB has midwives. Rads is worried about outsourcing, or the threat of big companies like nighthawk controlling salaries (but they do make a killing at the moment. Can't look at pics all day though.) Ophtho is worrying more and more every day about optometrists gaining surgical rights (I must admit, this is the one I'm least concerned about from a medical patient-care standpoint but most concerned about from a practical standpoint, as those OD's spend 4yrs in school learning about just the eye. If you add on a 3yr surgical residency, I'd be hard pressed to say they aren't qualified to recognize and treat occular disease, and to refer to a primary care doc if they see signs of systemic disease. Hopefully people will wake up and prevent this from happening. I'm still of the mantra if you wanna be a surgeon, just go to med school. The system has been in place for years, how come now everyone wants to just up and change it?)

Anyway, the point is, the surgical specialites seem to the be the most immune from outside competition, as even the lay person knows they want an MD-surgeon cutting them open (again, the ophtho thing is different as most people don't know the difference between an optom and and ophthal). And since medicine is a job, albeit one with the added responsibility to put patients first, I want my job to be secure in the future. And since I've found I pretty much like both surgery and clinic (and thus my interest in ent, ophtho, uro, ect), I'm looking towards the surgical subspecialties. Hence my curiosity about this subject.

The more info the better, so please keep it coming. Sorry for the long post. Losts of concerns on my mind given I have like 2 months to get my act together and decide.

 

[GSresident]

It is good that you are thinking about these issues now instead of later when there is little you can do about your choice. Here is how I would approach your decision.

1) The most important thing is that you will be happy doing whatever it is you end up doing for the rest of your life. Don't do something that you find boring just because it has an 'easier' lifestyle.

2) In the end, if you provide a healthcare service that people need, assume that you will eventually be prociding that service for very low cost. Like it or not, in this country 70% of people think that healthcare is a right. The fact that they need healthcare and you provide it means that they have a right to your services. In the minds of a lot of people, you should be doing cartwheels to be paid anything given that they have a right to your services. Ask teachers about the wonderful things that the right to education has done for their profession. I can't say whether or not we will end up with a socialized system, but it can't continue the way it is now.

3) The bottom line in healthcare is money. It may not be to you, but it is to the people who will be paying your bill. The ideal situation for the insurance company is to collect premiums and not have to pay for any care. In some cases the insurance company is able to accomplish that, but in most they have to pay something to someone. Have you looked lately at what is excluded from your health insurance policy? If the insurance company has to pay, then they want to pay very little. What this translates into is lower level providers providing care for less money. Walk-in care centers at Walgreen's are a perfect example. Most of us aren't at the age when we go to the doctor's office much, but if you were you would see that nurse practitioners do almost everything now. I took our baby to the pediatrition's office recently for a new patient visit - she saw the PA but not the physician.

4) Because money is the bottom line, I would avoid going into a specialty that can be done by lower level providers or that can be mass-produced in a medi-factory. Take a look around at some of the other boards on these forums for an idea of what I am talking about. Specifically look at what is happening to pathology and radiology with regards to the reading of films and slides. Some very disturbing things are happening there. Even though anesthesia seems like a great deal right now, I would avoid it like the plague. I have very many friends who are anesthesiologists and they hate it when I say these four letters - C R N A. I have scrubbed on all different kinds of surgeries from simple breast biopsies to liver transplants to GSW's to the heart. I have seen CRNA's perform very well in a wide variety of cases, delivering excellent care for less money. If I am seeing this, so are the insurance companies. I have worked in numerous environments where the only anesthesia available was from CRNA's so don't try to tell me it isn't possible.

5) Spend some quality time in the doctors lounge and listen to the attendings talk. Take notice of which ones are generally happy and which ones are angry and bitter. Having been in the surgery game now for over 5 years (board eligible) I can tell you that some specialties are happy and some are pissed and for good reason. I'll leave it to you to do your own research.

 

[boondocksaint]

5) Spend some quality time in the doctors lounge and listen to the attendings talk. Take notice of which ones are generally happy and which ones are angry and bitter. Having been in the surgery game now for over 5 years (board eligible) I can tell you that some specialties are happy and some are pissed and for good reason. I'll leave it to you to do your own research.[/QUOTE]

I'd love to hear more about your experiences here. I do have some idea given I've done my surgery months, but with 5 years, you've got me handily beat in exposure to surgeons. From my limited experience I have seen general surgeons 90% of the time telling me to be a radiologist. I have heard Neurosurgeons saying they love it, but if there's a chance you may want a family, don't do it. I've heard ENTs who are basically in love with their specialty, but hate declining reimbursement. The happier ones seem to do a decent amount of facial plastics.... I have seen some orthopods who love doing total knee and hips, and some who say they don't pay enough enough. Vascular love it, but seem to echo the neuro guys with the whole family thing. Thoracic... they seem pretty cool with their lives. Colorectal seem to be decently happy, but those who do more big ops versus scopes have directly said go into a RAP field. Plastics....well, they're plastics. They love it, and judging from their outfits and cars, are doing "comfortably." Too bad it's impossible for me to try for plastics now (with I'd done more thinking during 2nd and 3rd years instead of just focusing on getting through the years). Since you're a GS resident, how impossible is it to get into plastics after GS considering many programs are moving towards integration?

So after all that, who am I missing that is happy with their work, life, and compensation in the surgical fields? I understand your reluctance to divulge more info, but with a major life decision looming just ahead of me, I gotta at least ask ya know?

 

[neutropeniaboy]

Are you preaching, or did you think I was that naive?

It would be great if it was just 15 minutes of work. The fact is that the average ENT doc spent 13 years after highschool becoming an ENT doc. Have you called a plumber lately? Just before we sold our house a pipe started leaking where it was connected to a faucet. Whoever installed the faucet screwed it on too tight and the brass fitting cracked. The bill for the plumbers 30 minutes of work was about $250. How much does it cost to get brakes done on your car? I started doing my own car work because I have a VW jetta and the dealer wanted $550 to replace the rear brake pads and grind the rotors. He wanted an additional $220 to flush the brake lines. I told him to go fly a kite, bought the Bentley manual for VW service, a $20 rear brake calipur tool from metalnurds and a $30 power brake bleeder from parts4vw I was in business. I bought all new rotors and pads for $130 total. It took me 1 hour to change out the rear rotors and pads and bleed the brake lines. Total cost $180. Somehow a mechanic's time is worth $590 an hour but yours isn't? Give me a brake (parden the pun.)

Have you ever tried telling the mechanic that you are only going to pay 80% of his bill? Ever tried that with a plumber? Have you ever gone to the grocery store and bought $100 worth of groceries and just paid $80? I haven't, yet somehow I am expected to tolerate that treatment?

 

[GSresident]

Trying to get you fired up.

When you think about it, that's not bad for 15 minutes of work.

Sounded a little too accepting.

 

[TheThroat]

Find me a doc who DOESN'T complain. The fact is that the golden years of reimbursement are OVER. Docs who want to make serious money (>$500K) are reinvesting into ancillary money making ventures. For the oto, there is:

-audiology and hearing aids
-surgery centers
-CT scanners
-sleep labs
-videostrobes
-prob a few more that I can't think of