The movement towards hourly paid models

[aneftp]

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A little birdie (well not a little birdie, a personal friend of mine’s of over 25 years and this was her previous own private group as well as my sisters previous anesthesia group) informed me a mid Atlantic area with private equity backed anesthesia practice (that also has sites in multiple states) is moving forward with paying their employee docs strictly on an w2 hourly model. The salary model is vague gentlemen’s agreement hours of 40-45 hrs a week with some short long days are over.

This will be effective July 1 2025

Right now they are more productively based with the partners. But having tremendous issues hiring (like most anesthesia practices).

People want to clock in and out like locums

Embrace the future folks. Work more, get paid more. Work less get paid less.

Crnas are years ahead of us with the hourly model.

What’s gonna to really kill hospitals or employers with the hourly model is the calls hours. They are gonna to have to pay docs for their time. Especially premium pay for nights and weekends.

And the biggest elephant in the room employers do not want to address. HOW MUCH IS BEEPER CALL WORTH? I’ve explained to multiple people our time is not cheap when we are tied to being called in. And is not $100/hr to be on beeper plus whatever call back you negotiate ($400-500/hr). It will have to come with 8-12 hr $400/hr call guarantees regardless if you work or not.

Or they just won’t find anyone to take beeper calls. It’s that simple. The in house call pay is easier traditionally to understand. The beeper call pay is very difficult to understand to many of you on these message board.

This is how you advance the compensation of anesthesiologists. It’s the long game to play. And far cheaper than the 1099 locums model which is very costly.

 

[amyl]

My old shop is finally getting that no one wants to be a partner these days. Hell, I happily gave up my partnership that I slaved for to become an employee. They’re making everyone an employee. Metro tried to do this awhile back and it didn’t work. It’s hard to mix the two. The metro guys I spoke to said they were happy with the quality of doc they got - not clinically - but team player-wise. They didn’t want to pick up or help out unless they were extra extra compensated. I think the metro partners expected them to act like metro partners - and pitch in and help when asked. A division of USAP tried this mixed partner/employee model in 2017 and it didn’t work. It’s hard to mix a workforce of partners and employees. Usually one group feels like they aren’t being treated fairly.
I interviewed with a nice pp group I would’ve liked in NC. They really wanted a partner track person but I wasn’t going to take that much of a pay cut so I asked them to put together an employed deal for me. It sucked in terms of the number undesirable hours worked for the money. Lots of weekend call. They knew the $ id been offered elsewhere and to make the numbers work for them without a partnership buyin I was going to have to work 18 weekends a year. The work was ridiculously easy but any of my time is valuable. I also wasn’t sure how stable their contract with the hospitals were - Okay for now but a year or two ?
the sooner any pp or hospital or amc realize that it’s $/h w a premium in weekend and night work - that’s the only way you’ll hire good people

 

[aneftp]

My old shop is finally getting that no one wants to be a partner these days. Hell, I happily gave up my partnership that I slaved for to become an employee. They’re making everyone an employee. Metro tried to do this awhile back and it didn’t work. It’s hard to mix the two. The metro guys I spoke to said they were happy with the quality of doc they got - not clinically - but team player-wise. They didn’t want to pick up or help out unless they were extra extra compensated. I think the metro partners expected them to act like metro partners - and pitch in and help when asked. A division of USAP tried this mixed partner/employee model in 2017 and it didn’t work. It’s hard to mix a workforce of partners and employees. Usually one group feels like they aren’t being treated fairly.
I interviewed with a nice pp group I would’ve liked in NC. They really wanted a partner track person but I wasn’t going to take that much of a pay cut so I asked them to put together an employed deal for me. It sucked in terms of the number undesirable hours worked for the money. Lots of weekend call. They knew the $ id been offered elsewhere and to make the numbers work for them without a partnership buyin I was going to have to work 18 weekends a year. The work was ridiculously easy but any of my time is valuable. I also wasn’t sure how stable their contract with the hospitals were - Okay for now but a year or two ?
the sooner any pp or hospital or amc realize that it’s $/h w a premium in weekend and night work - that’s the only way you’ll hire good people

There is way more transparency in the hourly model.

The reason the mix private partners and hourly model doesn’t work well is the private partners need to skim off the employees. That’s how it had already worked the past 45-50 plus years in current anesthesia world. Because paying the employees a flat hourly rate completely destroys the mooching off money off the employees because employees knows the are getting money taken off their backs working more. Except they don’t know how much money is being taken off

With the hourly model. The employee at least knows they will get paid a certain amount for hours worked.

 

[Howard888]

This is all
Absolutely correct. Unfortunately it will be the death of most practice as private practices rely on revenue generated +stipends and the hourly model really only works if you’re contracted that way (so must be employed by some entity or locum type employment). However if good hourly rates come out of it employment isn’t terrible. It’s unfortunate to lose autonomy via private practice but end of day it’s about money for time.

The beeper call is also absolutely correct. I’ve told many a locums company my time is my time it doesn’t matter if I’m working or not especially if I have to be available in 30 minutes. I don’t feel that enough of the anesthesia work force is on the same page though. I still see many doing beeper call for $100/hr like you mention.

 

[aneftp]

This is all
Absolutely correct. Unfortunately it will be the death of most practice as private practices rely on revenue generated +stipends and the hourly model really only works if you’re contracted that way (so must be employed by some entity or locum type employment). However if good hourly rates come out of it employment isn’t terrible. It’s unfortunate to lose autonomy via private practice but end of day it’s about money for time.

The beeper call is also absolutely correct. I’ve told many a locums company my time is my time it doesn’t matter if I’m working or not especially if I have to be available in 30 minutes. I don’t feel that enough of the anesthesia work force is on the same page though. I still see many doing beeper call for $100/hr like you mention.

Yup. My friend has one case so far today. Even if he fudges the billing. He’s only looking at billing for 3 hrs and it’s 6 hrs already that’s he’s been “on call”

$100/hr beeper rate plus hourly pay. I just can’t do that.

I’d rather run errands Costco , than the pool and chill and not be worried about the hospital calling me in

They can be so many alternatives to beeper call coverage compensation in that if they want u on for 24 hrs. You should get pay u 8-12 hrs full pay the next day as well and not work.

Either way. Sitting around for $100/hr doesn’t work for me. Weeknight or weekend doesn’t work for me. And I don’t even drink alcohol. So drinking isn’t the rate limiting step to not being on beeper. It’s time and money.

 

[dmk5n]

some second order effects to ponder:

• nobody will be invested in running the department, running the board, going to meetings...
• some guys only cover easy gallbladder, gyn cases and others cover GI with 40 cases or do the cardiac cases.
• for context: We can barely hire locums. and when they arrive, they don't do kids, wont do blocks, wont do hearts, etc...we have to treat them with kid-gloves or they won't come back.

 

[GravelRider]

some second order effects to ponder:

• nobody will be invested in running the department, running the board, going to meetings...
• some guys only cover easy gallbladder, gyn cases and others cover GI with 40 cases or do the cardiac cases.
• for context: We can barely hire locums. and when they arrive, they don't do kids, wont do blocks, wont do hearts, etc...we have to treat them with kid-gloves or they won't come back.

Agreed. The second order effects are that these PE practices don’t do anything without cost savings in mind. What happens when the OR schedule is light that week? Are you paid for your full shift? Are you sitting around doing scut tasks until your shift is over? What happens when ORs are running late and they don’t have relief for you?

Of course there are also the downstream effects of demonstrating how easily interchangeable we are to everyone in the OR.

I am definitely a proponent of more hourly arrangements and transparency in how we are compensated for our time, but there are downsides and risks to consider with these models.

 

[Dantrolene FC]

Agreed. The second order effects are that these PE practices don’t do anything without cost savings in mind. What happens when the OR schedule is light that week? Are you paid for your full shift? Are you sitting around doing scut tasks until your shift is over? What happens when ORs are running late and they don’t have relief for you?

Of course there are also the downstream effects of demonstrating how easily interchangeable we are to everyone in the OR.

I am definitely a proponent of more hourly arrangements and transparency in how we are compensated for our time, but there are downsides and risks to consider with these models.

The key here is to structure it as a salary with an hourly route if you stay late or work an extra shift. That way if you leave two hours late, you get paid extra. But if you leave two hours early, you get paid a full day’s wage.

 

[PainInTheAnes]

Agreed. The second order effects are that these PE practices don’t do anything without cost savings in mind. What happens when the OR schedule is light that week? Are you paid for your full shift? Are you sitting around doing scut tasks until your shift is over? What happens when ORs are running late and they don’t have relief for you?

Of course there are also the downstream effects of demonstrating how easily interchangeable we are to everyone in the OR.

I am definitely a proponent of more hourly arrangements and transparency in how we are compensated for our time, but there are downsides and risks to consider with these models.

I think the examples dmk5n provided show that we're not interchangeable. The solution to me is differential rates for willingness/ability to do certain cases. Can't do something specific? Lower rate. Can do kids, cardiac, blocks, sick patients? Higher rate.

 

[GravelRider]

I think the examples dmk5n provided show that we're not interchangeable. The solution to me is differential rates for willingness/ability to do certain cases. Can't do something specific? Lower rate. Can do kids, cardiac, blocks, sick patients? Higher rate.

But when people are clocking in and out, are we not demonstrating interchangeability?

 

[PainInTheAnes]

But when people are clocking in and out, are we not demonstrating interchangeability?

I suppose, but there are many specialties where this occurs. General surgery has traumatologists in ICUs who take emergency surgery call while in ICU. OB has laborists that do 12s or 24s.

The international space station also has shift work 😉

 

[GravelRider]

I suppose, but there are many specialties where this occurs. General surgery has traumatologists in ICUs who take emergency surgery call while in ICU. OB has laborists that do 12s or 24s.

The international space station also has shift work 😉

“Traumatologists” don’t have a legion of midlevels engaged in an aggressive political campaign to be seen as co-equals to their physician counterparts.

 

[sbmed100]

You are advocating for the end of private practice...hell, you are basically calling for hospital employment for every group. And yes we will all pretty much be widgets to them and when supply increases they will lower this hourly rate. Until then we degrade the profession with our interchangeability. There is no incentive to provide good service to the hospital and we will reap what we sow.

 

[aneftp]

Agreed. The second order effects are that these PE practices don’t do anything without cost savings in mind. What happens when the OR schedule is light that week? Are you paid for your full shift? Are you sitting around doing scut tasks until your shift is over? What happens when ORs are running late and they don’t have relief for you?

Of course there are also the downstream effects of demonstrating how easily interchangeable we are to everyone in the OR.

I am definitely a proponent of more hourly arrangements and transparency in how we are compensated for our time, but there are downsides and risks to consider with these models.

What is your answer than? I just got paid $4800 1099 last night to do nothing 7p-7a locums on call from my own bedroom. Because no one else will do the beeper call without the call guarantees. People have gotten smart. Ur time is worth a lot of money. It’s not $1200 for 12 hrs beeper. It’s $4800 for 12 hrs beeper whether I’m there all night or not. I’m fine with that.

Payor mix and hospitals subsidies determine anesthesia revenue. No way to do own anesthesia billing unless you got some crazy lucrative 80% commercial paying private ob anesthesia practice that’s fairly busy. Those are so rare the days.

If OR is light. That’s the hospitals problem. Lock out the schedule 4 weeks in advance. If you don’t need me. Cancel me outside of 30 days per contract. I’m fine with that. Surgery centers can cancel me within 2 weeks of work. Im fine with that. Set the terms and abide by it.

Pay me within 30 or 14 days. That’s what an administrator gets paid to do. Fix things. Find solutions. If or is light for the week. It’s a you (employer problem). Not my problem. Hospitals need to change their models as well.

The times are changing. Everyone can’t stick to the old style of work model. They get outdated. And are outdated.

I joke about chaos in all aspects of life. But chaos is very good for locums.

I know the best solution to fix 90% of OR after hours coverage. But no one listens. I’d just shut down all ORs by 7pm in most major cities. Since there are so many mergers and acquisitions. Big hospitals systems like inova in northern Virginia can just transfer all their patients after hours to the main inova fairfax level 1. That’s an instant 30-50 millions savings for the hospital system each year not to have staff after 7pm.

But what do I know? I just like to collect the cash these days. That’s what I mean by how dumb hospital administrators are. They are so focus on marketing they don’t see the big picture.

 

[gunnershow]

What is your answer than? I just got paid $4800 1099 last night to do nothing 7p-7a locums on call from my own bedroom. Because no one else will do the beeper call without the call guarantees. People have gotten smart. Ur time is worth a lot of money. It’s not $1200 for 12 hrs beeper. It’s $4800 for 12 hrs beeper whether I’m there all night or not. I’m fine with that.

Payor mix and hospitals subsidies determine anesthesia revenue. No way to do own anesthesia billing unless you got some crazy lucrative 80% commercial paying private ob anesthesia practice that’s fairly busy. Those are so rare the days.

If OR is light. That’s the hospitals problem. Lock out the schedule 4 weeks in advance. If you don’t need me. Cancel me outside of 30 days per contract. I’m fine with that. Surgery centers can cancel me within 2 weeks of work. Im fine with that. Set the terms and abide by it.

Pay me within 30 or 14 days. That’s what an administrator gets paid to do. Fix things. Find solutions. If or is light for the week. It’s a you (employer problem). Not my problem. Hospitals need to change their models as well.

The times are changing. Everyone can’t stick to the old style of work model. They get outdated. And are outdated.

I joke about chaos in all aspects of life. But chaos is very good for locums.

I know the best solution to fix 90% of OR after hours coverage. But no one listens. I’d just shut down all ORs by 7pm in most major cities. Since there are so many mergers and acquisitions. Big hospitals systems like inova in northern Virginia can just transfer all their patients after hours to the main inova fairfax level 1. That’s an instant 30-50 millions savings for the hospital system each year not to have staff after 7pm.

But what do I know? I just like to collect the cash these days. That’s what I mean by how dumb hospital administrators are. They are so focus on marketing they don’t see the big picture.

You're basically saying you can't have more than 1 trauma center in a city. Or that a postsurgical takeback or duodenal perf in the ICU has to be shipped across town.

 

[aneftp]

You're basically saying you can't have more than 1 trauma center in a city. Or that a postsurgical takeback or duodenal perf in the ICU has to be shipped across town.

U can ship almost any patient from hospital to hospitals with the right coordination in less than 1 hr.

The rules allow patients to be shipped within 30 miles I believe (give or take) without their consent.

Remember most of the road blocks for transferring patients is due to Medicare reimbursement punishment for transferring patients. That’s why these crazy policy making metrics these Obamacare lovers love to cite to save money for Medicare doesn’t really work in real life. The Medicare punishment on transfers. Payment reductions etc.

 

[PainInTheAnes]

You're basically saying you can't have more than 1 trauma center in a city. Or that a postsurgical takeback or duodenal perf in the ICU has to be shipped across town.

I doubt that's the majority of the overnight cases getting done in most hospitals. I bet it's urgent appies, hip fractures that didn't get done that day, and OB.

Fix the OB problem by consolidating and you're already halfway to reducing the burdens.

 

[FatKid]

some second order effects to ponder:

• nobody will be invested in running the department, running the board, going to meetings...
• some guys only cover easy gallbladder, gyn cases and others cover GI with 40 cases or do the cardiac cases.
• for context: We can barely hire locums. and when they arrive, they don't do kids, wont do blocks, wont do hearts, etc...we have to treat them with kid-gloves or they won't come back.

Supply and demand, my friend.

Locums docs used to always get given the garbage cases the full-time people didn’t want to do (NORA, MRI, GI Lab, Cath Lab, EP etc.)

Now, the locums docs don’t NEED to accept that crap anymore…

 

[FatKid]

I doubt that's the majority of the overnight cases getting done in most hospitals. I bet it's urgent appies, hip fractures that didn't get done that day, and OB.

Fix the OB problem by consolidating and you're already halfway to reducing the burdens.

We all know that >75% of “emergencies” being done on-call are being done for Surgeon convenience.

As there becomes more amalgamation and less hospitals for Surgeons to “threaten” Administration to “take their patients elsewhere”, the Surgeons will be forced to accept less Anesthesia availability, unless the Department of Surgery subsidizes the Department of Anesthesia.

Most cities that used to have 5-6 hospitals in the 1990s now only have 2 or 3 …

 

[aneftp]

We all know that >75% of “emergencies” being done on-call are being done for Surgeon convenience.

As there becomes more amalgamation and less hospitals for Surgeons to “threaten” Administration to “take their patients elsewhere”, the Surgeons will be forced to accept less Anesthesia availability, unless the Department of Surgery subsidizes the Department of Anesthesia.

Most cities that used to have 5-6 hospitals in the 1990s now only have 2 or 3 …

Seems the opposite is true in Florida. There isn’t a real certificate of need required anymore. So hospitals pop up after 3 years of standing ER being built. So 3 full service hospitals have been built within a 15 mile radius where I live the last 8 years
2017
2020
2025

That’s in addition two hospitals already being 6 miles and 10 miles from where I live

 

[Drwine]

You are advocating for the end of private practice...hell, you are basically calling for hospital employment for every group. And yes we will all pretty much be widgets to them and when supply increases they will lower this hourly rate. Until then we degrade the profession with our interchangeability. There is no incentive to provide good service to the hospital and we will reap what we sow.

Given the current reimbursement and subsidy situation, everyone is either a hospital employee or a de facto one. Your private practice group is just a doctor's union in disguise.

 

[Lab Lover]

Given the current reimbursement and subsidy situation, everyone is either a hospital employee or a de facto one. Your private practice group is just a doctor's union in disguise.

It is all just about power. Whatever you call it.... Union...Private practice group...supply/demand balance... Non-compete....incriminating stuff on your employer, etc., etc.

 

[ProwlerturnGas]

I have dedicated my work to full time locums now. It has been unbelievably wonderful. More than I expected. I am in complete control of my schedule. No more slimy groups and shady partnerships. I’m done with that nonsense.

Edit: I do all cases except Hearts as I do not have a fellowship in cardiac, which is what everyone demands.

I am never unemployed unless I want an extended break. Maybe I am lucky in the places I pick but have never felt abused. I cannot say the same for my experience in PP groups

 

[nimbus]

I have dedicated my work to full time locums now. It has been unbelievably wonderful. More than I expected. I am in complete control of my schedule. No more slimy groups and shady partnerships. I’m done with that nonsense.

Edit: I do all cases except Hearts as I do not have a fellowship in cardiac, which is what everyone demands.

I am never unemployed unless I want an extended break. Maybe I am lucky in the places I pick but have never felt abused. I cannot say the same for my experience in PP groups

Do you have to travel or can you commute to your assignments from your own house?

 

[aneftp]

Given the current reimbursement and subsidy situation, everyone is either a hospital employee or a de facto one. Your private practice group is just a doctor's union in disguise.

Is anyone’s true private practice existing with no subsidies these days?

Even previous lucrative surgery centers contracts these days can’t survive without subsidies from the facilities.

Straight Anesthesia reimbursement cannot cover anesthesia salaries anymore in 90% of practices?

 

[ERRES2288]

Is anyone’s true private practice existing with no subsidies these days?

Even previous lucrative surgery centers contracts these days can’t survive without subsidies from the facilities.

Straight Anesthesia reimbursement cannot cover anesthesia salaries anymore in 90% of practices?

I know of group in Midwest. No subsidy. Decent payer mix. Do tons of blocks. Partners low 500 and work hard

 

[aneftp]

I know of group in Midwest. No subsidy. Decent payer mix. Do tons of blocks. Partners low 500 and work hard

That’s the trade off.

500k and retain autonomy and work hard….

While the locums are making double that and not working that hard and control their own schedule

That hospital is probably smiling thinking the group isn’t very smart.

Seems to be very similar to private group in Florida I know. Pay in the 500s. 4 doc MD only group. 13 weeks off

 

[NicholasPavona]

I know of group in Midwest. No subsidy. Decent payer mix. Do tons of blocks. Partners low 500 and work hard

Yuck!

 

[Arch Guillotti]

Is anyone’s true private practice existing with no subsidies

Yes. Nurses are hospital empoyees though.

 

[Dantrolene FC]

Yes. Nurses are hospital empoyees though.

Lots of those where I trained. But that’s indirectly a hospital subsidy because the CRNAs are being paid more than collections. So you’re having the hospital lose money on the CRNAs and break even on the anesthesiologists.

 

[nimbus]

I know of group in Midwest. No subsidy. Decent payer mix. Do tons of blocks. Partners low 500 and work hard

How is their recruiting going? Most groups in the 500s need a big subsidy on top of collections in order to recruit and retain staff.

 

[FatKid]

Seems the opposite is true in Florida. There isn’t a real certificate of need required anymore. So hospitals pop up after 3 years of standing ER being built. So 3 full service hospitals have been built within a 15 mile radius where I live the last 8 years
2017
2020
2025

That’s in addition two hospitals already being 6 miles and 10 miles from where I live

This is a good thing.

We need to get rid of this stupid Certificate of Need (CON) requirement in ALL 50 states!

 

[Howard888]

Is anyone’s true private practice existing with no subsidies these days?

Even previous lucrative surgery centers contracts these days can’t survive without subsidies from the facilities.

Straight Anesthesia reimbursement cannot cover anesthesia salaries anymore in 90% of practices?

Yes those where the hospital employs the CRNAs…but that’s basically a subsidy

 

[Arch Guillotti]

Yes those where the hospital employs the CRNAs…but that’s basically a subsidy

Of course it is a de facto subsidy. But you don't have to go begging for money.

 

[maxxor]

This is a good thing.

We need to get rid of this stupid Certificate of Need (CON) requirement in ALL 50 states!

CON should have been repealed nationally when CMS dropped the requirement.

It’s a huge problem that gives hospitals inordinate power.

 

[aneftp]

CON should have been repealed nationally when CMS dropped the requirement.

It’s a huge problem that gives hospitals inordinate power.

Having so many hospitals close together is great for me

I literally can work this weekend hourly Sunday 7am-7p , run across town and take over call 7p-7a Sunday night at hospital number 2. Than the next morning (Monday) 7a-7a and do 24 hrs

It’s incredible the options I have to make extra money. Even if I get stuck with case I’d be late only 15 minutes rushing over.

So you can continuously keep billing and save on commute time covering 3 different hospitals.

My master plan is to be on beeper call at the same time at all 3 hospitals and triple bill them all and kickback other docs with cash if I get stuck since they have privileges at the same places as me. Kidding I’m kidding on this …sorta Becuase the thought has gone through my head how I can pull this off being in 3 places at the same time.

I do have the other doc covering me if I get stuck while traveling over and will kick them back $300 cash for an hr so there is no coverage gap.