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EtherMD

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I thought this topic would be interesting for those in training and those about to enter. How do you think the politicians passing Universal Health Care for all U.S. Citizens will affect the specialty? Will Private Insurance be rare or dead?

Will the Mid-Levels be the main providers? Will "solo" Physician Anesthesia exist? Obviously, salaries will drop substantially but what about Mid-Level salaries? Will we have enough Mid-Levels? Will we have too many Physician Anesthesiologists?

I would like to remind everyone that the Democratic Party Platform WILL have Universal Health Care as one of its primary goals.

Finally, is the "Medicare" version of Universal Health Care the most likely result of such a system?
 

EtherMD

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A good public P.R. campaign is vital to the survival of the specialty if Universal Health Care becomes reality. The polticians will need to keep the specialty alive if the public demands it. Again, public pressure will be vital to our field. We have several things on our side:

1. Every First World Nation has Anesthesiologists. Even many third world countries. Canada, Britain, Germany, etc. all have Physician Anesthetists taking care of their patients.

2. Demanding Patients- We have the most demanding people in the world. Once educated they will want the best-for free of course.

3. Not Enough Mid-Levels- Even if the Mid-Levels wanted to do all the cases there are not enough of them. Anesthesiologists still represent a significant percentage of the Anesthesia work force. If the pay is CRNA level or lower many Anesthesiologists will look for other work or retire. Even if they do work for CRNA pay many will only work in a limited capacity (why kill yourself for Nurses' pay).

4. MD/DO vs. CRNA- Despite the rhetoric the "average" CRNA can not do all the cases "solo" at a major hospital. Anesthesiologists (perhaps fewer) will be needed to supervise and do cases.

The primary objective of the ASA in 2007 and 2008 should be PUBLIC EDUCATION and a powerful P.R. campaign.:thumbup:
 

loveumms

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In talking to people I have heard many arguments regarding Universal Health Care. One that seems to be repeated over and over is that of a two tiered medical system. Those under universal health care and those who are more wealthy - which will lead to two provider systems (those with physicians and those with NPs, PAs, CRNAs, ect). I am not really sure if this is even feasible however it seems like it a possibility. Those who can pay for private insurance or pay out of pocket will be able to afford the "best" health care. I know that this would go against the UHC ideal however, in a world fueled by the almighty dollar I definitely sense that this could happen.

I for one am kind of scared of UHC and what it will do to our salaries - and furthemore medical school admission. Even though being a doctor is a noble profession, I'm not so sure that as many would pursue the career knowing that they will only be making 80-100K (or less) upon finishing training. Especially knowing that many other fields require much less time, patience and dedication to make far more (with less rewards though).
 
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EtherMD

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In talking to people I have heard many arguments regarding Universal Health Care. One that seems to be repeated over and over is that of a two tiered medical system. Those under universal health care and those who are more wealthy - which will lead to two provider systems (those with physicians and those with NPs, PAs, CRNAs, ect). I am not really sure if this is even feasible however it seems like it a possibility. Those who can pay for private insurance or pay out of pocket will be able to afford the "best" health care. I know that this would go against the UHC ideal however, in a world fueled by the almighty dollar I definitely sense that this could happen.

I for one am kind of scared of UHC and what it will do to our salaries - and furthemore medical school admission. Even though being a doctor is a noble profession, I'm not so sure that as many would pursue the career knowing that they will only be making 80-100K (or less) upon finishing training. Especially knowing that many other fields require much less time, patience and dedication to make far more (with less rewards though).


I am not certain you are correct about the Medical School comment. An Orthopedic Physician just doing Medicare can still make a nice living. Ditto for Opthalmology, Neurosurgery, Dermatology, Interventional Cardiology etc.,
So, I am assuming you must be throwing the current Medicare pay scale out the window with the NEW Universal Health Care system.

Will we adopt a system like Canada? Because the current Medicare system is crap and if we want socialized Medicine then stop calling it Universal health Care and call it by its real name: Government Health Care System.

Will Co-Pays be allowed? Will the government limit the Co-Pay? Will Anesthesiology finally be treated by the government as a real Medical Specialty? Will the Relative Value system be scrapped? Will Family Practice Doctors become gatekeepers like in Britain?

Once you unleash the genie (Government Health Care for everyone) you won't be able to put her back in the bottle. 90% of the Country will have the "basic" health care and the other 10% will have Private health care.
 

proman

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Socialized healthcare in this country would be like a cross between the Post Office and the VA for the patients. For the physicians it'll be more like 100% Medicaid than 100% Medicare. Just pray that private insurance isn't outlawed (like some provinces in Canada until recently). The UK previously used to prohibit physicians from working for both the NHS and private insurance. You had to pick. That's been changed.

I give it 20 years before we have 100% Medicaid. Big business is actually pushing for it, not the individuals. If they can dump the costs of healthcare on the government, profit margins go up and they become more competitive with the world. I can't say I blame them.
 

EtherMD

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Socialized healthcare in this country would be like a cross between the Post Office and the VA for the patients. For the physicians it'll be more like 100% Medicaid than 100% Medicare. Just pray that private insurance isn't outlawed (like some provinces in Canada until recently). The UK previously used to prohibit physicians from working for both the NHS and private insurance. You had to pick. That's been changed.

I give it 20 years before we have 100% Medicaid. Big business is actually pushing for it, not the individuals. If they can dump the costs of healthcare on the government, profit margins go up and they become more competitive with the world. I can't say I blame them.

Perhaps, in twenty or more years we may have a "full" government run system. Until then, the Health Insurance business is quite lucrative and the big players like Humana, Aetna, Blue Cross, Cigna, etc., are not going to go "quietly into the night." They will fight like mad for a 'hybrid' system which allows people to pony up "extra" money for better care. Think of it, the government contributes its portion (paid by tax dollars) into Aetna's "Health Care Max Plan" which means I pay an additional $500.00 per month. But, the elderly and poor just get the "basic" plan which has a $0 per month payment.

The 'Max' Plan gives me more Physiciasn to choose from, more out-patient centers and hospitals. The 'basic' plan limits me to the local County hospital with 'standard care.' Basic Prescription coverage is included which means 'generic' medication only. Max Plan participants get all the medications available as prescribed by a Physician.

This sort of system seems to be a 'hybrid' of our current system but does give all U.S. Citizens basic health care. Our free market system and upper-middle class citizens will want such a plan. One more thing: forget about Malpractice at the County facility. Government run hospitals like the V.A. and the local county facility will be protected from lawsuits. NOT SO for 'Max Health Care Plan Members' as they will retain the current system's right to sue for malpractice. Remember, the trial lawyers like our current system and want to keep at least some of this business intact.

So, that is how I see "Universal Health Care" unfolding in the next 4-5 years.
Everyone gets something but nobody gets everything they want. The liberals get basic health care for everyone and the Republicans retain the free market (Private insurance) system to a degree. The Physicians take it up the [email protected]@ as usual.

Now the real question. How does my system affect the specialty of Anesthesiology? Does the government stay with Medicare rates or reduce all Physicians to Medicaid rates as the new standard? If so, Anesthesiology is impacted severely and the supervision ratio's at the county facilities are 7:1.
But, "solo" MD Anesthesia still exists albeit in a much more limited form for the "Ultra Max" plan members.

Pure fiction or future reality? The next Presidential Election may provide the answer.
 

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A good public P.R. campaign is vital to the survival of the specialty if Universal Health Care becomes reality. The polticians will need to keep the specialty alive if the public demands it. Again, public pressure will be vital to our field. We have several things on our side:

1. Every First World Nation has Anesthesiologists. Even many third world countries. Canada, Britain, Germany, etc. all have Physician Anesthetists taking care of their patients.

2. Demanding Patients- We have the most demanding people in the world. Once educated they will want the best-for free of course.

3. Not Enough Mid-Levels- Even if the Mid-Levels wanted to do all the cases there are not enough of them. Anesthesiologists still represent a significant percentage of the Anesthesia work force. If the pay is CRNA level or lower many Anesthesiologists will look for other work or retire. Even if they do work for CRNA pay many will only work in a limited capacity (why kill yourself for Nurses' pay).

4. MD/DO vs. CRNA- Despite the rhetoric the "average" CRNA can not do all the cases "solo" at a major hospital. Anesthesiologists (perhaps fewer) will be needed to supervise and do cases.

The primary objective of the ASA in 2007 and 2008 should be PUBLIC EDUCATION and a powerful P.R. campaign.:thumbup:


i agree with you..
 

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Didn't you guys see our educating the public thread?
 

EtherMD

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Didn't you guys see our educating the public thread?

Yes. I agree with that thread. Some threads have overlapping points and the P.R. campaign by the ASA is important to educate the public. However, this thread's main topic is Universal Health Care and your best guess what that means to Medicine and the specialty of Anesthesia. Comments?
 

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I suspect that we will do a lot less stool sitting....and a lot more of the stuff that many went into anesthesia to avoid.
 

mille125

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[QUOTE=EtherMD;4823714An Orthopedic Physician just doing Medicare can still make a nice living. Ditto for Opthalmology, Neurosurgery, Dermatology, Interventional Cardiology etc.,


Are you serious??...All of these specialties would be doomed if they are seeing just medicare patients at the current fee schedule.....have you seen the fee schedules..do you have a clue?????? The hospitals would be even bigger losers especially for cases that require a lot of equipment (ie implants like total hips). They would be lucky to break even. Most of these specialties make 80 to 85 percent of their profit off of 10-20% of their patient load (ie private insurance)............you are way off base on this assessment
 
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Sorry but Ethermd is correct. For example, many orthopedists have high volume, almost exclusively Medicare total joint practices that do very well. Where did you get your information? Medicare reimburses most other specialties at 80-85% of prevailing commercial rates. In anesthesia, we only get 30-35% of commercial rates, ie $17-18/unit vs $50/unit.
 

opa beleza?

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The socialist/goverment part: I think in anesthesia, and perhaps across the board in all medical specialties, mid levels will do everything that is not complicated. The doc, again in all specialties, would be a consultant for rare or complicated cases -- I think this could maintain salaries of physicians somewhat -- but only if their are fewer of them. Specifically to anesthesia -- I think docs would only do the hardest cases and even if salaries were maintained somewhat this would be at the expense of very rough days at work with the average day including much more complicated dicey work as the bread and butter gets cut up and distributed to the college funds of midlevels' kids. In this system the doctor should charge through the nose for his involvement whatever it may be. The case cannot happen without the doc, i.e. with a mid level, and the patient will die without doc involvement, so it is worth the cost.

If a bad outcome occurs in a bread and butter case with a midlevel provider than the public should sue the hell out of the government -- though as etherMD has said they will be protected.

As for the boutique -- maybe within this nightmare there will be a pure capitalistic system of medicine for cash payers. I would pay for this and I would certainly work for this. I'd pay cash to have a doc run my kids anesthesia for an ear piercing, it does'nt happen everyday so it may as well be the best.
 

EtherMD

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Sorry but Ethermd is correct. For example, many orthopedists have high volume, almost exclusively Medicare total joint practices that do very well. Where did you get your information? Medicare reimburses most other specialties at 80-85% of prevailing commercial rates. In anesthesia, we only get 30-35% of commercial rates, ie $17-18/unit vs $50/unit.

Average Private Payer is Mid 50's/unit. Many practices get 60/ unit.
Medicaid even lower than Medicare for Anesthesia. If Medicaid becomes the new norm we are in serious trouble.

I still believe a 'hybrid' system is the most likely "universal health care system" for the USA. This allows both sides to claim victory and insures all US Citizens. Comments?
 

mille125

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Sorry but Ethermd is correct. For example, many orthopedists have high volume, almost exclusively Medicare total joint practices that do very well. Where did you get your information? Medicare reimburses most other specialties at 80-85% of prevailing commercial rates. In anesthesia, we only get 30-35% of commercial rates, ie $17-18/unit vs $50/unit.


Lets make sure that we are comparing apples to apples. I would assume that these orthopedists that you refer to are in private practice. Academic orthopedists are not counted in this equation because they are salaried by their center. They also frequently have no idea about what they are getting paid or by whom (they dont care because they are salaried). Many times they have never looked at a fee schedule.

I am a private practice interventional pain management doctor. I share office space with a spine orthopedist. I can tell you that I look at and negotiate my own fee schedule myself. I can also tell you that many commercial insurances pay 4 to 5 times the medicare fee schedule for procedures. I know this from my own practice as well as his. This is not unusual. I have lived in three other states where this is also true. In very competitive areas the fee schedule is sometimes pegged to medicare without negotiation. Perhaps your orthopedists are in a very competitive market (or they just haven't negotiated their contracts) Orthopedists and other specialists cannot survive on medicare payments without taking a 50-60% hit in salary. If we all had accept 100% medicare most private practices would perish (or take the above hit in salary). This is not opinion..this is fact. Call your medical society and they can give you some numbers.

As an example: In our area a medicare total hip replacement pays the Dr. 1300 which include post op visits and hospital stay. Private insurance veries from 4000-9000 depending on carrier. Thus 1 private patient equals to 4-5 medicare patients in reimbursement. These are the facts....It is erroneous to think that these practices can function on just a medicare fee schedule.....If you dont believe me ask any orthopedist in private practice.....


I can tell you first hand in my practice that I receive 80 percent of my income from 20 percent of my practice.......
 

mille125

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Average Private Payer is Mid 50's/unit. Many practices get 60/ unit.
Medicaid even lower than Medicare for Anesthesia. If Medicaid becomes the new norm we are in serious trouble.

I still believe a 'hybrid' system is the most likely "universal health care system" for the USA. This allows both sides to claim victory and insures all US Citizens. Comments?


yes ...but the losers in your system are big business (ie insurance companies) they will not go quietly without a fight....they have a lot of lobbyists in Congress....this is the biggest impediment to your plan
 

EtherMD

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yes ...but the losers in your system are big business (ie insurance companies) they will not go quietly without a fight....they have a lot of lobbyists in Congress....this is the biggest impediment to your plan

Wrong. They are the big winners. Like the Medicare Prescription Drug Benefit the INSURANCE companies are going to be the "brokers" of Universal Health Care. Everyone is going to sign up for a health plan from a carrier. Each carrier can "compete" for business. The government taxes the general public and uses this money to pay for health care. Each Citizen must sign up for a plan from an insurance company. The plans range from basic "zero co-payment" to the Ultra Max plan (see my previous post). High income wage earners are the big losers because they will pay a high health care tax like 5% with no income limit PLUS the high Co-pay for the ultra-max plan. Seniors can also choose the ultra max plan or stick with the basic no co-payment plan. comments?

One more comment: I know an Optho guy that makes $700,000 plus working 40 hours a week who ONLY does Medicare. Similary, an Orthopedist who only does Medicare would still generate about $350,000 per year in salary. Compare that with Anesthesiology's $180,000 per year. These are "gross" numbers so "net" would be a lot less.
 

mille125

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EtherMD One more comment: I know an Optho guy that makes $700 said:
with all due respect, how can you have a serious conversation about salary using gross numbers.............I do believe your quote on the orthopedist....that sounds about right.....after his overhead he will be taking home about 150-160K per year if he is lucky which is 50 to 60 percent less than the national salary.....as for your optho friend... I would like to see his books....he probably has some private pay LASIK that he is doing as well if he truly generates those numbers....medicare fee schedule for optho has bottomed out (I am sure that he will tell you that) ....if he is working 40 hours a week then he is seeing 120-140 patients a day. Also i am assuming that you are talking about gross collections and not gross charges (otherwise it puts him in the 80-90K realm)


FYI: your anesthesiology salary is lower than average too...you must be in academics (which would explain some of your previous posts)
 

EtherMD

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with all due respect, how can you have a serious conversation about salary using gross numbers.............I do believe your quote on the orthopedist....that sounds about right.....after his overhead he will be taking home about 150-160K per year if he is lucky which is 50 to 60 percent less than the national salary.....as for your optho friend... I would like to see his books....he probably has some private pay LASIK that he is doing as well if he truly generates those numbers....medicare fee schedule for optho has bottomed out (I am sure that he will tell you that) ....if he is working 40 hours a week then he is seeing 120-140 patients a day. Also i am assuming that you are talking about gross collections and not gross charges (otherwise it puts him in the 80-90K realm)


FYI: your anesthesiology salary is lower than average too...you must be in academics (which would explain some of your previous posts)



I urge people reading your comments regarding income to ignore them. They are invalid and false. Medicare pays Optho and Orthopedics well. The fact that you don't understand this or recognize it is your problem. Here are the facts:

ASA Newsletter October 2002 Volume 66

Anesthesia gets 38.9% of typical commercial rates from Medicare
Other Services like Optho and Ortho get 83.2% of typical commercial rates

The Newsletter goes on to show an example of one "typical" service that was analyzed using Medicare RBRVS for 46 weeks times 45 hours per week (For Anesthesia Colectomy was chosen as the typical Anesthetic service).
The newsletter states practice expenses are deducted from these numbers and the numbers reflect NET income per year.

Cardiology: $276,000
General Surgery: $270,000
Ob/Gyn: $131,000
Gastroenterology: $123,000
Psychiatry: $96,000
ANESTHESIOLOGY: $54,000

Do you see the point? Medicare is blatantly unfair to Anesthesiology compared to the surgical specialties. We receive a fraction of our worth while most specialties get 83%! These are the real facts.

This PROVES my point that Medicare rates will destroy Anesthesia as we know it IF the NEW system adopts RBRVS as the source for payment information.

Medical Students will choose another specialty that gets 83% of TODAY's customary rates. The next generation of Physicians would accept that because this results in a "nice" living (like the Oprthopedist earning $350,000 per year net but working only 40 hours per week).

Don't believe everything you read. Check it out for yourself and find out the truth. A polished Opthalmologist can earn $600,000 plus after practice expenses in the real world. I know at least ten that earn that income with 95% Medicare patients.
 

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Once you unleash the genie (Government Health Care for everyone) you won't be able to put her back in the bottle. 90% of the Country will have the "basic" health care and the other 10% will have Private health care.

Then watch all the doctors fight each other tooth and nail for that 10%

Check out specialties like Cardiology in California.
 

mille125

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I urge people reading your comments regarding income to ignore them. They are invalid and false. Medicare pays Optho and Orthopedics well. The fact that you don't understand this or recognize it is your problem. Here are the facts:

ASA Newsletter October 2002 Volume 66

Anesthesia gets 38.9% of typical commercial rates from Medicare
Other Services like Optho and Ortho get 83.2% of typical commercial rates

The Newsletter goes on to show an example of one "typical" service that was analyzed using Medicare RBRVS for 46 weeks times 45 hours per week (For Anesthesia Colectomy was chosen as the typical Anesthetic service).
The newsletter states practice expenses are deducted from these numbers and the numbers reflect NET income per year.

Cardiology: $276,000
General Surgery: $270,000
Ob/Gyn: $131,000
Gastroenterology: $123,000
Psychiatry: $96,000
ANESTHESIOLOGY: $54,000

Do you see the point? Medicare is blatantly unfair to Anesthesiology compared to the surgical specialties. We receive a fraction of our worth while most specialties get 83%! These are the real facts.

This PROVES my point that Medicare rates will destroy Anesthesia as we know it IF the NEW system adopts RBRVS as the source for payment information.

Medical Students will choose another specialty that gets 83% of TODAY's customary rates. The next generation of Physicians would accept that because this results in a "nice" living (like the Oprthopedist earning $350,000 per year net but working only 40 hours per week).

Don't believe everything you read. Check it out for yourself and find out the truth. A polished Opthalmologist can earn $600,000 plus after practice expenses in the real world. I know at least ten that earn that income with 95% Medicare patients.




ha ha he he.................i am sorry give me a second.....i am still laughing at your last post
 
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mille125

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I urge people reading your comments regarding income to ignore them. They are invalid and false. Medicare pays Optho and Orthopedics well. The fact that you don't understand this or recognize it is your problem. Here are the facts:

Don't believe everything you read. Check it out for yourself and find out the truth. A polished Opthalmologist can earn $600,000 plus after practice expenses in the real world. I know at least ten that earn that income with 95% Medicare patients.



You are right about one thing. You should not believe everything that you read. The million dollar question is: "Why should the readers trust you over me". I am in private practice. I read my own EOB's daily as well as the EOB's that come in from the spine surgeon that shares my office. You have not identified your practice type. If I was to guess, I would say that you are an academic anesthesiologist. Most of these types think that they know everything about the real world when many have never experienced it. They know a lot about writing grants but very very little about real world practice management. But yet the readers should believe you..............

It is interesting that you know 10 opthalmologists who are making upwards of 600K on 95% medicare populations. Very interesting given that MGMA and many other reputable companies quote the average salary for optho at 220 to 260K. Somehow you know a bunch of doctors that our seeing the worst payer mix and working the least amount of hours and are earning 300 percent more than the average. Most of the readers are not stupid..Something has to give.....You really cant be so gullible...can you??

It is also interesting that your projections changed from gross to net income in a matter of hours.......


Your assumptions about medicare anesthesia pay may be valid. Most doctors are underpaid for their work. I dont know enough about anesthesia reimbursement to respond to your posts. One difference between you and I is that I admit when I do not know something...........



For all the readers that want to know the truth, let me supply you with projected numbers for an average ophthalmologist seeing 100% medicare:

Assumptions: dr works 50 wks per year, does 20 cataracts per week, sees 30 return pts and 5 new patients per week..(these are an overestimation of an actual practice but I will still make my point)

Other assumptions: medicare pays 625 dollars for cataracts (CPT 66984), 50 dollars for level 3 office visit, and 160 dollars for level 4 office consult


Gross income: surgery 20/week times 50 weeks times $625 equals 625K
Office: 5 new patients/day times 3 fulldays/week times 50weeks times $160 equals 120K then
30 returns/day times 3 fullday/week times 50 weeks times $50 equals 225K (assumes 5 full days of working and two are spent in the OR)

625 K plus 120K plus 225K equals 970K...lets round up to 1 million to make the numbers even. This represents theoretical gross income......


This simulation makes many overassumptions
1) It assumes a 100% collection rate. We all know that everyone has bad debt. The most efficient practice may collect 90-95%(this is 1-2% of practices) Most would be near 70-80%. Many more are worse than this. At any rate take off 100 to 350K for bad debt.

2) It assumes that the doctor will have no vacation other than holidays. This is also not true. You will need to take off 20K for each week of vacation that the dr takes. The average optho takes 6 weeks.

3) It assumes that you see 35 patients per day which may be a little high for optho.

4) It makes no assumptions for overhead. Very very efficient practices hover around 40%. Most practices are around 50%. This include salaries and benefits for staff and midlevels. 3 office staff members and one PA will cost the practice about 200K in salary in benefits. Many offices have 4 or 5 or more staff members. Also dont forget retirement, rent, malpractice, etc. Boy that 1 million is going down fast.

5) It assumes that the average billing will be for a 99213 and a 99244. Every encounter should not be a consult which will drop 30 dollars off of each 160 for nonconsult. Also the average billing will not likely be a 99213 since this dr is seeing one patient every 12 minutes. 99212 drops the rate to 35 dollars from 50 dollars

In the end when the dust settles the opthalmologist is not going to make 600K plus (more like 200 to 300 K). So Ether either your friends are lying, they are doing private pay patients, or they are working many more hours than thirty......


Ether...before you make another ridiculous post...do us all a favor and do your homework first...otherwise stay within your realm on the stool and keep out of practice management.
 

mille125

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Here are the facts:

ASA Newsletter October 2002 Volume 66

Anesthesia gets 38.9% of typical commercial rates from Medicare
Other Services like Optho and Ortho get 83.2% of typical commercial rates

The Newsletter goes on to show an example of one "typical" service that was analyzed using Medicare RBRVS for 46 weeks times 45 hours per week (For Anesthesia Colectomy was chosen as the typical Anesthetic service).
The newsletter states practice expenses are deducted from these numbers and the numbers reflect NET income per year.

Cardiology: $276,000
General Surgery: $270,000
Ob/Gyn: $131,000
Gastroenterology: $123,000
Psychiatry: $96,000
ANESTHESIOLOGY: $54,000





OMG....Ether...did you actually read the ASA newsletter that you just quoted.....If not please read it.


They used 1995 data and took the most common procedure performed by the specialty. They assumed that a cardiologist would be doing stenting all day long. They used a colectomy for the anesthesiology procedure. This is how they derived these numbers.....give me a break............and this is what you quote as evidence....i am sure that if a cardiologist did stenting on a medicare patient for 45 hrs per week and 46 wks a year he should make quite a tidy sum from medicare....we all know that this is not a real world scenario....What the authors were trying to state is that anesthesiology gets the short end of the stick when it comes to medicare.........you completely misapplied this information......if you took the simulated ophthalmologist that i just talked about I am sure that he would be in the high 500's-600's if he could do cataracts 8 hrs/day every day...maybe this is how you are getting the data from your friends.............please stay on the stool
 

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Ether,


I looked at some of your other posts...most of them have been right on except for the ones on this thread. I strongly agree with your statements regarding anesthesiology chairmen and SRNA schools. My program opened one about 2 months before a graduated. It was done behind closed doors..most of the faculty was against it. however, the chairmen saw a way to attract new CRNA's to his program...also several faculty members got "bonuses" for agreeing to teach these SRNA's....blood money if you ask me....so I must say that you actually do have a lot of sense, just not on this topic, :)
 

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:confused: Please realize that I do not have a very strong understanding of exactly the way healthcare is set up currently, nor do I understand the intricacies of hospital economics. I do think I have a fair grasp on economics in general, but I do not have a lot of knowledge concerning taxes, taxing, etc. What I will say is just some general ideas in my head not really evidenced by anything particular. So, most likely what I will say may seem stupid to those who better understand how healthcare works. But here it goes.....

I think that the trend is going to be more outpatient centers and fewer, larger regional tertiary care/trauma centers. The larger centers will be the tax-funded bare-bones health care and the outpatient or specialty hospitals will take more private paying patients. The place would likely be run like a VA:eek:, and most of the staff would obviously be govt employees (endowed with all the motivation they exude). This could be corrected or improved by some ideas below.

Doctors will have more regulations at these centers, and this is where most if not all residents will recieve training. The government will be able to negotiate with suppliers and make products/services the same interinstitutionally throughout the nation. Midlevels would be very involved at these institutions, offering an advantage of continuity for physicians and resident physicians. I think that since the government will be in control of these institutions it would be an improved set up for awarding research dollars, and could more easily facilitate interhospital record sharing for such.
This could also allow local businesses to donate specifically to that region's healthcare center for research.

The outside facilities would be available to those on the basic plan, only they would have to provide some out of pocket pay. Most procedures in the non-govt centers would be non-essential, therefore allowing the government to not provide monies/staffing to non-payors. This would allow the major govt centers to provide life saving treatment to people. There would need to be some sort of agreement between the government and out patient physicians allowing for treatment of those whose needs are not met at the major centers.

For example, I think it would be good to set up a flat tax for all non-govt facilities so that all of these tax monies are specifically for health care. I have a few other ideas as well. Rather than tax physicians individually for dollars, I think a better and more satisfying compromise is to tax time/service.
This could be done (and these numbers are totally arbitrary) by saying all non-govt hospital physicians visit and treat the lowest tier (medicaid) patients at the local govt hospital, or at their facility 1-2 full days/month. They could do procedures at their facility and the cost of equipment etc would be able to be counted as part of the portion of the flat tax. All employees would essentially be providing care "for free". Furthermore, medical equipment companies, pharmaceutical companies etc who contract with the non-govt physicians could donate products for that physician to use on these "tax workdays". These amount that these companies will be charged for their portion of health care could be drastically reduced by paying with equipment etc rather than money. It would be nice that in return for this the government allows a more free market for these physician outpatient facilities, equipment companies, pharmaceutical companies.

I would much rather pseudo-volunteer and not have to pay tax money for health care and wonder where it was spent along the line. I think that if we had all physicians "pay" health care tax this way it would give us a better feeling that our contribution is in fact not wasted. Furthermore, it includes all physicians so people feel that they are getting good healthcare.

Obviously, a lot of this is probably not feasible. I want to say more, but have to go do an epidural. I'll be back.:thumbup:
 

ReefTiger

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Ok, so I guess what I am trying to do is figure a way to cut taxpayer's costs while still allowing adequate access to care and a good market for physicians.

It seems to me that if you could get a fair amount of services and equipment donated in return for tax exemptions it is more of a win-win. This appears to me to save a lot of money for everyone, but not sacrificing quality necessarily. I think bare bones (government or national) health care should allow life-saving emergency treatment, preventative medicine, psychiatric sevices for serious psychiatric pathology, and limited pediatric care.

There could also be quality controls for patients that would allow access to free medicines and give them priority for non-essential care. Sounds like jumping through hoops? I don't think so. I think patients who take ownership of their health and make sincere efforts to follow medical advice should be rewarded. I think someone who quits smoking, starts excercising, and loses weight should have priority to additional care versus your lazy "just give me a pill", never shows up to appointment patients.

For the rest of people, there should be a tiered additional health insurance that is negotiated between physicians and insurance companies. Anyone that pays for additional insurance should be able to fully deduct all healthcare insurance dollars for themselves and their dependants.

I think it would be ideal for all companies to assist in national health care by donating time/services in lieu of tax money. This allows more community involvement, and a sense of well being. For example, electric companies could provide free electricity to the govt hospitals in return for having an appropriate decrease in their taxes. Food companies and or grocery stores could donate food. Chefs could donate their time to cooking meals for hospital patients in return for healthcare tax credits, etc.

Obviously the details would be very complex and it would not be the easiest system to get up and running. But don't you think healthcare costs for the government would decrease if this was how it worked? I don't know if there would still be a massive shortage of money or not.

I also am trying to figure out how reimbursements would work for us. So, since everyone would have basic healthcare, all optional procedures would be out of pocket or via supplemental health insurance. Perhaps it could be structured so that you could receive additional tax credits or a governmental stipend based on the number/percentage of bare-bones or lower-tiered-insurance patients you would see/treat.

I don't really know. I think that my posts started out as how I saw national healthcare in the future, and then morphed them into an idea about how I'd like to see it done.:oops:

I'm sure there are so many flaws in this idea, but maybe it's not all that crazy.

Now I guess I can sit back and watch everyone say I'm an idiot:laugh:
 

EtherMD

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Here are the facts:

ASA Newsletter October 2002 Volume 66

Anesthesia gets 38.9% of typical commercial rates from Medicare
Other Services like Optho and Ortho get 83.2% of typical commercial rates

The Newsletter goes on to show an example of one "typical" service that was analyzed using Medicare RBRVS for 46 weeks times 45 hours per week (For Anesthesia Colectomy was chosen as the typical Anesthetic service).
The newsletter states practice expenses are deducted from these numbers and the numbers reflect NET income per year.

Cardiology: $276,000
General Surgery: $270,000
Ob/Gyn: $131,000
Gastroenterology: $123,000
Psychiatry: $96,000
ANESTHESIOLOGY: $54,000





OMG....Ether...did you actually read the ASA newsletter that you just quoted.....If not please read it.


They used 1995 data and took the most common procedure performed by the specialty. They assumed that a cardiologist would be doing stenting all day long. They used a colectomy for the anesthesiology procedure. This is how they derived these numbers.....give me a break............and this is what you quote as evidence....i am sure that if a cardiologist did stenting on a medicare patient for 45 hrs per week and 46 wks a year he should make quite a tidy sum from medicare....we all know that this is not a real world scenario....What the authors were trying to state is that anesthesiology gets the short end of the stick when it comes to medicare.........you completely misapplied this information......if you took the simulated ophthalmologist that i just talked about I am sure that he would be in the high 500's-600's if he could do cataracts 8 hrs/day every day...maybe this is how you are getting the data from your friends.............please stay on the stool


You are incorrect on your facts. Most specialties are happy to get 130% of Medicare while in Anesthesia we must get 350%. As an Ortho or Optho M.D. you will earn a good living doing Medicare only cases. How many Optho M.D.'s in the State of Florida do anything except Medicare? Most of these practices are 90% plus Medicare and they are making big bucks. Ditto for Ortho in many Florida practices. Medicare pays these guys well. The ASA Newsletter has confirmed my facts and I hope other experienced private practice people will confirm this post.

Medicare pays me about 30% of my normal HMO fee. Medicare pays most surgeons 75% of their normal fee. This is fact not fiction and the ASA will back up my statement.
 

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You are incorrect on your facts. Most specialties are happy to get 130% of Medicare while in Anesthesia we must get 350%. As an Ortho or Optho M.D. you will earn a good living doing Medicare only cases. How many Optho M.D.'s in the State of Florida do anything except Medicare? Most of these practices are 90% plus Medicare and they are making big bucks. Ditto for Ortho in many Florida practices. Medicare pays these guys well. The ASA Newsletter has confirmed my facts and I hope other experienced private practice people will confirm this post.

Medicare pays me about 30% of my normal HMO fee. Medicare pays most surgeons 75% of their normal fee. This is fact not fiction and the ASA will back up my statement.

I want to prove my point on this subject once and for all. Medicare pays an opthalmologist about $680 for cataract surgery at an ASC. A good opthalmologist can do the case in 20 minutes. I work with several that average about 25 cataract surgeries per week. They do these cases at an ASC and operate two days a week. With room turn-over the Optho M.D. is done by lunch time. This leaves three full days a week for office and two afternoons per week to do whatever. Assuming the office breaks even (which is not true because they actually make a few bucks) the Optho M.D. earns $68,000 per month doing catarct surgery at the ASC. This translates into $680,000 per year (or $600,000 per year net plus full benefit package)) and 8 weeks of vacation. Not bad.

On top of this, the Optho M.D. can earn up to another $200 per cataract case from the ASC fee (depends on his deal with the ASC). The additional money is given per quarter as a bonus after ASC expenses are paid.

Again, most GOOD optho M.D.'s can do this surgery in 20 minutes under topical. Medicare pays Optho well.
 

EtherMD

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I want to prove my point on this subject once and for all. Medicare pays an opthalmologist about $680 for cataract surgery at an ASC. A good opthalmologist can do the case in 20 minutes. I work with several that average about 25 cataract surgeries per week. They do these cases at an ASC and operate two days a week. With room turn-over the Optho M.D. is done by lunch time. This leaves three full days a week for office and two afternoons per week to do whatever. Assuming the office breaks even (which is not true because they actually make a few bucks) the Optho M.D. earns $68,000 per month doing catarct surgery at the ASC. This translates into $680,000 per year (or $600,000 per year net plus full benefit package)) and 8 weeks of vacation. Not bad.

On top of this, the Optho M.D. can earn up to another $200 per cataract case from the ASC fee (depends on his deal with the ASC). The additional money is given per quarter as a bonus after ASC expenses are paid.

Again, most GOOD optho M.D.'s can do this surgery in 20 minutes under topical. Medicare pays Optho well.


Let me add the income from a "good" Optho office. If the Optho M.D. employs one or two assistants and/or Optometrists the office income can be substantial. These "assistants" can see patients five days a week while the Optho Physician is operating or doing other things. A busy office can add $200,000 in profit to the annual income. In addition, a busy office "feeds" the cataracts to the surgeon. A win-win situation. A "busy" Optho Surgeon with a good office can net $800,000 plus in my area with almost 100% Medicare working 40-45 hours per with minimal hospital call.

My figures are correct and are "real world." Even an "average" Cataract Surgeon who operates one day a week can still do 6 cases in one day. Combine this with a "decent" office (the Optho Physician is in the office 4 days a week in this scenario) the Net income is still $350,000 plus. Again, this assumes 100% Medicare patients.

However, with a busy practice the Opthalmologist lives like a king. Multi-Million dollar home on the water, yacht and second home are a reality. This occurs because the surgery takes about 20 minutes and Medicare pays $680 per case. All a good Optho Surgeon needs is lots of Medicare patients. There is no shortage of elderly patients in Florida needing cataract surgery and there are many cataract surgeons netting $800,000 plus per year from Medicare working 40-45 hours per week.

Now, even the most brilliant Anesthesiologist with outstanding technical skills could NEVER match that income doing Medicare. Most likely, this type of Physician Anesthesiologist doing 100% Medicare would earn $200-$250,000 NET. Clearly, this shows how poorly Medicare pays Anesthesiology compared to Opthalmology.
 

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I don't want to get into a "pissing" contest about other Specialties income.
The FACT remians that most sureons are happy to get 130% of Medicare from HMO contracts. In Anesthesia, we need 300-350% from these non-Medicare patient HMO contracts to survive.

A Universal Health Care systems that pays 100% Medicare rates for all patients (this means less than 5% bad debt/no pay) would mean a death sentence to Anesthesiology. Not so for most of the surgical specialties.
Our best hope is that a 'hybrid' system is adopted in the USA where Insurance carriers pay more than Medicare to our specialty for at least some of the patients.

In this case the survival of the private health insurance carriers is in our best interest. Even more so than the rest of Medicine we are reliant on the small percentage of patients with good insurance to sustain our specialty. The first to feel the impact of Medicare rates across the board are all MD practices. Most of these practices will "fold" and be replaced by Mid-Levels. This assumes that the Physician Anesthesiologists in these solo practices can find jobs as a "supervisor." If not, these Doctors will earn CRNA level income until a better situation comes along.

Thus, the need for an"insurance policy". Residents should complete a fellowship in a subspecialty area that will give them a 'leg-up' over the competition. Critical Care, Pain Medicine, Cardiac with TEE certification, etc. all provide insurance that if the job market becomes saturated those with advanced skills have a better chance at finding work than those who do not. Universal Health Care of some sort will happen in the next 5-10 years. An additional fellowship of 12-18 months will make you much more competitive for the future.
 

militarymd

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I would like to weigh in, but I don't know anything about non-anesthesia reimbursement rates.
 
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EtherMD

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I would like to weigh in, but I don't know anything about non-anesthesia reimbursement rates.

That is okay. The next time I am visiting my Optho friend at his two million dollar home and drinking wine on his yacht I will discuss this issue with him. I am sure he will get quite a laugh out of it.:laugh:

Ditto for the Cardiologist and Orthopedic Surgeon who are doing quite well with Medicare. The successful Surgeon knows how to make a lot of money from Medicare patients and even more from HMO patients. In Anesthesia we are completely dependent on the private payers for our high income. At Medicare Rates we are reduced to family practice type income.:eek:
 

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Those of you doubting how poor Medicare pays us compared to other specialties need to check this out:

www.rangelMD.com/2006/03 Make sure you click on "gass passer" on the page. Comments?
 

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Those of you doubting how poor Medicare pays us compared to other specialties need to check this out:

www.rangelMD.com/2006/03 Make sure you click on "gass passer" on the page. Comments?

My former ACT employer would actually lose money when we did a Medicare CABG exceeding six hours. After paying my salary, the partnered attending would personally suffer a negative cash flow.

The senior CT surgeon would routinely wait to check the quantity and quality of harvested saphenous before making sternotomy. Six hour-plus CABGs were not infrequent.

In the good old days, we could bill separately for Swan insertion, EKG interpretation, hypothermia, circ arrest, etc. Now it's all bundled together.
 

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My former ACT employer would actually lose money when we did a Medicare CABG exceeding six hours. After paying my salary, the partnered attending would personally suffer a negative cash flow.

The senior CT surgeon would routinely wait to check the quantity and quality of harvested saphenous before making sternotomy. Six hour-plus CABGs were not infrequent.

In the good old days, we could bill separately for Swan insertion, EKG interpretation, hypothermia, circ arrest, etc. Now it's all bundled together.


Now, in the USA an average CRNA package for 40 hours per week costs about $170-$180,000 (this includes every last dime including FICA). This means most Groups doing 100% Medicare "Break-Even" on these cases if they employ CRNA's. The Group makes money off the private pay cases ONLY. Thus, a Group with 10% private pay is not making a whole lot of money after CRNA costs. The % needs to be more like 30 for the Group to do well. So, how do Groups survive with Medicare, Medicaid and No-Pay plus a low % of private pay patients? The answer is simple: Hospital Subsidy.
These days more and more Groups need a hospital subsidy to survive. In fact, more than 80% of groups receive a subsidy in one form or another from the hospital. This can take the form of monthly checks or paying CRNA salaries. Either way the hospital pays money for Anesthesia services.

What does this model mean when Universal Health Care hits? Will hospitals have the money to pay Groups? Will the ratios remain at 4:1? Will the AANA lobby to get MD/DO Anesthesiology removed as a requirement in ALL STATES?
You think the propoganda war is bad now wait until Universal Health Care comes to the USA. The best strategy is to wage a war now with the AANA on the public level and at the University Level. The time has come to stop training CRNA's at the University and inform the public of the value of Physician Anesthesia. Do I believe the first part of my plan will happen? No Way. The Academic Chairs are going to ride this train until the end. The ASA is not going to rock the boat until it is FULL of water. By then, our ship is sunk. But, a "high-road" campaign by the ASA will occur. This is easy and will be non-offensive.:sleep: :scared:

The job of our leadership is to educate the Anesthesiologists of tomorrow and protect the specialty of Anesthesiology. They are educating you ALONG with your competition. How does this "protect" the specialty for the future?
By maintaining the status-quo our leadership has made a de-facto decision to do nothing and "stay the course."
 

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The Group makes money off the private pay cases ONLY. Thus, a Group with 10% private pay is not making a whole lot of money after CRNA costs. The % needs to be more like 30 for the Group to do well. So, how do Groups survive with Medicare, Medicaid and No-Pay plus a low % of private pay patients? The answer is simple: Hospital Subsidy.
."


My ACT group was at two places: a large "traditional" hospital with ~ 50/50 mix of private pay and Medicare/Medicaid/Tricare (which makes Medicare look generous :mad: ) and the ambulatory surgical center across town.

The surgical center was the proverbial cash cow for the group.
 

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My ACT group was at two places: a large "traditional" hospital with ~ 50/50 mix of private pay and Medicare/Medicaid/Tricare (which makes Medicare look generous :mad: ) and the ambulatory surgical center across town.

The surgical center was the proverbial cash cow for the group.

The ASC usually is the cash cow in most practices. Hopefully, Universal Health Care will leave them that way.
 

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You are incorrect on your facts. Most specialties are happy to get 130% of Medicare while in Anesthesia we must get 350%. As an Ortho or Optho M.D. you will earn a good living doing Medicare only cases. How many Optho M.D.'s in the State of Florida do anything except Medicare? Most of these practices are 90% plus Medicare and they are making big bucks. Ditto for Ortho in many Florida practices. Medicare pays these guys well. The ASA Newsletter has confirmed my facts and I hope other experienced private practice people will confirm this post.

Medicare pays me about 30% of my normal HMO fee. Medicare pays most surgeons 75% of their normal fee. This is fact not fiction and the ASA will back up my statement.



In am running out of patience....first of all let me say that I agree with you on medicare payments for anesthesiology. However, medicare payments are too low for all physicians. You keep quoting theoretical gross charges for these ophthalmologists. You havent take collection ratios, staff salaries and a slew of other things in your calculations. But I am tired of arguing with you (yes you wore me down). The readers can come to their own conclusions. I plugged in your calculation for a reimbursement of $685 times 25 cataracts for week times 44 weeks per year (8 wks vacation) as well as office visits and the calculations still come out to a gross of 1-1.2 million (which equates to about 300K (best case scenario)). This is far short of the 600,000 plus that all of your buddies are making on straight medicare. Maybe MGMA doesn't know about them. They still say that the average optho salary is 200K-250K. Maybe you know more than them. I do wish that your friends would share their secrets with the rest of us. You were correct in stating that PA's can add to the bottom line. But also remember that you are paying 100K (salary and benefits) a pop for each of these practitioners.


Concerning anesthesiology chairmen and support of SRNA training programs: you are right on and a salute your efforts

Concerning anesthesiology pay formulas: I also agree that all specialties are underpaid by medicare. Anesthesiology has helped to put itself in this situation by insisting on being paid by time units. This is your own doing..

Concerning universal health care: Good concept....big insurance business will never let it happen...Their profits shrink from the current even if they are included in your plan..


I feel that I have given you all the "education" that you can handle. I am going to bow out of the discussion because it is starting to get redundant. If you want to get the last word in, be my guess. The readers will be able to read both of our posts and decide for themselves.

PS: you still havent identified your practice type and i have you pegged for an academic anesthesiologist....................
 

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Lastly......here is the ASA newsletter that you keep referring to. The only thing that you have proven is that even good data can be misapplied and misused to make an invalid inference................


Medicare Is Still the Wrong Benchmark

Karin Bierstein, J.D.
Assistant Director of Governmental Affairs (Regulatory)


--------------------------------------------------------------------------------

Payers continue to seek anesthesia rates based on the Medicare conversion factor (CF), which, as we know all too well, is $16.60 at the national level. In 1999, ASA published a slide set with full narrative titled "Medicare and Anesthesia Reimbursement Methods: Why the Medicare Fee Schedule Is the Wrong Benchmark for Commercial Anesthesia Payments." This monograph, developed by Alexander A. Hannenberg, M.D., chair of the ASA Committee on Economics, contained a number of analyses based on 1998 payment data, which are now obsolete. An August trip to West Virginia to explain why Medicare is the wrong benchmark to several state governmental payers provided the opportunity to update some of the models developed three years ago.

1. Difference in Medicare Rates for Anesthesia Versus Other Services
According to our 2001 commercial reimbursement survey, the national average CF (unweighted) for anesthesia services was $45.75. The Medicare CF was $17.83. For all other services paid under the Resource-Based Relative Value Scale (RBRVS), the unweighted average of Blue Cross/Blue Shield, managed care and other non-Medicare, non-Medicaid plans reported by the American Medical Association (AMA) in 2001 was $45.98. The corresponding Medicare rate was $38.26.

Medicare/Commercial
Anesthesia 38.9%
Other services 83.2%


As a percentage of commercial payment levels, therefore, Medicare payment for anesthesia services is less than half of Medicare payment for other medical and surgical services.

2. In Absolute Dollars, the 2002 Anesthesia CF Is 14 Percent Lower Than It Was in 1991
In 1991, the last year before Medicare implemented the RBRVS-based Fee Schedule, the national average CF for anesthesia services was $19.27. In 2002, it is $16.60, a 14-percent decrease.

These are absolute dollar amounts, not adjusted for inflation. $19.27 in 1991 dollars has the same buying power as $25.48 in 2002. Adjusted for inflation, the 1991 anesthesia CF would have been 46 percent higher than it is today.

3. Hourly Rate for Anesthesia Versus Nonphysician Services

Payment for anesthesia is based in part on the time that it takes to provide the service. There are quite a few other codes in the Current Procedural Terminology (CPT) system with descriptors that depend on the amount of time involved in providing the service (e.g., "each 15 minutes" or "30 minutes or less"). Multiplying the Medicare payment for some of these codes by 4 or 2 or another appropriate factor yields a per-hour rate, which we can compare to one-third of the payment for a three-hour anesthetic for open reduction and internal fixation (ORIF) of an ankle fracture:



When the time that it takes to perform one of these services is normalized to one hour, the Medicare Fee Schedule (MFS) places a higher value on orthotics fittings and aquatic therapy than on a typical anesthesia service. An office visit for an established patient with minimal presenting problems "that may not require the presence of a physician" and where "typically, five minutes or less are spent performing or supervising these services" is worth 2.75 times five minutes of the anesthesiologist's time in the operating room.

Medicare payment for the office visit above is calculated using the higher relative values allowed for a private office's overhead. Even if the visit takes place in the hospital and the allowable, minus the office overhead and normalized to an hour, is just $104.28, it is still worth 18 percent more than the anesthetic.

4. Cross-Specialty Comparison of Medicare-Based Net Income
Health economist Peter McMenamin, Ph.D., calculated a 1995 annual net income for anesthesiology and other specialties using a model developed by the architect of the RBRVS, Harvard Professor William C. Hsiao, Ph.D. For each specialty studied, Dr. Hsiao chose a typical service, computed the Medicare payment for that service, determined annual hours worked, calculated an annual gross income based on providing only that one service to Medicare patients, subtracted practice expenses and came up with an annual net income figure.

Dr. McMenamin updated Dr. Hsiao's figures and added the specialty of anesthesiology using colectomy as a typical service. In 1995, net incomes based on Medicare payments for 46 weeks times 45 hours of providing the single service per specialty were as follows:



Updating the McMenamin analysis to 2002, we find that anesthesiologists would be earning just $304 more than they were in 1995. Multiplying the annual number of colectomies by the 2002 Medicare CF and subtracting practice expenses projected to 2002 through the inflation calculator on the Bureau of Labor Statistics' Web site, the 2002 net annual income for an anesthesiologist would be $54,073.

5. RBRVS-Based Payments for the Components of an Anesthesia Service
Any given anesthesia service as described in CPT or in the Relative Value Guide includes many components. The code covers preoperative, intraoperative and postoperative care; only a very few procedures, such as pulmonary artery catheterization or epidurals for postoperative pain management, are separately payable. Many of the procedures performed during the course of a normal anesthetic correspond (with varying degrees of precision) to separate CPT codes.

Looking at the individual components or building blocks of an anesthetic for ventral hernia repair (00832), we find that their RBRVS relative value units add up to a total of 13.59:



The total payment for the above components of an anesthesia service would be $491.96 (13.59 RVUs ¥ $36.30).

In contrast, Medicare payment for a one-hour ventral hernia repair would be as follows:

00752 (6 Base Units + 4 Time Units) ¥ $16.60 = $166


Breaking down an anesthesia service into its components and applying the RBRVS-based Medicare allowable to each of those CPT codes would thus yield a payment almost three times greater than billing for the service using the anesthesia code.

Conclusion
The above analyses show that Medicare greatly undervalues anesthesia services relative to the other medical and surgical services in the MFS.

• The ratio of Medicare:commercial payments for anesthesia services is less than half the ratio for other services;

• The minute-for-minute payment for a typical anesthesia service is lower than that for such nonphysician services as aquatics therapy;

• Annual net income for an anesthesiologist, calculated on the model of a single Medicare case, is less in 2002 than it was for all nonprimary care specialties in 1995;

• Breaking down an anesthesia service into its component services on the RBRVS and comparing the Medicare payment for the total of those component services produces a Medicare allowable three times greater than the payment for the all-inclusive anesthesia code. In other words, the MFS is internally inconsistent as well as inequitable across specialties.

The simplest demonstration of the inadequacy of the Medicare conversion factor for anesthesia services can be made without reference to other specialties. Had it kept pace with inflation since the implementation of the MFS, the CF today would have been nearly 1.5 times greater than it is.

ASA Argues the Case for an Increase One More Time

In our efforts to persuade the Centers for Medicare & Medicaid Services (CMS) to increase the Medicare CF, we have been limited to the one method that CMS recognizes in showing that anesthesia "work" is undervalued. After nearly three years of hard work at the AMA/Specialty Society Relative Value Update Committee (RUC), we are now trying to make sure that CMS at least implements the RUC's data and analyses showing that our services are undervalued by an average of about 10 percent. This is obviously far less than the increase needed to close the gap between anesthesia and other services. Because the physicians representing the various specialties on the RUC are acutely aware that any increase in the valuation of one specialty's "work" will come out of their own pockets, the RUC ultimately refused to make an affirmative recommendation that CMS apply its findings but instead sent its data and analyses to CMS.

In our formal "comments" on the proposed rule for the 2003 physician fee schedule, we recently urged CMS to take the final step and give some meaning to the entire RUC process by translating the analyses into a CF increase. A copy of Dr. Glazer's letter is available at < www.asahq.org/washington/pract_mgmt.html >. We are now seeking the help of key members of Congress to inspire CMS to take the appropriate action.

No, Aetna's Payment Levels Are Not Perfect

Editor Mark J. Lema, M.D., Ph.D., and the Washington Office have received several complaints about the August "Practice Management" column describing ASA's ongoing dialogue with Aetna and the payment policy changes that we have persuaded Aetna to make. We recognize that many anesthesiologists are legitimately dissatisfied with Aetna's payment amounts.

ASA cannot compel any payer to raise its rates. What we have been able to accomplish is to convince Aetna to change some of the policies that affect payment amounts, e.g., to cover monitored anesthesia care anesthesia in more circumstances than originally planned and to reinstate separate payments for invasive monitoring lines and postoperative pain management.

Aetna has just granted our request for an explicit statement that it will not attempt to apply the medical direction payment reductions to cases involving residents. Readers will recall that other large payers, notably United Healthcare, have taken advantage of the Medicare rules regarding payment for teaching anesthesiologists and reduced reimbursement by 50 percent in concurrent cases. The following statement forwarded on September 16, 2002, by Aetna's Jeffrey Livovich, M.D., is an important confirmation and example for other payers:

The [medical direction] modifiers should be used to report the supervision of CRNAs. These modifiers should not be used to report the supervision of residents in an academic institution within an anesthesia-training program. Aetna will pay up to two rooms of resident supervision, providing the attending physician is present for all critical portions of the anesthesia service (induction, etc.).

All of this took considerable effort on the part of several physicians inside Aetna (as well on ASA's part). We certainly appreciate Aetna's willingness to work with us even though we may not gain every policy change or action that we discuss, and we would be delighted if other payers were equally forthcoming.

Negotiating higher CFs must be, under the terms of the federal antitrust laws, up to individual physicians and integrated groups. ASA encourages its members to negotiate as forcefully as they believe appropriate.


--------------------------------------------------------------------------------

Don't forget about the Ninth ASA Practice Management Conference in San Antonio, Texas, January 31-February 2, 2003! For more information, contact Jeff R. Schultz at (847) 825-5586, ext. 45.

Source Materials:

• Hannenberg AA. Medicare and Anesthesia Reimbursement Methods: Why the Medicare Fee Schedule is the Wrong Benchmark for Commercial Anesthesia Payments. ASA, 1999.

• Bierstein K. Fees paid for anesthesia services: 2001 Survey Results. ASA Newsl. 2001; 65(9):34-37.

• Gallagher PE. Medicare RBRVS: The Physicians' Guide. AMA, 2002:120.

• U.S. Department of Labor, Bureau of Labor Statistics, inflation calculator: < www.bls.gov/cpi/ >.

• McMenamin P. Reassessing Anesthesia Fees Under the Medicare Fee Schedule, 1995. Paper prepared for ASA, available at < www.asahq.org/Washington/McMenamin.pdf > .

• Hsiao WC, Dunn DL, Verrilli DK. Assessing the implementation of physician payment reform. N Engl J Med. 1993; 328:928-933.
 

EtherMD

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For those of you who want a quick summary of the above post here it is:
Medicare is screwing Anesthesiologists harder than most other specialties.
Everyone is getting it from Medicare but Anesthesia is getting it extra hard.

This year Medicare froze the surgical specialties. But, they cut Anesthesia about 7% more (effective cut) from the already low rates. More is expected next year.
There is no other specialty that gets a lower% of usually customary fees from Medicare: Not Ortho and Not Optho.

One more thing: Doctors' offices don't lose money seeing patients. An office that doesn't generate revenue for the Physician is poorly run. Most Optho guys work at an ASC and have very low debt. Just try getting an operation at an ASC without Insurance.

In my area Optho guys make big bucks by combining a short surgery with a good office and ASC fees. Simple economics. Medicare pays well if you know how to run a business. However, in Anesthesia even the best Anesthesiologist can't make money from Medicare rates. This is NOT true for the best Ortho, Optho or Cardiology. They do quite well with Medicare rates provided they are efficient and run a god office.
 

EtherMD

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One of the problems with Universal Health Care is going to be payment.
Medicare has established "Anesthesia" at a CRNA level of reimbursement.
Currently, we Physician Anesthesiologists deal with issue in one of two ways:
We charge our private paying patients up the a#@ (350% of Medicare) and/or charge the hospital for providing services. This maintains our good level of income.

Assuming Universal Health Care 5 years from now, where will we get the money to maintain our salaries? We are talking about a 50% pay cut based on Medicare rates 2006. Imagine Medicare rates 2010. This may result in a 60% pay cut based on average 2006 MD income.

However, hospitals will need Anesthesiologists to supervise the Mid-Levels.
They will pay a subsidy to maintain some supervision. But, the ratio will be 7:1 and the subsidy will be a lot lower than today. The main reason for the lower subsidy is the GLUT of MD/DO's available to hire. Most all MD/DO solo practices will fold leaving a large number of Physician Anesthesiologists unemployed and looking for a job. Thus, hospitals will use the law of supply vs. demand to their advantage (simple economics). I expect this means a 40% pay cut based on average 2006 income for those MD/DO's LUCKY enough to find work as a hospital supervisor.

Where is the AANA in all of this? Loving every minute of it because they are now in CHARGE of the market place. How is that ? Simple Economics. The AANA's membership represents the "lowest bidder" in the market place. The government has to keep the lowest bidder working in the hospital. So, once the AANA's membership starts to cut back services then the system falls apart. Thus. Medicare will make sure that reimbursement stays at a decent level for the NURSES. But, even they will have to deal with a 10-15% pay cut (2006 average income for a CRNA).

Do I want this to happen? No. But, those of you in training better prepare yourself for dealing with this issue. I recommend the following:

1. A better certificate- lists you as a Peri-Operative Physician with skills in basic TEE, U/S and basic Critical Care

2. SubSpecialty Training- Critical Care or Pain Management. Peds or Hearts if you hate the other two.

3. Become active in your society- eliminate SRNA training at University based CRNA programs immediately. Start AA programs in their place.

4. Reduce the number of Residency slots- just a 10% reduction is good start. Bring the numbers back to the late 1990's level. This really improves the odds of being "needed" by society/hospitals in the future.

5. Public Relations campaign by the ASA- Like the Geico campaign that features a caveman we use a monkey at the head of the table. "Would you let a monkey put you under?" Demand a Board Certified Physician Anesthsiologist be in charge of you care. Anesthesia is not something a monkey should do. Your life depends on it.:laugh:

Please notice I left the government out of the equation. We keep banging our heads against the same proverbial wall year after year. The AANA has made sure to muck up the waters for us. We need a new direction and a new strategy. Thus, I list points 1-5.
 

EtherMD

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Should we send my previous post to Marke Lema? We have his university e-mail address. Anyone else have ideas? The issue is tough but I firmly believe my points 1-5 are in the best interest of incoming PGY 1 and CA-1 Residents.

They deserve the same opportunity to do well that that many of us have enjoyed.
 

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The issue is tough but I firmly believe my points 1-5 are in the best interest of incoming PGY 1 and CA-1 Residents.
.

I dont believe adding an extra year to already crazy long training will help anybody except the hospitals and the government and the banks who are racking up about 12K per year on interest each year we are in training. My loans increased 50K during my internship and residency. because i was already tapped out in expenses and no way could afford the 2000 dollar per month loan payment. so it continued to grow for four straight years.. to about 200 large..

If you cut out the clinical base year or abbreviate it.. Prolly would make more sense to me..
 

EtherMD

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I dont believe adding an extra year to already crazy long training will help anybody except the hospitals and the government and the banks who are racking up about 12K per year on interest each year we are in training. My loans increased 50K during my internship and residency. because i was already tapped out in expenses and no way could afford the 2000 dollar per month loan payment. so it continued to grow for four straight years.. to about 200 large..

If you cut out the clinical base year or abbreviate it.. Prolly would make more sense to me..

Economics again. Your situation is such that you needed to go to work as soon as possible. However, others may have more flexibility and can do the extra year. The additional year may be very, very helpful in the future.
 

toughlife

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One of the problems with Universal Health Care is going to be payment.
Medicare has established "Anesthesia" at a CRNA level of reimbursement.
Currently, we Physician Anesthesiologists deal with issue in one of two ways:
We charge our private paying patients up the a#@ (350% of Medicare) and/or charge the hospital for providing services. This maintains our good level of income.

Assuming Universal Health Care 5 years from now, where will we get the money to maintain our salaries? We are talking about a 50% pay cut based on Medicare rates 2006. Imagine Medicare rates 2010. This may result in a 60% pay cut based on average 2006 MD income.

However, hospitals will need Anesthesiologists to supervise the Mid-Levels.
They will pay a subsidy to maintain some supervision. But, the ratio will be 7:1 and the subsidy will be a lot lower than today. The main reason for the lower subsidy is the GLUT of MD/DO's available to hire. Most all MD/DO solo practices will fold leaving a large number of Physician Anesthesiologists unemployed and looking for a job. Thus, hospitals will use the law of supply vs. demand to their advantage (simple economics). I expect this means a 40% pay cut based on average 2006 income for those MD/DO's LUCKY enough to find work as a hospital supervisor.

Where is the AANA in all of this? Loving every minute of it because they are now in CHARGE of the market place. How is that ? Simple Economics. The AANA's membership represents the "lowest bidder" in the market place. The government has to keep the lowest bidder working in the hospital. So, once the AANA's membership starts to cut back services then the system falls apart. Thus. Medicare will make sure that reimbursement stays at a decent level for the NURSES. But, even they will have to deal with a 10-15% pay cut (2006 average income for a CRNA).

Do I want this to happen? No. But, those of you in training better prepare yourself for dealing with this issue. I recommend the following:

1. A better certificate- lists you as a Peri-Operative Physician with skills in basic TEE, U/S and basic Critical Care

2. SubSpecialty Training- Critical Care or Pain Management. Peds or Hearts if you hate the other two.

3. Become active in your society- eliminate SRNA training at University based CRNA programs immediately. Start AA programs in their place.

4. Reduce the number of Residency slots- just a 10% reduction is good start. Bring the numbers back to the late 1990's level. This really improves the odds of being "needed" by society/hospitals in the future.

5. Public Relations campaign by the ASA- Like the Geico campaign that features a caveman we use a monkey at the head of the table. "Would you let a monkey put you under?" Demand a Board Certified Physician Anesthsiologist be in charge of you care. Anesthesia is not something a monkey should do. Your life depends on it.:laugh:

Please notice I left the government out of the equation. We keep banging our heads against the same proverbial wall year after year. The AANA has made sure to muck up the waters for us. We need a new direction and a new strategy. Thus, I list points 1-5.

Excellent points. Your recs should be sent not just to Dr. Lema but to the entire ASA leadership. Everyone needs to be involved. An additional request would be to have a strategic plan developed in months not years to address all the issues you mention.

Gaspassers are passive people in general and we need to put some heat on their butts to get them moving.
 

EtherMD

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Excellent points. Your recs should be sent not just to Dr. Lema but to the entire ASA leadership. Everyone needs to be involved. An additional request would be to have a strategic plan developed in months not years to address all the issues you mention.

Gaspassers are passive people in general and we need to put some heat on their butts to get them moving.


The place to start is a flier to the ASA membership. If the ASA explains the need for a T.V., Internet and Radio (Internet is better than radio) education campaign for the public. Many ASA members will contribute to this campaign.
The ASA needs to include a plea for more PAC money as well.

It wouldn't cost more than a few thousand dollars to make a mock DVD of the monkey T.V. campaign. Hell, a few Residents could probably do the preliminary video with one dressed up in a monkey suit.

A funny educational campaign would sell well to our membership and the public. The movie "Awake" will provide Millions of dollars of free advertising for the internet campaign. People will use GOOGLE and YAHOO by the millions when the movie gets released. Think about the T.V. specials and talk shows about ANESTHESIA when the movie hits the theaters. We are talking about tens of millions of dollars of free advertising for our monkey campaign.
 

n2bait

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The place to start is a flier to the ASA membership. If the ASA explains the need for a T.V., Internet and Radio (Internet is better than radio) education campaign for the public. Many ASA members will contribute to this campaign.
The ASA needs to include a plea for more PAC money as well.

It wouldn't cost more than a few thousand dollars to make a mock DVD of the monkey T.V. campaign. Hell, a few Residents could probably do the preliminary video with one dressed up in a monkey suit.

A funny educational campaign would sell well to our membership and the public. The movie "Awake" will provide Millions of dollars of free advertising for the internet campaign. People will use GOOGLE and YAHOO by the millions when the movie gets released. Think about the T.V. specials and talk shows about ANESTHESIA when the movie hits the theaters. We are talking about tens of millions of dollars of free advertising for our monkey campaign.

haha. Sounds good.

But residents in monkey suits sound a little tacky. I'd say use one of those trained chimps (their goofy pursed-lips faces can make even the staunchiest critic smile). Lets see one put in a central line...
 

EtherMD

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haha. Sounds good.

But residents in monkey suits sound a little tacky. I'd say use one of those trained chimps (their goofy pursed-lips faces can make even the staunchiest critic smile). Lets see one put in a central line...

I agree. A trained chimp is the way to go. Should we put a badge on the Monkey's scrubs? List credentials?:laugh: :laugh: Imagine the monkey's face when things start going wrong (Cardiac arrest with the monitor showing V.Tach-V.Fib then asystole). The monkey panics and starts jumping around.
Whose in Charge of Your Anesthesia? You deserve better than any monkey putting you under. Your life depends on it. DEMAND a Board Certified Physician Anesthesiologist be in Charge of your care. A public message by the ASA.:D
 
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