USAP Colorado

[pgg]

Dude. I worked with tons of military people. There are flight logs federal officials can legally document to be tax free being in combat tax free zone.

Dude. I've done five deployments and spent, in aggregate, several years of my life on active duty in combat zones. I've claimed the exclusion on my taxes a number of times over the last 20 years. (And in later years, came up hard against the cap because as a senior officer my taxable military pay exceeded that of the seniormost enlisted member.) I don't know what your military buddies told you or how you misunderstood them, but again, you don't have the first goddamn clue what you're talking about.

The CZTE applies only to military service members. The IRS has a page that lists where these locations are. Ukraine isn't one of them, for reasons that should be obvious. "Congresspeople" aren't in the military and they aren't riding cargo planes anyplace to execute some kind of combat zone tax free stock trade. This myth is so mind-numbingly stupid on multiple levels I hardly know where to begin.

Military servicemembers have, indeed, been able to claim the exclusion for an entire calendar month merely by flying in and out of a combat zone. Stories abound of enlisted ground crew airmen hitching rides on cargo planes from Turkey or other places into Iraq and Afghanistan, in order to get the benefit.

US citizens working in combat zones, may, under some circumstances, be eligible for the Foreign Earned Income Exclusion, even if their permanent residence remains within the United States, but there are some other limits and requirements. The deduction is capped at about $100K. Federal employees are specifically excluded. So are military servicemembers (who get the CZTE). Notably, the "single day" bit that qualifies a military servicemember for the CZTE doesn't work for them. I think I've read that they need 330+ days in the zone to qualify but I'm not sure.

A few years ago a bill was introduced in the House that would have allowed civilians working in a combat zone to claim the CZTE, but I don't think it ever made it out of committee. It certainly isn't law. If nothing else, the fact that this bill was even introduced in the first place should clearly prove to you that civilians were not eligible for the CZTE benefit.

And yes. There is legislation in the works for the drones from remote locations as well.

I never said it wasn't; and I am in fact aware of efforts to extend certain benefits to drone "pilots" in CONUS as if they were actually overseas. There's legislation in the works for all kinds of things. What's most interesting about all of those things is that they're utterly irrelevant to any discussion of current tax law.


The killer is that anybody with 10 minutes and an understanding of where to find Google could've learned all of the above, but you're so sure you know everything that it never occurs to you to question or fact check anything.

I don't really have high hopes that you'll absorb or understand any of this information either. Try firing up that home theater screen you fraudulently claimed as a business expense, pull up this post, spin up the font size real big, and read it again. Maybe that'll help.

---

Members don't see this ad.

 

[GassYous]

Dude. I've done five deployments and spent, in aggregate, several years of my life on active duty in combat zones. I've claimed the exclusion on my taxes a number of times over the last 20 years. (And in later years, came up hard against the cap because as a senior officer my taxable military pay exceeded that of the seniormost enlisted member.) I don't know what your military buddies told you or how you misunderstood them, but again, you don't have the first goddamn clue what you're talking about.

The CZTE applies only to military service members. The IRS has a page that lists where these locations are. Ukraine isn't one of them, for reasons that should be obvious. "Congresspeople" aren't in the military and they aren't riding cargo planes anyplace to execute some kind of combat zone tax free stock trade. This myth is so mind-numbingly stupid on multiple levels I hardly know where to begin.

Military servicemembers have, indeed, been able to claim the exclusion for an entire calendar month merely by flying in and out of a combat zone. Stories abound of enlisted ground crew airmen hitching rides on cargo planes from Turkey or other places into Iraq and Afghanistan, in order to get the benefit.

US citizens working in combat zones, may, under some circumstances, be eligible for the Foreign Earned Income Exclusion, even if their permanent residence remains within the United States, but there are some other limits and requirements. The deduction is capped at about $100K. Federal employees are specifically excluded. So are military servicemembers (who get the CZTE). Notably, the "single day" bit that qualifies a military servicemember for the CZTE doesn't work for them. I think I've read that they need 330+ days in the zone to qualify but I'm not sure.

A few years ago a bill was introduced in the House that would have allowed civilians working in a combat zone to claim the CZTE, but I don't think it ever made it out of committee. It certainly isn't law. If nothing else, the fact that this bill was even introduced in the first place should clearly prove to you that civilians were not eligible for the CZTE benefit.


I never said it wasn't; and I am in fact aware of efforts to extend certain benefits to drone "pilots" in CONUS as if they were actually overseas. There's legislation in the works for all kinds of things. What's most interesting about all of those things is that they're utterly irrelevant to any discussion of current tax law.


The killer is that anybody with 10 minutes and an understanding of where to find Google could've learned all of the above, but you're so sure you know everything that it never occurs to you to question or fact check anything.

I don't really have high hopes that you'll absorb or understand any of this information either. Try firing up that home theater screen you fraudulently claimed as a business expense, pull up this post, spin up the font size real big, and read it again. Maybe that'll help.

This is sad i was planning on getting into congress to take advantage of this tax loophole

 

[amyl]

So what’s the latest in Colorado? How’s the market look post USAP? Private groups forming or hospital employed positions abound? Seemed like there were a few more gasworks postings.

 

[rowsdower88]

https://www.npr.org/2024/04/23/1246430110/noncompete-agreements-ftc-ban-lina-khan

FTC voting soon to ban noncompete clauses for most Americans. It took a little over 15 months from when it was first proposed with over 26,000 public comments.

We'll see how the vote goes, the board is composed of 5 members - currently 3D and 2R (the board can't be composed of more than 3 people of the same party). I'm cautiously optimistic, but there's no doubt even if it goes through it will still be challenged in Court and that could go on for a while.

"FTC estimates a rule banning noncompetes would increase the earnings of the American workforce by as much as $296 billion per year."

 

[Dr. Rude]

https://www.npr.org/2024/04/23/1246430110/noncompete-agreements-ftc-ban-lina-khan

FTC voting soon to ban noncompete clauses for most Americans. It took a little over 15 months from when it was first proposed with over 26,000 public comments.

We'll see how the vote goes, the board is composed of 5 members - currently 3D and 2R (the board can't be composed of more than 3 people of the same party). I'm cautiously optimistic, but there's no doubt even if it goes through it will still be challenged in Court and that could go on for a while.

"FTC estimates a rule banning noncompetes would increase the earnings of the American workforce by as much as $296 billion per year."

If they truly do away with noncompetes in healthcare, it will be the wild west.

 

[aneftp]

If they truly do away with noncompetes in healthcare, it will be the wild west.

The may try to make healthcare mid levels and physician the exceptions

 

[rowsdower88]

The may try to make healthcare mid levels and physician the exceptions

I'm not sure I understand your thought. You think removing non-competes will be bad for anesthesiologists because it will lead to more midlevel encroachment?

Presumably midlevels would benefit from the lack of non-competes as much as physicians and would be equally capable of moving to greener pastures.

 

[Dr. Rude]

I'm not sure I understand your thought. You think removing non-competes will be bad for anesthesiologists because it will lead to more midlevel encroachment?

Presumably midlevels would benefit from the lack of non-competes as much as physicians and would be equally capable of moving to greener pastures.

No he is saying that maintaining noncompetes for docs and midlevels ould be bad for hospitals. So the FTC may carve out an exemption and keep those in place.

 

[rowsdower88]

No he is saying that maintaining noncompetes for docs and midlevels ould be bad for hospitals. So the FTC may carve out an exemption and keep those in place.

Ah ok.

The article did list at least one exception, but there could be other future exceptions made:

"The FTC's proposed rule did include a notable exception for noncompete agreements between sellers and buyers of businesses, meant to protect the value of the businesses being acquired. The two sides could still enter a noncompete agreement provided the seller had at least a 25% ownership interest in the business being sold."

 

[nimbus]

FTC Announces Rule Banning Noncompetes

Today, the Federal Trade Commission issued a final rule to promote competition by banning noncompetes nationwide, protecting the fundamen

www.ftc.gov

 

[rowsdower88]

FTC Announces Rule Banning Noncompetes

Today, the Federal Trade Commission issued a final rule to promote competition by banning noncompetes nationwide, protecting the fundamen

www.ftc.gov

So the vote was along party lines. As much as I think this is a good thing for America, I'm very skeptical this will survive SCOTUS.

Chevron deference is hanging on by a thread.

The legal arguments Republicans will hang their hats on are going to find a sympathetic ear. But the practical arguments against this policy that I've heard are garbage.

 

[kidthor]

But the practical arguments against this policy that I've heard are garbage.

The mental gymnastics people (/corporate shills) engage in to claim that noncompete magically help workers is creepy and shameless, to say the least.

 

[amyl]

so non competes have been gone for awhile - is the Colorado market any better? I see the gasworks posting for another pp group but the offer seems similar to USAP - two year partnership track. PAS? Thought things might get better after the non compete issue was settled

 

[nimbus]

Fluff piece in ASA Monitor. Capital from PE is key? The definition of “investor” is someone who expects to get back more than they put in. PE are apex investors.


Is this for real?

“We wanted physician shareholders to own equity alongside their capital partners to ensure that incentives are aligned, i.e., earnings would not be returned to any financial partner ahead of physician shareholders.“

“When the founding partners of our group surveyed the landscape, it was clear that USAP had the right model for us. USAP governance was created to keep the physicians in charge of clinical decisions, while benefitting from the investments that an outside partner can enable. In USAP, there are no preferred shares or different classes of equity. All shareholders, including physicians, receive the same distribution of dividends per share. Value is returned to shareholders via growth in stock price or through declared dividends. As a result, USAP has benefited from its PE partners, which have offered access to capital as well as excellent business and financial expertise.“

https://pubs.asahq.org/monitor/article/88/9/19/141895/Access-to-Investment-Capital-Including-PE-Is-Key

 

[CopaceticOne]

Fluff piece in ASA Monitor. Capital from PE is key? They NEVER give more than they take.

https://pubs.asahq.org/monitor/article/88/9/19/141895/Access-to-Investment-Capital-Including-PE-Is-Key

Good to know that Google Review ratings are what's important. Why don't we all just focus on that metric?

 

[nimbus]

The stock has always been part of the pitch when signing on with USAP. I'm still curious to know if any departing or retiring USAP partners have made money by selling back USAP stock.

 

[nimbus]

Interesting who the rating agencies consider to be a “cost” and who they consider to be a “controlling owner”. For physician shareholders, it seems like higher income will adversely effect “shareholder return”. The PE owners care only about shareholder return.

https://disclosure.spglobal.com/ratings/en/regulatory/article/-/view/type/HTML/id/3127783

U.S. Anesthesia Partners Holdings Inc. Outlook Revised To Stable From Negative On Strong Performance; Ratings Affirmed​

• U.S. Anesthesia Partners Holdings Inc. (USAP) delivered stronger-than-expected performance in 2023, primarily driven by volume increases and the ability to manage clinician and non-clinician labor costs.
• USAP's EBITDA margin for the trailing 12 months ended in September 2023 was 11.1% (12% in fiscal 2022) and adjusted leverage at the end of third quarter of 2023 was 7.3x (7.3x as of Dec. 31, 2022). We expect leverage to remain in the 6x-7x range over the next few years.
• We revised our outlook on USAP to stable from negative and affirmed our 'B' rating. We also affirmed our 'B' rating on the first-lien term loan and 'CCC+' rating on the second-lien term loan.
• The stable outlook reflects our expectation that the labor situation in Colorado is nonrecurring, the company will reduce its temporary staffing usage, and effectively manage its labor challenges such that it maintains EBITDA margin in 11%-12% range and adjusted leverage between 6.5x and 7.5x for the next few years.

TORONTO (S&P Global Ratings) Feb. 20, 2024--S&P Global Ratings today took the rating actions listed above.

​

USAP delivered strong operating performance in 2023, primarily due to volume increases and despite higher staff costs.USAP delivered strong performance in 2023, primarily from strong volume during the period. We expect high-single-digit percent volume increases for 2024, moderating to mid-single digits in 2025 and beyond. USAP continues to face higher staff costs amid the still-tight labor market. In the second quarter of 2022, USAP modified its physician compensation model in its third-largest market, Colorado, to a hybrid model incorporating elements of both direct compensation and standard partner model to address adverse labor market issues that raised staff costs. In other markets, USAP continues to recruit to reduce elevated locums and premium pay levels. We expect higher subsidies paid by hospitals and the variable compensation model to help mitigate a portion of higher staffing costs. USAP has already increased subsidies to 13% of revenues year to date as of September 2023 from 9.5% in 2022.

​

The U.S. Federal Trade Commission (FTC) complaint against USAP and financial sponsor Welsh Carsen raises risk. The September 2023 complaint in federal district court alleged USAP and Welsh Carson engaged in anticompetitive conduct through roll-up acquisitions completed over years, price-setting arrangements between USAP and other competitors, and an agreement between USAP and one of its competitors to allocate markets, which monopolized the anesthesiology market in Texas and drove up prices in the region. In November 2023, USAP and Welsh Carsen filed motions to dismiss the case. For now, we assume $20 million of legal costs in our base-case forecasts. While the outcome is uncertain, in a worst-case scenario, there is a risk USAP may need to divest some of its business in Texas.

​

Although reimbursement risk is indirect, we believe USAP is still exposed to adverse reimbursement changes by private or public payers. We expect reimbursement pressure to persist in 2024, reflected in a 3.7% Medicare Physician Fee Schedule (MPFS) rate cut after a 2% cut in 2023. However, we believe the impact will be minimal because only about 12% of USAP's revenue comes from Medicare, and we expect it will be partially offset by flat to low-single-digit percent increases from commercial payers (which contribute 80% of revenue). A variable physician compensation model gives USAP cost flexibility to mitigate other adverse reimbursement events, minimalizing impact on EBITDA margins.

​

We expect a small free cash flow surplus in 2023 and estimate free cash flow to debt close to 3% in 2024.We expect free cash flow of $20 million-$25 million for the full year 2023. It to improve in 2024 despite higher clinician and non-clinician compensation costs and interest expenses. We expect working capital to improve as USAP focuses on reducing Days in Sales Outstanding (DSOs), but it likely will remain an outflow in 2023 and 2024. We estimate free operating cash flow to debt in the 1%-2% range in 2023 but improving to above 2.5% in 2024 due to better operating performance from strong volumes, moderation in labor costs, and possible reduction in interest expense if there's a rate cut. USAP entered an interest rate cap on its first-lien and second-lien term loan debt in December 2022 at a three-month SOFR of 5.5%, maturing in March 2025, providing some protection against further interest rate increases.
The stable outlook reflects our expectation that the situation in Colorado is nonrecurring, USAP will reduce its temporary staffing usage, and effectively manage its labor challenges such that it maintains EBITDA margin between 11% and 12% and adjusted leverage between 6.5x and 7.5x for the next few years.
We could lower our rating on USAP if margins decline more than 200 basis points, most likely due to lower-than-expected volumes and higher staff costs. Under this scenario, we would expect adjusted free cash to debt will decline below 2.5% or adjusted leverage to remain sustainably above 8x. This could occur if:

• USAP cannot offset compensation costs with higher subsidies from hospitals;
• It cannot increase payer rates; and
• Penalties by the FTC or mandatory divestitures in Texas reduce profit and negotiation power with payers.

While unlikely at this time, we could raise our rating if USAP reduces leverage below 5x. We view this as unlikely because it would require the company to prioritize debt repayment overgrowth and shareholder returns.
Governance is a moderately negative consideration. Our assessment of the company's financial risk profile as highly leveraged reflects corporate decision-making that prioritizes the interests of controlling owners, in line with our view of most rated entities owned by private-equity sponsors. Our assessment also reflects the generally finite holding periods and a focus on maximizing shareholder returns. Social factors are, on balance, neutral. Although anesthesia services are subject to the risk of surprise billing legislation, USAP's out-of-network exposure is limited, providing some insulation against this risk.

 

[kidthor]

“In USAP, there are no preferred shares or different classes of equity. All shareholders, including physicians, receive the same distribution of dividends per share. Value is returned to shareholders via growth in stock price or through declared dividends.”

The implication that physician shareholders somehow get the same financial benefit as the PE predators is so laughable. It’s a farce that USAP’s share value is what they’re after - given that PE saddled it with debt, pulled money out as “profit”, and charges USAP a bunch of management fees. Then they’ll pump and dump those worthless shares once it’s bankrupt and they’re done sucking the money out.

 

[NumTacos]

Yeah, anyone in their right mind joining any of these PE backed AMCs should just assume any of these “shares” are funny money. Look at those guys and gals from Phymed, some of them ended up with nothing.

 

[aneftp]

Yeah, anyone in their right mind joining any of these PE backed AMCs should just assume any of these “shares” are funny money. Look at those guys and gals from Phymed, some of them ended up with nothing.

The original partners already got their money from usap, mednax , Sheridan, team health between 2007-2017

All that’s left is scraps and leftovers.

I few minor (less than 7 figure buyouts after 2018-2020). I haven’t heard of any buyouts since Covid. Doesn’t mean it didn’t occur. Just that I don’t know of any.

 

[NumTacos]

The original partners already got their money from usap, mednax , Sheridan, team health between 2007-2017

All that’s left is scraps and leftovers.

I few minor (less than 7 figure buyouts after 2018-2020). I haven’t heard of any buyouts since Covid. Doesn’t mean it didn’t occur. Just that I don’t know of any.

Interesting. I still feel like counting on those shares being there for financial planning purposes is probably not a good idea though.

 

[aneftp]

Interesting. I still feel like counting on those shares being there for financial planning purposes is probably not a good idea though.

The goal of welsh Carson was never to manage a practice. It was to flip it. I’m sure they were truly profitable till early 2022 but as seen by official press release. Labor costs are skyrocketing. And they are begging hospitals and surgery center for subsidies.

So much for being a well oil machine based on metrics and high quality care. It was never based on any of that bs. It was based on payor mix and market share leverage to demand $140/unit while the smaller companies could only get $90/unit.

So even at $140/unit they can’t keep up. That’s scary. Because 20% goes back to PE which means they are only really collecting $110/unit for commercial. Still good. Except crnas salaries are going up way more than doc salaries.

 

[kidthor]

PS if anyone is going to ASA meeting - George Tewfik is giving a talk on private equity in anesthesia (on Sunday I think). I will 100% be there!

 

[aneftp]

PS if anyone is going to ASA meeting - George Tewfik is giving a talk on private equity in anesthesia (on Sunday I think). I will 100% be there!

https://www.usap.com/sites/default/files/2023-03/Tewfik%20Private%20Equity%20Monitor_0.pdf

So what’s usap (and other amc) response for all their bs quality metrics? Why isn’t quality metrics working for usap?

Because it doesn’t make a damn difference. That’s why. The only Quality metric in anesthesia is did the patient live or die. That’s it. Anyone who wants to believe otherwise about pain scores, patient satisfaction etc. They are just zombies.

 

[NumTacos]

PS if anyone is going to ASA meeting - George Tewfik is giving a talk on private equity in anesthesia (on Sunday I think). I will 100% be there!

 

[nimbus]

https://www.usap.com/sites/default/files/2023-03/Tewfik%20Private%20Equity%20Monitor_0.pdf

So what’s usap (and other amc) response for all their bs quality metrics? Why isn’t quality metrics working for usap?

Because it doesn’t make a damn difference. That’s why. The only Quality metric in anesthesia is did the patient live or die. That’s it. Anyone who wants to believe otherwise about pain scores, patient satisfaction etc. They are just zombies.

You can give a ****ty anesthetic but click a few buttons on ePreop and your quality metrics are 100%.

 

[nimbus]

The original partners already got their money from usap, mednax , Sheridan, team health between 2007-2017

All that’s left is scraps and leftovers.

I few minor (less than 7 figure buyouts after 2018-2020). I haven’t heard of any buyouts since Covid. Doesn’t mean it didn’t occur. Just that I don’t know of any.

Cash buyouts>>>cash+stock buyouts

 

[centdoc]

The original partners already got their money from usap, mednax , Sheridan, team health between 2007-2017

All that’s left is scraps and leftovers.

I few minor (less than 7 figure buyouts after 2018-2020). I haven’t heard of any buyouts since Covid. Doesn’t mean it didn’t occur. Just that I don’t know of any.

Interest rates are too high. Even the PE entities can’t afford to borrow money and saddle that debt onto the groups they buy.

 

[aneftp]

Interest rates are too high. Even the PE entities can’t afford to borrow money and saddle that debt onto the groups they buy.

Interest rates close to zero in 2020. It wasn’t the interest rates.

 

[amyl]

a PE group is currently forbidden by court order from acquiring new practices. the rest cant staff what they already have so they cant acquire new practices because they offer shady deals with changing terms or undermarket compensation. The PE MO in anesthesia is dead but most people want to ignore that elephant in the room. If i were graduating right now I would probably consider academics if I couldnt find a hospital employed position in a location I liked. I think its just starting but there are some VERY good hospital employed jobs out there right now

 

[Coffee PRN]

a PE group is currently forbidden by court order from acquiring new practices. the rest cant staff what they already have so they cant acquire new practices because they offer shady deals with changing terms or undermarket compensation. The PE MO in anesthesia is dead but most people want to ignore that elephant in the room. If i were graduating right now I would probably consider academics if I couldnt find a hospital employed position in a location I liked. I think its just starting but there are some VERY good hospital employed jobs out there right now

Not to throw salt in the wound, but weren't you very confident of USAP's future just a little over a year ago, even after the NSA had passed? Genuinely curious what changed.

 

[aneftp]

Not to throw salt in the wound, but weren't you very confident of USAP's future just a little over a year ago, even after the NSA had passed? Genuinely curious what changed.

The anesthesia has changed a lot in 12 months. Even blade recommended any new grads consider usap as little as 12-18 months ago as well. Because it was still a well run entity.

It’s not just usap in terms of private equity struggling. The true private groups are struggling with asking for subsidies from hospitals.

One of the guys I met in the locums tour down in Florida is from northeast. He just left his lucrative private practice making no less than 750k in the northeast the past 15 years. It just became too much for him. You can see the writing on the wall

 

[amyl]

“Became too much for him” - meaning too much work?

 

[aneftp]

“Became too much for him” - meaning too much work?

Yes. He’s making 750k. But it’s like 1 million dollars of worth. Sound familiar?

Keeps going back to hospital admin to go line by line the locums crna charges etc.

The partners are working like dogs 60-65 hrs gets old

I’m actually trying to convince him and another doc to tag team with me on some locums gigs so we can provide the equivalent of 1.0 fte for the hospital but at locums terms. And job share a w2
Job to get base w2 income

 

[amyl]

Not to throw salt in the wound, but weren't you very confident of USAP's future just a little over a year ago, even after the NSA had passed? Genuinely curious what changed.

It’s ok. But I have to be very careful what I say as everyone knows who I am.
USAP is still a good fit for someone who wants to work hard and is willing to do a three year partnership track and do extended care team because they want to live in dallas.
That’s not really a good fit for me anymore. I’ll admit I was a little naive and can admit when I’m wrong.
If someone has a serious interest and wants to discuss offline pm me

 

[amyl]

Yes. He’s making 750k. But it’s like 1 million dollars of worth. Sound familiar?

The partners are working like dogs 60-65 hrs gets old

Yes - that sounds familiar.

 

[aneftp]

There are very few private places left in the USA where you can work 40/45 hours including as a partner and still expect to generate 700k and up factoring 10 weeks off.

I’ve been asked to take over surgery center billing couple of downtown places and I’m going through the pay or mix. Im looking at 2.5-3 million in revenue collections. But the center is demanding 4 crnas up to 3pm and 2 crnas up to 5pm and peel off up to 7pm.

4 crnas plus vacation coverage will eat up close to 2 million dollars alone.

Running it with 4 docs doesn’t make sense either.

No easy solution. This is a center usap left.

 

[Shimmy8]

^hit the nail on the head. The finances just don’t work, even in supposed “profitable” ASCs unless you’re in a statistical outlier of payor mix OR hospital heavily supporting the group.

 

[amyl]

If USAP left there’s a reason. Probably unrealistic admin that doesn’t realize they have to dip into those nice facility fees to pay anesthesia. Dictating coverage costs, especially past 3. Either control surgeons expectations past 3 or pay $ or both.
I know lots of places whining about costs of coverage that perpetuate the problem with expensive locums without increasing regular full time pay.
I was talking with one of the senior members of our group and he remarked about how surgeons used to be more realistic about timing… now they throw a fit if they can’t do whatever they want whenever they want. The result is that we run elective cases until 11pm regularly. The other day on call they ran two elective rooms until 11pm. Crazy. Seems to have changed in recent years.

 

[Howard888]

Hospital employed jobs have hit the 600 mark with better schedules and hours than many/most amcs including USAP.

Would have to be upper 10% of amc job to do any sort of partnership track over one of these employed jobs. Just not worth it from an hourly/call standpoint anymore

 

[aneftp]

Hospital employed jobs have hit the 600 mark with better schedules and hours than many/most amcs including USAP.

Would have to be upper 10% of amc job to do any sort of partnership track over one of these employed jobs. Just not worth it from an hourly/call standpoint anymore

Thus the usap partnership track days are over.

Even private practice partnership track days outside of one year track is over. Look the Minnesota ad the doc posted in the other sdn anesthesia positions from. That job sounds good…5-6 years ago. Not in 2024.

 

[PainInTheAnes]

It’s ok. But I have to be very careful what I say as everyone knows who I am.
USAP is still a good fit for someone who wants to work hard and is willing to do a three year partnership track and do extended care team because they want to live in dallas.
That’s not really a good fit for me anymore. I’ll admit I was a little naive and can admit when I’m wrong.
If someone has a serious interest and wants to discuss offline pm me

😂

Good fit for…no one then?

I don’t understand this whole “we like to work hard” thing that’s going on in the partnership tracks.

If someone “likes to work hard”, then they should be doing travel work for a few years. “Work hard” and make 20k+ per week. Rinse and repeat until satisfied with having “worked hard”

There are zero usap practices that pay fairly on an hourly basis any more. And they force partners into picking up the slack from call and gaps.

Every additional hour one works is marginally worse return on investment, and they require it or your partnership will be taken away.

I’ve literally never seen a practice where they tout “we work hard” and there is adequate compensation for the hard work. It’s always just practices in desirable areas with the undertone of “we think you’re a replaceable fool, but we can trick you into thinking that Dallas, Chicago, Philadelphia, Irvine, Seattle are worth it to live in to sacrifice every waking hour of your life on call for not extra”

The arrogance of these places in interviews to pretend it isn’t just market forces that allow them to run terrible practices is staggering.

Only in anesthesia are current partners so willing to lie to prospective partners. I don’t know what it is about this field that attracts such toxic jerks everywhere in big cities.

 

[aneftp]

😂

Good fit for…no one then?

I don’t understand this whole “we like to work hard” thing that’s going on in the partnership tracks.

If someone “likes to work hard”, then they should be doing travel work for a few years. “Work hard” and make 20k+ per week. Rinse and repeat until satisfied with having “worked hard”

There are zero usap practices that pay fairly on an hourly basis any more. And they force partners into picking up the slack from call and gaps.

Every additional hour one works is marginally worse return on investment, and they require it or your partnership will be taken away.

I’ve literally never seen a practice where they tout “we work hard” and there is adequate compensation for the hard work. It’s always just practices in desirable areas with the undertone of “we think you’re a replaceable fool, but we can trick you into thinking that Dallas, Chicago, Philadelphia, Irvine, Seattle are worth it to live in to sacrifice every waking hour of your life on call for not extra”

The arrogance of these places in interviews to pretend it isn’t just market forces that allow them to run terrible practices is staggering.

Only in anesthesia are current partners so willing to lie to prospective partners. I don’t know what it is about this field that attracts such toxic jerks everywhere in big cities.

Agree. But some people need to stick around Dallas or Orlando or Houston.

It’s a trade off. The big practices are depending on your inflexibility to sell their practice for you to work at. Some people have kids in school which makes it really hard to move especially with grand parents near by.

As much as we talk about money here. Family is the most important thing. I had to give up a massive weekend pay as locums cause my daughter wanted me take her to the Sabrina carpenter concert in Tampa. Thank god I didn’t get tickets for swift’s Miami concert the week before. That would have been two massive weekends I would have given up.

But that’s what staying in the area means to be in those cities.

 

[PainInTheAnes]

Agree. But some people need to stick around Dallas or Orlando or Houston.

It’s a trade off. The big practices are depending on your inflexibility to sell their practice for you to work at. Some people have kids in school which makes it really hard to move especially with grand parents near by.

As much as we talk about money here. Family is the most important thing. I had to give up a massive weekend pay as locums cause my daughter wanted me take her to the Sabrina carpenter concert in Tampa. Thank god I didn’t get tickets for swift’s Miami concert the week before. That would have been two massive weekends I would have given up.

But that’s what staying in the area means to be in those cities.

Idk, academic jobs in those areas are generally available. In the places like that that I’ve lived they’re always preferable to the big partnership jobs.

Besides, go 30 minutes outside of any of these places and you’re “in the city” without being “in the city”. Jobs are much much better and you’ve got perfect access to what you need still

 

[amyl]

😂

Good fit for…no one then?

I don’t understand this whole “we like to work hard” thing that’s going on in the partnership tracks.

If someone “likes to work hard”, then they should be doing travel work for a few years. “Work hard” and make 20k+ per week. Rinse and repeat until satisfied with having “worked hard”

There are zero usap practices that pay fairly on an hourly basis any more. And they force partners into picking up the slack from call and gaps.

Every additional hour one works is marginally worse return on investment, and they require it or your partnership will be taken away.

I’ve literally never seen a practice where they tout “we work hard” and there is adequate compensation for the hard work. It’s always just practices in desirable areas with the undertone of “we think you’re a replaceable fool, but we can trick you into thinking that Dallas, Chicago, Philadelphia, Irvine, Seattle are worth it to live in to sacrifice every waking hour of your life on call for not extra”

The arrogance of these places in interviews to pretend it isn’t just market forces that allow them to run terrible practices is staggering.

Only in anesthesia are current partners so willing to lie to prospective partners. I don’t know what it is about this field that attracts such toxic jerks everywhere in big cities.

I can’t disagree. The other guys are right as well - we work more. Hospital employed jobs at 600 are available with less work… you just have to be out of the regions dominated by the AMCs or hca - (like south Florida).
I thought the market in Denver would open up a little - but I spoke to two independent non USAP groups that were completely predatory and paying nothing. Denver is just desirable so I guess they get away with it. Nashville seems the same. Idk guys I’m finding these cities overrated - If you’re working all the time you can’t enjoy them anyway. Starting to make bfe and lots of vacation time (especially with a husband with a plane) look really good…

 

[3pin3phrine]

Yes. He’s making 750k. But it’s like 1 million dollars of worth. Sound familiar?

Keeps going back to hospital admin to go line by line the locums crna charges etc.

The partners are working like dogs 60-65 hrs gets old

I’m actually trying to convince him and another doc to tag team with me on some locums gigs so we can provide the equivalent of 1.0 fte for the hospital but at locums terms. And job share a w2
Job to get base w2 income

Hi aneftp,
If you need help with locums coverage and those other docs who were interested fall through, please send me a DM. I'll be interested in filling in. I live in Orlando.

Thanks!

 

[kidthor]

I don’t understand this whole “we like to work hard” thing that’s going on in the partnership tracks.

This sentiment has always weirded me out too. I think it’s typically just a code or subtext for exploitative people at the top to make the underlings work more while they themselves (predatory partners and the like) work less and skim off the top.

As noted by others - anyone smart who actually wants to work hard would just do locums for the highest bidders in this environment, rather than mindlessly slogging away for free.

 

[aneftp]

This sentiment has always weirded me out too. I think it’s typically just a code or subtext for exploitative people at the top to make the underlings work more while they themselves (predatory partners and the like) work less and skim off the top.

As noted by others - anyone smart who actually wants to work hard would just do locums for the highest bidders in this environment, rather than mindlessly slogging away for free.

But there are some locums jobs that are harder than others

I’m all about the workload these days.

Making an extra $50/hr to me to go to $425/450/hr may not be worth it.

All these locums jobs are all over the place in terms of workload.

Is it worth it for me to make $450/hr and run around and do 6-12 blocks a day plus inducing a case on my own while the crna is dropping off the patient in the pacu just to save the surgeon 6-8 minutes?

 

[sevoflurane]

I can’t disagree. The other guys are right as well - we work more. Hospital employed jobs at 600 are available with less work… you just have to be out of the regions dominated by the AMCs or hca - (like south Florida).
I thought the market in Denver would open up a little - but I spoke to two independent non USAP groups that were completely predatory and paying nothing. Denver is just desirable so I guess they get away with it. Nashville seems the same. Idk guys I’m finding these cities overrated - If you’re working all the time you can’t enjoy them anyway. Starting to make bfe and lots of vacation time (especially with a husband with a plane) look really good…

Denver has always been that way. Goes as far back as the first USAP groups (SDA). Great city, vibe and access to the mountains. Kaiser is still decent for a long term plan.
BFE isn’t an end of career plan either. It’s something you muster early. Plenty of decent jobs in desirable locations in this market.

 

[sevoflurane]

This sentiment has always weirded me out too. I think it’s typically just a code or subtext for exploitative people at the top to make the underlings work more while they themselves (predatory partners and the like) work less and skim off the top.

As noted by others - anyone smart who actually wants to work hard would just do locums for the highest bidders in this environment, rather than mindlessly slogging away for free.

Times are changing. People want to live their lives as they live it. Delayed gratification is not as prevalent as it used to be.
It’s common for a new grad to come in as a part time FTE right out of the gate. I support that thinking 100%. 30s-40s are great years.
Flexibility in anesthesia remains one of it’s biggest merits.