VA job vs. Private Practice

[DiveMD]

Can someone look at these numbers and provide a private practice perspective? Is this a reasonable salary compared to most private practice docs? What's the average take home pay for a glaucoma doc out there?

VA job: Glaucoma Specialist
Starting Salary: $230,000 w/ all the VA benefits (TSP, pension, affordable health insurance, no malpractice, paid vacations and lifestyle) and pains (lack of control over the clinic flow and staff, minimal salary growth, bureaucracy, unions protecting mediocre employees).

Considering this starting salary, will a move to the private sector in a couple years be wise? How long will it take a glaucoma specialist before he/she can make 230K take home salary? I know these are very generic questions but any advice is appreciated.

Thanks in advance for your opinions.

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[Visionary]

Complex question. The starting salary and benefits of a VA job, like any hospital or HMO job, sound great compared to those for private practice; however, the potential for income growth is simply not there. While you will start out lower in private practice, you have to potential to earn far more down the road. How much is dependent on your practice setup, though. If you are a glaucoma doc who sees a good volume (~50 patients per day) and also does cataracts (fairly common, actually), you could easily be making $300-400k in a few years. More, if you have an optical and/or stake in an ASC or the building you're in. You will never make that as an employee. Most medical students/residents have a rather myopic view, so they balk at the small starting salaries of private practice. It's all relative. I'm medical retina and I started out with a base salary of $150k 3 years ago. That's very low for retina, but I saw the potential here. As a partner, I should easily clear over $500k next year from the various income sources, and my practice is still growing.

 

[Eyefixer]

Complex question. The starting salary and benefits of a VA job, like any hospital or HMO job, sound great compared to those for private practice; however, the potential for income growth is simply not there. While you will start out lower in private practice, you have to potential to earn far more down the road. How much is dependent on your practice setup, though. If you are a glaucoma doc who sees a good volume (~50 patients per day) and also does cataracts (fairly common, actually), you could easily be making $300-400k in a few years. More, if you have an optical and/or stake in an ASC or the building you're in. You will never make that as an employee. Most medical students/residents have a rather myopic view, so they balk at the small starting salaries of private practice. It's all relative. I'm medical retina and I started out with a base salary of $150k 3 years ago. That's very low for retina, but I saw the potential here. As a partner, I should easily clear over $500k next year from the various income sources, and my practice is still growing.

Ok I'lI bite.

I think this is even more complex than that.

Private practices around me are dying slow and painful death. Ever increasing overhead, employee wages, decreasing reimbursements, Obamacare, increasing competition, optometrists, etc. etc. Also, private practice is a 24/7 job which is VERY hard (especially if you are a solo practitioner).

Yes, there is higher earning potential in private practice NOW. What do you think is going to happen in 2013, 2014, etc? Do you think you will still be clearing over $500K as your per injection reimbursement drops from $160 to $120 to... They are already decreasing cataract surgery RVUs in 2013 from 11 to 9 on a simple cataract and from 16 to 11 on complex. These are huge cuts.

VA offers stability, no stress of running your own business, resident teaching, no actual call, guaranteed pension, plenty of benefits, reasonable schedule, all federal holidays off, etc.

I am not saying one is better then the other; just saying you have to find what fits your personality and your ability to tolerate future risk.

 

[LightBox]

Ok I'lI bite.

I think this is even more complex than that.

Private practices around me are dying slow and painful death. Ever increasing overhead, employee wages, decreasing reimbursements, Obamacare, increasing competition, optometrists, etc. etc. Also, private practice is a 24/7 job which is VERY hard (especially if you are a solo practitioner).

Yes, there is higher earning potential in private practice NOW. What do you think is going to happen in 2013, 2014, etc? Do you think you will still be clearing over $500K as your per injection reimbursement drops from $160 to $120 to... They are already decreasing cataract surgery RVUs in 2013 from 11 to 9 on a simple cataract and from 16 to 11 on complex. These are huge cuts.

VA offers stability, no stress of running your own business, resident teaching, no actual call, guaranteed pension, plenty of benefits, reasonable schedule, all federal holidays off, etc.

I am not saying one is better then the other; just saying you have to find what fits your personality and your ability to tolerate future risk.

My completely biased opinion: working at the VA sucks. No offense to those who work primarily at the VA, but I couldn't imagine a "career" of working just at the VA. But I'm one of those people who could not imagine working at Kaiser either. I just see so much lazy Medicine coming out of those places. I personally prefer either an academic or "academic private practice" setting.

But I agree, the cuts in RVUs you described are just simply ridiculous. We continue to have no voice politically and we continue to be penalized for having amazing results. There is a reason why practices have to "hard-sell" the premium lenses and focus more on refractive. There is just no financial incentive to take care of "regular" Ophthalmology problems anymore, when you could be spending that time actually making a profit.

 

[Eyefixer]

My completely biased opinion: working at the VA sucks. No offense to those who work primarily at the VA, but I couldn't imagine a "career" of working just at the VA. But I'm one of those people who could not imagine working at Kaiser either. I just see so much lazy Medicine coming out of those places. I personally prefer either an academic or "academic private practice" setting.

I completely agree with you. Unfortunately, Kaiser-like jobs will become more and more competitive as we move forward. This is the future folks, like it or not. P.S. I do not work for VA or Kaiser.

 

[Visionary]

Ok I'lI bite.

I think this is even more complex than that.

Private practices around me are dying slow and painful death. Ever increasing overhead, employee wages, decreasing reimbursements, Obamacare, increasing competition, optometrists, etc. etc. Also, private practice is a 24/7 job which is VERY hard (especially if you are a solo practitioner).

Yes, there is higher earning potential in private practice NOW. What do you think is going to happen in 2013, 2014, etc? Do you think you will still be clearing over $500K as your per injection reimbursement drops from $160 to $120 to... They are already decreasing cataract surgery RVUs in 2013 from 11 to 9 on a simple cataract and from 16 to 11 on complex. These are huge cuts.

VA offers stability, no stress of running your own business, resident teaching, no actual call, guaranteed pension, plenty of benefits, reasonable schedule, all federal holidays off, etc.

I am not saying one is better then the other; just saying you have to find what fits your personality and your ability to tolerate future risk.

I won't argue the future. It looks dire for all of medicine, no doubt. Of course, that is really nothing new. Medicine is one of the only fields I can think of where you can pretty much expect to make less over time in adjusted dollars during your career (ask any doc who practiced in the golden days of cataract and, more recently, refractive surgery). I will, however, stand by my contention that the earning potential of a private practitioner will always exceed that of an employee. The fact is that reimbursement levels are a constant in the equation. Any changes in them will apply to both private and employed scenarios. You just aren't privy them in the latter (they can't just print money, you know). In private practice, you have control over certain variables that can allow you to compensate (to a degree, mind you) for decline in reimbursement...and you're smarter than the CMS bureaucrats, right? The dying practices you mention are likely dying because of poor management, I'm sorry to say. For instance, my practice recently went to EHR, which was a large investment of capital and staff overhead, yet we are about to post a record year for earnings. It's about making adjustments in how your business runs, which is something that we unfortunately are not typically taught in medical school, residency, or fellowship.

 

[Visionary]

My completely biased opinion: working at the VA sucks. No offense to those who work primarily at the VA, but I couldn't imagine a "career" of working just at the VA. But I'm one of those people who could not imagine working at Kaiser either. I just see so much lazy Medicine coming out of those places. I personally prefer either an academic or "academic private practice" setting.

But I agree, the cuts in RVUs you described are just simply ridiculous. We continue to have no voice politically and we continue to be penalized for having amazing results. There is a reason why practices have to "hard-sell" the premium lenses and focus more on refractive. There is just no financial incentive to take care of "regular" Ophthalmology problems anymore, when you could be spending that time actually making a profit.

Could not agree more. I am a VA contractor, so I only spend a couple half days a month there. I love the resident interaction, and the veterans are a great population, but the red tape there is suffocating. I could never be there full time.

A little insight into those cuts: they were based on surveys of ophthalmologists regarding surgical times and outcomes. In other words, we did this to ourselves! Most docs out there probably do 15 minute uncomplicated cataracts (heck, I was at the end of residency). Sounds awesome, huh? Oh, wait, that must mean it doesn't take as much effort as it once did. *Snip* That's how it happens, folks. CMS is constantly looking for ways to cut. Cataract surgery = high cost per unit time = cut. OCT = high utilization = cut. Intravitreal injection = high utilization = cut. So, what do you do? You can start to emphasize additional cash procedures, such as premium IOLs and combined refractive surgery. You can do more angiograms (probably should, anyway--OCT doesn't tell the whole story--off soapbox). You can reduce your injection overhead (e.g., materials, how you compound certain drugs--I saved over $30k per year doing this). There are ways to compensate to reduce the hit you take. Rolling with the punches, as they say.