This is a much trickier question, in part because the presence of some departments are important for revenue of other departments, and some departments are more "slow burns." Organ transplants don't bill anywhere near as much as orthopedic procedures, but they make plenty of money, because with that organ comes over a hundred follow-up visits to various specialties over the years - it's an "investment." Etc.
Agreed. Partly because most of those services have to be preapproved so collection rates are high. Ditto for elective procedures - most/all hospitals usually require prior authorization before scheduling, and many will also have the patient pay their estimated portion up front.
Somebody needs to keep the post-op patients alive!
That is also complicated, as the neurology department in an academic institution is going to lose money, but good luck running an academic hospital without one. From an outpatient perspective, general outpatient neurology is generally going to be net positive, but that is counterbalanced by all the specialists/subspecialists who are seeing third opinion cases, etc. A generalist who only sees migraine and sees 30 patients a day is going to make plenty of money for the hospital, but that person is also probably just going to go into private practice and keep that money for themselves.
Net negatives for the hospital. The money makers are the surgeons and proceduralists. Which is why a lot of systems are pushing for medicine to admit everyone (even the healthy 22 yo with appendicitis), to keep the surgeons and proceduralists off of the floors and in the OR’s generating revenue.
Good to know! Does that mean that the hospitalists round on the healthy 22yo with appendicitis post-op instead of the acute care surgeons? Or is appendectomy outpatient now?
They round and are primary. The surgeons do too, but just manage things directly related to the surgery.
Most non-procedural specialties like IM, FM, peds, neuro, ID, endocrine will technically be net negative if you're only looking at their revenue generated by billing E&M codes to the patients' insurances, and require subsidization from money coming elsewhere from the system. However, the generalists like IM, FM, peds generate referrals to the other high-reimbursing specialties that allow those specialties to make those profits. In that sense, they are often considered a necessary business expense. However, the exact value of these referrals is difficult to quantify and it all comes down to budgeting/accounting, which usually shows most non-procedural specialties as net negative.
The procedural specialties overall bring in the most, especially the outpatient elective ones (where the procedure will only get done if the patient's insurance is paying for it and the resources used are usually more controlled). The inpatient emergent procedures can be money losers in some cases (and this depends a lot on the insurance payor mix and demographics of the local community), especially because many academic medical centers are affiliated with safety net health systems that have a lot of patients with no insurance or poorly reimbursing Medicaid but obviously any emergent inpatient surgery/procedure can't be avoided just because there is no payor source; when that happens and they can't collect from the patient, the hospital just has to eats the cost.
Both round on the patient. But usually the primary admitting team has the most responsibilities for the discharge planning, and ends up doing most of the work required as part of the admission, including a lot of work that doesn't really generate any revenue. Tasks like reconciling home meds, answering nursing pages, updating families, filling out FMLA paperwork, doing peer-to-peers with insurance companies. In academic medical centers, there's usually residents to take care of a lot of that, but in community hospitals it does get pushed more towards IM or FM to admit sometimes and limit the surgical specialties to only the management related to the surgery (unless the surgeons have a PA or NP to help them with the routine admitting work).
My shop does this and it’s f-ing magical. They’ll admit any fresh post op and they’re awesome. They handle all the paperwork and medicine related nursing pages and the only things I get are true surgical questions.
This model seems like a raw deal for the internists especially as you alluded to how the less desirable tasks (paperwork/pages) are offloaded to them. Can you speak to the internists' perceptions? Thanks.
Sure. They’re paid on a base + rvu bonus structure. The more admits the more rvus they generate and the more they make. And these are usually pretty easy admits and low maintenance patients who were healthy enough for elective surgery, but the decision making and data review involved can push these to fairly high level notes.
Psych at a lot of places I've been isn't necessarily a cost center, but rather a break-even endeavor. Big cities it likely is more costly, but in smaller cities it can pay for itself but little more. The problem with that is when you can be making no money on 20+ beds or millions on same-day surgery beds there becomes no incentive to provide psych services. Peds has been a net loss everywhere, OB has been profitable in community areas. EDs live or die on productivity, which tends to be inversely correlated with acuity. Smaller hospital EDs staffed by midlevels seeing minor stuff can be quite profitable, but city EDs basically only financially exist to allow for flow to the more profitable areas of the hospital.
Probably, since costs are already prepaid for HMOs and thus they maximize profits by using the least resources, which often means providing the least amount of care. But this is only a small portion of the healthcare market right now.
Radiology is a hit or miss. Outpatient imaging usually is the most profitable since it's almost always paid for by the patient's insurance. ED and inpatient however, hospitals are paid on DRGs (ie bundled payments) so so for example ordering multiple expensive MRI scans will just just drive up costs of the hospitals even if the patient has insurance. If they have no insurance, the hospital will probably have to eat pretty much all those costs.
Depends on the set up and their pay structure. If the IM/FM hospitalists are paid by base salary only and covering surgical patients would add additional patients to their census without any additional pay, and their census is already high, they probably won't be happy and there may be high turnover at this place. If they are paid at least partly by RVUs, and the census numbers even with these surgical patients ig still reasonable, it could end up being easy RVU-based money. Most elective surgery patients are pretty healthy and usually don't end up being dispo headaches, but once in a while there will be one that the hospital gets stuck with. In such a case, usually the primary admitting team has the most responsibility in getting them out while the consult services can sign off.
Kaiser is a pretty straightforward situation. Every dollar they spend on their own patients —that is, those who have Kaiser health insurance—is a loss, whether medical or surgical. They’d prefer to just collect the premiums and hope nobody gets sick.
OMG. I mean, I knew this. But I never really thought about it like that.
Now, there's an honest answer.
The labs are submitted and reimbursed through insurances and medicare. There is a technical component and a professional component for those necessitating interpretation. Many of these labs like CBCs and BMPs are automatically resulted now with the burden of interpretation on the ordering provider. The cost of overhead and starting a lab are quite high and above the ability of most individuals to afford. The regulatory burden alone is a significant hurdle. Most pathologists are employed. The remaining ones in private practice most often contract with a hospital owned lab and bill for anatomic pathology (slide reading) while providing medical director oversight of the lab.
