The paradigm has changed, but dialysis remains by far the most profitable part of nephrology care. I have worked within both systems, physician owned and with DaVita, and both systems have pros and cons. On the one hand, a practice can be more responsible for the logistics of the unit and reap more of a financial benefit, and on the other hand, a practice can relinquish that responsibility and spend its time elsewhere. Dialysis is very territorial; the companies cannot just establish their own dialysis clinic down the road and bully out the already established doctors. Number and range of dialysis clinics is tightly regulated. A need has to be established. If dialysis patients are already being served, there is not a need for a new unit. Historically, DaVita and others bought out practices who crunched the numbers and found it beneficial to let it go. I would liken it to IR taking over many procedures. Sometimes it's not worth the hassle.
However, DaVita and practices have joint ventures all the time. Practices will often own the property, and DaVita rent space to perform dialysis. These companies' business models are really focused on the dialysis component. They do not necessarily want to buy property. They do not want to hire their own doctors. They are happy to work with practices and rent space. There are also medical directorships that can be lucrative.
So it's a nice setup. Bill for the patient care. Bill for the medical directorship. Possibly collect rent on top of that.
Now, I'll be clear and say that working with a large health care entity is not all rainbows and butterflies, but my complaints are about other things and not what was just discussed.
Reimbursement is controlled by Medicare primarily, not DaVita. Coincidentally, reimbursement for nephrology is expected to go up quite a bit with changes to how dialysis compensation works, efforts to promote home modalities, etc.
It remains to be seen if the current fellowship load is still too much or enough for the specialty. The number of spots filled has not changed much over the years. There might have been slightly more over this past year. The lower end programs continue to run half full. There is a world where the field may be contracting, and good graduates will be in high demand. Anecdotally, it may take a practice a couple of years to find a good candidate. That has been the experience in my region.
That was probably more than you wanted! The above does not have much to do with midlevels. We use midlevels to help with dialysis rounding. Each patient needs to be seen four times monthly (3 quicker visits and 1 comprehensive visits) for maximum billing so docs will do the comprehensive visit and maybe a limited visit while the midlevels do the rest. That frees us docs up to be more productive in clinic (or maintain our 4-day work weeks).
I think nephrology is safe from midlevel takeover for a while. There is not more money in regular clinic visits...more complicated patients with similar billing to everyone else (unless they are transplants or GNs). They cannot handle the complexity. They cannot treat GN. We have to teach them how to manage hypertension for Pete's sake. Midlevels would have to go after dialysis and see patients independently for it to be worthwhile, but dialysis is so tightly regulated by the government/Medicare that I think it is going to be a long time before we see anything like that. I'm sure DaVita would like to make a buck, but dialysis patients are complicated, and we provide a lot of oversight. Outcomes would be poor. Midlevels don't learn any nephrology in their training so if there is not a nephrologist, DaVita would have to train them, and they have not shown much interest in doing that at this time.
Just do what you want. As long as you do private practice, you have a lot of control as far as midlevels go. You have less say if you are employed.
