Why are MD salaries going down and CRNA salaries going up

[gasresident1]

You see in Merritt Hawkins, etc. You see it in the trends on gasworks. I see it in the jobs my fellow co residents and I took. No one is getting 500k+ starting salaries that inflation should dictate for this profession by now. Instead we are going backwards, to the point that job offers 5 years ago were much much better than today.

Instead CRNA's salaries are going up. Who's making the profit off this? Is greed destroying this profession.

Soon or later, our salaries will be equal or worse.

Ie:

this is a gasworks CNRA posting:
-$300 K;1099
- 2/28 start but will consider dates after
- 8 weeks off!
- Call Every 3rd night
-Good case mix to include podiatry, ent and ob

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Members don't see this ad.

 

[GassYous]

Call every third night is terrible

Since when is podiatry ent and ob considered to be good case mix?? That's about the worst possible.

 

[JoelJoel84]

300k as a 1099 employee is like 200k, with q3 24h call covering OB and podiatry vasculopaths.

I’d rather be a resident again.

 

[gcc322]

There are several jobs around me for $500K plus for generalists. Everyone is short staffed and hiring. Our profession is not grim like portrayed on this board.

 

[Mman]

No one is getting 500k+ starting salaries that inflation should dictate for this profession by now.

physician salaries nationwide have not kept up with inflation for decades. The real money was being made in the 1970s and 1980s, but I think salaries have been creeping up at a faster rate the last 10 years or so. 10-15 years ago, most jobs would offer to start you between $225K-$300K depending on the details.

 

[BLADEMDA]

So, thigs aren't as dire as the Residents believe based on this thread. CRNA salaries are indeed keeping up with inflation, if not even more, than anesthesiologists. This is going to continue to occur until the gap narrows to around 20-25%. For a new graduate in 2022 that gap will occur at some point in his/her career. As CRNA base pay increases the need to actually run 1:3 vs all MD/DO diminishes greatly. Only the 1:4 or 1:5 model works with CRNA salaries being very high.

Starting salaries for new grads are still quite good as the demand far exceeds the supply. Anesthesiology is the most "highly exposed" specialty to both the midlevel encroachment and the CMS reimbursement which is spilling over into 2022 as part of the NO SURPRISE ACT. But, ER/EM is also exposed to a high degree as well.

Like it or not, the future long term for Anesthesiology is a gradual coming to terms with the CRNA DNP earning about 20-25% less than their physician counterpart. The No surprise LAW will bring salaries down for those independent groups who aren't large enough to take on the insurance companies like the AMCs will end up doing in 2022/2023.

The cup will remain half full or even 3/4 full for the near future; I recommend you save and invest well just in case.

 

[dabears505]

The key thing to look at is per hour pay. There is not much of a difference at all. Crnas where I'm at are making 225 w2 for 40 hr jobs and if an md wants that job, they are getting 275. Also, as soon as this shortage ends, that job is going to the crna and that md is going to be out.

This field is not good if you want to be an md and have good work life balance. Sure there are some stand alone surgery center jobs that have no call, but as a new grad, working that kind of job, are you really any different than a crna after a few years?

 

[D P356]

this is a gasworks CNRA posting:
-$300 K;1099
- 2/28 start but will consider dates after
- 8 weeks off!
- Call Every 3rd night
-Good case mix to include podiatry, ent and ob

There’s a lot of unknowns in that posting.

Location? Probably a small town with a critical access hospital that services only OB, ent and podiatry.
Post call? Probably working.
Case mix? As above

Q3 call actually means Q2 when the other 2 are on vacation (16 weeks a year).
That could be a rough schedule.

What’s the minimum you’d do that job for if you have options elsewhere?

 

[caveat87]

OP, there are many W2 jobs paying >500K when you factor in total comp. Even AMC jobs in my area (the dreaded northeast) are paying 450-475k plus signing bonus and benefits.

And that CRNA job looks terrible, especially if it involves any OB on calls.

 

[pjl]

CRNAs tend to be paid salary. MDs in PP are typically paid on productivity, with actual collections mattering.

As the rate of government payers and “self pay” increases, and private insurances pay the same, the average unit pay goes down.

Combine increased expenses for CRNAs and decreased reimbursement, and the money for group owners (physicians/hospital/AMC) declines.

You will always have a job, and it will cycle back around, but it’s just a good market for job hopping right now as a CRNA. Groups are offering 50-150k signing bonuses and they are jumping at the chance, even without looking at the terrible payback arrangements or work conditions. I expect all the crazy signing bonuses will roll back within 2 years.
CRNA salaries will probably stick at the higher levels, but MDs will become more and more enticing as the gap decreases. I know we are looking to adjust our ratio depending on how the market keeps evolving.

 

[IlDestriero]

You see in Merritt Hawkins, etc. You see it in the trends on gasworks. I see it in the jobs my fellow co residents and I took. No one is getting 500k+ starting salaries that inflation should dictate for this profession by now. Instead we are going backwards, to the point that job offers 5 years ago were much much better than today.

Instead CRNA's salaries are going up. Who's making the profit off this? Is greed destroying this profession.

Soon or later, our salaries will be equal or worse.

Ie:

this is a gasworks CNRA posting:
-$300 K;1099
- 2/28 start but will consider dates after
- 8 weeks off!
- Call Every 3rd night
-Good case mix to include podiatry, ent and ob

I wouldn’t take that job for $600k

 

[nimbus]

I wouldn’t take that job for $600k

Yeah q3 is torture unless it’s home call and you rarely get called in. Even then the call stipend alone should be close to 300k.

 

[aneftp]

300k as a 1099 employee is like 200k, with q3 24h call covering OB and podiatry vasculopaths.

I’d rather be a resident again.

Depends on the case load. Most rural hospital (rural isn’t exactly rural as you think) usually 40-45 min from big metro area. Known crna only practice make 300k with 16 weeks off. Yes 1:3 calls

But when you exclude gi cases that jack case census. They literally less than 30 OR cases max in 3 rooms 5 days a week. It’s literally 2-3 or cases a day in each room. And they are done at 1Pm. Call crna done by 4pm most days. No ob. Beeper.

And 1099 is good deal especially if u have spouse who works with good health benefits

When I www 1099 making 500k. I literally paid Less than 15% TOTAL taxes or less each year off my 1099 income. Aka. 500k 1099. Paid total self employment taxes 70k.

Vs being w2. I paid 65k federal taxes alone on 320k-340k w2 income plus $7000-8000 social security employee portion taxes plus $5000 in Medicare taxes.

 

[drmwvr]

I wouldn’t take that job for $600k

Well, the multiples that were in that job wouldn't do it for 300K.

 

[vector2]

Senate votes to avert Medicare cuts to providers

The Senate voted Thursday evening to avert billions of dollars in Medicare cuts to providers.

mailview.bulletinhealthcare.com

 

[coffeebythelake]

View attachment 346726

Senate votes to avert Medicare cuts to providers

The Senate voted Thursday evening to avert billions of dollars in Medicare cuts to providers.

mailview.bulletinhealthcare.com

And still Medicare isn't allowed to negotiate drug prices with pharma companies. SMH.

 

[Blockit]

And still Medicare isn't allowed to negotiate drug prices with pharma companies. SMH.

Of course not. Remember how much these corrupt members of Congress accept from the pharmaceutical industry.
Just about everything in America is completely and utterly corrupt.

 

[narcotics999]

Depends on the case load. Most rural hospital (rural isn’t exactly rural as you think) usually 40-45 min from big metro area. Known crna only practice make 300k with 16 weeks off. Yes 1:3 calls

But when you exclude gi cases that jack case census. They literally less than 30 OR cases max in 3 rooms 5 days a week. It’s literally 2-3 or cases a day in each room. And they are done at 1Pm. Call crna done by 4pm most days. No ob. Beeper.

And 1099 is good deal especially if u have spouse who works with good health benefits

When I www 1099 making 500k. I literally paid Less than 15% TOTAL taxes or less each year off my 1099 income. Aka. 500k 1099. Paid total self employment taxes 70k.

Vs being w2. I paid 65k federal taxes alone on 320k-340k w2 income plus $7000-8000 social security employee portion taxes plus $5000 in Medicare taxes.

I need to know your CPA and your tricks to pay 15% tax!

 

[epidural man]

I doubt compensation is dropping.

But if there is a metric saying this - I wonder about that math.

It seems to me that pay is going up.

I also am noticing a trend of a lot more anesthesiologists going to locum work full time.

A long time ago, we had discussions about how locums only was a red flag. I wonder if that is still true. Locums can pay very well these days, with a LOT of freedom and flexibility.

 

[kidthor]

I doubt compensation is dropping.

But if there is a metric saying this - I wonder about that math.

It seems to me that pay is going up.

I also am noticing a trend of a lot more anesthesiologists going to locum work full time.

A long time ago, we had discussions about how locums only was a red flag. I wonder if that is still true. Locums can pay very well these days, with a LOT of freedom and flexibility.

I have several friends in academics who jumped out and into locums because of poor pay and lifestyle at their current (academic) shops. Most of them are boarded subspecialists with impressive CVs and were publishing regularly. They were just fed up and under-appreciated. They're all happier now.

I don't know that I'd personally want to do locums at this point, but certainly I'm seeing top tier talent doing it.

 

[deleted941485]

I have several friends in academics jump out and into locus because of poor pay and lifestyle at their current (academic) shops. Most of them are boarded subspecialists with impressive CVs and were publishing regularly. They were just fed up and under-appreciated. They're all happier now.

I don't know that I'd personally want to do locums at this point, but certainly I'm seeing top tier talent doing it.

Academics esp in the big cities was never a gold mine but up until recently there was an understanding that you will make less but have the time to pursue your academic interests, publish, and teach. Since the ACA, the management now has decided you will not only have a full clinical schedule but also have the same academic expectations in order to squeeze more out of them. Most of them will either move out or just take a full time clinical gig.

 

[aneftp]

I need to know your CPA and your tricks to pay 15% tax!

It’s not that hard. Open up solo 401k. Pay the spouse 20k. Put 25k into their retirement account pay urself 150k ish. Put the max 57k ish into ur account.

Expense everything. Education trips (travel cme online stuff)

Some people pay less than 10% of their total 1099 income. My pain buddy just made 110k federal tax payment off over 1.3 million gross revenue. He pays himself 30k salary.

 

[coffeebythelake]

It’s not that hard. Open up solo 401k. Pay the spouse 20k. Put 25k into their retirement account pay urself 150k ish. Put the max 57k ish into ur account.

Expense everything. Education trips (travel cme online stuff)

Some people pay less than 10% of their total 1099 income. My pain buddy just made 110k federal tax payment off over 1.3 million gross revenue. He pays himself 30k salary.

does this work when you already have a 401k, 457b, roth IRA from previous employer?

 

[Arch Guillotti]

Some people pay less than 10% of their total 1099 income. My pain buddy just made 110k federal tax payment off over 1.3 million gross revenue. He pays himself 30k salary.

I mean it's a great anecdote but the IRS guidelines explicitly say that you have to pay yourself a reasonable salary. Otherwise asking for trouble.

 

[pjl]

I mean it's a great anecdote but the IRS guidelines explicitly say that you have to pay yourself a reasonable salary. Otherwise asking for trouble.

Would reasonable be what you would make if all your collections were from Medicare?

Cause that would drop my tax burden substantially.

 

[narcotics999]

does this work when you already have a 401k, 457b, roth IRA from previous employer?

If you have 1099, you can put 20% of your net earning into a solo 401K or SEP IRA up to 58K. You can't do individual contribution of 19.5K into solo 401K if you do it from your W2.

 

[ERRES2288]

It’s not that hard. Open up solo 401k. Pay the spouse 20k. Put 25k into their retirement account pay urself 150k ish. Put the max 57k ish into ur account.

Expense everything. Education trips (travel cme online stuff)

Some people pay less than 10% of their total 1099 income. My pain buddy just made 110k federal tax payment off over 1.3 million gross revenue. He pays himself 30k salary.

Lol they are lucky the IRS is too understaffed to actually audit anyone. 30k a year far from reasonable salary

 

[coffeebythelake]

For those of you who are 1099, what's the process like for getting health insurance for self and family? What kind of $ are we talking about?

 

[narcotics999]

For those of you who are 1099, what's the process like for getting health insurance for self and family? What kind of $ are we talking about?

Working spouse.

 

[pgg]

It’s not that hard. Open up solo 401k. Pay the spouse 20k. Put 25k into their retirement account pay urself 150k ish. Put the max 57k ish into ur account.

Expense everything. Education trips (travel cme online stuff)

Some people pay less than 10% of their total 1099 income. My pain buddy just made 110k federal tax payment off over 1.3 million gross revenue. He pays himself 30k salary.

Jesus Christ I'm not generally a fan of more government but this is why we need better IRS enforcement. Your pain buddy openly admits illegal tax evasion ($30K isn't even remotely close to a reasonable salary for a pain doc who's needling and pill-milling his way to $1.3M gross) and you act like it's normal.

"Pay the spouse $20K" - for what?!?

 

[thinkorswim]

For those of you who are 1099, what's the process like for getting health insurance for self and family? What kind of $ are we talking about?

Anywhere from $10-20k per year for a family of 4 depending on deductible and coverage. Not ideal, but not as bad as you’d think since it can be paid pre-tax and you can deduct medical expenses as well.

As mentioned above, a working spouse is the best option if available.

 

[gasresident1]

I don't know what I'm more surprised about

1) Pain making 1.3 million a year

2) Paying yourself 30k in an S corp and not going to jail

You forgot about cash balance plans, real estate (esp short term rentals), deducting wifey's Range Rover....

There is a lot of money to be saved in 1099. The hard part is finding the right job. I'm on a mission to find a 600k+ 1099 job. I know it's out there.

 

[gasresident1]

I kinda feel bad for those working at tech companies. Ie: Amazon pays their level 7s comparable to Anesthesia salaries. However HALF of that is paid as bonus (max salary at these companies is 160k). So these poor soles are paying like 50% comp tax on a good amount of their income. YET, the housing market in those areas (San Francisco, Seattle, etc) is untouchable rn unless you have zero brain cells and believe the prices are true (ie: 2x what they were 3 years ago)

 

[coffeebythelake]

I kinda feel bad for those working at tech companies. Ie: Amazon pays their level 7s comparable to Anesthesia salaries. However HALF of that is paid as bonus (max salary at these companies is 160k). So these poor soles are paying like 50% comp tax on a good amount of their income. YET, the housing market in those areas (San Francisco, Seattle, etc) is untouchable rn unless you have zero brain cells and believe the prices are true (ie: 2x what they were 3 years ago)

Wtf are you taling about. Many of thrm are compensated with large stock options. Plus remote working. They are doing AOK

 

[Guillemot]

I think many people over estimate the value of the (legitimate) deductions one can take as a 1099 physician.

Cash balance plans & automobile deduction are good. CME trip could be good occasionally I suppose.

Deduction of stuff like health insurance and some other mandatory expenses is something one does, but AFAIK its not any better or worse than W2 as part of your W2 compensation.

There is more $ overhead as 1099 and more time overhead spent on paperwork.

 

[NitroS]

For those of you who are 1099, what's the process like for getting health insurance for self and family? What kind of $ are we talking about?

You can go through the open marketplace. The cheapest option for me was 7k/year for high deductible plan with 7k deductible before insurance kicks in. If you want PPO, probably around 10-12k for single person and 20k for family

 

[GassYous]

I kinda feel bad for those working at tech companies. Ie: Amazon pays their level 7s comparable to Anesthesia salaries. However HALF of that is paid as bonus (max salary at these companies is 160k). So these poor soles are paying like 50% comp tax on a good amount of their income. YET, the housing market in those areas (San Francisco, Seattle, etc) is untouchable rn unless you have zero brain cells and believe the prices are true (ie: 2x what they were 3 years ago)

I think you have things backwards

 

[NitroS]

I guess it’s easy to save a lot of money as 1099 if you just don’t pay your taxes 30k salary as physician…lol ok. You can try to push the envelope and see what kind of stuff you can get away with, but for me I like going to sleep with peace of mind. Not worrying if IRS is gonna audit me or if I can pass the audit

 

[DocMcCoy]

I guess it’s easy to save a lot of money as 1099 if you just don’t pay your taxes 30k salary as physician…lol ok. You can try to push the envelope and see what kind of stuff you can get away with, but for me I like going to sleep with peace of mind. Not worrying if IRS is gonna audit me or if I can pass the audit

I’ve recently been audited. Simple w2 with not a lot of other stuff going on. Easy pass but that was stressful enough. I don’t have the acumen to finesse a 1099. I’d probably end up in jail. I’ll pay the extra not to deal with the headache.

 

[GoBeers]

I don't know what I'm more surprised about

1) Pain making 1.3 million a year

2) Paying yourself 30k in an S corp and not going to jail

You forgot about cash balance plans, real estate (esp short term rentals), deducting wifey's Range Rover....

There is a lot of money to be saved in 1099. The hard part is finding the right job. I'm on a mission to find a 600k+ 1099 job. I know it's out there.

ya I am pretty busy in coastal city with standard mix of HMO/PPO/medicare (no fancy cash pay, PRP, stem cell , PI , etc). No where close to 1.3 million while trying to practice honest medicine.

Most of my friends on the west side of town give themselves somewhere in the high 100k "reasonable salary" and so far they haven't been audited.
i give myself an even higher salary to avoid audit
but 30k is absolutely sketch.

at the end of the day though, audits aren't big a deal. worst case scenario they tell you to pay the taxes you owe and that's it. hopefully they're not buying lambos and other depreciating junk assets with their sheltered money.

What is "cash balance plans." ?

 

[Arch Guillotti]

What is "cash balance plans." ?

Self funded retirement plan and means to lower taxes. Google it or search the forum, tons of info.

 

[GassYous]

ya I am pretty busy in coastal city with standard mix of HMO/PPO/medicare (no fancy cash pay, PRP, stem cell , PI , etc). No where close to 1.3 million while trying to practice honest medicine.

Most of my friends on the west side of town give themselves somewhere in the high 100k "reasonable salary" and so far they haven't been audited.
i give myself an even higher salary to avoid audit
but 30k is absolutely sketch.

at the end of the day though, audits aren't big a deal. worst case scenario they tell you to pay the taxes you owe and that's it. hopefully they're not buying lambos and other depreciating junk assets with their sheltered money.

What is "cash balance plans." ?

Basically like a 401k

It's all about the facility fees. Partnership in a surgicenter + high volume + good payor mix = $$$

 

[Mman]

at the end of the day though, audits aren't big a deal. worst case scenario they tell you to pay the taxes you owe and that's it.

If you underpay your taxes, you owe the back taxes AND penalties on top of it. If the IRS feels it was egregious avoidance of tax, they can refer you to the Justice Department to consider charging you with tax evasion which could put you in prison. Pretend the IRS audited your taxes for 2020. If they found something suspicious, they can also look at several years prior to it (though per IRS FAQs they usually won't go back more than 6 years). Do you really want them finding you underpaying by a large amount for year after year after year?

Personally I'd pay myself a wage of whatever the going rate was in my area for a W2 employee doing the same job, or at least close to it.

 

[anbuitachi]

free room and food in prison. not bad in this high inflationary period

 

[IMGASMD]

free room and food in prison. not bad in this high inflationary period

Can I get name brand toilet paper?

Our accountant basically said, if they come for an audit, 9 times out of 10, they already have something. They won’t waste time for some small stuff. And yes they can go far back…. Ask my SO. She was lucky they only went back 3 years.

Just think about the example above, 1.3 M revenue, with 30K salary. Conservatively, you owe government what?200K? Multiply that by 6 yrs. And penalties and interests? 1.5M easy….. not sure if they take payment plans. I have a feeling “they” may also look at any of the business dealings that you may have. That being said, if the govt cannot touch Elon Musk… maybe they wouldn’t catch me either.

 

[DrOwnage]

It’s not that hard. Open up solo 401k. Pay the spouse 20k. Put 25k into their retirement account pay urself 150k ish. Put the max 57k ish into ur account.

Expense everything. Education trips (travel cme online stuff)

Some people pay less than 10% of their total 1099 income. My pain buddy just made 110k federal tax payment off over 1.3 million gross revenue. He pays himself 30k salary.

This is bull#$%^. You're gonna pay 30% taxes as a 1099 in the 400-500k bracket with all the deductions. If you're paying less, you're doing some shady crap that will be very hard to defend.

 

[chocomorsel]

This is bull#$%^. You're gonna pay 30% taxes as a 1099 in the 400-500k bracket with all the deductions. If you're paying less, you're doing some shady crap that will be very hard to defend.

I think I was paying like 25-28% with that salary. All through a large CPA firm.
I think I want to go back to 1099.
Now like 38% as W2. Sucks.

 

[aneftp]

This is bull#$%^. You're gonna pay 30% taxes as a 1099 in the 400-500k bracket with all the deductions. If you're paying less, you're doing some shady crap that will be very hard to defend.

It’s not BS.

My malpractice insurance alone was 17k
Expense section 179 deduction Range Rover 45k ish write off (it was 50% bonus depreciation at that time…they keep tweaking the rules). Used to be able to write off entire 100k (aka hummer loophole closed a long time ago)
Healthcare was close to 20k in premiums
Yearly iPhones ($1200)
Cell phone bills ($2400)
Internet $1200
Everything food (50% deduction) $8000 (anything i go out and discuss anything business related (aka $300 steakhouse bill)
Amex plat biz fee $595 is write off (soon to be $695)

It all adds up (the deductions)

 

[narcotics999]

It’s not BS.

My malpractice insurance alone was 17k
Expense section 179 deduction Range Rover 45k ish write off (it was 50% bonus depreciation at that time…they keep tweaking the rules). Used to be able to write off entire 100k (aka hummer loophole closed a long time ago)
Healthcare was close to 20k in premiums
Yearly iPhones ($1200)
Cell phone bills ($2400)
Internet $1200
Everything food (50% deduction) $8000 (anything i go out and discuss anything business related (aka $300 steakhouse bill)
Amex plat biz fee $595 is write off (soon to be $695)

It all adds up (the deductions)

In spite of these tricks, I think it is no better than a 400K academic W2 job with stellar healthcare, 403b with 36K retirement match, 457b, vacation, sick leave, and some CME $.

 

[kidthor]

In spite of these tricks, I think it is no better than a 400K academic W2 job with stellar healthcare, 403b with 36K retirement match, 457b, vacation, sick leave, and some CME $.

This of course assumes your academic job gives all that. Having had two now. none checked off all those boxes.

I must say I'd LOVE to be able to put away the employer side 401k 55K. My academic job has a match that caps at 28K with a 5 year vesting period. F that.