Doctors Employed by Hospitals Earn More than Independents...Implications for Pain?

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drusso

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"The reason that doctors employed by hospital systems can make more money than independent physicians is because employed doctors can have their income additionally #subsidized by the hospital #FacilityFees that they generate by ordering tests and performing procedures. The #StarkLaw was intended to prevent these hospital '#kickbacks' to doctors, but physician employment effectively circumvents this spirit of the Stark Law."

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I am not getting the SOS kickback. Where do I sign up?
Also, I have a salary cap. Anyone in PP have that?
Grass is always greener.
 
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Do the employed physicians actually see this additional money?

They will never love you back.
if an employed physician is getting paid more, doesnt that mean that they are seeing additional money?


agree they will never love you back. but then again technically neither do the owners of a private practice
.
 
Geography geography geography
 
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why a cap, doesn't make sense

Wage and compensation caps are a time-tested feature of "truck systems," "Tommy wages," and other forms of exploitation of labor for monopolistic purposes.


Perhaps the best-known example in our society is something called "Graduate Medical Education."

Didn't you ever wonder why the hospital janitor got paid overtime and you didn't?
 
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Salary caps may be unconstitutional if the cap functions to make you work for free. No one should work for free.
Not if you willingly sign the contract with that in it. Same reason that unpaid internships and volunteering are not unconstitutional.

My understanding is that the salary caps are designed to prevent people from just churning through as many patients as is humanly possible chasing more money.

My current job did away with those about 2 years ago, but before that the salary cap for family medicine was $500,000. Even when I was seeing 30 patients a day and hitting every single quality measure, I wasn't in any danger of hitting that cap.
 
Completely agree with this. Hospital employed docs can easily earn over $600-700k in my area by seeing 20 patients per day (40 wrvu per day) x $60-75 per wrvu.

9-10k wrvu per year at this pace = $600-750k

20 patients per day wouldn't keep you afloat in private practice (maybe $300-400k salary). Obviously the hospital is subsidizing docs.
 
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Not if you willingly sign the contract with that in it. Same reason that unpaid internships and volunteering are not unconstitutional.

My understanding is that the salary caps are designed to prevent people from just churning through as many patients as is humanly possible chasing more money.

My current job did away with those about 2 years ago, but before that the salary cap for family medicine was $500,000. Even when I was seeing 30 patients a day and hitting every single quality measure, I wasn't in any danger of hitting that cap.

Unless the inactivity/subsidization/laziness is not "fair market." Then, hospital subsidized salaries could be construed as a Stark violation which was the point of the video...
 
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Completely agree with this. Hospital employed docs can easily earn over $600-700k in my area by seeing 20 patients per day (40 wrvu per day) x $60-75 per wrvu.

9-10k wrvu per year at this pace = $600-750k

20 patients per day wouldn't keep you afloat in private practice (maybe $300-400k salary). Obviously the hospital is subsidizing docs.
Wait really? That’s pretty solid, is that the same in most areas?
 
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Wait really? That’s pretty solid, is that the same in most areas?
Probably more like 500k in densely populated areas. Still pretty damn good for how they work. I know a guy who was in a private ortho group , and is now joining another ortho group acquired by a hospital system that is going to start base salary at 450k and this is in southern New Jersey. That kind of base salary doesn’t happen in the glorious state of New Jersey in any private group I know of and we all know docs don’t typically move laterally on income..
 
510k+ bonus for a 4 day workweek here. I get out at 4 on most days.
 
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How difficult to make > 1M a year as a hospital employed pain doc? or is it even possible I know some KOLs make close to 2M or more.
 
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An employer doesn’t know or care if you are a KOL. They care about RVUs and collections…
 
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How difficult to make > 1M a year as a hospital employed pain doc? or is it even possible I know some KOLs make close to 2M or more

On straight production I can get close but it’s not really worth it as a w2 employee. Diminishing returns.
I value my time more honestly
 
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To make $1M as HOPD employed depends on your hospital system in some ways more than you.

1. Do you have a cap on income or a diminished return (lower conversion factor) on units past 10,000? I have seen both terrible problems many, many times.
2. Will the system allow you to see enough patients? No double booking, no work ins, cancel patients 1 min late, 20 min appt slots do more to cripple your productivity than any personal physician factor.
3. Will the OR allow you to do more than 2-3 procedures per hour? Will you be given time to do an implant or even be allowed to do an implant, SI fusion, vertiflex due to hospital territorial/cultural issues? I made much, much more money doing implants hospital employed than I do now. I lived off the big, giant RVU cases.
4. Will patients get scheduled in a timely manner? Probably 30-40% of procedures I ordered were never done due to being lost in scheduling/prior auth limbo. 98% of them eventually happen in my office as I have the always affordable cash price if it is actually denied. Humana/Medicaid auths are nearly instant in the office but would take 6 weeks at the hospital.
5. Lost units. This happened, it wasn’t malicious. But required vigilance.


So if you can overcome or not be challenged by these 5 factors, anyone with reasonable skills and EQ can do great at the HOPD.
 
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Completely agree with this. Hospital employed docs can easily earn over $600-700k in my area by seeing 20 patients per day (40 wrvu per day) x $60-75 per wrvu.

9-10k wrvu per year at this pace = $600-750k

20 patients per day wouldn't keep you afloat in private practice (maybe $300-400k salary). Obviously the hospital is subsidizing docs.
Probably gotta do closer to 50 wRVUs per day to get in the mid 600’s to 700
 
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To make $1M as HOPD employed depends on your hospital system in some ways more than you.

1. Do you have a cap on income or a diminished return (lower conversion factor) on units past 10,000? I have seen both terrible problems many, many times.
2. Will the system allow you to see enough patients? No double booking, no work ins, cancel patients 1 min late, 20 min appt slots do more to cripple your productivity than any personal physician factor.
3. Will the OR allow you to do more than 2-3 procedures per hour? Will you be given time to do an implant or even be allowed to do an implant, SI fusion, vertiflex due to hospital territorial/cultural issues? I made much, much more money doing implants hospital employed than I do now. I lived off the big, giant RVU cases.
4. Will patients get scheduled in a timely manner? Probably 30-40% of procedures I ordered were never done due to being lost in scheduling/prior auth limbo. 98% of them eventually happen in my office as I have the always affordable cash price if it is actually denied. Humana/Medicaid auths are nearly instant in the office but would take 6 weeks at the hospital.
5. Lost units. This happened, it wasn’t malicious. But required vigilance.


So if you can overcome or not be challenged by these 5 factors, anyone with reasonable skills and EQ can do great at the HOPD.
This is about the only way to have a chance at 7 figs as a hospital employee without income diversification. I would add influence on staffing and their training to create a reasonably efficient system of care delivery. I’ve never heard of a system that doesn’t have several of these barriers. Whether these inefficiencies are a bug or a feature is another matter. Many (most) of the people you work with aren’t incentivized to participate in being efficient.

There are too many points of resistance to make the $1M goal worthwhile with straight patient care in most hospitals, particularly considering the marginal tax rate at this level. Doing some work on the side to create income diversification and, more importantly, lower tax liability seems a lot better use of one’s time. I think I fought enough battles to make the system efficient enough to allow for a 7 figure salary, but I would be miserable. I’ll take the relatively efficiency and 4 days a week.
 
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Here’s what It looks like for me. That last 1000 wrvus are the hard ones at least on the old values that we are still using.
IMG_2201.jpeg
 
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To make $1M as HOPD employed depends on your hospital system in some ways more than you.

1. Do you have a cap on income or a diminished return (lower conversion factor) on units past 10,000? I have seen both terrible problems many, many times.
2. Will the system allow you to see enough patients? No double booking, no work ins, cancel patients 1 min late, 20 min appt slots do more to cripple your productivity than any personal physician factor.
3. Will the OR allow you to do more than 2-3 procedures per hour? Will you be given time to do an implant or even be allowed to do an implant, SI fusion, vertiflex due to hospital territorial/cultural issues? I made much, much more money doing implants hospital employed than I do now. I lived off the big, giant RVU cases.
4. Will patients get scheduled in a timely manner? Probably 30-40% of procedures I ordered were never done due to being lost in scheduling/prior auth limbo. 98% of them eventually happen in my office as I have the always affordable cash price if it is actually denied. Humana/Medicaid auths are nearly instant in the office but would take 6 weeks at the hospital.
5. Lost units. This happened, it wasn’t malicious. But required vigilance.


So if you can overcome or not be challenged by these 5 factors, anyone with reasonable skills and EQ can do great at the HOPD.
💯
 
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I really dont see how PP can hire docs anymore. 700k base wow. Have 2 different PE meetings next week and don’t get how those guys could afford to buy me out either.

Hospital seems like the only real game these days for unestablished docs which is 1000% upside down from 15-20 years ago for pain.
 
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I really dont see how PP can hire docs anymore. 700k base wow. Have 2 different PE meetings next week and don’t get how those guys could afford to buy me out either.

Hospital seems like the only real game these days for unestablished docs which is 1000% upside down from 15-20 years ago for pain.
They buy your practice, then sell their concept to "investors". Then everyone loses money. That's what constitutes investing these days.
 
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I really dont see how PP can hire docs anymore. 700k base wow. Have 2 different PE meetings next week and don’t get how those guys could afford to buy me out either.

Hospital seems like the only real game these days for unestablished docs which is 1000% upside down from 15-20 years ago for pain.
They low ball them, entice partnership, asc ownership, then some **** happens and the partnership deal gets pushed off and the asc buy in gets bigger despite diminishing distribution. Then the doc gets grounded, starts a family, plants roots, then by the time the doc realizes it’s too late they are stuck out of fear to move on because who knows it may just suck ass worse somewhere else. Then they just hang their heads and show up to work everyday hoping for change but realizing it will never happen.

Oh wait that’s just my story..and thousands of other docs
 
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For me the cap is irrelevant. I’m at about 12000 wrvu annual using the old numbers. This will go to approximately 14000(the cap) this year with the new values supposedly. I’m going to
Drop another 1/2 day a week so down to 3 1/2 days. Good income to work ratio.
 
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"The reason that doctors employed by hospital systems can make more money than independent physicians is because employed doctors can have their income additionally #subsidized by the hospital #FacilityFees that they generate by ordering tests and performing procedures. The #StarkLaw was intended to prevent these hospital '#kickbacks' to doctors, but physician employment effectively circumvents this spirit of the Stark Law."


I can tell you that this absolutely has not been my experience in rheumatology.

I currently make more than double as a PP doc vs what I made at my first hospital job. ~$550k vs ~$275k at best. And I was treated like complete garbage at the hospital job. I will never work for a hospital system again. It’s all about the ancillaries, and no, the hospitals will not be sharing those with you.

(Granted, there are a lot of crappy and exploitative PP deals out there too. I managed to find a PP that is actually willing to share the milk and honey and doesn’t scalp all the newcomers. I know a lot of PPs out there aren’t like that. I have seen PP deals that were worse than any hospital deal out there, but also PP deals that were far better than any hospital deal out there. If you’re smart about it and know how to shop and when to walk away from a PP interview that is a joke, you can find something awesome.)
 
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I can tell you that this absolutely has not been my experience in rheumatology.

I currently make more than double as a PP doc vs what I made at my first hospital job. ~$550k vs ~$275k at best. And I was treated like complete garbage at the hospital job. I will never work for a hospital system again. It’s all about the ancillaries, and no, the hospitals will not be sharing those with you.

(Granted, there are a lot of crappy and exploitative PP deals out there too. I managed to find a PP that is actually willing to share the milk and honey and doesn’t scalp all the newcomers. I know a lot of PPs out there aren’t like that. I have seen PP deals that were worse than any hospital deal out there, but also PP deals that were far better than any hospital deal out there. If you’re smart about it and know how to shop and when to walk away from a PP interview that is a joke, you can find something awesome.)
Do you have any friends in your specialty who are looking for a private practice job? Our area’s 2 rheumatologists both retired about a year ago, so patients have to travel an hour or more to see one if they’re lucky enough to find one taking new patients. I’m with an orthopedic group so we’d love to host a rheumatologist who wants to do the profitable things that rheum can do in private practice. We even have a space that could be built out into an infusion center. We aren’t looking to make a bunch of money off of someone - we just want somewhere to send our patients with RA, etc.
 
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They low ball them, entice partnership, asc ownership, then some **** happens and the partnership deal gets pushed off and the asc buy in gets bigger despite diminishing distribution. Then the doc gets grounded, starts a family, plants roots, then by the time the doc realizes it’s too late they are stuck out of fear to move on because who knows it may just suck ass worse somewhere else. Then they just hang their heads and show up to work everyday hoping for change but realizing it will never happen.

Oh wait that’s just my story..and thousands of other docs
Truth here!
 
I agree, rheumatology doesn’t work in the hospital employed setting. Long office visits, landmark based joint injections with minimal conversion factor, getting cut out of the infusion center profit since they can’t assign an RVU for it. So that all results in low professional collections, low conversion factor, and low pay. But the hospital gets joint replacements, lots of lab and imaging, infusions, major spine surgeries, and a base of sick, immunosuppressed patients to help fill up the floor.
 
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For me the cap is irrelevant. I’m at about 12000 wrvu annual using the old numbers. This will go to approximately 14000(the cap) this year with the new values supposedly. I’m going to
Drop another 1/2 day a week so down to 3 1/2 days. Good income to work ratio.
Are jobs like this hard to come by these days? This seems like a dream
 
Do you have any friends in your specialty who are looking for a private practice job? Our area’s 2 rheumatologists both retired about a year ago, so patients have to travel an hour or more to see one if they’re lucky enough to find one taking new patients. I’m with an orthopedic group so we’d love to host a rheumatologist who wants to do the profitable things that rheum can do in private practice. We even have a space that could be built out into an infusion center. We aren’t looking to make a bunch of money off of someone - we just want somewhere to send our patients with RA, etc.

Hire a rheumatology NP and “supervise” them, print money

;)
 
Are jobs like this hard to come by these days? This seems like a dream
Sure but you’re gonna work very hard and you need a super efficient system. He’s seeing a ton of patients and doing a ton of procedures to make 14,000 wRVUs in 3 1/2 days/week.

With the change in conversion I’m expected to get to 11-12,000 wRVUs and I work 4 1/2 days/week and consider myself plenty busy
 
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For me the cap is irrelevant. I’m at about 12000 wrvu annual using the old numbers. This will go to approximately 14000(the cap) this year with the new values supposedly. I’m going to
Drop another 1/2 day a week so down to 3 1/2 days. Good income to work ratio.
Are you rural? I'm all about PP but must say this is a good deal
 
Are you rural? I'm all about PP but must say this is a good deal
Suburban. My numbers are boosted because I have an NP and I get credit for all their wrvus. Plus it’s a mature full practice with a two month wait so busy

But you are correct. I see a lot of patients. In the wrvu system it’s all about volume not necessarily complex procedures
 
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For me the cap is irrelevant. I’m at about 12000 wrvu annual using the old numbers. This will go to approximately 14000(the cap) this year with the new values supposedly. I’m going to
Drop another 1/2 day a week so down to 3 1/2 days. Good income to work ratio.

can someone please educate me about the "new RVU values"

are some common clinic visits/procedures now going to get more RVUs that they did in the past?
 
can someone please educate me about the "new RVU values"

are some common clinic visits/procedures now going to get more RVUs that they did in the past?
All E/M codes got a boost in 2021. Hospitals are now finally paying their physicians the updated rates although some including mine have cut the $/wrvu conversion factor to account for the increase in total wRVUs.
 
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Looks like I'll be doing a pain fellowship after seeing these numbers
 
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I agree, rheumatology doesn’t work in the hospital employed setting. Long office visits, landmark based joint injections with minimal conversion factor, getting cut out of the infusion center profit since they can’t assign an RVU for it. So that all results in low professional collections, low conversion factor, and low pay. But the hospital gets joint replacements, lots of lab and imaging, infusions, major spine surgeries, and a base of sick, immunosuppressed patients to help fill up the floor.

You have to negotiate based on Physician Enterprise Value not RVU. RVU comp is for suckers. It's no mistake that how Admin wants to negotiate with physicians because it only represents a small sliver of the pie.


The beauty is that you don't have to be employed by the enterprise to have high PEV. You only need to know what you're worth and threaten to take your business elsewhere. Once EVERYONE understands this, the alignment becomes natural. Once they know that you know your PEV, they'll negotiate with you.

1711861564835.png
 
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You have to negotiate based on Physician Enterprise Value not RVU. RVU comp is for suckers. It's no mistake that how Admin wants to negotiate with physicians because it only represents a small sliver of the pie.


The beauty is that you don't have to be employed by the enterprise to have high PEV. You only need to know what you're worth and threaten to take your business elsewhere. Once EVERYONE understands this, the alignment becomes natural. Once they know that you know your PEV, they'll negotiate with you.

View attachment 384797
drusso has gleaned this based off of his years of negotiating the best possible $/RVU contract with his local hospital.
 
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