Which job would you choose?

[GassYous]

We are a very small group that covers Q4 home call and every 4th weekend. Community Hospital refuses to pay a subsidy other than a couple of hundred a day for call. Pay is continuously going down thanks to a poorly reimbursement area and high Medicare population. Vacation time off is what you can get a locums to cover you. So basically I’m working 1.3 FTE to maintain above average pay but I’m sacrificing a substantial amount of lifestyle for it. Being part of a small group has its issues.

Every medicare cut kills us. I'd probably bill like 20% more if we were at 2015 rates.

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[Southpaw]

We are a very small group that covers Q4 home call and every 4th weekend. Community Hospital refuses to pay a subsidy other than a couple of hundred a day for call. Pay is continuously going down thanks to a poorly reimbursement area and high Medicare population. Vacation time off is what you can get a locums to cover you. So basically I’m working 1.3 FTE to maintain above average pay but I’m sacrificing a substantial amount of lifestyle for it. Being part of a small group has its issues.

I would not blame your group if you arranged a buyout. Let the hospital or someone else deal with those issues.

 

[Guillemot]

We are a very small group that covers Q4 home call and every 4th weekend. Community Hospital refuses to pay a subsidy other than a couple of hundred a day for call. Pay is continuously going down thanks to a poorly reimbursement area and high Medicare population. Vacation time off is what you can get a locums to cover you. So basically I’m working 1.3 FTE to maintain above average pay but I’m sacrificing a substantial amount of lifestyle for it. Being part of a small group has its issues.

Sounds like your group wont exist for much longer.

 

[shepardsun]

Lol getting paid for backup call in academics

 

[pgg]

Option 1. 1099 (but covers malpractice), shift work. $180/hr for the day, $200/hr for call. In house call. Malpractice covered, nothing else (group offers discounted health insurance). Average for the group is $450k - to achieve that is about 2 weekday calls per mo, 1 weekend call per mo. All calls are in house. Pre and post call day off. Avg 6 to 8 wk vaca. Level 2 trauma with OB, and ASC. Can choose to work more, for more pay, or as little as you want. No partnership, everyone equal day 1.

Not horrible, but not great. Looks like about 50 hours/week. I wouldn't exert myself doing 4:1 supervision for that, but if it's solo work, and the pace isn't outrageous, it might be OK.

Option 2. Corporate. W2 (all benefits covered including tail), partnership, 300k for 3 years with regular calls (roughly the same as Option 1) and 6-8 weeks vacation. Calls are mixture of in house call and back-up calls. Work pre and post call, but out early. Then $500k after partnership with 9-11 wk vaca. No guarantee in partnership but supposedly everyone makes it.

The job as a partner sounds good. The long partnership track would be a dealkiller for me. I wouldn't even go to an interview for a job with a 3 year track. A $600K buy-in with no guarantee of partnership is bull****.

Maybe I'd tolerate a 2 year track if I really, really liked the place. Maybe.

Option 3. W-2 (all benefits covered not including tail), no partnership. Everyone equal. $400k base + relocation bonus + $15k annual bonus. 24h in-house calls split evenly roughly 1:8. First to leave postcall day and usually can sleep some at night. 8 weeks PTO. Community hospital/bread butter, level 3 trauma.

Seems OK, maybe, if it's a 40-50 hour/week job and it's not 4:1 supervision.

Something important is missing from these job descriptions - what kind of work is it? There's a world of difference between solo sitting your own cases and running 4 rooms that are a mix of sick sick patients and high turnover GI stuff, plus covering OB, plus covering preop, plus doing blocks, plus covering PACU, plus carrying the consult phone.

Have offers from these jobs in the location I want to be at. Which would you choose and why?

I'd probably choose another location, but if you're stuck there, you're stuck. They don't call the paradise tax a "tax" for no reason.

 

[nimbus]

A ton of jobs I’ve encountered recently (mine included) expect people to do be various forms of backup call for free. You bill when you do cases, but the backup call status is not reimbursed. Is that common in other people’s shops?

At my hospital, we get $0/day to be heart call from home but there’s another local hospital that pays $1k/day to be home heart call.


We get a decent stipend to be in-house trauma call and a nominal stipend to be backup 2nd call.

 

[Guillemot]

At my hospital, we get $0/day to be heart call from home but there’s another local hospital that pays $1k/day to be home heart call.


We get a decent stipend to be in-house trauma call and a nominal stipend to be backup 2nd call.

I guess Its not surprising that PP groups are becoming less common. Its not financially viable to work for free. So a subsidy is required. That subsidy can either be provided indirectly through the patients via good % commercial insurance percentage subsidizing unpaid work and/or directly through the hospital via a stipend.

It sounds like the hospital administration dunces don't always understand and/or choose not to understand.

What I dont understand is how such things are sustainable, even by an AMC that claim to be able to bill more for commercial insurance cases... From reading this forum, it sounds like it is in fact often not sustainable. AMC/PE takes over and then just provides less services.

 

[BLADEMDA]

I guess Its not surprising that PP groups are becoming less common. Its not financially viable to work for free. So a subsidy is required. That subsidy can either be provided indirectly through the patients via good % commercial insurance percentage subsidizing unpaid work and/or directly through the hospital via a stipend.

It sounds like the hospital administration dunces don't always understand and/or choose not to understand.

What I dont understand is how such things are sustainable, even by an AMC that claim to be able to bill more for commercial insurance cases... From reading this forum, it sounds like it is in fact often not sustainable. AMC/PE takes over and then just provides less services.

AMCs have much better leverage with both insurance companies and hospital administrators. Their MBAs know how to talk the language CEOs understand and unless the hospital wants to forgo anesthesia services they pay up. Plus, the AMCs have better contracts with the commercial insurance companies.

That 1-2 punch makes it very hard for small groups to survive unless the payor mix is good.

The situation in Reno is about GREED not profitability as Mednax was making a profit but NAPA wants an even bigger profit.

 

[BLADEMDA]

Option 1. 1099 (but covers malpractice), shift work. $180/hr for the day, $200/hr for call. In house call. Malpractice covered, nothing else (group offers discounted health insurance). Average for the group is $450k - to achieve that is about 2 weekday calls per mo, 1 weekend call per mo. All calls are in house. Pre and post call day off. Avg 6 to 8 wk vaca. Level 2 trauma with OB, and ASC. Can choose to work more, for more pay, or as little as you want. No partnership, everyone equal day 1.

Option 2. Corporate. W2 (all benefits covered including tail), partnership, 300k for 3 years with regular calls (roughly the same as Option 1) and 6-8 weeks vacation. Calls are mixture of in house call and back-up calls. Work pre and post call, but out early. Then $500k after partnership with 9-11 wk vaca. No guarantee in partnership but supposedly everyone makes it.

Option 3. W-2 (all benefits covered not including tail), no partnership. Everyone equal. $400k base + relocation bonus + $15k annual bonus. 24h in-house calls split evenly roughly 1:8. First to leave postcall day and usually can sleep some at night. 8 weeks PTO. Community hospital/bread butter, level 3 trauma.

Have offers from these jobs in the location I want to be at. Which would you choose and why?

(Some updates added)

Now you need to post what the job entails for options 1-3? Are you solo? Covering 3 or 4 rooms? How busy is the call shift? What about COLA or annual raises? Will Option 3 ever give you a raise?

 

[drdan4]

No shortage of Enemies...Ungrateful Surgeons, militant CRNAs, Exploitive Administrators and Private Equity. It's sad that the field has to crash and burn every decade for people to understand our value. That is squarely on Leadership and Marketing...which is probably the worst in Anesthesia. And Reimbursement reflects these two factors. If you want to practice on your own terms...aka not work with useless CRNAs or AMCs...then don't plant roots...be able to pick up and leave in 90 days.

I've never Supervised..always done my own cases...actually think CRNAs should not even exist. Currently a partner in PP making over 900k but it's been a tough road. My take after several jobs...is that Private Practice 1099 Solo Anesthesia is best gig.and truly wish all Anesthesiologist had access to this. AMCs just can't compete..if you're not making money because of payor mix, subsidy etc they can't either. I don't care if they can extract a better subsidy or get better rate from insurers. Trust me, you as an Anesthesiologist ain't seeing any of those profits with their overhead...and plus...you were always disposable for them anyway.

 

[ans2021]

No shortage of Enemies...Ungrateful Surgeons, militant CRNAs, Exploitive Administrators and Private Equity. It's sad that the field has to crash and burn every decade for people to understand our value. That is squarely on Leadership and Marketing...which is probably the worst in Anesthesia. And Reimbursement reflects these two factors. If you want to practice on your own terms...aka not work with useless CRNAs or AMCs...then don't plant roots...be able to pick up and leave in 90 days.

I've never Supervised..always done my own cases...actually think CRNAs should not even exist. Currently a partner in PP making over 900k but it's been a tough road. My take after several jobs...is that Private Practice 1099 Solo Anesthesia is best gig.and truly wish all Anesthesiologist had access to this. AMCs just can't compete..if you're not making money because of payor mix, subsidy etc they can't either. I don't care if they can extract a better subsidy or get better rate from insurers. Trust me, you as an Anesthesiologist ain't seeing any of those profits with their overhead...and plus...you were always disposable for them anyway.

How and where are you making 900k doing solo cases? Are you working post call, 70+ hours/week? Good payer mix?

 

[Sliu238]

Now you need to post what the job entails for options 1-3? Are you solo? Covering 3 or 4 rooms? How busy is the call shift? What about COLA or annual raises? Will Option 3 ever give you a raise?

I am not solo. All three options are care team model so I will be covering 3-4 rooms. I can choose to do some solo work with option 1 though. Call shifts are busier with option 2 and 1. I would say 2 > 1 > 3. Option 3 will very likely have annual raises but no guarantee.

 

[Guillemot]

I am not solo. All three options are care team model so I will be covering 3-4 rooms. I can choose to do some solo work with option 1 though. Call shifts are busier with option 2 and 1. I would say 2 > 1 > 3. Option 3 will very likely have annual raises but no guarantee.

Regardless of how you feel about ACT model in other regards, ACT models should be paid more. I had assumed that all these jobs were solo MD when I posted my opinions.

 

[GassYous]

I am not solo. All three options are care team model so I will be covering 3-4 rooms. I can choose to do some solo work with option 1 though. Call shifts are busier with option 2 and 1. I would say 2 > 1 > 3. Option 3 will very likely have annual raises but no guarantee.

That is seriously bad then

Your pay covers for one room. Where is the money for the other 2-3 rooms going?

 

[Sliu238]

Regardless of how you feel about ACT model in other regards, ACT models should be paid more. I had assumed that all these jobs were solo MD when I posted my opinions.

The place I am trying to go is very saturated and I would consider MCOL to HCOL. I didn’t realize how terrible the jobs are being ACT model. What should be a reasonable pay for ACT models in your opinion?

 

[Guillemot]

The place I am trying to go is very saturated and I would consider MCOL to HCOL. I didn’t realize how terrible the jobs are being ACT model. What should be a reasonable pay for ACT models in your opinion?

I dont know the answer to that exactly from a financial standpoint.

Consider though that your involved in 3-4x the RVU generation minus the expense of the 3-4 CRNAs, and possibly additional CRNA to relieve them if they work shifts or give breaks.

Lets say that 60% of the revenue generated from each room goes to pay CRNA and 40% for MD.

3:1 = .4*3 = 120%
4:1 = 0.4*4 = 160%


I cant therefore see being paid less than 20% more than what the current offers are to be ballpark of equivalent...

 

[drdan4]

How and where are you making 900k doing solo cases? Are you working post call, 70+ hours/week? Good payer mix?

50 hr week. Ofcourse decent payor mix 🙂. You seem to know...and no offense but most of you are DUMB. If you don't know the the total units you generated and what either the blended unit was or what the unit rate that each of your insurers pays, then I have no sympathy for you. You are doing the work anyway, you might as well know what you are generating as a Slave for your Overlord AMC or Hospital. For you employed guys (academic and definitely AMC), most of this info is shrouded in secrecy because as soon as you know...you will DEFINITELY bail. Sorry...but even with a garbage Medicare percentage of greater than 60%, we still made more in my last PP than the scumbag AMC the Hospital tried to replace us with.

 

[Guillemot]

Lets examine Dr. Dan's claim. He says he works 50 hours a week and makes 900k.

$900,000 /50 hours / 44 weeks(Just guessing he takes 8 weeks vacay but no idea) = $409/hr average.

 

[GassYous]

Lets examine Dr. Dan's claim. He says he works 50 hours a week and makes 900k.

$900,000 /50 hours / 44 weeks(Just guessing he takes 8 weeks vacay but no idea) = $409/hr average.

It is very possible and there are people that make more.

 

[narcotics999]

50 hr week. Ofcourse decent payor mix 🙂. You seem to know...and no offense but most of you are DUMB. If you don't know the the total units you generated and what either the blended unit was or what the unit rate that each of your insurers pays, then I have no sympathy for you. You are doing the work anyway, you might as well know what you are generating as a Slave for your Overlord AMC or Hospital. For you employed guys (academic and definitely AMC), most of this info is shrouded in secrecy because as soon as you know...you will DEFINITELY bail. Sorry...but even with a garbage Medicare percentage of greater than 60%, we still made more in my last PP than the scumbag AMC the Hospital tried to replace us with.

50hrs per week, average 1200units/month (unless you mainly do CT or joints/blocks)

2 month vacation.

12K units per year.

900k/12K = 75.

Assume 30% medicare, 15% medicaid, 55% private

You are getting 120$/unit private.

It is extremely rare to get such high unit value.

 

[Gaseous Clay]

I find 900k at 50 hours per week solo MD to be fairly far fetched. I will say I met a guy my intern year who told me he made $70k a month (he had zero reason to lie to me during my anesthesia rotation) but he was a single guy and he did a ton of call, mainly OB. He admitted this wouldn’t be sustainable long term but was trying to set himself up for early retirement and make money while he was young. I also know this group was getting in the mid $60s per unit.

Anyways it’s very unrealistic for many to make anywhere near that and I have a feeling most of us aren’t “dumb.”

 

[drdan4]

50hrs per week, average 1200units/month (unless you mainly do CT or joints/blocks)

2 month vacation.

12K units per year.

900k/12K = 75.

Assume 30% medicare, 15% medicaid, 55% private

You are getting 120$/unit private.

It is extremely rare to get such high unit value.

It's 6 weeks vacation. I don't know why you need 8 weeks if you work 50 hr/week but you never know with the new grads...we never really hire them anyway.

 

[GassYous]

I find 900k at 50 hours per week solo MD to be fairly far fetched. I will say I met a guy my intern year who told me he made $70k a month (he had zero reason to lie to me during my anesthesia rotation) but he was a single guy and he did a ton of call, mainly OB. He admitted this wouldn’t be sustainable long term but was trying to set himself up for early retirement and make money while he was young. I also know this group was getting in the mid $60s per unit.

Anyways it’s very unrealistic for many to make anywhere near that and I have a feeling most of us aren’t “dumb.”

OB heavy with good unit value and a busy l&d is a money maker.

 

[BLADEMDA]

50hrs per week, average 1200units/month (unless you mainly do CT or joints/blocks)

2 month vacation.

12K units per year.

900k/12K = 75.

Assume 30% medicare, 15% medicaid, 55% private

You are getting 120$/unit private.

It is extremely rare to get such high unit value.

But $90 per unit isn't "rare" so re-calculate the %: 25% Medicare, 10% medicaid and 65% Private. Those places really do exist.

 

[nimbus]

50hrs per week, average 1200units/month (unless you mainly do CT or joints/blocks)

2 month vacation.

12K units per year.

900k/12K = 75.

Assume 30% medicare, 15% medicaid, 55% private

You are getting 120$/unit private.

It is extremely rare to get such high unit value.

Mean and median private payor rate is $100/unit in several states now.

 

[anbuitachi]

for those of you saying salaries have gone UP since 2019. how has it gone up? as far as i know reimbursements have NOT been matching inflation at all. so are you doing more cases? working more hours? how? my salary has gone up as well but we get hospital stipend

 

[anbuitachi]

Option 1. 1099 (but covers malpractice), shift work. $180/hr for the day, $200/hr for call. In house call. Malpractice covered, nothing else (group offers discounted health insurance). Average for the group is $450k - to achieve that is about 2 weekday calls per mo, 1 weekend call per mo. All calls are in house. Pre and post call day off. Avg 6 to 8 wk vaca. Level 2 trauma with OB, and ASC. Can choose to work more, for more pay, or as little as you want. No partnership, everyone equal day 1.

Option 2. Corporate. W2 (all benefits covered including tail), partnership, 300k for 3 years with regular calls (roughly the same as Option 1) and 6-8 weeks vacation. Calls are mixture of in house call and back-up calls. Work pre and post call, but out early. Then $500k after partnership with 9-11 wk vaca. No guarantee in partnership but supposedly everyone makes it.

Option 3. W-2 (all benefits covered not including tail), no partnership. Everyone equal. $400k base + relocation bonus + $15k annual bonus. 24h in-house calls split evenly roughly 1:8. First to leave postcall day and usually can sleep some at night. 8 weeks PTO. Community hospital/bread butter, level 3 trauma.

Have offers from these jobs in the location I want to be at. Which would you choose and why?

(Some updates added)

high cost of living state? id choose option 1 probably. do some deductions

 

[shepardsun]

Me in academics when I hear about 900k pp

 

[GassYous]

View attachment 349265
Me in academics when I hear about 900k pp

Trust me it is rare

 

[x10694]

A partner in my group make 800-900k a year using his vacations to Moonlight at another hospital taking 1-2 weeks vacay only. It is possible but he works hard. Practice like dr dan where u work reasonable hours and reasonable vacations and still make 900k ...they r few and far in between with regard to their availability to the young docs like us. Thats a fact.

 

[Velefunt]

No shortage of Enemies...Ungrateful Surgeons, militant CRNAs, Exploitive Administrators and Private Equity. It's sad that the field has to crash and burn every decade for people to understand our value. That is squarely on Leadership and Marketing...which is probably the worst in Anesthesia. And Reimbursement reflects these two factors. If you want to practice on your own terms...aka not work with useless CRNAs or AMCs...then don't plant roots...be able to pick up and leave in 90 days.

I've never Supervised..always done my own cases...actually think CRNAs should not even exist. Currently a partner in PP making over 900k but it's been a tough road. My take after several jobs...is that Private Practice 1099 Solo Anesthesia is best gig.and truly wish all Anesthesiologist had access to this. AMCs just can't compete..if you're not making money because of payor mix, subsidy etc they can't either. I don't care if they can extract a better subsidy or get better rate from insurers. Trust me, you as an Anesthesiologist ain't seeing any of those profits with their overhead...and plus...you were always disposable for them anyway.

I'm glad you're doing well. I don't understand two of your statements though: You indicate that now you're a partner in PP making 900k, but then advocate that the best gig is PP 1099 solo anesthesia - do you mean you're a locums-for-hire making bank at an hourly rate at various gigs or do you mean no CRNA/AAs in a "stable" regular job setting?

 

[nimbus]

Depending on payor mix, I think $90/unit is possible in certain areas of some states.

 

[GassYous]

I'm glad you're doing well. I don't understand two of your statements though: You indicate that now you're a partner in PP making 900k, but then advocate that the best gig is PP 1099 solo anesthesia - do you mean you're a locums-for-hire making bank at an hourly rate at various gigs or do you mean no CRNA/AAs in a "stable" regular job setting?

1099 vs w2 is just how you are paid. A lot of groups are basically 1099 but paid as w2 and expenses go through the company.

 

[IMGASMD]

Depending on payor mix, I think $90/unit is possible in certain areas of some states.


View attachment 349275

Didn’t know FL is that high. Most of you who is working for Envision in FL, is getting boned….

 

[BLADEMDA]

Didn’t know FL is that high. Most of you who is working for Envision in FL, is getting boned….

Partially true because in Florida CMS is typically 70% of the patients leaving about 30% commercial. Medicaid pays pennies on the dollar vs commercial insurance and Medicare is about $21 per Unit. The majority of groups require a subsidy from the hospital to survive so the fact Envision/NAPA/Northstar gets $140 per unit just means the subsidy is less.

 

[IMGASMD]

Partially true because in Florida CMS is typically 70% of the patients leaving about 30% commercial. Medicaid pays pennies on the dollar vs commercial insurance and Medicare is about $21 per Unit. The majority of groups require a subsidy from the hospital to survive so the fact Envision/NAPA/Northstar gets $140 per unit just means the subsidy is less.

True. Totally forgot that’s not the blended value….
Those envision numbers, still is below what I would work for. Supervision all day everyday, for at most 450. No thank you.

 

[BLADEMDA]

OP, Job 1 is your best option. There is no track and you can save a great deal for retirement as a 1099. There is no corporate overlord and you can work extra for additional money. If you decide to relocate there is no "vesting" in the retirement plan. Your Pre and Post call days are off. Job 1 is the clear winner IMHO.

 

[anbuitachi]

Every medicare cut kills us. I'd probably bill like 20% more if we were at 2015 rates.

thats why i dont know how salary reports like medscape/doximity reports almost yearly increase in salary despite cuts or steady medicare rates. are anesthesiologists just WORKING more? or are private insurances increasing reimbursement despite medicare cuts?

According to doximity 2021 reports, physician income went up 3.8%, more than the 1.5% increase the year before..

2021:

 

[nimbus]

thats why i dont know how salary reports like medscape/doximity reports almost yearly increase in salary despite cuts or steady medicare rates. are anesthesiologists just WORKING more? or are private insurances increasing reimbursement despite medicare cuts?

According to doximity 2021 reports, physician income went up 3.8%, more than the 1.5% increase the year before..

2021:

View attachment 349289

The mean and median commercial rates have gone up every year for the past several years.

 

[anbuitachi]

The mean and median commercial rates have gone up every year for the past several years.

Wow that's nice of them. Didn't expect them to adjust for inflation a bit

 

[GassYous]

Wow that's nice of them. Didn't expect them to adjust for inflation a bit

what?

They aren't adjusting for inflation

They are being negotiated with by groups

 

[anbuitachi]

what?

They aren't adjusting for inflation

They are being negotiated with by groups

yea i mean they increased the rates. im surprised. esp with everything going on i hear on the news... and ASA.. about insurances cutting rates for anesthesiologists and outright kicking groups out due to no surprise bill

 

[GassYous]

yea i mean they increased the rates. im surprised. esp with everything going on i hear on the news... and ASA.. about insurances cutting rates for anesthesiologists and outright kicking groups out due to no surprise bill

My premium went up by 20% the past two years but the billings sure didn't go up by 20%

 

[turnupthegas]

Mean and median private payor rate is $100/unit in several states now.

CA? I doubt it. Maybe in parts of Silicon Valley, even then, the profitable groups there is a high blended but not crazy high. 900k? You are working for it.

 

[nimbus]

CA? I doubt it. Maybe in parts of Silicon Valley, even then, the profitable groups there is a high blended but not crazy high. 900k? You are working for it.

Median commercial is about $80/unit in CA, mean is close to $100/unit. A few years ago, CA was in the $60s so it’s a significant rise. It’s over $100 in NY and FL. Blended unit is typically much lower of course.

 

[anbuitachi]

Median commercial is about $80/unit in CA, mean is close to $100/unit. A few years ago, CA was in the $60s so it’s a significant rise. It’s over $100 in NY and FL. Blended unit is typically much lower of course.


View attachment 349321

New York high of 323?!?!?!?!

Ny across the board as high rates yet salary in NY sucks...

 

[nimbus]

New York high of 323?!?!?!?!

Ny across the board as high rates yet salary in NY sucks...

AMCs and academics taking their cut.

 

[GassYous]

New York high of 323?!?!?!?!

Ny across the board as high rates yet salary in NY sucks...

Not for the "leadership team"

 

[anbuitachi]

Median commercial is about $80/unit in CA, mean is close to $100/unit. A few years ago, CA was in the $60s so it’s a significant rise. It’s over $100 in NY and FL. Blended unit is typically much lower of course.


View attachment 349321

wait it says managed care conversion factors... what about unmanaged care

 

[chocomorsel]

OB heavy with good unit value and a busy l&d is a money maker.

Oh God. My worst nightmare. I don’t care how much you pay me, I will turn into a total monster.