First 2 weeks in Practice

[DOCTORSAIB]

Cataract business is much less profitable for the hospital then retina surgery on a per case basis (this according to my hospital CEO whom I was discussing this about a week ago)

Very true doc. Retina cases are generally more complicated and labor intensive, hence more $$$ for everyone involved, including the hospital.

I was referring simply to volume, in which case cataract >> any retina procedure.

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[GSresident]

The question in my mind is whether aesthetics is actually worth it. The sucking up to patients, having to get a fancy office, taking ED call, sweating results and all the other hassles that go with it might outweigh getting paid crap for a 10 hour free flap.

Aesthetics is nice work when you can get it. I actually don't take any ED call and I never will. The Urologist you mention almost certainly will HAVE to take ER call as well as specialty call for the hospital. Driving in at 3 in the morning to put a foley in is no fun.

The problem with the crap they pay you for the 10 hour free flap is that stuff goes wrong with free flaps. Sometimes really disasterous and aweful stuff. A free flap can eat your time and your life very quickly. I don't offer free flaps in my practice.

I also don't have a fancy office (yet). You don't really need one if you are the only guy around.

But if the salary figures I've seen over and over are accurate, all that effort to get aesthetic patients ends up getting you paid the same as the urologist who puts minimal effort in and bangs out cystos all day. The only benefit to doing aesthetics seems to be if you're one of the 30 guys in the country who books completely with high fee cosmetics.

I wouldn't pay much attention to salary figures. Whatever you make will be pretty good money so you have to choose something that you enjoy doing. If you don't enjoy aesthetics patients then concentrate on the reconstructive patients or choose another field entirely.

There is another benefit to aesthetics that you might be missing entirely (see below).

I think PRS is quite cool but the future as an attending actually seems worse than other surgical subspecialties.

That statement is bordering on ludicrous, especially given that every specialty that provides a service that people 'need' is in for a big freaking surprise if Obama gets his way and socializes medicine. I can at least supplement my meager government income with the aesthetics cases. What is the poor cardiologist going to do? Make the heart look hotter? There is a reason every Tom, Dick and Harry is trying to muscle in on the cosmetic business. Even without socialized medicine the PCP's and a lot of specialists are seeing their overheads go up and reimbursements go down.

 

[GSresident]

Rob:
I'm a little surprised at your experience with hospitals. I have had nothing but good luck so far in negotiating fees and other arrangements with hospitals. Looking at the population of Birmingham (1.1 Million) it seems like there are quite a few plastic surgeons where you live. There are some GIANT names there too and a University with a plastic surgery faculty. I couldn't figure out from your phone book exactly how many plastic surgeons there are in Birmingham but it seemed pretty well populated.

 

[Mariah246]

I wouldn't pay much attention to salary figures. Whatever you make will be pretty good money so you have to choose something that you enjoy doing. If you don't enjoy aesthetics patients then concentrate on the reconstructive patients or choose another field entirely.

So from reading this thread, it seems like you're doing very, very well with a mostly reconstructive practice? Awesome!

 

[dilated]

I wouldn't pay much attention to salary figures. Whatever you make will be pretty good money so you have to choose something that you enjoy doing. If you don't enjoy aesthetics patients then concentrate on the reconstructive patients or choose another field entirely.

Thanks for the response. I agree that at least PRS has cash only to fall back on if worst comes to worst.

I'm less concerned by whether you can make 1 gajillion dollars by doing aesthetic and more whether living in a desirable place, not getting much aesthetic due to oversaturation and doing predominantly insurance work would put you way below an average surgical subspecialist due to unfavorable procedural reimbursement. Average or close to would be 100% fine for me, as long as it's not insultingly low (like I hear panniculectomies are). Is that feasible?

 

[GSresident]

I'm less concerned by whether you can make 1 gajillion dollars by doing aesthetic and more whether living in a desirable place, not getting much aesthetic due to oversaturation and doing predominantly insurance work would put you way below an average surgical subspecialist due to unfavorable procedural reimbursement. Average or close to would be 100% fine for me, as long as it's not insultingly low (like I hear panniculectomies are). Is that feasible?

I find reimbursement for reconstructive codes to be very adequate and in line or better than what you would get in another field.

I have never done a panniculectomy by itself. I have always requested and gotten pre-approval to add abdominoplasty to the procedure. Here is how the codes break down.

15830 - panniculectomy 29.98 RVU's
15847 - abdominoplasty (no RVU value)

The average reimbursement per RVU up here is $65 for private insurance. The average payment for panniculectomy is then $1948.70. Since there is no RVU value for abdominoplasty, it varies from company to company how much you will get paid for abdominoplasty as an ad-on, but around here I get an extra $1000. So the total, on average I would get paid for a pannic/abdominoplasty is $2948.70. I have done a huge number of these because i have a built in referral base from a bariatric surgeon. The last 6 I have done we all just under 2 hours skin to skin. It isn't quite what you get paid for cosmetic surgery but it compares very favorably with what other specialties get for procedures of similar length. By comparison, a general surgeon would get ~$2000-2500 (from private insurance) for a gastric bypass and all the misery pre and post-op that one involves. Here is another one to consider:

48150 - whipple 78.09 RVU. Most of them are medicare and you will get paid $2758.94. That includes all of the post op care, the week in the ICU, the week on the floor and 90 days of post-op visits. Plus its a miserable 4-8 hour surgery with death as a potential complication. Anyway it is something to think about.

 

[dilated]

The average reimbursement per RVU up here is $65 for private insurance. The average payment for panniculectomy is then $1948.70. Since there is no RVU value for abdominoplasty, it varies from company to company how much you will get paid for abdominoplasty as an ad-on, but around here I get an extra $1000.

I find this fascinating. The reason I quoted pannic as a poorly reimbursed procedure is that one of the attendings once showed me his billing data to demonstrate how terribly it pays. The three largest insurance plans in our state were all "charged" around 3k but ended up paying around 1k. I guess it's because they're HMOs.

I'm glad to hear that it's apparently reasonable to run a minimal aesthetic practice and still do ok in pp though.

 

[loren646]

GS, i respect you for going after this. Nothing pisses me off more than waiting for my money. Then after a while they forget they owed me. They never got the papers. Blah blah blah. It just sickens me sometimes. And gives me a massive headache.

Good on you for keepin up with it. Even if only on the side

 

[Chuck's Right Foot]

GS, i respect you for going after this. Nothing pisses me off more than waiting for my money. Then after a while they forget they owed me. They never got the papers. Blah blah blah. It just sickens me sometimes. And gives me a massive headache.

Good on you for keepin up with it. Even if only on the side

I'm not even in med school yet, but I am very curious how this works... Could there be eventually a class action lawsuit against this type of practice? It shouldn't be this hard just to get paid.... Isn't it some astronomical % of the national health care budget that goes to overhead?

Kind of sad.

 

[droliver]

It isn't quite what you get paid for cosmetic surgery but it compares very favorably with what other specialties get for procedures of similar length.

Panniculectomy is not something to point to as much of a revenue producer. Very labor intensive surgery with a very high complication rate and frequent office visits in larger BMI patients. Only collecting $600-700/hr for surgery will leave you with very narrow margins in most practice situations when you analyze your costs and overhead.

The only reason to make a habit of these is that you'll get more referrals from the bariatric surgeons, some will pay out of pocket for ancillary procedures, some have hernias that you may fix and bill for.

Of all things time/$$$ for reconstruction, full thickness skin grafts + the prep code blow everything out of the water. The medial upper arm makes an excellent,pain free donor site of good skin that can cover fairly large areas and avoid the morbidity of a dermatome harvested site from the thigh.

Skin flaps for skin cancers & Nipple reconstuction flaps under local in your office also pay fairly well and you can do it on your own schedule with minimal supplies.

 

[GSresident]

Panniculectomy is not something to point to as much of a revenue producer. Very labor intensive surgery with a very high complication rate and frequent office visits in larger BMI patients. Only collecting $600-700/hr for surgery will leave you with very narrow margins in most practice situations when you analyze your costs and overhead.

That is exactly why I don't do panniculectomies. I do pannics +abdominoplasty. The average reimbursement for those in my area is about 2900 and I did the last 6 in under 2 hours. Occasionally I will find and fix a hernia but you only get paid 1/2 for doing that since it is an ad on code but I guess it will buy you a nice dinner. Trust me, pannic + abdominoplasty pays extremely well for my practice model. Which brings me to another point. Maybe when the economy is in the crapper you don't need an espresso machine in the lobby for your medicaid patients. If people want to survive this era they are going to have to readjust the business model. You have to do exactly what the big businesses do when revenue drops - CUT OVERHEAD.

Of all things time/$$$ for reconstruction, full thickness skin grafts + the prep code blow everything out of the water. The medial upper arm makes an excellent,pain free donor site of good skin that can cover fairly large areas and avoid the morbidity of a dermatome harvested site from the thigh

I haven't found a situation where I needed one of these yet. How do you use a prep code with that?

Skin flaps for skin cancers & Nipple reconstuction flaps under local in your office also pay fairly well and you can do it on your own schedule with minimal supplies.

I am leery of doing anything too complicated in my office during my case collection period. I've mostly just done stuff as outpatient in the hospital.

 

[GSresident]

The cosmetic business is picking up again. I think it is tax refund business.

 

[maxheadroom]

The cosmetic business is picking up again. I think it is tax refund business.

We've seen the same thing. Our calls for aug consults in the last three weeks are substantially higher than we saw in January & February. Of course, some of that could be people just getting ready for summer -- we've always seen that uptick, but our schedulers tell us that it seems to be a bigger jump than usual.

We also didn't see as much of a slowdown, but our area hasn't been hit as hard.

 

[GSresident]

This is kind of funny. I was appointed to represent the plastic surgeons in Iowa today. I'm now a member of the State Committee on Medical Services, whatever that means. And thus begins my career in state politics! I'm unsure what my duties would be or even what the committee does, but I've been told I'll have to go to a few meetings a year at the state capital. I'm sure it will be an interesting experience.

 

[hans19]

This is kind of funny. I was appointed to represent the plastic surgeons in Iowa today. I'm now a member of the State Committee on Medical Services, whatever that means. And thus begins my career in state politics! I'm unsure what my duties would be or even what the committee does, but I've been told I'll have to go to a few meetings a year at the state capital. I'm sure it will be an interesting experience.

Wow,
How the hell did I miss this thread? I'm just a radiologist, but man your story about building a solo practice from the ground up, on your own terms is fascinating! Beats any episode of Dr. 90210 (ok thats not saying much), but nice job and good luck! Please keep us posted.

 

[MossPoh]

I'm amazed I missed this too. Great work. Must be great to see all that hard work and planning come to fruition.

 

[JaggerPlate]

Beats any episode of Dr. 90210 (ok thats not saying much).

I think we should reserve judgment until we get a photograph of GsResident's hair highlights. That way we can compare them to Dr Rey's, and see which ones are better, ergo ... cooler.

 

[GSresident]

I think we should reserve judgment until we get a photograph of GsResident's hair highlights. That way we can compare them to Dr Rey's, and see which ones are better, ergo ... cooler.

Hehehe! I have no hair highlights and I'm really a pretty normal looking/dressing/acting guy. Dr. Rey definitely has me beat on the 'looks like a plastic surgeon' measure. Oh well.

I am a couple weeks from adding a new satellite location. It is a ways away but should be a profitable venture.

 

[GSresident]

I just now realized - this is the 1 year anniversary of starting my practice. It has been an incredible year. It has exceeded my expectation both professionally and personally. I am very, very, very, very, very happy.

 

[surag]

I just came across your thread, its very impressive.

Can you give any advice for a student interested in plastic surgery? Is it possible to succeed like you have even if I come from a state school?

I saw from your blog you matched into louisville...where did you attend medical school? TMI?

5 years from now what are your salary expectations?

thanks.

 

[JackieMoore]

You should also identify a mentor now so that you can establish a good personal and professional relationship with that person. The more "important" the surgeon, the better. That way, by the time you apply, you have a strong ally that is willing to go to bat for you when you try to match.
---------------------------
Plastic Surgeon In Miami

 

[Converge]

paying the cost to be the boss - b.b. king

 

[JackADeli]

...If I do accept an employer/employee relationship it will be for ...I get a piece of the hospital fees for the cases I bring to the hospital...

Not sure you can do this... the stark laws and all really put a damper on this sort of arrangement. If you can do this, I would be very interested in details to enhance my practice... which is not in your field or your state and thus would not be competing with you.

 

[Spiker]

Hello,

I would like to thank you in sharing your incredibly fascinating experience as a solo practitioner. It is something I aspire to in the future but doctors keep telling me that it is a dieing breed...largely for financial reasons.

I was wondering if you taken any useful business classes in college?

I am getting a business minor precisely because I want to ensure financial viability in my future practice. So far I learned how to do basic accounting, html/.css excel access extremely well, all of which you seem to use quiet a bit.

Please keep posting about your experience!

 

[austinblnd]

Very interesting, any updates though?

 

[Soldatik]

I think he is retired already

 

[ineed2stpsmurfn]

hopefully the OP can update this thread as it's highly fascinating... just read the entire thing.

 

[jojo100]

would love to hear how you're doing?

 

[AxeJ]

Too bad there's not been any updates in a while.

 

[Grurik]

This all extremely interesting. The truth is, you seem very organized and put together. You seem like you knew what you were doing from day one. My question for you is, where did you actually get the expert training like this to begin with? Did you learn all this business sense in Medical school or did you pick it up from internships and other programs? Or is it possible you are just a genius and just knew what to do?

Anyway, thank you for sharing this. Very interesting and original. I don't think I've seen anything like this thus far.

I guess almost anyone can gain the knowledge on how to run a business, how profitable it will be will depend on your sense of business though. The best tips would be to discuss with someone educated in business alternatively a friend that is good at it. I think the best would be to consult someone early so that one does not have to try new things, due to the low income in the beginning.

You can also learn a lot from reading business magazines, such as The Economist, Financial Times etc. The principles of earning cash is the same for small and large companies.

 

[prettyNURSEtoMD]

I established a satellite clinic in another small town. The hospital is advertising for me. That one will run the 2nd and 4th Friday of every month.

I am all set up to go to a wound healing course (hahahaha) in Columbus Ohio. After I do that I will have yet another clinic, Wednesday afternoons, to see wound healing patients. Since the hospital runs that clinic I pay no overhead for it. They heavily advertise that clinic. They have it set up so that I see patients and I can bill for supervision for services by other providers.

This brings my total clinic time to:
2 half days of my own clinic
1 half day of wound healing clinic
1 half day of satellite clinic

That should be enough for now. If I decide to move to Des Moines I will keep these clinics open so that I will have the referral base. When I get busy enough with cosmetics to not need those clinics I will recruit a partner. If it will feed me it will feed the partner until he/she gets up and running with cosmetics.

(continued below)

 

[brokenjaw]

Great thread. Is there anything similar around?

 

[percyeye]

I wonder what he would think if he saw that this has been viewed >80,000 times. Great thread.