Is CMS trying to kill private practice?

[blue.jay]

https://www.ama-assn.org/system/files/medicare-pay-chart-2021.pdf

CMS reimbursement for hospital DRGs are adjusted for CPI but it seems physician RVUs conversion factors have not changed significantly over a decade. Inflation has soared over the last one year and the cost of running a practice has gone high. Few big health system employed physicians are getting pay raises.



How are private practice individual doctors or groups surviving. New job report shows 5.2% YOY growth in wages and CMS has proposed ~4% cut in conversion factor for 2023. Will individual physician private practice survive with higher overhead from high rent, EMR costs, malpractice premiums and labor costs from RN/MA pay rise ?

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[blue.jay]

@InvestingDoc do you think >90% of physicians will be employed by health systems in a decade or so ?

 

[bronx43]

https://www.ama-assn.org/system/files/medicare-pay-chart-2021.pdf

CMS reimbursement for hospital DRGs are adjusted for CPI but it seems physician RVUs conversion factors have not changed significantly over a decade. Inflation has soared over the last one year and the cost of running a practice has gone high. Few big health system employed physicians are getting pay raises.



How are private practice individual doctors or groups surviving. New job report shows 5.2% YOY growth in wages and CMS has proposed ~4% cut in conversion factor for 2023. Will individual physician private practice survive with higher overhead from high rent, EMR costs, malpractice premiums and labor costs from RN/MA pay rise ?

Real inflation over past 2 years is MUCH higher than stated, and adjustments by Medicare are not even close to keeping up. Even with the new 4.5% increase for inpatient reimbursement, most financially weak hospitals are going to be on the brink of collapse.

892 hospitals at risk of closure, state by state

More than 500 rural hospitals in the U. S. are at immediate risk of closing because of financial losses and lack of financial reserves to sustain operations, according to a report from the Center for Healthcare Quality and Payment Reform.

www.beckershospitalreview.com

At the same time, the one time change to E&M billing was essentially a life raft for cognitive specialties. Level 4 and 5 return visits went up like 25-30%, while the billing requirements actually went down. Which means if you are an established practice with mostly return patients, your Medicare revenues probably went up 30-40%. Private payers are a mixed bag on that one...

In short, yes. CMS has been trying to consolidate the industry and destroy independent practices for decades - this isn't new. But, many hospitals have gotten so big and fat on this endless CMS buffet that inflation and labor costs alone can burst their bubble.

If inflation keeps up and labor shortages don't correct, then I actually think lean private practices may be the last ones standing. Key word: lean. Private clinics with an army of staff and a big building they don't own won't survive.

 

[NewYorkDoctors]

While the payments have been reducing year by year, I get by with increased patient volumes.
Join a large IPA in a large metro area so patients get funneled to you, minimize staff you do not need (a nurse - do your own injections if applicable, billing staff - i do my own billing not too hard with the EMR and not those red scantron sheets of the past, phlebotomist - do it yourself with a vein finder), keep essential staff that help you take care of patients and sustain the increased revenue (i have an RT for my PFT/CPET lab and sufficient secretarial staff to help with "patient navigation")

Basically cut overhead (though not to bare bones) and do more things yourself that do not require special training.

Basically what bronx43 said above

 

[bronx43]

While the payments have been reducing year by year, I get by with increased patient volumes.
Join a large IPA in a large metro area so patients get funneled to you, minimize staff you do not need (a nurse - do your own injections if applicable, billing staff - i do my own billing not too hard with the EMR and not those red scantron sheets of the past, phlebotomist - do it yourself with a vein finder), keep essential staff that help you take care of patients and sustain the increased revenue (i have an RT for my PFT/CPET lab and sufficient secretarial staff to help with "patient navigation")

Basically cut overhead (though not to bare bones) and do more things yourself that do not require special training.

Basically what bronx43 said above

You draw your own blood? Doesn't that slow you down enough where it would make financial sense to hire a phlebotomist?

 

[NewYorkDoctors]

You draw your own blood? Doesn't that slow you down enough where it would make financial sense to hire a phlebotomist?

fortunately for pulmonary blood work isn't required that much. usually i ask for PMD to send labs and find prior labs in a portal somewhere.

on the occasional situation in which I want something special (like ANCA, absolute eosinophils, IgE, RAST) and I cannot rely on the patient or PMD getting it done (not putting them down - just saying sometimes its faster if I do it myself) then I will just draw it. with a vein finder (the $600 from VeinLite LED) and a 25G needle, even the most "vasculopathic" patients are not too hard to get some blood from.
this increases some kind of patient satisfaction when you use a vein finder and get the flash on the first draw. i hear all these stories from patients about how "mean and bad the other places are and multiple pokes" etc..

usually once the butterfly goes in, I auscultate their lungs or something to make efficient use of that time


i also set up a self vital sign triage station (more elderly patients may not be able to use this) to get vitals up front and save time. nothing too fancy but electronic scale, electronic BP machine like the ones at pharmacies, hand pad single lead ECG, a pulse ox machine that does not need patient to press anything...

 

[Osteoth]

While the payments have been reducing year by year, I get by with increased patient volumes.
Join a large IPA in a large metro area so patients get funneled to you, minimize staff you do not need (a nurse - do your own injections if applicable, billing staff - i do my own billing not too hard with the EMR and not those red scantron sheets of the past, phlebotomist - do it yourself with a vein finder), keep essential staff that help you take care of patients and sustain the increased revenue (i have an RT for my PFT/CPET lab and sufficient secretarial staff to help with "patient navigation")

Basically cut overhead (though not to bare bones) and do more things yourself that do not require special training.

Basically what bronx43 said above

Does your nurse not have the time to draw the blood? Do you think you could get by with just you and a nurse if you were just starting up or would you start with an MA?

 

[NewYorkDoctors]

Does your nurse not have the time to draw the blood? Do you think you could get by with just you and a nurse if you were just starting up or would you start with an MA?

Well a RN costs anywhere from 65-130K in NyC . The higher range is probably icu nurses . Even if we used a median number of 90K , that’s quite a bit as well as insurance and benefits .

Hence a start up may not have the funds to hire a nurse off the bat .

The best thing would be to have a lab service center very close to you

 

[blue.jay]

Over the long run these frugal measures aren't sustainable without increase in reimbursement. There is only a finite number of days/hours you can work (or patients you can see).
It's totally demoralizing that in many careers individuals are getting pay raise to match inflation for doing the same job. Unfortunately for doctors we just have to work more, see more patients to afford the same standard of living. This means our skill set is losing $ value every year while cost of living is sky rocketing.

 

[bronx43]

Over the long run these frugal measures aren't sustainable without increase in reimbursement. There is only a finite number of days/hours you can work (or patients you can see).
It's totally demoralizing that in many careers individuals are getting pay raise to match inflation for doing the same job. Unfortunately for doctors we just have to work more, see more patients to afford the same standard of living. This means our skill set is losing $ value every year while cost of living is sky rocketing.

Well... yeah. We all knew that healthcare in its current form wasn't sustainable. The only question on everyone's minds is when and how does it collapse.
Unless macroeconomic issues correct themselves (highly unlikely), then this is likely it.
It'll be painful. Your income and purchasing power will drop. Many in the economy will lose their livelihoods, savings, and property. With that said, no matter what, low cost/high value care will always have its place in society.
That's also why I've been bullish primary care as things unravel.

 

[NewYorkDoctors]

Over the long run these frugal measures aren't sustainable without increase in reimbursement. There is only a finite number of days/hours you can work (or patients you can see).
It's totally demoralizing that in many careers individuals are getting pay raise to match inflation for doing the same job. Unfortunately for doctors we just have to work more, see more patients to afford the same standard of living. This means our skill set is losing $ value every year while cost of living is sky rocketing.

True to that . But Medicare is going to keep cutting due to overall economic downturn , inflation , and current funneling of taxpayer dollars and federal reserve printed fiat currency (fake money ) into the military industrial complex. We’re gonna have to buckle down as long as possible with every more frugal measures . It sure beats being a hospital (corporate) employee

 

[chessknt]

True to that . But Medicare is going to keep cutting due to overall economic downturn , inflation , and current funneling of taxpayer dollars and federal reserve printed fiat currency (fake money ) into the military industrial complex. We’re gonna have to buckle down as long as possible with every more frugal measures . It sure beats being a hospital (corporate) employee

It does? Having to fill out a bunch of preauth bull****, call high school dropouts that work for insurance companies to fight denials, draw your own blood, work with a discount **** EMR, empty your own clinic trash and vacuum the floors beats working for a hospital?

 

[blue.jay]

Well... yeah. We all knew that healthcare in its current form wasn't sustainable. The only question on everyone's minds is when and how does it collapse.
Unless macroeconomic issues correct themselves (highly unlikely), then this is likely it.
It'll be painful. Your income and purchasing power will drop. Many in the economy will lose their livelihoods, savings, and property. With that said, no matter what, low cost/high value care will always have its place in society.
That's also why I've been bullish primary care as things unravel.

I agree, most of us know that this career was slowly getting less lucrative over the years. Covid and it's accompanying inflation has made this worse. We got exposed to a dangerous virus while most people were staying home, without paying rent/mortgage and getting unemployment paycheck. Now when the economy is booming they all get at least 5% pay raise and also get to work from home.
Our health system is cutting the medical groups reimbursement because they lost so much money by paying travel nurses hospitalist level wages. Now, RNs are claiming there is a workforce shortage and they won't work for 2019 wages. They can unionize and lobby to get pay raise while most employed doctors lost real $. Some employers are giving pay raise by increasing patient load or replacing doctors with midlevels.

We were like frogs in a slow boiling water, but since 2021 the heat has increased so rapidly and we are feeling the pain.

 

[blue.jay]

That's also why I've been bullish primary care as things unravel

This area is also encroached by holistic NPs with fraction of student loan debt which might also be forgiven, while rich doctors don't qualify for loan forgiveness.

 

[NewYorkDoctors]

It does? Having to fill out a bunch of preauth bull****, call high school dropouts that work for insurance companies to fight denials, draw your own blood, work with a discount **** EMR, empty your own clinic trash and vacuum the floors beats working for a hospital?

Meh making 7 plus figures a year makes it worth it lol . I’d wipe butts too at this rate

I will agree working as hospitalist or intensivist (as I’m ccm also ) would be a much better gig if the pay were comparable

 

[bronx43]

I agree, most of us know that this career was slowly getting less lucrative over the years. Covid and it's accompanying inflation has made this worse. We got exposed to a dangerous virus while most people were staying home, without paying rent/mortgage and getting unemployment paycheck. Now when the economy is booming they all get at least 5% pay raise and also get to work from home.
Our health system is cutting the medical groups reimbursement because they lost so much money by paying travel nurses hospitalist level wages. Now, RNs are claiming there is a workforce shortage and they won't work for 2019 wages. They can unionize and lobby to get pay raise while most employed doctors lost real $. Some employers are giving pay raise by increasing patient load or replacing doctors with midlevels.

We were like frogs in a slow boiling water, but since 2021 the heat has increased so rapidly and we are feeling the pain.

Yes, exactly. But the problem with this approach by hospital systems is that there's a floor to what they can do to outpatient docs. Inpatient docs have less leeway here.
No matter what, outpatient docs can leave and hang a shingle. It won't be pretty. It won't be easy. But it's still a viable strategy.

 

[NewYorkDoctors]

This area is also encroached by holistic NPs with fraction of student loan debt which might also be forgiven, while rich doctors don't qualify for loan forgiveness.

Still the NP will end up referring a patient with too many diagnoses for an “internal medicine consultation “ after a while .

 

[blue.jay]

Still the NP will end up referring a patient with too many diagnoses for an “internal medicine consultation “ after a while .

True they have been grabbing the low hanging fruit, easier patient's with good insurance and turfing train wrecks, opioid addicts and complex social issues to internists. So you end spending more time for these patients for low rate per time spent.

This exact thing happened to my friend and she got burnt out and quit the job. Majority of her visits are patients being mismanaged by midlevels or pts demanding arguing for early opioid refills while NPs see quick HTN follow up visits.

 

[bronx43]

True they have been grabbing the low hanging fruit, easier patient's with good insurance and turfing train wrecks, opioid addicts and complex social issues to internists. So you end spending more time for these patients for low rate per time spent.

This exact thing happened to my friend and she got burnt out and quit the job. Majority of her visits are patients being mismanaged by midlevels or pts demanding arguing for early opioid refills while NPs see quick HTN follow up visits.

My experience is that well insured patients who are not train wrecks prefer a MD/DO. This is especially true in a metro area. They only tend to go to NPs if the wait for a doc is prohibitive. At the major metro close to me where I used to work, the PCPs in the nicer suburbs were all physicians. The specialties were loaded with NPs, but the PCPs were almost devoid of them.

Also, If you're relying on a NP to refer to you as an internist, then you're doing something very wrong.

 

[NewYorkDoctors]

My experience is that well insured patients who are not train wrecks prefer a MD/DO. This is especially true in a metro area. They only tend to go to NPs if the wait for a doc is prohibitive. At the major metro close to me where I used to work, the PCPs in the nicer suburbs were all physicians. The specialties were loaded with NPs, but the PCPs were almost devoid of them.

Also, If you're relying on a NP to refer to you as an internist, then you're doing something very wrong.

Pretty much .

Though I’ve had colleagues from med school in rural areas tell me how underserved those areas are and family practice NPs do the bulk of “routine health care” in the community while the community hospital based internists see those “IM consults .” These internists are probably doing clinic wards and icu in these community hospitals . A true classical internists I suppose

 

[chessknt]

Meh making 7 plus figures a year makes it worth it lol . I’d wipe butts too at this rate

I will agree working as hospitalist or intensivist (as I’m ccm also ) would be a much better gig if the pay were comparable

Uh huh. What's your government insurance mix again?

 

[NewYorkDoctors]

Uh huh. What's your government insurance mix again?

Believe what you will. I’m just saying private docs who own the practice make much more than hospital based docs . Once you go private you never go back. However , certain specialties are hospital based only so it’s a moot point and not applicable to those doctors . Something like full time intensivist.

 

[chessknt]

Believe what you will bruh . I’m just saying private docs who own the practice make much more than hospital based docs . Once you go private you never go back.

So 10%? Cherry picking all private patients to fill a private practice isn't a strategy that works at scale, especially in a field where the majority of patients are on medicare. I definitely refuse to believe that you pull 7 figures doing no bronchs in an outpatient setting even in your unstaffed clinic unless you are only seeing private patients with high 2 low 3 figure conversion rates.

 

[NewYorkDoctors]

So 10%? Cherry picking all private patients to fill a private practice isn't a strategy that works at scale, especially in a field where the majority of patients are on medicare. I definitely refuse to believe that you pull 7 figures doing no bronchs in an outpatient setting even in your unstaffed clinic unless you are only seeing private patients with high 2 low 3 figure conversion rates.

Don’t be so mad . Take a deep breath and remind yourself you are the intensivist and the king of the icu . I’m sure you have a lot of pubmed citations to your name also . Carry on .

 

[VA Hopeful Dr]

Believe what you will. I’m just saying private docs who own the practice make much more than hospital based docs . Once you go private you never go back. However , certain specialties are hospital based only so it’s a moot point and not applicable to those doctors . Something like full time intensivist.

I'm actually genuinely curious how you pull this off. Absolutely no snark or ill intent meant.

I've owned a practice and will never do so again (I hate running a business) but I like knowing what's out there and possible.

 

[NewYorkDoctors]

well I never said I earned seven figures … I inferred it … maybe I do maybe I don’t . Yeah it sounded like a flex but that wasn’t really the intent to taunt anyone here . The point was the potential of a job for any specialty in which you are independent in your own small business can lead to higher revenue generation than being a salaried physician .

A junior partner no buy in guarantee private practice job (like renal lol ) is in no way better than a hospitalist , intensivist job , or academic job . But if you can build your own small business , you can make more and be happier and free of administration . If that route is not for you , you will find happiness in your academic career track as well

I will just say large patient volume , strong IPA to negotiate the best rates , and doing procedures (nothing more than clinically indicated as insurances routinely check my charts to ensure proper frequency and documentation - if they find something amiss they deduct the payment from a future paycheck )

One procedure I would suggest all internists (and relevant subspecialties ) to look into is remote patient monitoring . 99453 99454 99457 99458 makes a large bit of coin and can help you provide better care for your patients .

Bronchs don’t pay well at all . I will still do it for my patients if clinically indicated . I dont pawn off all cases to thoracic or IR . For a case that I suspect it’s sarcoidosis HP NTM TB I would do my own bronchs and EBUS . If it’s most likely cancer most likely , I would just have thoracic do a better job at the EBUS or lobectomy and MLND and not subject the patient to two invasive procedures . After all I am not a full time fellowship faculty member who has to find bronchs for fellows to do . I have pfts and cpets to do for them

 

[chessknt]

I'm actually genuinely curious how you pull this off. Absolutely no snark or ill intent meant.

I've owned a practice and will never do so again (I hate running a business) but I like knowing what's out there and possible.

The CMS conversion rate in 2022 is $33.59. Assuming you have a good payor mix of half private that pays 2.5x CMS rate your average rate would be ~60/RVU. To get to 1MM you would need 16667 RVU. A level 5 followup appointment is 5.29 total RVUs for an office and a level 4 is 3.75. Assuming you split these half and half you would need to see about 3700 pts/year to get to that 7 figure mark. Assuming you take 4 weeks and holidays off that comes out to about 230 days per year which is 16 pts/day which sounds fine. The problem of course is that we haven't accounted for any expenses yet. We also havent accounted for any ancillary income (like the PFT lab).

In the (apparently not) hypothetical scenario of a clinic where the only employee is a front office person getting paid 45k/yr (inc benefits) you still have billing software + rent + supplies and presumably some kind or EMR. You can convert each of these costs to a patient per day to get there--750 RVU for the front office person which is another 0.5 pt per day. If rent is the same per year (seems low) now we are up to a (still doable) 17 patients per day. Now let's assume our conversion rate is not so generous because of denials and decreased collections. For every 10% drop in our conversion rate we have to see an additional ~1.5ish patients per day. There are capital expenses and other costs like your own benefits etc.

These are rough numbers so it is hypothetically possible but as soon as you start to add any quality of life measures (like an RN or a biller to handle all the stupid insurance bull****) your workload increases as well to maintain that number. You can see how easy it would be to get to 20+ patients per day (assuming you can find volume to fill your clinic that full literally every day). It is obviously a lot easier if you can get 100% private insurance conversion rates that make everything you do count for 2-3x more, the problem is that you are practicing in a fairy tale world.

As an example, I do EBUS in my community because I am literally one of two people in the entire area that do it. I do a CMS EBUS and get paid about 300 for a 45 minute procedure which isnt too bad but a privately insured patient who is out of network will get charged about 2k. The other guy in the community who does them will only do privately insured patients, he makes a lot of money but it means that if I dont step up and do any for the medicare people they go for a mediastinoscopy instead. I see probably 80% government insured people in my clinic because the other pulmonologist in the area wont see them.

 

[NewYorkDoctors]

The CMS conversion rate in 2022 is $33.59. Assuming you have a good payor mix of half private that pays 2.5x CMS rate your average rate would be ~60/RVU. To get to 1MM you would need 16667 RVU. A level 5 followup appointment is 5.29 total RVUs for an office and a level 4 is 3.75. Assuming you split these half and half you would need to see about 3700 pts/year to get to that 7 figure mark. Assuming you take 4 weeks and holidays off that comes out to about 230 days per year which is 16 pts/day which sounds fine. The problem of course is that we haven't accounted for any expenses yet. We also havent accounted for any ancillary income (like the PFT lab).

In the (apparently not) hypothetical scenario of a clinic where the only employee is a front office person getting paid 45k/yr (inc benefits) you still have billing software + rent + supplies and presumably some kind or EMR. You can convert each of these costs to a patient per day to get there--750 RVU for the front office person which is another 0.5 pt per day. If rent is the same per year (seems low) now we are up to a (still doable) 17 patients per day. Now let's assume our conversion rate is not so generous because of denials and decreased collections. For every 10% drop in our conversion rate we have to see an additional ~1.5ish patients per day. There are capital expenses and other costs like your own benefits etc.

These are rough numbers so it is hypothetically possible but as soon as you start to add any quality of life measures (like an RN or a biller to handle all the stupid insurance bull****) your workload increases as well to maintain that number. You can see how easy it would be to get to 20+ patients per day (assuming you can find volume to fill your clinic that full literally every day). It is obviously a lot easier if you can get 100% private insurance conversion rates that make everything you do count for 2-3x more, the problem is that you are practicing in a fairy tale world.

As an example, I do EBUS in my community because I am literally one of two people in the entire area that do it. I do a CMS EBUS and get paid about 300 for a 45 minute procedure which isnt too bad but a privately insured patient who is out of network will get charged about 2k. The other guy in the community who does them will only do privately insured patients, he makes a lot of money but it means that if I dont step up and do any for the medicare people they go for a mediastinoscopy instead. I see probably 80% government insured people in my clinic because the other pulmonologist in the area wont see them.

Good read. I enjoyed it . I see you put a lot of hard work into this post .

I also do primary care (for those without a subspecialty issue and have a PA see those patients and do the work (I see each patient at each visit like attending and resident in that sense and make the overall decision making ). That’s the other revenue stream . That’s also why I post so much about primary care (when I am not bashing non-academic nephrology )

Sub specialists can do as much primary care as they want. Often , this entails send all other complaints to other subspecialists while you get that sweet 99395-7 money and some flu shot money. I happened to do my residency in the primary care track and got some good training with the PCMH model , doing sbirts, evaluating social determinants of care , etc all that good buzzword primary care stuff.

I also do my own billing . It’s not bad at all . The EMR populates the icd and cpt codes for me and I press the button to send to clearing house . That gets sent out to the insurances . I have set up my EMR to receive era and my bank accounts to receive EFT . I’ve asked the insurance companies not to send me paper EOB. Such a waste of paper and ink.

Once A week I open up the accounts panel in the emr and see what was rejected and forward to my office manager who will correct the errors .

Not every EMR is as expensive or hard to use like EPIC or all scripts

My outpatient solo office EMR costs $400 a month

 

[Osteoth]

Good read. I enjoyed it . I see you put a lot of hard work into this post .

I also do primary care (for those without a subspecialty issue and have a PA see those patients and do the work (I see each patient at each visit like attending and resident in that sense and make the overall decision making ). That’s the other revenue stream . That’s also why I post so much about primary care (when I am not bashing non-academic nephrology )

Sub specialists can do as much primary care as they want. Often , this entails send all other complaints to other subspecialists while you get that sweet 99395-7 money and some flu shot money. I happened to do my residency in the primary care track and got some good training with the PCMH model , doing sbirts, evaluating social determinants of care , etc all that good buzzword primary care stuff.

I also do my own billing . It’s not bad at all . The EMR populates the icd and cpt codes for me and I press the button to send to clearing house . That gets sent out to the insurances . I have set up my EMR to receive era and my bank accounts to receive EFT . I’ve asked the insurance companies not to send me paper EOB. Such a waste of paper and ink.

Once A week I open up the accounts panel in the emr and see what was rejected and forward to my office manager who will correct the errors .

Not every EMR is as expensive or hard to use like EPIC or all scripts

My outpatient solo office EMR costs $400 a month

What EMR do you use

 

[InvestingDoc]

@InvestingDoc do you think >90% of physicians will be employed by health systems in a decade or so ?

I think that the shift will continue to move towards employment of physicians by large health systems and lower private practice.

However, I think we will eventually cross a threshold where we see a rise in private practice for non procedural physicians.

The writing is on the wall. The CEOs and private equity want profits. It is cheaper to pay a NP or PA to do non surgical jobs and have a physician sign off on all their notes rather than have a bunch of doctors there.

The trend of APP employment will only increase for these types of jobs, pushing their pay higher and MD/DO pay stagnant or higher for those positions where you sign off on all APP charts to bring in big bucks.

Once we see that flip occur, then you will see doctors going out on their own to start their own thing because people are willing to pay to see a physician.


How do I know? We recently threw up a crazy price of $600 an hour for an annual physical and executive wellness with $100 worth of labs included in my practice to test the market since we now have a few PAs and some people are very vocal that they want to see an MD.

I opened 4 of these hour long spots in my schedule per week and within 48 hours I had 3 weeks worth of these appointments booked up. My jaw literally hit the floor when that happened. I seriously threw up a number so high that I thought no one would pay, but here we are. I did 2 of these exams this morning.

I made the mistake of valuing my time less than some of my patients value my time....and clearly some people are willing to pay a premium for our services while PE and admins want to pay us pennies.

 

[bronx43]

I think that the shift will continue to move towards employment of physicians by large health systems and lower private practice.

However, I think we will eventually cross a threshold where we see a rise in private practice for non procedural physicians.

The writing is on the wall. The CEOs and private equity want profits. It is cheaper to pay a NP or PA to do non surgical jobs and have a physician sign off on all their notes rather than have a bunch of doctors there.

The trend of APP employment will only increase for these types of jobs, pushing their pay higher and MD/DO pay stagnant or higher for those positions where you sign off on all APP charts to bring in big bucks.

Once we see that flip occur, then you will see doctors going out on their own to start their own thing because people are willing to pay to see a physician.


How do I know? We recently threw up a crazy price of $600 an hour for an annual physical and executive wellness with $100 worth of labs included in my practice to test the market since we now have a few PAs and some people are very vocal that they want to see an MD.

I opened 4 of these hour long spots in my schedule per week and within 48 hours I had 3 weeks worth of these appointments booked up. My jaw literally hit the floor when that happened. I seriously threw up a number so high that I thought no one would pay, but here we are. I did 2 of these exams this morning.

I made the mistake of valuing my time less than some of my patients value my time....and clearly some people are willing to pay a premium for our services while PE and admins want to pay us pennies.

Good hearing from you, InvestingDoc!

That is great to know that there are patients out there willing to shell out premium dollar for time and attention of a doctor. This is honestly my assessment as well. There are some patients who wouldn't mind seeing a NP/PA, but this business model is only sustainable if there are no other doctors in the area offering their services. In a world where corporate controls the entire market, then they can basically deprive patients of this option - it's either the NP/PA or nothing.
However, once doctors are willing to go off on their own and offer either DPC or even private clinics, then corporate medicine loses this ability.

The more I see, the more I think we are post-peak for corporate medicine and the NP/PA encroachment honestly.

 

[chessknt]

Good hearing from you, InvestingDoc!

That is great to know that there are patients out there willing to shell out premium dollar for time and attention of a doctor. This is honestly my assessment as well. There are some patients who wouldn't mind seeing a NP/PA, but this business model is only sustainable if there are no other doctors in the area offering their services. In a world where corporate controls the entire market, then they can basically deprive patients of this option - it's either the NP/PA or nothing.
However, once doctors are willing to go off on their own and offer either DPC or even private clinics, then corporate medicine loses this ability.

The more I see, the more I think we are post-peak for corporate medicine and the NP/PA encroachment honestly.

You can't scale medical practice off wealthy people who expect their demands to be met because they paid extra (which is also bad medicine--a lot harder to say no abx for that viral uri to the medicaid person than the CEO who paid $600 for an appointment with you). The vast majority of care is still going to be either set rates from the government or negotiated against insurances both of which are agnostic to whoever provides that care.

 

[bronx43]

You can't scale medical practice off wealthy people who expect their demands to be met because they paid extra (which is also bad medicine--a lot harder to say no abx for that viral uri to the medicaid person than the CEO who paid $600 for an appointment with you). The vast majority of care is still going to be either set rates from the government or negotiated against insurances both of which are agnostic to whoever provides that care.

I'm not talking about creating an entire clinic with $600 physicals. Obviously that's not feasible.

Have you actually looked at what the typical "negotiated" rates are for outpatient specialties? It's all public now. You can look up what your hospital charges for a level 4 new with you. With so much of the cost of healthcare shifted to patients, it doesn't even matter what the insurances negotiate (small differences for most part). The patient will essentially be paying for it out of pocket until they hit their $4-6k deductible. And people are literally paying $300-400+ for a level 4 new visit with a specialist. It's usually around $100-200 for the professional fee, then another $100-200 for the facility fee. And that's ALL non-Medicare/Medicaid insurances.
And the more mindboggling thing is that if you have insurance but pay out of pocket, you pay LESS than if you use your insurance. The only difference is that it technically won't go towards your deductible. I've been having more and more patients come in as "self-pay" despite carrying a private insurance card.

And even with Medicare, the new reimbursement for level 4-5 isn't bad, and can sustain a practice with low overhead.

Ultimately, the point I'm trying to make is that it's actually making more and more sense nowadays for outpatient based specialties to hang a shingle, especially as compensations get squeezed by money-losing hospital systems. Medicare reimbursements are up, and private insurance patients are paying top dollar either way, so they prefer a MD/DO over the local NP/PA.

 

[InvestingDoc]

Good hearing from you, InvestingDoc!

That is great to know that there are patients out there willing to shell out premium dollar for time and attention of a doctor. This is honestly my assessment as well. There are some patients who wouldn't mind seeing a NP/PA, but this business model is only sustainable if there are no other doctors in the area offering their services. In a world where corporate controls the entire market, then they can basically deprive patients of this option - it's either the NP/PA or nothing.
However, once doctors are willing to go off on their own and offer either DPC or even private clinics, then corporate medicine loses this ability.

The more I see, the more I think we are post-peak for corporate medicine and the NP/PA encroachment honestly.

I recently moved to a new house in the same city, and my god.....moving and renovating the new house at the same time was not the smartest decision haha. I feel like I'm finally getting back into checking social media...blog...and catching up on my favorite websites now that I'm settled into the new place.



We have noticed month over month an increase in patients who are new who demand to only see a physician. Even though I have a PA as an employee, it is great to see the average patient start to know the difference. I'm not saying that to mean that I look down at our PA. She is a great person and she really knows what she knows and knows where her limitations are at. Our PA has been a huge plus to our practice. I believe that there is a possibility to work with APPs without any turf war. However, PE and large corps only care about profits, and if you set up a practice correctly, you can make way more money having a PA or NP "farm" of employees rather than MD/DOs.

Our PA often sees same day urgent visits for mild things like UTIs, STD screening or treatment, mild cellulitis same day calls...you get the idea. It has been amazing to use our PA as a way to keep our patients from going to urgent care or the ER. Also, if they have a cancellation, they help clear out physicians inbox for things like helping triage inbox messages or imaging results (and will message the normal results on our behalf).

I hope you are right. I hope we have seen peek APP encroachment.


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You can't scale medical practice off wealthy people who expect their demands to be met because they paid extra (which is also bad medicine--a lot harder to say no abx for that viral uri to the medicaid person than the CEO who paid $600 for an appointment with you). The vast majority of care is still going to be either set rates from the government or negotiated against insurances both of which are agnostic to whoever provides that care.

True I can't scale this type of medical practice for executive wellness as quickly or big as a traditional practice. So far I have had 6 of these executive wellnesses in our practice. Each one of them has been an hour of patients who are highly motivated CEO's or high up in a company to live as healthy as they can. We were surprised that so far, not a single Rx has come from one of these executive wellnesses. I too was nervous that maybe these patients will think that because they paid all this money, they are going to get whatever they ask for. I didn't want this to turn into a give me a stimulant or testosterone type of visit.

So far, that has been the exact opposite of what I have experienced. One of these patients even told me something along the lines of...look I know how to run a billion dollar business and pick good managers. I'm here because I want a good manager to help me achieve my health goals 10 to 30 years from now. We spent the whole time talking about carbs, their alcohol intake, sleep quality and hygiene, my thoughts on Galleri test and labs to "dig deeper" in to their health (like crp and apo b to name a few).

Yes, it could be argued that this is wasting resources in healthcare when these tests are not indicated. I get that.

However, maybe I'm fooling myself but gosh....I really love talking to someone who is invested in their wellbeing and wants to be healthy by changing their lifestyle with diet and other lifestyle changes. It is never going to fill my schedule every day, but the one or two of these a day that I may do is a nice change to the patient who has an A1c of 11 that gives yet another reason why their A1c is still high and I'm there trying to figure out the barrier to achieving their (or maybe my A1c) goals.

I think we are struggling with the idea that as we expand these executive wellnesses, that we are taking time and visits away with an MD in our practice with our commercial insurance patients or Medicare, pushing up wait times and access to care. There has been a lot of debate among the MDs in the practice about this and a two tier system that favors those with cash that can get in to see the MD. This debate is ongoing and we will adjust depending on what happens with Medicare and commercial payments in the future.

 

[VA Hopeful Dr]

You can't scale medical practice off wealthy people who expect their demands to be met because they paid extra (which is also bad medicine--a lot harder to say no abx for that viral uri to the medicaid person than the CEO who paid $600 for an appointment with you). The vast majority of care is still going to be either set rates from the government or negotiated against insurances both of which are agnostic to whoever provides that care.

As things are now, it's pretty damned hard to say no antibiotics for that Medicaid patient.

I know I don't.

 

[dozitgetchahi]

So 10%? Cherry picking all private patients to fill a private practice isn't a strategy that works at scale, especially in a field where the majority of patients are on medicare. I definitely refuse to believe that you pull 7 figures doing no bronchs in an outpatient setting even in your unstaffed clinic unless you are only seeing private patients with high 2 low 3 figure conversion rates.

Several points here:

- there is a huge difference between being a solo practitioner and being in a sizable multispecialty private practice. The multispecialty PP has, ideally, some economies of scale that should help keep down overhead (obviously practices differ in how well they do this), and they take care of a lot of the drudgework so that you’re not emptying garbage cans and shoveling snow etc.

- Reimbursement varies a lot from state to state, and from dx to dx. I’m happy to take Medicare because in my state the Medicare reimbursement rate is actually quite good, and a lot of those patients have supplemental private insurance policies that make their reimbursement basically as good as private insurance.

- Midlevels are awful and I clean up a lot of their messes. I am a rheumatologist, and I work with a lot of “refugee” patients fleeing the cross town rheumatology “NP farm” practice…the patients are horribly mismanaged and the doc cosigning the notes is asleep at the wheel. Maybe the “NP farms” make a lot of money for docs, but it is at the cost of patient safety and quality of care (which a few of us out here still care about).