Revenue generation in medicine is pretty opaque and not straightforward, but I'm curious if anyone knows what makes the most money for the hospital/medical system on average. Specifically, I'm interested in medical subspecialties only, and finding out what is the most revenue-generating and/or profit-maximizing in the inpatient and outpatient settings. I'm guessing these would be procedures like cardiac stents, endoscopies, or bone marrow transplants? Is there a way this information can be found?
What is most revenue-generating?
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Probably a rotating group of Onc GI and Cards depending on the specific department.
You can find this information by becoming a C-suite goon or a department chair.
You can find this information by becoming a C-suite goon or a department chair.
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Based on a career of being goon-adjacent, I can say that in most places, Cards and Onc vie for the #1 revenue generating medical sub-specialty in most places.
But the real cash comes from the "total joint" ortho bros.
But the real cash comes from the "total joint" ortho bros.
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Elective surgeries by far. The facility fees on those are eye popping. A 90 minute TKA nets the hospital $12.6k.
If talking about nonsurgical then it’s cards, GI, onc. Pulm doesn’t do a whole lot of procedures and the ICU isn’t exactly a cash cow. You can find what Medicare pays online, it’s all public info.
If talking about nonsurgical then it’s cards, GI, onc. Pulm doesn’t do a whole lot of procedures and the ICU isn’t exactly a cash cow. You can find what Medicare pays online, it’s all public info.
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for some cash values for pulmonary (outpatient) procedures (for reference, this is what CMS allows and what I see on my EOBs under Amount Allowed- if the patient has Medi/Medi or a cadillac commercial plan that has zero out of pocket costs, then I get to pocket the whole amount. If they have deductible or copay, then that amount is applied and the insurance paid is less of course)
PFT with bronchodilator study and plethysmography (94060, 94726, 94729) pays about $150
FENO (95012) pays about $20
6MWT (94618) pays about $35
Sputum induction with hypertonic saline + chest vest (89220, 94669, 94640) pay about $45
Lung u/S (76604) pays about $40
CPET pays about $150 - the EKG stress test part (93015) pays about $70 (of note, the EKG stress test and CPET cannot be billed on the same day unless two different providers split the billing. this is usually where pulmonary vs cardiology turf wars happen in a hospital system)
Bronchoprovocation testing (95070 + 94070) pay about $100 (though the methacholine and mannitol are billed separately and those may not get reimbursed by all insurances)
Home Sleep Study (95800) pays $200
doing an ultrasound guided thoracentesis pays about $200
A bronchoscopy with BAL and some transbronchial biopsies nets about $400.
I would not know about EBUS as I refer these to hospital's IP or thoracic surgery to do
(though when I do these in the hospital, I relinquish the facility fee. I would not and cannot do these in my own office)
but the big advantage I have is most of these (except 95800) do not need prior authorization. Moreover, PA for 95800 tends to be approved on Day 2. Therefore, I usually give a new OSA consult the HST on Day 1. When they return on Day 2, the PA is done and I can bill 95800 right away.
PFT with bronchodilator study and plethysmography (94060, 94726, 94729) pays about $150
FENO (95012) pays about $20
6MWT (94618) pays about $35
Sputum induction with hypertonic saline + chest vest (89220, 94669, 94640) pay about $45
Lung u/S (76604) pays about $40
CPET pays about $150 - the EKG stress test part (93015) pays about $70 (of note, the EKG stress test and CPET cannot be billed on the same day unless two different providers split the billing. this is usually where pulmonary vs cardiology turf wars happen in a hospital system)
Bronchoprovocation testing (95070 + 94070) pay about $100 (though the methacholine and mannitol are billed separately and those may not get reimbursed by all insurances)
Home Sleep Study (95800) pays $200
doing an ultrasound guided thoracentesis pays about $200
A bronchoscopy with BAL and some transbronchial biopsies nets about $400.
I would not know about EBUS as I refer these to hospital's IP or thoracic surgery to do
(though when I do these in the hospital, I relinquish the facility fee. I would not and cannot do these in my own office)
but the big advantage I have is most of these (except 95800) do not need prior authorization. Moreover, PA for 95800 tends to be approved on Day 2. Therefore, I usually give a new OSA consult the HST on Day 1. When they return on Day 2, the PA is done and I can bill 95800 right away.
The real revenue generation of those non-surgical fields is still the procedures though--especially elective--the caths, and scopes. Oncology money is related to chemo/immunotherapy infusions (which still has a procedural CPT code compared to the treatments done by other 'medicine' treatments such as endocrinology for example)
From the point of view of the administrative goons, the perfect hospital would only do elective cardiothoracic surgery, elective spine, TKA/THA, elective cath (no STEMIs/ACS), scopes, and infuse chemo/immunotherapy. Everyone else can get bent.
Lo and Behold: At every hospital I've ever worked at, those "rainmakers" in the specialties that facilitate/provide the above dictate institutional policy and priorities.
I'm waaay out of my depth (I'm EM) but if you were financially motivated outpatient any IM is your background, your options would be to specialize in cards/GI to do procedural work (cath, scope) or something that uses a lot of infusions and you can find a way to own/operate or have a stake in the infusion center or home IV (some ID, rheum, onc).
The fact that most ID/rheum people I know are NOT killing it financially suggests to me that its easier said than done to get involved with that kind of thing though.
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This all comes down to drug pricing. If you're an academic institution, you can get 340b pricing which is a huge discount, but still bill insurance the same as any other healthcare entity giving the same drug.
Large non-academic health systems get around this by bargaining with manufacturers directly.
Smaller (but still large) organizations go through wholesalers like McKesson and Cardinal, to get better prices than they would on the open market.
But if you're not a big enough fish, none of those are going to be options for you. Doesn't mean you can't still buy and bill, but the margins are going to be small enough that it probably won't be worth it, especially if you also have to pay nurses to do the actual infusion work.
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I don’t know ID people who are killing it.
I DO know rheum people who are killing it, however, so it is absolutely possible to pull that off as a rheumatologist. I am currently in a large, ~100 doc multispecialty practice and the highest biller in the entire institution is my rheumatology partner, who has been there for 15 years or so.
He bills more than onc.
He bills more than the surgeons.
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If by billing you mean gross revenue (total amount to payer), then I can totally see that. However, if by net revenue (total amount minus cost of drug) then that's really hard to do as non-procedural, since high volume surgeons/proceduralists are just able to pull the most dollars pound for pound.
My previous partner billed insane amounts of money but it is a lot less impressive when you realize that you can bill $4M but only pocket $250k since the drugs themselves cost $3.75M.
Compare that to a surgeon who bills $4M - that whole amount goes to the group.
This is pretty eye-opening to me - our pharmacists talk about 340b drug pricing all the time to get patients affordable drugs, but in reality this also seems like a huge profit line. Am I understanding this correctly, that the payer reimburses the drug at the standard rate, but our purchasing of the drugs at 340b discounts is marked down significantly? By how much? Why would pharma agree to this - I'm assuming the profit loss is backstopped by the Fed?
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"Hospitals are failing to fulfill the promise of the 340B program, which offers discounted drugs to hospitals that treat a large proportion of underinsured and uninsured patients, The Wall Street Journal reported Dec. 20.
The program has long been controversial as nonprofit organization 340B Health has pointed to 19 drugmakers that have restricted their involvement in the drug pricing program, and hospital pharmacy leaders have said it is part of an unclear revenue cycle.
Among the 2,600 hospitals that are part of the 340B program, they often shuffle the discounts to well-off locations not part of the program, the Journal found.
3 things to know:
1. Hospitals that are part of the program are not required to transfer the discounts they receive from pharmaceutical companies to their patients, insurers or Medicare. They also do not have to report their profits from 340B discounts or spend those earnings to support low-income patients.
Cleveland Clinic's flagship hospital, for example, does not pass on specific drug discounts to patients, though a spokesperson told the Journal it has multiple programs that benefit its community, including many Medicare patients.
2. The criteria for what qualifies as a rural hospital is murky because if a facility is not in a rural area, a hospital can still be tagged as one if it meets other requirements, including having at least 275 beds. The rural referral centers are buying the program's discounted drugs faster than any other type of 340B hospital, by more than 700 percent over five years, the Journal said. Some of the hospitals defined as rural include Chicago-based Northwestern Memorial Hospital, Boston-based Brigham and Women's Hospital and Cleveland Clinic."
The loopholes of the 340B program
Hospitals are failing to fulfill the promise of the 340B program, which offers discounted drugs to hospitals that treat a large proportion of underinsured and uninsured patients, The Wall Street Journal reported Dec. 20.
