Eyeball RVUs

[Thepassageofgas]

An eyeball ASC is opening a few minutes down the road and somehow they got my name. I’m a full time locum/per diem right now, and they are asking if I will provide them with coverage two to three days a week as they grow their practice. They would eventually like to start doing GETA retinas there too. I have a Zoom call with the COO this evening. I feel like this could be a great chance to help grow a brand new surgery center—maybe?

My question for you all is: should I ask them for a flat rate, or to do my own billing? One of the surgeons is younger and efficient, says she wants to do 24 cases a day. However, she’s warned me that one of the older surgeons makes an 8 hour day out of 8 cases. I’ve searched high and low and I can’t find a spreadsheet or calculator to help me estimate the RVUs per case.

Sorry if this question is super dumb, but I wish they taught us about practice management in residency

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[teacher2md]

Cataract surgery is 4 base units. Assume that all these patients are Medicare. For a 20 minute total procedure, that’s $120.

If you do fee-for-service, best case scenario, you’re looking at $2800 per day. And that’s a mind-numbingly boring but busy day.

If you get stuck with the slow surgeon, you’re looking at $1100 per day.

If I were you, I would absolutely ask for a guaranteed flat rate.

 

[GassYous]

Cataracts are 4 units, I think retina is 5 or 6. Let's say 2 time units for each fast case and 4 for each slow one. 8 x 8 = 64. 24 x 6 = 144. Let's say they're all medicare which pays 22? Slow surgeon day may be 1400 or so, fast surgeon may be 3000 if they are consistently doing 20+ cases.

 

[DocMcCoy]

Guaranteed rate based off the fast surgeons predicted RVU

 

[Hoya11]

An eyeball ASC is opening a few minutes down the road and somehow they got my name. I’m a full time locum/per diem right now, and they are asking if I will provide them with coverage two to three days a week as they grow their practice. They would eventually like to start doing GETA retinas there too. I have a Zoom call with the COO this evening. I feel like this could be a great chance to help grow a brand new surgery center—maybe?

My question for you all is: should I ask them for a flat rate, or to do my own billing? One of the surgeons is younger and efficient, says she wants to do 24 cases a day. However, she’s warned me that one of the older surgeons makes an 8 hour day out of 8 cases. I’ve searched high and low and I can’t find a spreadsheet or calculator to help me estimate the RVUs per case.

Sorry if this question is super dumb, but I wish they taught us about practice management in residency

Probably being offered to you because no one else wants it .. no offense . These places can’t be profitable if it’s just eyes even if they do 40 cases per day.

You’d make more and do more interesting cases as a per diem getting just a base rate of 250 from a hospital.

 

[dumbmedstudent]

Guaranteed rate 100%. Agree with the above. It’s a miserable day, and even on the most efficient days you will be barely breaking even with the market rate of 250-300/hr

 

[Simba1711]

Also are they going to ask you to do blocks or do they do they give topical anesthesia ?

 

[osumd]

They already have a number that they want to pay, and you’re not going to like it.

 

[cchoukal]

It would be interesting to know what the surgeon is making on each case (probably knowable) and what the ASC is making in facility fees. Absent that, I’d want $400/hr, free espresso (the good stuff, not keurig), and fast WiFinto do eyeballs all day.

 

[Thepassageofgas]

They already have a number that they want to pay, and you’re not going to like it.

Well, the commute is literally five minutes, so I’m willing to hear them out.

But, I’m not going to leave my current gig for less than 350/hr. So it’s their move.

Could be a very short phone call I guess! Thanks all for the info!

 

[Thepassageofgas]

Probably being offered to you because no one else wants it .. no offense . These places can’t be profitable if it’s just eyes even if they do 40 cases per day.

You’d make more and do more interesting cases as a per diem getting just a base rate of 250 from a hospital.

I agree with this. I enjoy hospital anesthesia too much to give it up entirely.

They have a proposal from a nearby practice, but I’m guessing they asked for a lot? Or what they view as “a lot”? We’ll see! A learning experience to be sure.

 

[pgg]

Gut reaction - I would want nothing to do with it.

Eyeballs are exhausting. Talking to dozens of old people every day, same conversation, same non-anesthetic ...

And they're not going to offer you a significant piece of the facility profits.

But I agree with the above. If for some reason you want to do eyeballs in a no weekend no call gig, a guaranteed rate that is acceptable to you is probably the way to go. I'd want a substantial premium over what I get elsewhere. And I would be wary about leaving a good job for it. The instant they figure a way to get anesthesia service for less, you're gone.

Call me a cynic but I can't fathom any surgeon anywhere choosing to split the riches of their ASC baby with the anesthesia widget in the corner. So as great as the anesthesia market is these days, I'm skeptical this idea can be worth it.

 

[Thepassageofgas]

Gut reaction - I would want nothing to do with it.

Eyeballs are exhausting. Talking to dozens of old people every day, same conversation, same non-anesthetic ...

And they're not going to offer you a significant piece of the facility profits.

But a I agree with the above. If for some reason you want to do eyeballs in a no weekend no call gig, a guaranteed rate that is acceptable to you is probably the way to go. I'd want a substantial premium over what I get elsewhere. And I would be wary about leaving a good job for it. The instant they figure a way to get anesthesia service for less, you're gone.

Call me a cynic but I can't fathom any surgeon anywhere choosing to split the riches of their ASC baby with the anesthesia widget in the corner. So as great as the anesthesia market is these days, I'm skeptical this idea can be worth it.

Thanks pgg. “Anesthesia widget” put me right in my place! Sometimes you need a harsh wake up, and this is mine.

 

[sbmed100]

The fact that insurance still pays for our services during this time of shortage is just stupid. Cataracts with topical anesthesia = sedation nurses. No need for a board certified anesthesiologist.

 

[jwk]

I'd at least be

Probably being offered to you because no one else wants it .. no offense . These places can’t be profitable if it’s just eyes even if they do 40 cases per day.

You’d make more and do more interesting cases as a per diem getting just a base rate of 250 from a hospital.

The "place" is profitable - just not for anesthesia.

 

[nimbus]

https://www.reddit.com/r/Ophthalmology/s/1zJOYbiCtt

 

[circleK]

There’s not enough money in the world to make me do cataracts everyday. Eyeball days make me feel like my overqualified presence is ridiculous. I always feel like an idiot introducing myself as their anesthesiologist and then explaining to them that they’re not getting any anesthesia.

 

[nimbus]

There’s not enough money in the world to make me do cataracts everyday. Eyeball days make me feel like my overqualified presence is ridiculous. I always feel like an idiot introducing myself as their anesthesiologist and then explaining to them that they’re not getting any anesthesia.

Mostly agree but I’d do it for the right price. It would have to be a lot.

 

[ethernet]

I think our average cataract is reimbursing around $75 and most surgeons are doing a bit over 2 per hour on a good day. Total billing is around 2k including the facility fee and surgeon charge. There is no profit for us in eyes. Run away unless they are paying a kings ransom from those sweet facility fees.

Besides, as stated above, I'm not keen on being overpriced patient transport.

 

[rick roller pump]

Does anyone work at a place that does RN sedation for cataracts? Any resistance from ophthalmology? We are short docs and CRNAs and I just don't see the point of covering this.

 

[IDGARA]

An eyeball ASC is opening a few minutes down the road and somehow they got my name. I’m a full time locum/per diem right now, and they are asking if I will provide them with coverage two to three days a week as they grow their practice. They would eventually like to start doing GETA retinas there too. I have a Zoom call with the COO this evening. I feel like this could be a great chance to help grow a brand new surgery center—maybe?

My question for you all is: should I ask them for a flat rate, or to do my own billing? One of the surgeons is younger and efficient, says she wants to do 24 cases a day. However, she’s warned me that one of the older surgeons makes an 8 hour day out of 8 cases. I’ve searched high and low and I can’t find a spreadsheet or calculator to help me estimate the RVUs per case.

Sorry if this question is super dumb, but I wish they taught us about practice management in residency

I'm doing eyeball stuff on the side. I asked for $400 an hour, 6hr guarantee, and they took it with no negotiation. No way they're making that off the anesthesia billing, I just figure its better than them cancelling 20+ cataracts and missing out on the facility fees.

Also, check out the ASA's Relative Value Guide. It's got a breakdown on the startup units for all types of cases. I think it was $40 and totally worth it.

And I agree with what circleK said. "Hi, I'm Dr. IDGARA. I'll be your anesthesiologist. My plan is to do nothing and charge you for it."

 

[BLADEMDA]

I'm doing eyeball stuff on the side. I asked for $400 an hour, 6hr guarantee, and they took it with no negotiation. No way they're making that off the anesthesia billing, I just figure its better than them cancelling 20+ cataracts and missing out on the facility fees.

Also, check out the ASA's Relative Value Guide. It's got a breakdown on the startup units for all types of cases. I think it was $40 and totally worth it.

And I agree with what circleK said. "Hi, I'm Dr. IDGARA. I'll be your anesthesiologist. My plan is to do nothing and charge you for it."

Anyone working at any ASC should be getting a guaranteed rate of $300-$400 per hour. "Billing" isn't worth the effort as you will be denied or paid $35 per unit by the insurance company or $22 per unit by Medicare. I will never again do my own billing when a guaranteed rate is an option.

I usually LMA most Retina cases rather than intubate them. My cataract surgeons can do 3-4 per hour but it's still a boring day. I totally agree we aren't needed for cataract surgery. FYI, I typically administer 0.5 mg IV of midazolam for these cases, if I am feeling generous then 1 mg IV.

 

[Guillemot]

In my first job out of residency, the boomers not infrequently ripped off the drapes and intubated their topical cataracts after pushing so much versed and fentanyl that they caused respiratory arrests.

 

[GassYous]

In my first job out of residency, the boomers not infrequently ripped off the drapes and intubated their topical cataracts after pushing so much versed and fentanyl that they caused respiratory arrests.

If you're giving more than 2 and 2 you're doing it wrong

 

[aneftp]

The easy solution for the eye center is very easy. Same solution as gi center these days.

Just hire crnas @$220/hr. Solo provider (or have eye doc sign off on the charts depends on state laws)

And I’m not being sarcastic.

But even crnas may not take $220/hr these days

My non Florida case locums crna friend won’t work for less than $240/hr and scuffs Florida pays so low for crnas when I told her I can probably get her $215-hr plus housing stipend

 

[pgg]

My cataract surgeons can do 3-4 per hour but it's still a boring day.

There ain't nothing boring about doing paperwork for 40+ patients when directing a couple of cataract rooms, on top of whatever real ASC cases are going on in the other 1-2 rooms. It's soulsucking misery even if you can temporarily believe the lie that your part in the procedure is necessary.

Even if working solo it's still 20+ people you've got to talk to (30% you'll need to TALK TO because they respond to every other question with HUH?). God it makes me tired just typing about it.

You guys can have the eyeballs. All of them.

 

[aneftp]

There ain't nothing boring about doing paperwork for 40+ patients when directing a couple of cataract rooms, on top of whatever real ASC cases are going on in the other 1-2 rooms. It's soulsucking misery even if you can temporarily believe the lie that your part in the procedure is necessary.

Even if working solo it's still 20+ people you've got to talk to (30% you'll need to TALK TO because they respond to every other question with HUH?). God it makes me tired just typing about it.

You guys can have the eyeballs. All of them.

Yup. I had 30 plus eyes. Plus 8-10 peds cases plus 30 eyes. I literally was pre oping 60-70 cases a day. Like the worse out patient gig I ever did. I did it for 8 months in between jobs.

If it’s strictly eyes. all supervision. It is easy. But with other non eyes cases going on it can be a problem.

 

[Howard888]

Yes RN sedation works well. Oral Valium plus some places use melts. It’s how it should be. Only do the occasional cataract that can’t still still or something.

Just make your stipend ask or rate too high. They’ll try oral sedation and never go back. Patients like it much better too. No IV.

 

[GaseousClay]

Yes RN sedation works well. Oral Valium plus some places use melts. It’s how it should be. Only do the occasional cataract that can’t still still or something.

Just make your stipend ask or rate too high. They’ll try oral sedation and never go back. Patients like it much better too. No IV.

its amazing insurance is still paying for anesthesia services for cataracts

 

[BobLoblaw78]

An eyeball ASC is opening a few minutes down the road and somehow they got my name. I’m a full time locum/per diem right now, and they are asking if I will provide them with coverage two to three days a week as they grow their practice. They would eventually like to start doing GETA retinas there too. I have a Zoom call with the COO this evening. I feel like this could be a great chance to help grow a brand new surgery center—maybe?

My question for you all is: should I ask them for a flat rate, or to do my own billing? One of the surgeons is younger and efficient, says she wants to do 24 cases a day. However, she’s warned me that one of the older surgeons makes an 8 hour day out of 8 cases. I’ve searched high and low and I can’t find a spreadsheet or calculator to help me estimate the RVUs per case.

Sorry if this question is super dumb, but I wish they taught us about practice management in residency

How did it go?

 

[eyeeye_captain]

Out of curiosity, how do you folks feel about retina cases? Different arena than playing with the cataract cowboys.

 

[DocMcCoy]

Out of curiosity, how do you folks feel about retina cases? Different arena than playing with the cataract cowboys.

Can be even easier depending on the surgeon. Our last guy was slick. Buzz them with propofol while he did a retrobulbar block, then kick back and relax for an hour or two.

 

[woopedazz]

In Aus you get $178.85 (or 200.65 for ASA3+) from our universal health system per cataract. That's for a quick consult while placing cannula and then a quick block, then a nurse wheels them into theatre and does the charting (no sedation, literally just charts the vitals) while you repeat the process on the next patient.

Works out to approximately 500-750 dollar-idoos/hour of good surgeon/facility. I don't charge any OOP/private health fund, I just take the government funding.

They're highly coveted lists as you get to do stuff and they're low risk and pay well. They are fantastic quality of life operations for the patient, etc... but I find them extremely boring/soul destroying.

 

[Howard888]

Blocks for cataracts….overkill. Topical works great with a little sedation (oral fine) by nurse. I haven’t seen a block for a routine cataract in 15-20 plus years. But hey you’re getting paid for it…

 

[IDGARA]

Blocks for cataracts….overkill. Topical works great with a little sedation (oral fine) by nurse. I haven’t seen a block for a routine cataract in 15-20 plus years. But hey you’re getting paid for it…

I just did peribulbars on 15 cataracts this week. Thank god I'm paid by the hour and not the case.
So 15 people got slugs of propofol they didn't need so they could get a block they didn't need.
There's no way the risk/benefit ratio is in my favor.

 

[Howard888]

Not at all. So beyond the standard of care

 

[Thepassageofgas]

How did it go?

So, they wanted to guarantee me 2700/day; their idea was, I do my own billing, and if, after collections, i made less than 2700, they’d top me off. If I made more, I’d get to keep it. This is a net loss for me compared to my current rate, so I told them thanks but no thanks, and that was the end of it.

Thank you to everyone who chimed in!

 

[pocafx]

2700 for 8 hours isn’t bad? 337/h. Even 270/h not bad if 10 hours. But billing seems like a hassle

 

[DocMcCoy]

That’s not a bad deal if you are out by 3.

 

[nimbus]

Can be even easier depending on the surgeon. Our last guy was slick. Buzz them with propofol while he did a retrobulbar block, then kick back and relax for an hour or two.

We have one retina guy who is so quick and gentle and sweet talks the patients while he blocks and does the procedure that his patients don’t ever need propofol. He also does exclusively 25g vits.

 

[DocMcCoy]

We have one retina guy who is so quick and gentle and sweet talks the patients while he blocks and does the procedure that his patients don’t ever need propofol. He also does exclusively 25g vits.

Nice. Some of those guys are absolutely awesome. Some not so much.

 

[eyeeye_captain]

Nice. Some of those guys are absolutely awesome. Some not so much.

It’s very much a spectrum. I know some people that only operate under general and take 2+ hours per case. I’m cool with a minimal propofol hit for a retrobulbar and can knock 4 routine cases out in a 7:30-noon block with time to spare.

 

[Thepassageofgas]

2700 for 8 hours isn’t bad? 337/h. Even 270/h not bad if 10 hours. But billing seems like a hassle

Doing my own billing sounded like a massive ass ache, and I’m not sure about the sustainability of it in a place that at most is hoping for 2 cases/hr, and has one doc that does one case per hour.

 

[Howard888]

30 minutes a cataract? An hour? Run and hide. God insurance companies need to stop paying for anesthesia for these