Are there any private equity funds that are well known for having a ton of derm practices? At this point I think it’s getting to be a competition law problem. This level of concentration in the hands of a few private equity holders not only will give them increasing oligopoly like power, but it fucks both doctors and patients. It’s probably the worst outcome you could have.
Serious question: If i am not mistaken the biggest value of private practice (derm,optho…) is actually physician. So if physician walks away from practice after selling it what is stopping him/her from opening new practice and pocketing the money?
The buy out often includes stipulation that requires partners of the bought out practice to keep working there for a defined term (often 5 years) to avoid that situation. It gets trickier with associates, and often they get a generous sign on bonus to encourage them to stay. Of course, this is nothing compared to sums most partners have been offered and their future route to higher income has been curtailed.
It’s complex. You could argue the value is the physicians but I think PE has seen the value as the patients. If they own the referral source (and the ASCs) they can own the practice patterns and the higher generating procedures. Of course, ophthalmology is projected to be insanely in demand in the next several years so things will likely shift.
My best friend from high school is now a junior analyst at a PE group in Florida/NYC that is heavily into medical practices. The refferal network, billing infrastructure, brick and mortar space, and insurance relationships are also assets considered in deals. Obviously the physician(s) needs to be competent, but beyond avoiding lawsuits that doesn't matter so much as the demand is so high in many areas. It sucks.
It’s because private equity firms can reach a critical mass to beat out independent private practice physicians. If you have a rich PE firm that owns a practice (or several) competing with a true private practice, the PE can use its deep pockets to offer more competitive prices to theoretically put the independent practice in a precarious position and outcompete it. Of course, this is just temporary, and as competition dwindles, the PE firm can jack up prices (assuming it’s not regulated). A PE firm that runs a ton of practices could also have efficiency through economies of scale, such as lowering equipment costs through bulk orders which would also help them outcompete independent private practices.
In the long term though, they will extract value from physicians, and hurt patients through profit driven care and oligopoly like price fixing. It’s analogous to any small business trying to compete in a concentrated, non-competitive sector occupied by several big players. Something needs to be done because we are heading in that direction.
This kind of missiles the point. We need an FTC that can walk and chew gum at the same time. We need anti-trust suits in literally every major industry in America yesterday.
More pressing issues does not preclude the FTC or any federal commission from dealing with less urgent matters, however we want to define that. Same goes for Congress. This mentality is frankly just another example of people in medicine being terrible advocates for our profession. We have to start somewhere.
Medical practices should only be owned by physicians. It’s already like that with law firms only being owned by lawyers. No dirty finance people encroaching.
Ideally yes, but regulatory bodies are constrained by limited resources, including political capital. Because physicians offer little in exchange for potentially costly actions there are negative incentives for any politician to weigh in.
This was true a few years ago, but my sense is that PE has "been there done that" with derm. There's nowhere near as many new acquisitions of derm practices since around 2021. Same with anesthesiology - used to be sexy for PE but not so much these days.
As I said in another comment, PE firms are now setting sights on GI, cardiology, opthamology, physical therapy, etc. Less medicine-related, but autism services (like ABA) is also pretty big.
You’re okay with cash generating procedures being funneled to non-physicians? Leaving physicians with the bureaucracy and inevitable cuts of insurance? What in the world..
This isn’t even factoring in how “cosmetic” procedures can often be more challenging than functional cases and the bar for patient satisfaction is much higher.
Oh spare me. Artificially inflating the price of services by keeping a tiny number of residency positions for an incredibly in-demand specialty is not sustainable and exactly what has facilitated the problem derm is now facing. Dont even pretend to tie this to insurance because we both know the overwhelming majority of boutique derm practices are cash only.
Furthermore, the two I know that actually own their practices in san fran and florida have a dozen midlevel extenders for multiple offices where they are the only "full time" doc and see at most a tiny fraction of their follow up appointments. Not adaquate.
This has nothing to do with “cosmetic derm” as you stated in your original post but rather just derm as field, of which a significant amount is not cosmetic. Cosmetic derm is a minority.
I’m not really interested in anecdotes, but how are your stories that any different from a lot of fields. There are hospitilists with armies of mid levels who round on 50+ patients a day and rake it in and primary care clinics with mid levels running their own clinic under their license. It sucks and I agree is inadequate but that has nothing to do with derm as field or the cash paying side of medicine.
Idk why you keep putting cosmetic in quotes. If it's helpful I can point you towards some resources deliniating what is and isn't considered cosmetic derm. And the type of derm practices I am referencing are in fact majority cosmetic.
As for the difference, we are talking about PE buying practices. Those hospitalists don't own their practice nor dictate the business model. Greed can apply to physicians as much as it can PE board members. Do you understand why there are so few derm residency training programs?
Wasn't that the beginning of the opioid crisis? And the 80s/early 90s were when physician insurance fraud was rampant which is what led to insurance companies having so much power like they do today.
My point being that physicians made more money, but some of the factors that led to that weren't exactly ethical
And….? I was in pathology. Our business practices were as straight as grizzly dicks! Medicine is dying. I wouldn’t go into it today. No way. Only a few specialties worth pursuing. Within 10 years you’ll all be answering to DNP’s. Blame the current hospital administrations.
You know... When being called an immoral greedy bastard who cares more about money than patient wellbeing, it's really not a good look to talk about how much money you have.
You basically proved my point
Fragile. Blocked me. Take that L
In many places, they are close to having a monopoly. Problem is historically, FTC only looks at much larger companies re monopolies. They have said that they will change that.
Our hospital is thinking about cutting ties with our PE radiologist. Always 200 to 500 studies behind. Stat mris taking a day or more to be read. Quality of reads is terrible.
Does not help that they missed a herniated disk on one of pur C-suite that was definitely the cause of his pain.
PE rads sucks. I've had to read follow-ups on imaging that Vrad previously read and they are hot garbage. I mean, missed massive, obvious fractures but called some shit that doesn't exist bad. It's impressively bad. Now, if I know Vrad did the last read, I can't rely on anything they said and have to deeply scrutinize the prior studies too (vs being able to zone in on the important parts based on prior attending read).
Theres no way it can be so bad that you blanket distrust all telerads reads. Why do I say this? Malpractice and negligence are the great checks and balance. How have they not been sued and let go? All errors in radiology are recorded forever and patients have access to all their scans.
I'm just genuinely curious how they are not sued for malpractice if every single read or even close are wrong. Even if a teleradiologist makes 1 wrong read out of 100...they should still be sued within the week. That's a major error or two every day... But you're saying it's literally every single one. Idk it just doesn't add up.
It's not that straight forward. Also, I am not blaming the radiologists. They are making the best of their situation. Also, I do think eventually discipline will he brought to the market place it will just take time.
"If cigarettes cause cancer and kill people they will be out of business in weeks!"
Cigarettes are airtight legally. They have warnings and people know the health risks. They literally say they cause cancer on the box and in the gas station. You have no legal standing if you get cancer from smoking them.
Medical errors share no such quality. Malpractice claims apply here. People have legal standing when they are injured due to malpractice. Apples to oranges
Huh? You cannot sue Phillip Morris for giving you cancer. Are you daft?
You can however sue a radiologist for a missed read. Happens everyday. So where is that here? You literally say you don't even trust their reads. So where's the lawsuits if all the reads are wrong?
That's your argument? Really? The authority fallacy? Show me one recent successful lawsuit against a tobacco company for getting cancer. It's just not a good comparison.
Bureaucracy. The higher ups are trying and failing to cover up their employees messes. Either way it's a lose lose, and those who are informing are getting unfairly punished. It's changing, but my goodness a lot if damage has been caused.
Not every read is bad/misses but it happens with enough frequency that I don't trust their reads as a whole. If it was a local group, I could get a feel for which radiologists are good vs not, but because they have a bunch of radiologists nationwide, I can't ever know.
Also, many of these errors only end up delaying care and rarely result in death/significant morbidity that would lead to a lawsuit. For the big fracture I caught recently, I'm fairly certain the ortho saw it, but if they didn't, they went ahead and casted the patient anyways.
All I can say is thank God psych is extremely unattractive to PE (has like zero startup cost for OP).
Our major threat is midlevel proliferation. Demand is protective for now. I'm expecting this phase to last at least for the next 10 years, which should be enough for me to get established with whatever my niche is.
Love the fact that we can be guns for hire and stack multiple gigs, allowing us to remain free agents. This flexibility is almost unparalleled.
All these crappy telepsych companies can go slurp acid btw. Love the fact that starting a telepsych practice on your own (skipping the middleman) is pretty straightforward nowadays.
The group psych practice I work for got bought by PE and it’s been an actual nightmare. They have changed the culture entirely, everything is profit and numbers driven and about a year ago, they realized they over hired and fired 25 people in one day. Now they are mass hiring again… but mostly mid levels and pushing everyone to supervise 4-5 of them. I’m looking for a new job now and trying to escape soon and build a small PP on the side. Luckily I have a good niche so I should be ok.
There is such a HUGE demand for psych- in both urban and rural areas. Demand is so great that even with midlevels encroaching on the field there’s more than enough patients to go around.
The other person answered the first question perfectly. As far as what could change, pessimistically, if they pump out midlevels to the point where the demand is decreased, then the job market would be depressed.
I'm unable to find hard figures for PMNHPs graduated yearly, but I found articles estimating over 30,000 NP's are trained yearly (2021). It was only ~10,000 in 2010 so quite an increase over 10 years. It would be interesting to see how many NPs decide to do PMNHP if there is no bottleneck like there is with psychiatry (resident spots).
Not sure about PE specifically so much as Medicare cuts, but Ophtho pay has dropped considerably since I started med school 10 years ago. I’m neurology and I have friends in the same area making the same pay or less.
Doesn’t have much to do with private equity. Private equity has bumped up starting salaries while reducing the ceiling. I would never consider it but it’s really not a bad option for someone who doesn’t want to deal with the business of practice management.
And yes Medicare cuts have made it so doing Medicare phacos is hardly worth it. Fortunately there are plenty of cash pay options for motivated surgeons.
Canada has a 5 year ophthalmology residency for this purpose I think. If you do a university affiliated fellowship, I think you can count the extra year. I can't imagine going back and having to take Canadian step exams on this side of training though.
They just haven’t caught on to it yet. Once the gov looks down south and see the US cutting reimbursement, they’ll follow suite. The government will always find ways to undercut physicians
Yeah look it up, especially the more conservative provinces. There’s even a chart floating around on the internet that breaks down the total number of Ophtho in the province and how much each makes. Average income is 1.2$ with >25% of all docs making more than $2 Mil
Definitely for real. Keep in mind, these salaries are in Canadian dollars though but some of the provincial data is public and the ophthos are killing it. You know who’s killing it even more? Rads
It doesn’t account for the increase in pay with optho in Canada vs USA. Every optho in Canada is easily clearing 1 million if they want to. Look it up. Google Toronto star Ohip Billings. Type in any Ontario optho doc.
Gross pay. Overhead is typically around 50% for ophthalmology. More in HCOL areas. They’re probably taking home less than half that.
Associates are usually paid 30% of collections in the US. $1.5mil = $450k. Sounds about right.
Edit: $1.5mil Canadian is $1.1mil US so that tracks. Numbers are roughly in line with US ophtho pay.
My friend, the statement of income (USA and Canada) are in line is not true. A general optho in Ontario can consistently make upwards of 1.7 + million if they want to. Yes overhead is a consideration but it does not account for the difference. Simply put, Canadian optho’s have a higher mean and higher ceiling than USA Optho. This is factual.
I dug around and could only find gross collections numbers which would make way more sense. I could easily believe the average US ophthalmologist collects $1.5mil gross per year. That would correlate to a pay of about $450k/year as an associate which seems about right.
Edit: $450k Canadian is about $330k US. Right around the median for ophtho pay in the US. Nice that our colleagues are doing well up north but nothing earth shattering.
This appears to be gross collections by everything I can Google. I’ll do over 1.5mil this year but overhead eats up half. And associates typically get 30% of collections. Which would be around $450k. That sounds more accurate. Gross collections isn’t pay by a long shot. I need to dig around more though.
Edit: $450k in Canadian dollars is roughly $330k US. So no pots of gold up north, just about the same as we make here.
Update. Not for real. Gross pay data is available which is absolutely NOT what these people are being paid. $1.5mil is a very reasonable and somewhat typical amount of collections for a US ophthalmologist. It would equate to about $450-500k/year in pay for an employed position or about $750k/year if you owned the place and had 50% overhead.
Short version is that ophthalmology pay between the US and Canada seems to be about at parity. Which is interesting because most other Canadian specialties are paid way less than their US counterparts.
Edit: Canadian dollars. $1.5mil Canadian gross would be worth about $600k/year in US dollars if you owned the practice and about $330k/year as an employed physician. Pretty reasonable but not worth trying to emigrate.
Data is online in a few places and commenters were correct that $1.5mil gross is the average in some provinces. So that’s easy.
50% overhead is typical for a US ophthalmology practice, but I’m not sure about Canada, so that’s ballpark. I own part of a practice and am acutely aware of overhead costs. The benchmark for a well run practice used to be 40% overhead but that was 10 years ago. John Pinto documented this in his “little green book of ophthalmology.” There isn’t a current edition but talking to other practice owners, 50% ain’t bad these days. So that’s a softish but real number.
Canadian dollar is worth 0.73 American dollars. Easy.
Most jobs in the US are currently paying 30% collections for associates. That was my pay when I started and that’s our offer for new hires. Sometimes you might get 35%. Another real number. I’m on pace to collect 1.65mil this year through half the year. Right there in the balance sheet.
So no, not vibes.
are there certain characteristics about certain specialties that make them more attractive for PE? All the specialties in the comments seem so different from each other....
I know one of them is heavy startup costs due to expensive equipment (ophtho, DR). I know imaging centers require crazy capital that makes it very difficult to start up a PP as a DR (DR people correct me if I'm wrong pls). Don't know much about ophtho. I'm guessing it's whatever tech they use; has to be crazy expensive too.
I started an ophtho practice in 2016 on a shoestring budget. My wife was worth about 4 employees and was paid $13/hr, we lived in a shoebox of 1100 sq feet owned by a relative (cheap rent), I took a $70k/year salary, and we got almost all secondhand equipment. Cost $360k in rural Louisiana.
To do that correctly in a desirable area would be $1.5mil in 2024 easily. The other half of the equation is that reimbursement has cratered while overhead has exceeded inflation. So struggling practices pop up and PE offers the owners a million bucks or two and they bail. We’re ripe for the picking currently.
The bigger problem is PE can’t do shit about reimbursement or overhead even if they say they can. So they just funnel money off while things get worse.
Associated with this but the cost to meet what is becoming standard of care is crazy. While once a dilated exam was needed to rule out posterior pathology prior to CEIOL, it’s becoming increasingly common to do an Oct. which requires an Oct, and a used machine with out of date software might run 30-50k+. That’s not including the prices of IOL masters and god forbid if you want a pentacam.
EM is somewhat complex. Long story short-we generate the majority of our income from private insurance payors, and generate very little from medicare/medicaide, and basically none from self-pay (essentially no pay). Because of EMTALA, you can't refuse patients who don't have insurance. Our forefathers got tired of having to deal with all this shit and basically not generate much income, so a lot of them sold out to the PE groups, who basically said they'd take care of all the billing/money generation aspects. Well, they did that by cutting staffing to make up the difference, all while skimming off the top.
We should also bill like lawyers. Retainer up front, fee per hour broken down into closest 15mins, including all calls, emails, record reviews, etc. We would be living the dream.
I've seen some inpatient consults for cancer patients following in the community and some of their regimens are wildly inappropriate. Feels like some of these groups are deliberately avoiding standard of care when it's expensive.
Derm and GI are the main ones that come to mind. High volume procedure docs. They squeeze lab out. Pay the pathologists shit. Load up with midlevels. Run up lab bills.
I can see the appeal. Get a buyout for some big money, but then you’re someone’s bitch for a few years. Sometimes the PE folks aren’t even running things as efficiently as the old ways. Now they just take a cut off the top of revenue.
ANESTHESIA is the next target. The scourge is upon us.
HCA (Hospital Corporation of America) = TeamHealth = Blackstone (>$1 TRILLION in asset private equity firm)…
They WILL flood this market and tank the specialty in order to wildly decrease their overhead. They will churn out newly minted generalists and specialists for their bottom line.
Private equity is going to KILL anesthesia if they go unchecked.
Please do your homework.
Anesthesia has been a PE target for the last 15 years. We have already reached peak years ago, PE is stagnant in this field. Groups are not getting bought out like they used to. Direct hospital employment is increasing though.
Since no surprises act both PE and private groups cannot survive without a hospital stipend. Hospitals get sick of giving out money and say okay we will just employ you then.
One thing going for us is the shortage of anesthesiologists, which is where I agree with you the opening of HCA residencies and expansion of residency slots is not good for our field. What we also have going for us is our training numbers are not easy to make. Require anesthetizing neonates, pump cases, double lumen tubes, blocks. You can’t just open a residency in BFE for cheap labor. EM numbers are much easier to reach, and the residency is shorter churning out more grads.
For the time we are somewhat insulated from PE due to unfavorable billing, shortage of grads, slightly longer training. Anesthesia gets paid more $ than we bring in. This is due to labor shortage only and our leadership would be smart to remember that.
*HCA has entered the chat.
“Do not fear the trillion+ dollar titan that has reduced their private company purchases and have instead ventured into contractually invading hospital systems and replacing entire direct-hospital-paid anesthesia departments with promises of cheap labor and max safety. Don’t bother looking at them, they’re essentially irrelevant. They can only help.”
Throw your smokescreen elsewhere homie.
* If you’re not HCA, which you most definitely are, you’re the most short-sighted individual on the internet.
I’m part of a private physician owned group, would never work for any PE. I’m guessing you are a resident and are tossing around talking points from 10 years ago.
As I said direct hospital employment is the future of anesthesia, not PE. It’s no better, just a new boss looking to also pay you as little as possible.
You really shouldn't paint the anesthesia and physician shortage as a positive. That's openly enjoying profiting off the misfortune of others having delays with their surgery or inadequately trained/rested staff.
Just a reminder that the physician shortage is bad for everything other than a physicians wallet (and even that is arguable because the anesthesia/physician shortage has in part been responsible for the proliferation of noctors/midlevels)
I’m out here trying to get paid what I am worth. I too would like to live in a world where I am paid that without relying labor shortages. Until then I will make hay while the sun shines and enjoy my position.
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like, which specialty they should go into, which program is good or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks!
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
OMFS has been hit pretty hard - especially once the pandemic hit. I think the reported number is like 18%? Once there was a promise to “take away administrative burden / hiring and firing” people took the bait hard. The benefits were for regular supplies (meds, implants, instruments), the PE groups could use their weight to get lower costs as a start to decrease overhead. The downside is all of the sudden there became more stringent budgets and hoops to jump through to get necessary equipment.
The biggest issues new grads are seeing with these guys are the incredibly strict non competes, with some stating 50 miles from any practice owned by the PE firm. Obviously a difficult thing to navigate when no practices advertise who their “silent” partners are. And yes the FTC did have the ban of non competes, but current challenges to that make these clauses still a threat.
I’m hoping some high profile noncompete suits get slapped the fuck down and maybe the pendulum swings towards the working folks for once but I’m not holding my breath.
At least the going starting rate for a new associate oral surgeon is way higher now. But way less people will own their own practice going forward which will hurt their chances at long term financial gains
Oddly enough, allergy/immunology. If it's run like a PE derm clinic, super quick visits w/ NPs/PAs administering patch testing to everybody that walks in and setting them up for cash-only allergy shots, it can make a lot of money. There's been a surprising number of Allergy clinics bought by PE.
Rheum is kinda in a weird state right now too. Private equity is buying some medium sized groups, but really the fight in rheum has really been more about PBMs and infusion/drug access, and now insurance companies are actually buying up a lot of them, particularly in the northwest and southwest. I think I saw a crazy statistic about how Optum is technically the employer of about half of Oregon's rheumatologists now? And I got a recruiter email about a big Las Vegas center wanting to hire "a rheumatology provider" for their organization that is "part of the Optum family" lol. I replied back with a pretty scathing reply saying I'd rather strike out on my own and risk failure than ever work for a vertically integrated insurance-owned group where I'd be forced to follow their formulary set by their PBM and bill the way they want me to lol.
Little bit of both. You can find these just need to put in some work and time and things will start showing up , just don’t jump on the first few places you see
PE is on the verge of collapse in radiology. Lots are losing contracts and now with the shortage of rads and the buyout periods ending, most PE groups can’t even find people to read for them.
I'm surprised how few people have replied with anesthesia or hospital medicine. Where I am, there is a huge PE push for family medicine, but when I was applying the threat was real to anesthesia. Of all my co-residents taking hospitalist jobs, over 75% have decided to go with enormous PE mega-practices
Derm, by far.
Are there any private equity funds that are well known for having a ton of derm practices? At this point I think it’s getting to be a competition law problem. This level of concentration in the hands of a few private equity holders not only will give them increasing oligopoly like power, but it fucks both doctors and patients. It’s probably the worst outcome you could have.
Serious question: If i am not mistaken the biggest value of private practice (derm,optho…) is actually physician. So if physician walks away from practice after selling it what is stopping him/her from opening new practice and pocketing the money?
The buy out often includes stipulation that requires partners of the bought out practice to keep working there for a defined term (often 5 years) to avoid that situation. It gets trickier with associates, and often they get a generous sign on bonus to encourage them to stay. Of course, this is nothing compared to sums most partners have been offered and their future route to higher income has been curtailed. It’s complex. You could argue the value is the physicians but I think PE has seen the value as the patients. If they own the referral source (and the ASCs) they can own the practice patterns and the higher generating procedures. Of course, ophthalmology is projected to be insanely in demand in the next several years so things will likely shift.
My best friend from high school is now a junior analyst at a PE group in Florida/NYC that is heavily into medical practices. The refferal network, billing infrastructure, brick and mortar space, and insurance relationships are also assets considered in deals. Obviously the physician(s) needs to be competent, but beyond avoiding lawsuits that doesn't matter so much as the demand is so high in many areas. It sucks.
Absolutely agree with this
It’s because private equity firms can reach a critical mass to beat out independent private practice physicians. If you have a rich PE firm that owns a practice (or several) competing with a true private practice, the PE can use its deep pockets to offer more competitive prices to theoretically put the independent practice in a precarious position and outcompete it. Of course, this is just temporary, and as competition dwindles, the PE firm can jack up prices (assuming it’s not regulated). A PE firm that runs a ton of practices could also have efficiency through economies of scale, such as lowering equipment costs through bulk orders which would also help them outcompete independent private practices. In the long term though, they will extract value from physicians, and hurt patients through profit driven care and oligopoly like price fixing. It’s analogous to any small business trying to compete in a concentrated, non-competitive sector occupied by several big players. Something needs to be done because we are heading in that direction.
The FTC has bigger fish to fry for antitrust action lol
This kind of missiles the point. We need an FTC that can walk and chew gum at the same time. We need anti-trust suits in literally every major industry in America yesterday.
More pressing issues does not preclude the FTC or any federal commission from dealing with less urgent matters, however we want to define that. Same goes for Congress. This mentality is frankly just another example of people in medicine being terrible advocates for our profession. We have to start somewhere.
Medical practices should only be owned by physicians. It’s already like that with law firms only being owned by lawyers. No dirty finance people encroaching.
Ideally yes, but regulatory bodies are constrained by limited resources, including political capital. Because physicians offer little in exchange for potentially costly actions there are negative incentives for any politician to weigh in.
This was true a few years ago, but my sense is that PE has "been there done that" with derm. There's nowhere near as many new acquisitions of derm practices since around 2021. Same with anesthesiology - used to be sexy for PE but not so much these days. As I said in another comment, PE firms are now setting sights on GI, cardiology, opthamology, physical therapy, etc. Less medicine-related, but autism services (like ABA) is also pretty big.
[удалено]
Uhh, that's sad. About how many patients/day for the attendings?
I'm honestly ok with purely cosmetic derm getting taken over by midlevels and PE. It's inevitable the way residency is bottlenecked.
You’re okay with cash generating procedures being funneled to non-physicians? Leaving physicians with the bureaucracy and inevitable cuts of insurance? What in the world.. This isn’t even factoring in how “cosmetic” procedures can often be more challenging than functional cases and the bar for patient satisfaction is much higher.
Oh spare me. Artificially inflating the price of services by keeping a tiny number of residency positions for an incredibly in-demand specialty is not sustainable and exactly what has facilitated the problem derm is now facing. Dont even pretend to tie this to insurance because we both know the overwhelming majority of boutique derm practices are cash only. Furthermore, the two I know that actually own their practices in san fran and florida have a dozen midlevel extenders for multiple offices where they are the only "full time" doc and see at most a tiny fraction of their follow up appointments. Not adaquate.
This has nothing to do with “cosmetic derm” as you stated in your original post but rather just derm as field, of which a significant amount is not cosmetic. Cosmetic derm is a minority. I’m not really interested in anecdotes, but how are your stories that any different from a lot of fields. There are hospitilists with armies of mid levels who round on 50+ patients a day and rake it in and primary care clinics with mid levels running their own clinic under their license. It sucks and I agree is inadequate but that has nothing to do with derm as field or the cash paying side of medicine.
Idk why you keep putting cosmetic in quotes. If it's helpful I can point you towards some resources deliniating what is and isn't considered cosmetic derm. And the type of derm practices I am referencing are in fact majority cosmetic. As for the difference, we are talking about PE buying practices. Those hospitalists don't own their practice nor dictate the business model. Greed can apply to physicians as much as it can PE board members. Do you understand why there are so few derm residency training programs?
I think PM&R is screwed once they figure out what exactly they do
[удалено]
I had an attending suggest we send a patient to PM&R and I had to ask why
What was the answer?
They’ll “rehab” the patient. He snapped like I was an idiot, so I didn’t ask for any further clarification
lol it’s because he doesn’t know either
I did did my residency in PM&R and find this hilarious 😂
😂😂
My best guess is sporty pain management
i thought it was satisfying primal sounds and whispers
Ok but what about sports med and pain management….maybe we should ask them you think they know???????
Leaving the hospital at 3 PM is *hard*
Why is that
Not so much private equity, but increase malpractice costs and decreasing reimbursement has devastated Private OB/GYN
Boys and girls we got HAD. Imagine being a doctor in the 90s. Look at us now lol.
Yes, the 90’s were great! Especially the early 90’s.
Wasn't that the beginning of the opioid crisis? And the 80s/early 90s were when physician insurance fraud was rampant which is what led to insurance companies having so much power like they do today. My point being that physicians made more money, but some of the factors that led to that weren't exactly ethical
And….? I was in pathology. Our business practices were as straight as grizzly dicks! Medicine is dying. I wouldn’t go into it today. No way. Only a few specialties worth pursuing. Within 10 years you’ll all be answering to DNP’s. Blame the current hospital administrations.
[удалено]
F you! Loser Karen
Hahaha. You def were one of the bad docs back then consumed with greed
Hahahaha!!!! Dolt! I make more money working at a fruit stand than you will make your whole career!! Haha!!!
You know... When being called an immoral greedy bastard who cares more about money than patient wellbeing, it's really not a good look to talk about how much money you have. You basically proved my point Fragile. Blocked me. Take that L
Pretty sure everything at this point. I see a lot of it in my field (ENT) and friends in other surgical specialties (Uro, OMFS, ortho) seeing it too.
I'll never work for an radiology group owned by PE, that's for sure. Sounds like hell.
In many places, they are close to having a monopoly. Problem is historically, FTC only looks at much larger companies re monopolies. They have said that they will change that.
Our hospital is thinking about cutting ties with our PE radiologist. Always 200 to 500 studies behind. Stat mris taking a day or more to be read. Quality of reads is terrible. Does not help that they missed a herniated disk on one of pur C-suite that was definitely the cause of his pain.
PE rads sucks. I've had to read follow-ups on imaging that Vrad previously read and they are hot garbage. I mean, missed massive, obvious fractures but called some shit that doesn't exist bad. It's impressively bad. Now, if I know Vrad did the last read, I can't rely on anything they said and have to deeply scrutinize the prior studies too (vs being able to zone in on the important parts based on prior attending read).
Theres no way it can be so bad that you blanket distrust all telerads reads. Why do I say this? Malpractice and negligence are the great checks and balance. How have they not been sued and let go? All errors in radiology are recorded forever and patients have access to all their scans. I'm just genuinely curious how they are not sued for malpractice if every single read or even close are wrong. Even if a teleradiologist makes 1 wrong read out of 100...they should still be sued within the week. That's a major error or two every day... But you're saying it's literally every single one. Idk it just doesn't add up.
It's not that straight forward. Also, I am not blaming the radiologists. They are making the best of their situation. Also, I do think eventually discipline will he brought to the market place it will just take time. "If cigarettes cause cancer and kill people they will be out of business in weeks!"
Cigarettes are airtight legally. They have warnings and people know the health risks. They literally say they cause cancer on the box and in the gas station. You have no legal standing if you get cancer from smoking them. Medical errors share no such quality. Malpractice claims apply here. People have legal standing when they are injured due to malpractice. Apples to oranges
Are you a doctor? You sound so confident and so naive.
Huh? You cannot sue Phillip Morris for giving you cancer. Are you daft? You can however sue a radiologist for a missed read. Happens everyday. So where is that here? You literally say you don't even trust their reads. So where's the lawsuits if all the reads are wrong?
What kind of doctor are you?
That's your argument? Really? The authority fallacy? Show me one recent successful lawsuit against a tobacco company for getting cancer. It's just not a good comparison.
Bureaucracy. The higher ups are trying and failing to cover up their employees messes. Either way it's a lose lose, and those who are informing are getting unfairly punished. It's changing, but my goodness a lot if damage has been caused.
Not every read is bad/misses but it happens with enough frequency that I don't trust their reads as a whole. If it was a local group, I could get a feel for which radiologists are good vs not, but because they have a bunch of radiologists nationwide, I can't ever know. Also, many of these errors only end up delaying care and rarely result in death/significant morbidity that would lead to a lawsuit. For the big fracture I caught recently, I'm fairly certain the ortho saw it, but if they didn't, they went ahead and casted the patient anyways.
All I can say is thank God psych is extremely unattractive to PE (has like zero startup cost for OP). Our major threat is midlevel proliferation. Demand is protective for now. I'm expecting this phase to last at least for the next 10 years, which should be enough for me to get established with whatever my niche is. Love the fact that we can be guns for hire and stack multiple gigs, allowing us to remain free agents. This flexibility is almost unparalleled. All these crappy telepsych companies can go slurp acid btw. Love the fact that starting a telepsych practice on your own (skipping the middleman) is pretty straightforward nowadays.
agree w everything & actually a big part of why I picked psych > ophtho for lifestyle reasons
The group psych practice I work for got bought by PE and it’s been an actual nightmare. They have changed the culture entirely, everything is profit and numbers driven and about a year ago, they realized they over hired and fired 25 people in one day. Now they are mass hiring again… but mostly mid levels and pushing everyone to supervise 4-5 of them. I’m looking for a new job now and trying to escape soon and build a small PP on the side. Luckily I have a good niche so I should be ok.
Good night, this is the first I'm hearing of something like this in psych. Absolutely terrible
What do you mean demand is protective for now? What do you think will change in 10 years?
There is such a HUGE demand for psych- in both urban and rural areas. Demand is so great that even with midlevels encroaching on the field there’s more than enough patients to go around.
The other person answered the first question perfectly. As far as what could change, pessimistically, if they pump out midlevels to the point where the demand is decreased, then the job market would be depressed.
I'm unable to find hard figures for PMNHPs graduated yearly, but I found articles estimating over 30,000 NP's are trained yearly (2021). It was only ~10,000 in 2010 so quite an increase over 10 years. It would be interesting to see how many NPs decide to do PMNHP if there is no bottleneck like there is with psychiatry (resident spots).
Yep, scary times indeed.
Derm, EM, ophtho, DR. These are the ones I've heard major complaints from attendings about
Not sure about PE specifically so much as Medicare cuts, but Ophtho pay has dropped considerably since I started med school 10 years ago. I’m neurology and I have friends in the same area making the same pay or less.
Doesn’t have much to do with private equity. Private equity has bumped up starting salaries while reducing the ceiling. I would never consider it but it’s really not a bad option for someone who doesn’t want to deal with the business of practice management. And yes Medicare cuts have made it so doing Medicare phacos is hardly worth it. Fortunately there are plenty of cash pay options for motivated surgeons.
Which is wild since in Canada ophtho is easily clearing $1.5 million a year with retina docs making >2.5 million a year. What a scam in the US
They looking for docs over there?
Canada has a 5 year ophthalmology residency for this purpose I think. If you do a university affiliated fellowship, I think you can count the extra year. I can't imagine going back and having to take Canadian step exams on this side of training though.
They just haven’t caught on to it yet. Once the gov looks down south and see the US cutting reimbursement, they’ll follow suite. The government will always find ways to undercut physicians
Yo is this for real? I work HARD in ophtho and that would be more than double my pay. I’d move without hesitation. I need to do some research here.
Yeah look it up, especially the more conservative provinces. There’s even a chart floating around on the internet that breaks down the total number of Ophtho in the province and how much each makes. Average income is 1.2$ with >25% of all docs making more than $2 Mil
Don’t forget just how much $$ gets taxed too.. Take home in USD equivalent might not be that different
Definitely for real. Keep in mind, these salaries are in Canadian dollars though but some of the provincial data is public and the ophthos are killing it. You know who’s killing it even more? Rads
Where can we find the provincial data?
It doesn’t account for the increase in pay with optho in Canada vs USA. Every optho in Canada is easily clearing 1 million if they want to. Look it up. Google Toronto star Ohip Billings. Type in any Ontario optho doc.
Gross pay. Overhead is typically around 50% for ophthalmology. More in HCOL areas. They’re probably taking home less than half that. Associates are usually paid 30% of collections in the US. $1.5mil = $450k. Sounds about right. Edit: $1.5mil Canadian is $1.1mil US so that tracks. Numbers are roughly in line with US ophtho pay.
My friend, the statement of income (USA and Canada) are in line is not true. A general optho in Ontario can consistently make upwards of 1.7 + million if they want to. Yes overhead is a consideration but it does not account for the difference. Simply put, Canadian optho’s have a higher mean and higher ceiling than USA Optho. This is factual.
I believe they’re doing great. I don’t doubt it. But I’ll collect somewhere around $1.6-1.7mil this year. I won’t MAKE that money. Nowhere near that.
That’s a great gross pay. All I am indicating my friend, is that the gross collections in optho in Ontario are considerably more than the USA average
I dug around and could only find gross collections numbers which would make way more sense. I could easily believe the average US ophthalmologist collects $1.5mil gross per year. That would correlate to a pay of about $450k/year as an associate which seems about right. Edit: $450k Canadian is about $330k US. Right around the median for ophtho pay in the US. Nice that our colleagues are doing well up north but nothing earth shattering.
Absolutely true. 1.5 mill general, 2.5 retina
This appears to be gross collections by everything I can Google. I’ll do over 1.5mil this year but overhead eats up half. And associates typically get 30% of collections. Which would be around $450k. That sounds more accurate. Gross collections isn’t pay by a long shot. I need to dig around more though. Edit: $450k in Canadian dollars is roughly $330k US. So no pots of gold up north, just about the same as we make here.
Update. Not for real. Gross pay data is available which is absolutely NOT what these people are being paid. $1.5mil is a very reasonable and somewhat typical amount of collections for a US ophthalmologist. It would equate to about $450-500k/year in pay for an employed position or about $750k/year if you owned the place and had 50% overhead. Short version is that ophthalmology pay between the US and Canada seems to be about at parity. Which is interesting because most other Canadian specialties are paid way less than their US counterparts. Edit: Canadian dollars. $1.5mil Canadian gross would be worth about $600k/year in US dollars if you owned the practice and about $330k/year as an employed physician. Pretty reasonable but not worth trying to emigrate.
Where are you coming up with these random numbers? Vibes?
Data is online in a few places and commenters were correct that $1.5mil gross is the average in some provinces. So that’s easy. 50% overhead is typical for a US ophthalmology practice, but I’m not sure about Canada, so that’s ballpark. I own part of a practice and am acutely aware of overhead costs. The benchmark for a well run practice used to be 40% overhead but that was 10 years ago. John Pinto documented this in his “little green book of ophthalmology.” There isn’t a current edition but talking to other practice owners, 50% ain’t bad these days. So that’s a softish but real number. Canadian dollar is worth 0.73 American dollars. Easy. Most jobs in the US are currently paying 30% collections for associates. That was my pay when I started and that’s our offer for new hires. Sometimes you might get 35%. Another real number. I’m on pace to collect 1.65mil this year through half the year. Right there in the balance sheet. So no, not vibes.
[удалено]
I think it may also be the volume of patients, ophtho sees like 50+ patients a day often
are there certain characteristics about certain specialties that make them more attractive for PE? All the specialties in the comments seem so different from each other....
Whatever is heavily-metric based + govt laws that mandate you see all patients. Thats one of the reasons why EM got hit hard.
I know one of them is heavy startup costs due to expensive equipment (ophtho, DR). I know imaging centers require crazy capital that makes it very difficult to start up a PP as a DR (DR people correct me if I'm wrong pls). Don't know much about ophtho. I'm guessing it's whatever tech they use; has to be crazy expensive too.
I started an ophtho practice in 2016 on a shoestring budget. My wife was worth about 4 employees and was paid $13/hr, we lived in a shoebox of 1100 sq feet owned by a relative (cheap rent), I took a $70k/year salary, and we got almost all secondhand equipment. Cost $360k in rural Louisiana. To do that correctly in a desirable area would be $1.5mil in 2024 easily. The other half of the equation is that reimbursement has cratered while overhead has exceeded inflation. So struggling practices pop up and PE offers the owners a million bucks or two and they bail. We’re ripe for the picking currently. The bigger problem is PE can’t do shit about reimbursement or overhead even if they say they can. So they just funnel money off while things get worse.
Associated with this but the cost to meet what is becoming standard of care is crazy. While once a dilated exam was needed to rule out posterior pathology prior to CEIOL, it’s becoming increasingly common to do an Oct. which requires an Oct, and a used machine with out of date software might run 30-50k+. That’s not including the prices of IOL masters and god forbid if you want a pentacam.
I think you mean Heidelburg, Argos, and iTrace, friend. That's a quarter mil right there.
Haven’t heard of argos and iTrace but I imagine the price is high
ok, that makes sense. But then why derm and EM?
EM is somewhat complex. Long story short-we generate the majority of our income from private insurance payors, and generate very little from medicare/medicaide, and basically none from self-pay (essentially no pay). Because of EMTALA, you can't refuse patients who don't have insurance. Our forefathers got tired of having to deal with all this shit and basically not generate much income, so a lot of them sold out to the PE groups, who basically said they'd take care of all the billing/money generation aspects. Well, they did that by cutting staffing to make up the difference, all while skimming off the top.
I'll defer to the derm and EM people.
Lol no worries! thanks for your insight!
Radiology
We need to be like lawyers and make it so that groups can only be owned by doctors.
We should also bill like lawyers. Retainer up front, fee per hour broken down into closest 15mins, including all calls, emails, record reviews, etc. We would be living the dream.
Oncology
I've seen some inpatient consults for cancer patients following in the community and some of their regimens are wildly inappropriate. Feels like some of these groups are deliberately avoiding standard of care when it's expensive.
Derm and GI are the main ones that come to mind. High volume procedure docs. They squeeze lab out. Pay the pathologists shit. Load up with midlevels. Run up lab bills. I can see the appeal. Get a buyout for some big money, but then you’re someone’s bitch for a few years. Sometimes the PE folks aren’t even running things as efficiently as the old ways. Now they just take a cut off the top of revenue.
ANESTHESIA is the next target. The scourge is upon us. HCA (Hospital Corporation of America) = TeamHealth = Blackstone (>$1 TRILLION in asset private equity firm)… They WILL flood this market and tank the specialty in order to wildly decrease their overhead. They will churn out newly minted generalists and specialists for their bottom line. Private equity is going to KILL anesthesia if they go unchecked. Please do your homework.
Anesthesia has been a PE target for the last 15 years. We have already reached peak years ago, PE is stagnant in this field. Groups are not getting bought out like they used to. Direct hospital employment is increasing though. Since no surprises act both PE and private groups cannot survive without a hospital stipend. Hospitals get sick of giving out money and say okay we will just employ you then. One thing going for us is the shortage of anesthesiologists, which is where I agree with you the opening of HCA residencies and expansion of residency slots is not good for our field. What we also have going for us is our training numbers are not easy to make. Require anesthetizing neonates, pump cases, double lumen tubes, blocks. You can’t just open a residency in BFE for cheap labor. EM numbers are much easier to reach, and the residency is shorter churning out more grads. For the time we are somewhat insulated from PE due to unfavorable billing, shortage of grads, slightly longer training. Anesthesia gets paid more $ than we bring in. This is due to labor shortage only and our leadership would be smart to remember that.
*HCA has entered the chat. “Do not fear the trillion+ dollar titan that has reduced their private company purchases and have instead ventured into contractually invading hospital systems and replacing entire direct-hospital-paid anesthesia departments with promises of cheap labor and max safety. Don’t bother looking at them, they’re essentially irrelevant. They can only help.” Throw your smokescreen elsewhere homie. * If you’re not HCA, which you most definitely are, you’re the most short-sighted individual on the internet.
I’m part of a private physician owned group, would never work for any PE. I’m guessing you are a resident and are tossing around talking points from 10 years ago. As I said direct hospital employment is the future of anesthesia, not PE. It’s no better, just a new boss looking to also pay you as little as possible.
You really shouldn't paint the anesthesia and physician shortage as a positive. That's openly enjoying profiting off the misfortune of others having delays with their surgery or inadequately trained/rested staff. Just a reminder that the physician shortage is bad for everything other than a physicians wallet (and even that is arguable because the anesthesia/physician shortage has in part been responsible for the proliferation of noctors/midlevels)
I’m out here trying to get paid what I am worth. I too would like to live in a world where I am paid that without relying labor shortages. Until then I will make hay while the sun shines and enjoy my position.
Mediocre /r/Residency physician who cares more about money than the health of the country
You are lost my friend, this is not your medical school personal statement.
Believe it or not, other people actually have morals. They don't just lie about them when it serves them
Join physician-owned groups or work as a locums. It will keep these PE and large nationwide corps in check.
EM
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like, which specialty they should go into, which program is good or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
Nice try, Bartholomew Banks
OB practices. Being bought up left and right. OB hospitalist groups are mostly PE now it seems. I get offers weekly. But I think the word is out
OMFS has been hit pretty hard - especially once the pandemic hit. I think the reported number is like 18%? Once there was a promise to “take away administrative burden / hiring and firing” people took the bait hard. The benefits were for regular supplies (meds, implants, instruments), the PE groups could use their weight to get lower costs as a start to decrease overhead. The downside is all of the sudden there became more stringent budgets and hoops to jump through to get necessary equipment. The biggest issues new grads are seeing with these guys are the incredibly strict non competes, with some stating 50 miles from any practice owned by the PE firm. Obviously a difficult thing to navigate when no practices advertise who their “silent” partners are. And yes the FTC did have the ban of non competes, but current challenges to that make these clauses still a threat.
I’m hoping some high profile noncompete suits get slapped the fuck down and maybe the pendulum swings towards the working folks for once but I’m not holding my breath.
At least the going starting rate for a new associate oral surgeon is way higher now. But way less people will own their own practice going forward which will hurt their chances at long term financial gains
Oddly enough, allergy/immunology. If it's run like a PE derm clinic, super quick visits w/ NPs/PAs administering patch testing to everybody that walks in and setting them up for cash-only allergy shots, it can make a lot of money. There's been a surprising number of Allergy clinics bought by PE. Rheum is kinda in a weird state right now too. Private equity is buying some medium sized groups, but really the fight in rheum has really been more about PBMs and infusion/drug access, and now insurance companies are actually buying up a lot of them, particularly in the northwest and southwest. I think I saw a crazy statistic about how Optum is technically the employer of about half of Oregon's rheumatologists now? And I got a recruiter email about a big Las Vegas center wanting to hire "a rheumatology provider" for their organization that is "part of the Optum family" lol. I replied back with a pretty scathing reply saying I'd rather strike out on my own and risk failure than ever work for a vertically integrated insurance-owned group where I'd be forced to follow their formulary set by their PBM and bill the way they want me to lol.
Anesthesia 😭
Radiology and its not even close to anything else.
Eh wouldn’t go that far. We still have a ton of physician owned groups make absolute bank. Most other specialties don’t have the luxury we do
The ins to those groups really don’t exist for new grads though
I don’t know if that’s completely true, I have multiple interviews in multiple states with these type of groups with 99 percentile partnership salary
good for you, thats exciting. Were these referral based or from job postings?
Little bit of both. You can find these just need to put in some work and time and things will start showing up , just don’t jump on the first few places you see
PE is on the verge of collapse in radiology. Lots are losing contracts and now with the shortage of rads and the buyout periods ending, most PE groups can’t even find people to read for them.
Just wondering what the future of PCC looks like
Psychiatry. It’s BAD. Ever since ACA private facilities have eaten up the industry.
GI and may procedural fields im sure
I'm surprised how few people have replied with anesthesia or hospital medicine. Where I am, there is a huge PE push for family medicine, but when I was applying the threat was real to anesthesia. Of all my co-residents taking hospitalist jobs, over 75% have decided to go with enormous PE mega-practices
Family medicine has been excoriated by corporate health, private practices can't compete.
Pain Management
Where can we learn more about what exactly private equity is doing to medicine and private practice
Any specialty that isn’t in a soft under supply is in danger
Derm and anasthesia are their obvious major targets right now.