Subscribe to The Podcast by KevinMD. Catch up on old episodes!

Join Brian Hudes, a gastroenterologist. We’ll delve into the evolving landscape of gastroenterology in the United States, exploring historical decisions, changing demographics, and the impact on physician salaries. Discover the challenges and potential solutions in this vital medical specialty as we navigate the complex interplay of factors shaping its future.

Brian Hudes is a gastroenterologist.

He discusses the KevinMD article, “The shifting landscape of gastroenterology manpower and compensation.”

Careers by KevinMD is your gateway to health care success. We connect you with real-time, exclusive resources like job boards, news updates, and salary insights, all tailored for health care professionals. With expertise in uniting top talent and leading employers across the nation’s largest health care hiring network, we’re your partner in shaping health care’s future. Fulfill your health care journey at KevinMD.com/careers.

VISIT SPONSOR → https://kevinmd.com/careers

Discovering disability insurance? Pattern understands your concerns. Over 20,000 doctors trust us for straightforward, affordable coverage. We handle everything from quotes to paperwork. Say goodbye to insurance stress – visit Pattern today at KevinMD.com/pattern.

VISIT SPONSOR → https://kevinmd.com/pattern

SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://earnc.me/Lf6WwD

Powered by CMEfy.

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Brian Hudes. He’s a gastroenterologist. His KevinMD article is titled “The shifting landscape of gastroenterology manpower and compensation.” Brian, welcome to the show.

Brian Hudes: Thank you, Kevin. Pleasure to be here.

Kevin Pho: So we’ll get into your article in a little bit. First off, briefly share your story and journey.

Brian Hudes: Well, I went through my internal medicine training and then had interests in GI and liver disease, and I did that training at the Medical College of Virginia. I had a couple of moves in my practice, settled down in the Atlanta area and practiced up until about 2015, when, with the changes from Obamacare, I wound up selling my practice to one of the large groups in town and retiring briefly. Now I’m mostly doing GI shift work, or part-time work. I work about one to two weeks per month doing GI hospital work.

My perspective is that when I first sold my practice, in 2016, there was a demand for GI hospital work, or GI locums, but the pay was not very competitive. What I’ve seen since then, in the last several years, is that the pay scale has basically doubled, and it really made sense. That’s what led me to write the article: what I’ve seen and what I’ve heard talking to other gastroenterologists I know.

Kevin Pho: OK, so let’s talk about your article, titled “The shifting landscape of gastroenterology manpower and compensation.” What made you write this article?

Brian Hudes: Well, what made me write it was the rising demand for GI coverage at hospitals and outpatient centers, but the biggest push has really been for the GI hospitalist. Of course, the hospitalist role has grown dramatically in the last 20 years, to the point where internists for the most part don’t really work in the hospital anymore, and we’re starting to see gastroenterologists and other specialists do the same thing. Because we are in such demand in larger hospitals, we have to be there to do the consults and the procedures. It’s just not efficient to try to run an office practice and go to the hospital to do all those patients. Going back and forth between the hospital and the office, you just lose a lot of time. So a lot of practices are now hiring GI hospitalists just to cover the hospital, and what I’ve seen is that the demand is great.

It really starts to make sense when you realize that back in the ’90s, when I did my training, we had about a thousand doctors a year becoming board-certified, and last year we had about 600. The thing about gastroenterology is that, as a specialty, it only started with the invention of the first colonoscope, back in the early ’70s. The first GI training programs got going in the early ’80s. I came out of my training in 1995, and if I went to a GI meeting in the early ’90s, there was nobody over the age of 45, because no gastroenterologist had ever retired; there were no old gastroenterologists. There were a few guys in academics, but they didn’t scope, and the big push was scoping.

Then, of course, the federal government came out and said that everybody in the country has to have access to colon cancer screening, and your insurance has to pay for it 100 percent, so that increased demand. Then the baby boom hit, which increased demand further. But right around the time all that was happening, Obamacare came out, and it became more and more difficult to have a private practice. Back in the early 2000s, Medicare said, “We need to shift these procedures out of the hospital into private endoscopy centers, so we’re going to raise the facility fees.” So a lot of gastroenterologists like myself opened up endoscopy centers, and we saved Medicare billions, with a B, billions of dollars, because we got paid less than the hospital to do the same procedure as a facility. But it also gave us additional income, and that’s really how we were making money: by owning the facilities and owning an anesthesia service. Because actually, Kevin, the reimbursement for a colonoscopy in 1992 was $540, and today it’s about $160, so when you factor in inflation, it’s a 90 to 95 percent fee cut.

So when I was looking at this back in 2015, I talked to my accountant and asked, “Do you think my practice is worth more today or tomorrow?” And with the way fees were getting cut by Medicare, I said, “My practice isn’t going to be worth more in five years.” So I sold and I retired. But it wasn’t just me who did that; it was a flurry. If you talk to any of the practice consultants, they were doing all these deals, big groups acquiring small groups, and then came the entrance of private equity into the GI market, which is now flourishing and growing more and more.

What happened is that you had a lot of doctors who had done well during the ’80s, ’90s and early 2000s, and now, all of a sudden, there was a big lump-sum payment, seven figures, and we all just walked away or were able to cut back and work less, all at a time when fewer gastroenterologists were coming out. Plus, demographically, we now have gastroenterologists who are 65, 70 years old and in their 70s. Those guys are going to naturally retire, or they have to leave because of health problems, or they don’t want to work as much. So now we have over a thousand doctors a year leaving the specialty but only 600 new ones a year coming out. And if you look at the demographics, in 1995 we were a population of 270 million, and now it’s more like 330 million in the country, and it’s aging, so the demand for services has skyrocketed.

So from 2016 to today, I’ve seen the locum tenens rate, the daily rate for coverage, double. It used to be that if I asked for a rate, they would say, “Well, no, we can’t really do that.” Now they’re coming in and offering more than I ever thought I would get paid. I just got a call today offering about $4,500 a day for me to go work in a state out west, which is more than I made owning a practice with an endoscopy center.

Kevin Pho: Now, how are hospitals and medical institutions responding to these changing gastroenterology market dynamics?

Brian Hudes: Well, it’s interesting, because Medicare fee schedules have not doubled for GI services. But what the hospitals have realized, I think, is that if I’m not there, they don’t get the facility fee, they don’t get the anesthesia fee, they don’t get the radiology fees from all the tests I would order, and they don’t get pathology and lab fees. So they’re really having to dip into other sources of ancillary income to pay us.

Now, is it reasonable and realistic that this trend will continue? No, because at some point the hospitals are going to have to say, “Well, we can’t pay that,” and they’re going to have to cut GI as a service they provide and ship the patients out. But right now, they don’t want to lose those patients.

Kevin Pho: And from a patient standpoint, I know you talked about the shortage of gastroenterologists because of these market dynamics, but give us some practical scenarios of how that specifically affects patients. Is it just long wait times for colonoscopies, or anything more than that?

Brian Hudes: Oh yeah, there are very long wait times. I worked up in Marietta for a couple of weeks, and the endoscopy staff told me that they had 8,000 patients waiting for screening colonoscopies, because they didn’t have enough manpower even to take care of the sick patients.

In terms of what people are experiencing, if you call any of the large groups in a significant metropolitan area, it could be several months to get in, and for routine screenings it can be a long wait. It’s like everything else in medicine: The gastroenterologists are spending more time scoping and less time in the office, and so now when you go in, you have to see a physician assistant or a nurse practitioner. That’s fine if they’re going to see you to say, “Well, we’re going to set you up for colon cancer screening,” or if it’s something routine. But the reality is that, like everything else in medicine, when you get the complex liver patient, or the complex chronic colitis patient, or the patient with abdominal pain where nobody can figure out what’s going on, at some point you need the experience of a gastroenterologist with the training we have. And now the pharmacology, especially for inflammatory bowel disease, has gotten so advanced and complicated that it’s hard even for us doctors to stay up to date.

Kevin Pho: You mentioned earlier the impact of private equity, and it’s affecting so many other parts of medicine, emergency departments and anesthesia. But as it relates to gastroenterology specifically, tell us the impact private equity has had on these practices.

Brian Hudes: Well, private equity firms think they can buy a practice because they say, “Oh, look at the profit margin.” Well, that profit margin is not really profit margin; of course, it was the doctors’ income. So they think they’re going to come in and make the practice more lucrative, but they really can’t negotiate with the insurance companies. We proved that the last time this was done, back in the ’90s, when some companies got involved, and they all went belly up because they couldn’t make practices more efficient. The reality is that they’re trying to pay doctors less, and they’re trying to control the patient flow. They want you to see more patients in less time, which of course lowers patient satisfaction.

The other thing is marketing. When I did marketing for my practice, I was Advanced Gastrology Associates, but I would go around and introduce myself, and I had a one-on-one relationship with my referring doctors. That was the key to my success. Well, now these private equity companies don’t want you to market, because they don’t want referring doctors sending to Dr. Hudes; they want them sending to the practice. They want to treat doctors like replaceable cogs in a machine. But the reality is that patients have a one-on-one personal relationship and interaction with their physician, and not every patient works with every doctor. I can probably work great with 80 or 90 percent of patients, but there are 10 to 20 percent of patients I don’t click with, and for them it’s not going to be a therapeutic environment. The private equity company sees us all as interchangeable: “Well, you’re a gastroenterologist; you can see those patients.” It’s like, “Well, no, I don’t really do that. I mostly do this kind of work,” or “I don’t work well with this type of patient; I work better with that kind of patient.” And they don’t care. They want you to just see everything and everyone, no matter what.

Kevin Pho: So let’s say you’re a practicing gastroenterologist now, confronted with the market dynamics you described earlier. Tell us some of the choices that face gastroenterologists today and what kind of advice you would give them.

Brian Hudes: Well, to today’s gastroenterologists, I think that as individuals you have to remain flexible and independent. You have to be very careful about the contracts you’re signing. Everyone’s talked about restrictive covenants. In this market, with the shortage, you should not be signing a restrictive covenant; that’s just ridiculous. That’s number one. Number two, you have to be thinking to yourself: If you’re working for somebody else, at the end of the day you have your 401(k) and your savings, and that’s it. You’ve built no equity.

What made me able to walk away when I was 52 was that I owned the building I was in, and when I sold my practice, I signed a lease on my building, so they’re leasing it. Then I was able to play real estate: take the equity from my building and buy another building, and then another building, and then start to venture out, because I had passive income coming in. Now I work not because I have to; I work because it’s what I want to be doing. Part of it is that I feel responsible. I have all these years of experience doing what I do, literally 40,000 or 50,000 procedures under my belt, and an expertise and an ability to treat people, so I don’t want to walk away 100 percent from contributing back what I’ve learned. But at the same time, I can now do it on my terms. I work when I want to work, and what does that mean? I’m a happier doctor. I have the time to actually have work-life balance.

A lot of young doctors want work-life balance, and my response to them is that the work-life balance you chose is to be a doctor. You have to be committed early in your career to absorbing as much experience and knowledge as you can, interacting with the senior doctors in your area and having the time to actually see patients and work with them in a linear fashion, over time, to see how they respond. The insurance companies and private equity want us to work based on a formula. They say, “Well, according to this study.” It’s like, “Well, that study worked in 82 percent of patients. What about the other 18 percent?” These organizations forget that people are individuals, not populations, so studies don’t always apply to individuals. We have to sit and talk to that patient. Yes, this treatment might theoretically be the best for that patient, but will the patient be compliant with taking a medication three times a day? Or does somebody need to be on something once a day or once a week? Or they don’t have access to get an injection, or they don’t have access to this expensive, fancy new medicine, so we need to start with something less expensive. That’s where the art of medicine comes into being a physician.

Doctors have to be able to retain their independence, and so you have to recognize your value: “Hey, I am a gastroenterologist. It takes a long time to make one of me, and it takes a long time to get the experience to be good at what we’re doing, and I have to remain independent so I can treat people the way I believe, as a physician, I should be treating them.” Because I’m a doctor. I’m a physician. I am not a provider.

Kevin Pho: And my final question, Brian: Tell us some of the take-home messages that you want to leave with the KevinMD audience.

Brian Hudes: Be smart. Be independent. Be willing to move for a better opportunity. Do not put up with a nonphysician telling you how to practice.

Kevin Pho: Brian, thanks again for coming on the show and sharing your perspective, time, and insight.

Brian Hudes: Thank you, Kevin. I appreciate it.