How Much Are YOU Actually Worth?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
To that point, who awards bonuses to the admins? I have a feeling they give bonuses to themselves, but I hope I'm wrong and just too cynical.

Quick and dirty answer; the district/regional admins above them.

Members don't see this ad.
 
Quick and dirty answer; the district/regional admins above them.
It's basically a pyramid scheme; they're just really good at getting us to look the other way

(I kid, but seriously...)
 
Finally found this thread again - I keep thinking it's been 45 days. The first month or few of CMG-time will be lousy, so hopefully any docs who sign will stay as locums to avoid the hassle (and risk).
 
  • Like
Reactions: 1 users
Members don't see this ad :)
A friend of mine's SDG just lost their contract to Apollo. They're all threatening to jump ship. It's pretty comical.
 
A friend of mine's SDG just lost their contract to Apollo. They're all threatening to jump ship. It's pretty comical.
if this is the same group that I've been reading on emdocs, there's a huge conversation on it. jumping ship is always "the word" whenever a take over happens. it happened to that summa debacle so who knows
 
Out of curiosity why'd you quit? I also noticed the EMdocs discussion about the contract to Apollo which is usually followed by the damning of all ER docs working for CMGs.
 
Yeah basically it's a Facebook group just for Em physicians called EMDocs. I'd be careful about using your real name on the group though because apparently people have been burned on there. Complete BS but it's a million times better than the usual drivel I see on Facebook
 
  • Like
Reactions: 1 user
Transition...

So after several weeks of waiting, and several unanswered questions, the transition to the new group has been very interesting on both sides. EMGA was able to band together and drag out the CMG deadline by about 4 weeks, waiting for things to be reviewed and signed. CMG initially offered to pay 225/hr as a flat rate for the first 6 months while they "collected data" with plans to apply an "RVU inventive plan" down the road. There was no explanation of what the RVU incentive plan was going to be, how it was structured, or what that would ultimately mean for the group. In addition, CMG's initial offer was to come in as an employment model, with full benefits, and offer a "generous" benefit package in the form of malpractice, life, disability, and health insurance, 401(k) with match, and CME reimbursement. EMGA, to say the least, was not impressed by this offer, and felt it put them far below market rate - especially since they had been thriving as business partners for the past several years with a higher overall rate and limited payroll taxes to be paid. After several phone calls from the recruiter and several consistent "no" responses, CMG was willing to maintain an independent contractor status for the contract, and also increased the rate to $235/hr as a fixed rate for the first 6 months. The RVU incentive plan was a nebulous plan that was not concrete and not guaranteed. They wanted an example of how the plan would be structured, and all that CMG could provide was that "it would be some combination of a fixed minimum and an RVU component." They stated that they would be collecting practice data to determine the amount.

This is good time to pause and discuss exactly what is happening here.

1) Whenever a CMG states they "need time to collect data" what they are really saying is "We already have the data that we needed to calculate our operating and startup expenses and we intend to spend the next 6 months recuperating these expenses while you work for a reduced rate for us." EMGA was a successful practice prior to being taken over, and any data that the company needs can easily be gained from their records. The will use words such as "we will get your documentation up to speed" and "give you time to adapt to our way of doing things" while really meaning "Our worst case for the first 6 months is that we will use your current documentation to give to our advanced billing department with better insurer rates and skilled coders to earn more than you did as a group, and once you improve your documentation, we will begin to earn even more." The way they expect you to improve your documentation is to send you reminders that you missed documentation (critical care, etc) and expect you to modify your charting to meet their needs. They will also contract that you have a duty to adhere to your corporate documentation compliance requirements and make you feel that if you don't modify your documentation the way they want it you won't get paid and could lose your job. The way this can be done can border on medicare fraud, and they will send you polite emails from time to time using vague terminology and tips for how to document things such as critical care to increase your RVU generation per hour. In short, your RVU productivity will increase, their profits will rise, and they will earn even more.

2) Benefits are a way for the CMG to control their costs. "Benefits" are very inexpensive at group rates, and the more employees they can get to sign up, the lower their overall group costs will be. A typical physician benefits package costs CMG around $22/hr, and they will advertise that package as a huge bonus to the base rate of $225, making their effective package appear to be in excess of $243/hr. In reality, Malpractice insurance is the most expensive cost to CMG, and they will pay this regardless of hire status (employee or IC) so it should NEVER be counted as a benefit. Malpractice is an industry standard requirement and customarily paid by the group. The remainder of their benefits combined are more expensive than what an independent contractor can negotiate on the private market and, in the case of EMGA, completely unnecessary because the providers have already figured out what they need. Benefits are, however, useful to the midlevel providers, and often a reason for them to stay on board. For this reason, most groups employ midlevels due to their relative income:benefits ratio.

3) CMG's target a healthy operating budget for each contract. This can lead to operating margins of 30-60%. With any business, their most expensive fixed cost is labor which, in the case of physicians, is very high. From the start of this thread, EMGA had an initial income of $6,000,000, and a labor cost of $300,000 before partner bonus was distributed. Under a CMG, who bills higher amounts for the same service, has more favorable insurer rates, and a very aggressive billing team, they may collect $8,000,000 for the same volume. That was almost 15,000 patients ago, and the hospital now sees a higher percentage of trauma victims than they did. The only factor that can limit a CMG's profit margin more than volume is a major change in payer mix for a contract. This caused some of the financial changes for EMGA, but for CMG this means they are likely coming into the contract in a more stable and realistic time. Payer mix is just as it describes - the mix (usually percentage) of the payers that compose a market. The payer mix for this contract is as follows:

BlueCross 5.4%
Other Private Insurance 9.5%
Medicare 27%
Medicaid 25%
Other Government Ins 12%
Managed Care 15%
Self Pay 6.1%

The Self pay rate is the most important part of the contract for any CMG, because it essentially tells them the percentage of their profits that they are not likely to be paid for. The rest of this is gravy. In this case, the self pay rate for this contract is very low, which is a very lucrative situation for the contract holder. It is estimated by CMG that with a volume of 55k and their insurance contracts, they will earn $12M conservatively as a group. Their anticipated labor costs at $235/hr for the first 6 months will be a little over $3.8M which brings their post labor income to $8.2M annually (projected). This is before additional overhead costs (management fee that is typically taken immediately off the top, operating costs, director stipend, benefits, etc). CMG expects to comfortably profit $6M annually on this contract (50% margin). The basic Medicare rate of reimbursement is around $36 per RVU. Private insurance typically pays 300-400% of the government rate and, depending on diagnosis or RVU, even higher. Some self-pay patients will pay their bill, but most are charity care (read: write off) for the company.

4) Any RVU "Incentive" plan is a carrot dangled by CMG groups to psychologically trick you into working harder for the perception of earning more income. They are carefully calculated to insure that CMG does not increase their annual expense, and are usually modeled over the group practice average to be budget neutral or, in some cases, even more profitable for the company. Typically CMGs will target their average RVU rate to be equal to (or appear to be even higher than) the initial startup fixed rate they pay physicians. Once their models are implemented, the high performers will see a moderate increase in their rate, the average producers will stay the same, and the low producers will earn considerably less. This comes in the form of a surprise when the first paycheck a provider receives is $40/hr less than the contracted rate they were receiving for the first 6 months. Sadly, the first people effected by this are the night providers, who are often not given a differential, and have the lowest productivity. In these cases, the CMG will often dangle a night differential to the group as a solution, again, with the intention of making compensation budget neutral, which effectively wipes out any reasonable productivity bonus to be gained by a bonus program. Sneaky huh? Then, after a year or so, they will revise their model again (after they collect more "data") to reduce the overall amount paid to the group. They usually wait for more volume to come in to paychecks stay the same, but more patients are seen. It typically isn't until the group complains that either a raise is given or, more realistically, more coverage is added and RVU productivity is diluted by another provider, effectively costing the CMG less for full time coverage.

Anyway - back to the current group situation. EMGA knows what they were worth, but likely has no idea how much CMG is going to squeeze out of their hard work. They would actually be surprised to know how much more they are giving away. Think about this for a minute - EMGA's initial operating income was equivalent to the forecast profit after expenses by CMG. The negotiation is won when both sides feel they are getting a good deal. Economically, CMG will win the argument every day due to their economy of scale. The only leverage EMGA has in the process is the need to staff the department. CMG wants to transition smoothy, without any coverage gaps, to staff the ED they agreed to staff. The hospital CEO expects no different outcome and also does not want to be surprised or bothered by the vendor. EMGA knows the CEO better than CMG does, and were able to use him as leverage to negotiate a final rate of $250/hr fixed for the group, with the option of a RVU bonus model to be applied after 6 months. Both sides were happy, and the physician in EMGA took a bite out of the RVU carrot, and each signed their contracts for a $45/hr reduced pay rate as independent contractors.

What are your thoughts and questions about this process? Who won? Who lost? How does this make you feel about your current job situation?

More to come - the transition may not be easy...
 
  • Like
Reactions: 6 users
Out of curiosity why'd you quit? I also noticed the EMdocs discussion about the contract to Apollo which is usually followed by the damning of all ER docs working for CMGs.
Mostly because of willful ignorance and HIPAA violations.
 
CMG won big time, with that ridiculous profit margin. The docs in the transition stage should NOT be taking a pay cut. Just look at what they had to do with summa health right now...$1000/hr, with a 150 k bonus for 2 years.


Sent from my iPhone using Tapatalk
 
  • Like
Reactions: 1 user
Members don't see this ad :)
Had this happen to one Texas group I worked with. A smaller group was taken over by ESP who changed us from IC at a fixed rate to employee. They implemented an RVU system. Initially they were paying $36/RVU which isn't bad. Some docs were able to have productivity at 13 RVU/hour, which adds up to a very nice amount of money. The CMG seeing this, arbitrarily dropped the RVU to $32/hour, in order to limit the amount they were paying. ESP was subsequently absorbed by USACS, with yet a further drop in the RVU/hour.

The moral is, beware the "RVU incentive" system, and make sure the contract doesn't allow them to arbitrarily drop the amount they pay for RVU.
 
  • Like
Reactions: 1 users
EmCare capped the total dollar payout for RVUs at $275/hr at one point down here, before they just flat out removed the RVU system.
Their rationale? People were complaining that other docs were getting paid too much. I would love to see that discussion. "Hey, the guy who works twice as hard as me, shows up early, has a higher patient per hour and higher RVU per patient than me is getting paid more. I mean, we are doing the same job, right?"
 
  • Like
Reactions: 2 users
Niner, thanks so much for an another awesome, epic post.

This thread continues to be more and more eye opening, thanks to all the wise folks contributing to it.

I'm only 1 year out of residency but feel like I've gotten a crash course in the dynamics of the small group getting eaten up by a bigger group as this happened at one of my jobs. I've seen what it looks like to quickly go from having control of staffing, reimbursement model, etc to have zero control.

One thing I still cannot wrap my head around is how big groups/CMGs have been able to wedge us into the position of being total profit centers for them while we ALSO accept their liability for situations they've devised to maximize their profits (ie they reduce staffing to cut costs, require docs to sign midlevel charts for pts they never saw to snag that extra fee, etc).

And even more insulting are the groups who say you're a "shareholder" or "partner" from day one, yet you have zero control over decisions and don't get to see the books. It implies that we're stupid, because who the hell would "buy in" or "partner" with a group with such a setup? The cognitive dissonance is astounding and yet it seems to get quietly put in a corner.

If I'm going to be an employee then just eff'ing say that and don't expect me to be on hospital committees without paying me, get my name off the chart if I'm sued while working for you, and don't expect me to work an overnight without either complete shift equity or a significant differential.

I agree with what GeneralVeers mentioned, if you have an RVU system keep a close eye on how it's calculated and how your overlords can change it. Even better, just negotiate a flat hourly you are satisfied with. There's far fewer ways to have the wool pulled over your eyes if you have an hourly rate.
 
  • Like
Reactions: 1 users
Had this happen to one Texas group I worked with. A smaller group was taken over by ESP who changed us from IC at a fixed rate to employee. They implemented an RVU system. Initially they were paying $36/RVU which isn't bad. Some docs were able to have productivity at 13 RVU/hour, which adds up to a very nice amount of money. The CMG seeing this, arbitrarily dropped the RVU to $32/hour, in order to limit the amount they were paying. ESP was subsequently absorbed by USACS, with yet a further drop in the RVU/hour.

The moral is, beware the "RVU incentive" system, and make sure the contract doesn't allow them to arbitrarily drop the amount they pay for RVU.

ESP is worse than a CMG who tries to squeeze every penny out of their hard work. Beware.
 
  • Like
Reactions: 1 user
Do groups actually disclose the dollar per rvu amount? This was not mentioned in any of the contracts I was offered when I signed ...


Sent from my iPhone using Tapatalk
 
Once a hospital puts your contract to bid, the independent SDG is doomed. There is no going back. Even if the SDG wins, they will eventually lose.

CMGs are programmed to make more than a SDG can. Walmart makes more than a local store even if they sell the same items at the same price. Walmart has leverage on every possible end and eventually the local store will close as they can not compete on pricing/labor.

CMGs are no different.

Nothing OP has told me is new. But for all of the new docs, read it carefully. You are the ones making them profit. You leave residency and feel making 200/hr is great. Yes that is alot of money but you can make more.

This is the reason why I work for no less than 400/hr doing locums. I will never get a CMG to contract me at 400/hr but I know they can. They will only pay this rate when they can't find some new grad to work for 200/hr.
 
  • Like
Reactions: 2 users
Is there any leverage when it comes to signing midlevel charts? How would it go over if you just said, "No, I'm not signing a chart and accepting liability for patients I did not examine." Are you obligated by your contract?
 
Last edited:
  • Like
Reactions: 1 user
Is there any leverage when it comes to signing midlevel charts? How would it go over if you just said, "No, I'm not signing a chart and accepting liability for a patients I did not examine." Are you obligated by your contract?
Typically yes. The other is that typically you can get fired without notice by hospital for any reason. Assuming it wasn't specifically in the CMG contract, the CMG would get the hospital to demand you be fired raising the specter of liability for unsupervised midlevels which would be a violation of most hospital's by-laws. Depending on state you may only be obligated to co-sign a certain percentage of charts (IN was 10%) which could give you wiggle room since you're likely be staffing at least 10% anyway.
 
Do groups actually disclose the dollar per rvu amount? This was not mentioned in any of the contracts I was offered when I signed ...


Sent from my iPhone using Tapatalk

Depends on the group and how the pay is structured. If there is an RVU component, they should state the amount per RVU that you will be paid in your contract, and provide you with details about how many RVU's you are earning each month. The formula should be easy to calculate and completely reproducible with basic math - no calculus required.

Regardless of the amount you are contracted for per RVU, remember the medicare rate of reimbursement is around $36 per RVU. Private insurers are 300-400% of that number. If an emergency physician sees 2 patients per hour, with an average of 4.5 RVU per patient, they are generating 9 RVU per hour of revenue for the company, or $324 per hour on medicare rates. With private insurers in a good payer mix, that can be $1200 per hour. Interesting to know when you get your check for $240 per hour huh?

It would be great to have every new graduate entering the work force begin to routinely ask about payer mix at every job interview. That information alone would tell you how much your work earns for the employer. That sad thing is that they will likely never give that information out. You always hear about "open books" as a true test of integrity and how well a job is going to pay. All I need is the payer mix...
 
  • Like
Reactions: 3 users
Anyone have any RVU/incentive/bonus related experiences or other pay models they would like to share?
 
So the way it works at my group is all the rvus and rvu money is pooled together at the end of the month. The amount of rvu money one gets is commensurate with the percentage of his contribution to the total rvu pool. So if you generated 15% of the total rvus you get 15% of the rvu money


Sent from my iPhone using Tapatalk
 
So the way it works at my group is all the rvus and rvu money is pooled together at the end of the month. The amount of rvu money one gets is commensurate with the percentage of his contribution to the total rvu pool. So if you generated 15% of the total rvus you get 15% of the rvu money


Sent from my iPhone using Tapatalk

I imagine you do it that way to keep people from cherry-picking patients based on insurance?
 
  • Like
Reactions: 1 user
I imagine you do it that way to keep people from cherry-picking patients based on insurance?
RVUs generated has nothing to do with insurance. It's simply a way of measuring amount of work done.
 
RVUs generated has nothing to do with insurance. It's simply a way of measuring amount of work done.
Some insurances pay better per RVU than others. IE, Joe Partner might be seeing all of the United patients, leaving you with Medicaid.
 
  • Like
Reactions: 1 users
Some insurances pay better per RVU than others. IE, Joe Partner might be seeing all of the United patients, leaving you with Medicaid.
If you're doing eat what you kill that matters. Otherwise most places put collections in a pot then disperse based on RVUs. The differing pay for RVU by insurer is factored into either an average multiplier per RVU (common for some CMGs) or as a straight percentage of RVUs you made/RVUs per groups x collections.
 
  • Like
Reactions: 1 user
BUMP. This thread was so educational and hoping to learn more.

Are the EMGA doctors super unhappy? What are their options? Find another democratic group and start a partnership track? With those profit margins, why didn't they negotiate for more? Is this standard?

What happened to the Summa docs, i.e. where are they practicing today?

When CMG takes over another CMG, is it generally still profitable? Why do hospitals go with different CMGs?
 
  • Like
Reactions: 1 user
BUMP. This thread was so educational and hoping to learn more.

Are the EMGA doctors super unhappy? What are their options? Find another democratic group and start a partnership track? With those profit margins, why didn't they negotiate for more? Is this standard?

What happened to the Summa docs, i.e. where are they practicing today?

When CMG takes over another CMG, is it generally still profitable? Why do hospitals go with different CMGs?

Find out on the next episode of Dragon Ball Z!!!
 
  • Like
Reactions: 1 users
So are EM docs in desirable locations where CMGs & big hospital groups dominate screwed then?
 
Not necessarily. There are SDGs in those areas too. I know someone who is partner with a group in LA making close to $300/hr


Sent from my iPhone using Tapatalk
 
Not necessarily. There are SDGs in those areas too. I know someone who is partner with a group in LA making close to $300/hr


Sent from my iPhone using Tapatalk

But... how? From what I understand, both big hospital groups & CDGs can beat you with scale. How do they survive?


So what is the option there? Avoid the field in general or accept you're basically signing up to be a slightly-larger sized corporate cog for $150-$250 an hour?
 
So, It's August, and roughly halfway through the customary 90-day signup rate guarantee for those of you who chose to work with CMG's. How are your experiences so far? How is your pay? How is your pay compared to your peers? Give this thread some feedback about how your job is going. I'm going to check in again in September/October once the "real" paychecks start to roll in, and then ask the same questions. Learning what you have learned from the evolution of this thread, is your revenue what you expected?
 
  • Like
Reactions: 1 users
But... how? From what I understand, both big hospital groups & CDGs can beat you with scale. How do they survive?



So what is the option there? Avoid the field in general or accept you're basically signing up to be a slightly-larger sized corporate cog for $150-$250 an hour?
fly away...seriously many of my friends fly to tx for a few days a month and rake up the cash. another options is locums, even in town. the rates are typically higher but there's a reason for it. it's places that are not adequately staffed for various reasons. or you can start a side gig outside of EM like day spa, massage parlors, financial services, day trading....etc. otherwise you're stuck working for "da man"
 
So, It's August, and roughly halfway through the customary 90-day signup rate guarantee for those of you who chose to work with CMG's. How are your experiences so far? How is your pay? How is your pay compared to your peers? Give this thread some feedback about how your job is going. I'm going to check in again in September/October once the "real" paychecks start to roll in, and then ask the same questions. Learning what you have learned from the evolution of this thread, is your revenue what you expected?

So are there any advantages to CMGs other than they get you a job? Based on this thread I now think they're evil and hate me.

fly away...seriously many of my friends fly to tx for a few days a month and rake up the cash. another options is locums, even in town. the rates are typically higher but there's a reason for it. it's places that are not adequately staffed for various reasons. or you can start a side gig outside of EM like day spa, massage parlors, financial services, day trading....etc. otherwise you're stuck working for "da man"

Wow, so unless you're trying to work in the local dump of a hospital or take a week out of your life every month and head half way across the country its tough times to live in a beautiful place it seems...
 
So are EM docs in desirable locations where CMGs & big hospital groups dominate screwed then?
Great Questions - the answer is yes... and maybe not.

Big hospital chains typically side with "preferred vendors" or "Joint Venture Partners" which are contracted EM groups that are compensated in the form of a shared bonus plan based on hospital revenue. This is a relatively new thing because hospitals are being held more and more to the value-based purchasing and quality reimbursement structures from the government (google search these terms, and also "MIPS" and "MACRA"). The belief (founded or unfounded) is that by their size and economy of scale, large CMG's will be able to bundle their service lines into cost-effective business streams that reduce the individual length of stay for patients, and also streamline hospital efficiencies. This is seen with Envision (Emcare/Sheridan) and the Hospital Corporation of America (HCA) hospitals, who rely on multiple service lines for this purpose. Community Health Systems (CHS), the next largest hospital corporation, has a group of preferred vendors that participate in their competitive bidding process when contract changes are needed, again, often times to bundle service lines. There are pros and cons to these arrangements, but typically at the level of the individual provider, they can be more beneficial for a number of reasons:

1) Pay rate can be higher because not many people want to work for hospitals that have corporate barriers to provider care. For example, HCA has started to affix tracking devices to physicians to keep track of where they spend their time. No joke - If you take a 20 minute bathroom break, they will know, and ask about your productivity on that shift. If patients are not seen in 15 minutes, or there is a delay, pages are sent to the medical director, regional hospital director, and hospital CEO and a "meeting of the minds" (read: beating of the staff) takes place to identify and solve the problem. These places often need locums (for obvious reasons) and their rate of pay is higher than other locations.

2) When a single group dominates a majority of major service lines (Emergency Medicine and Hospitalist Medicine), they are harder to remove from the hospital because of the startup time needed to become operational, and turnover of medical staff. Once staffed, these are usually very stable contracts.

3) Clinical practice on the EM side can be much easier because hospitalists don't argue over or refuse admissions, and radiologists (if also part of a contract bundle) are very fast with reads. The support from clinical providers allows for high patient throughput and increased RVU potential.

The only major downsides for working for a large hospital corporation are the following:

1) Metrics and pressure from administration is magnified by the contract group management.
2) Large corporations are not likely to provide effective staffing volumes, leading to high levels of nursing turnover.
3) Capital expenses are limited because, unlike not for profit hospitals, there is no donor base. This results in run down departments, poor upkeep and maintenance, and limited availability of new equipment.

Interestingly, competition for market share between large corporate hospital groups and locally dominated hospital systems actually determines rate to some extent, and larger cities have more hospitals in competition, often with themselves. Most major cities have 3 or 4 locally run hospitals that are part of the larger state-wide hospital system, and may even compete with each other for revenue. Here's a neat link to the largest not-for-profit and for-profit systems in the country:

http://www.compassphs.com/blog/heal...s-top-30-largest-hospital-systems-in-america/

While it is "generally" true that saturated and popular markets may have a lower rate due to supply and demand (for the companies who write the checks) that does not mean that all hospitals in the same area are subject to the same rate. As larger hospitals gain market share but dilute themselves because they cannot staff emergency physicians who are board certified, you will begin to see rates go up (like they have exploded in the past 5 years). This is because they are competing with themselves for staff to sustain contractual agreements at the hospital system level.

Do the math - how is this sustainable? Reading through the prior posts in this thread, the answer should become clear that there is a ceiling that can be paid before corporations take a hit to their margins. While some places are willing to pay $300 to $600 per hour to staff locations, they cannot do so indefinitely. Further, they don't want to jeopardize the business relationships they have made with hospital corporations. This is why locums rates are temporary and migratory. Once they can stabilize a contract for a rate structure that supports their margin, the locums well dries up and appears somewhere else. The problem is, more and more physicians are refusing jobs paying $250/hr based on current income trends. This is great for us in the short term, but once market share shifts to the CMG's, new graduates enter the workforce (some being trained by the same hospital/CMG residency programs) they will again be able to dictate market rates, and their rates will be dramatically lower than what is being paid now.

Also remember - the goal of Government-focused reimbursement is to keep patients out of hospitals. The fee for service model is going away, and insurance companies are already beginning to penalize patients and hospitals for unnecessary emergency department visits (read Anthem and Georgia). This will result in a decrease in ED volumes, and with decreasing volumes will come the perceived need for decreased staff. The large CMGs are banking on this, and rates will drop across the board as departments become overstaffed and the shortage of EP's narrows. The only logical way that hospitals will truly be able to keep patients out of the inpatient wards will be to increase their outpatient facilities (SNF's, LTACs, CHF Clinics, etc). These will come at a cost to the hospital systems and - by way of their joint venture - to the CMG's contracted with them. Emcare, as an example, is going to lose revenue because they are tied to the overall operating success of HCA. This is likely part of the reason they have reorganized and rebranded as "Envision."

In the middle of all of this is the occasional local solo community hospital that relies on private donations to keep it's doors open and provide services. These are just as lucrative to CMG's, but also have more likelihood of being staffed by private democratic groups who also need to compete with local market forces. The death of the local democratic group comes when partners retire, realize they can't compete with local market rates being driven up by CMG's, can't recruit new providers, and eventually sell or lose their contracts to the CMG's who come in and offer a lower rate because the hospital is nice and shiny. Again, another contract to the side of the CMG, who will increase their economy of scale and have more market influence to dictate rate. Thats pretty much how this works.

Note, I did not include academic hospitals in this discussion, because pure academic hospitals are always going to have a lower rate due to their CMS funding structure. The only exceptions to this are academic programs that are hybrid university owned/CMG run. Also consider that larger cities may have a larger number of academic centers, which may mean a larger number of VA medical centers, which will always negatively impact physician salary surveys.

Again - back to my solicitation for feedback to the new grads: How is your first job going? How is your pay? Where do you think your salary is going to go after your 90 day income guarantee? What is your plan when you take a pay cut?
 
  • Like
Reactions: 2 users
Holy ****, there are doctors that agree to the tracking devices? Arguments about mobile phones aside, getting harassed about sitting on the toilet is a level of big brother that I would never accept. I didn't agree to go through medical school and residency so some douchebag 40 year old suit with zero medical knowledge can dictate how I spend my time.
 
  • Like
Reactions: 6 users
Great Questions - the answer is yes... and maybe not.

Big hospital chains typically side with "preferred vendors" or "Joint Venture Partners" which are contracted EM groups that are compensated in the form of a shared bonus plan based on hospital revenue. This is a relatively new thing because hospitals are being held more and more to the value-based purchasing and quality reimbursement structures from the government (google search these terms, and also "MIPS" and "MACRA"). The belief (founded or unfounded) is that by their size and economy of scale, large CMG's will be able to bundle their service lines into cost-effective business streams that reduce the individual length of stay for patients, and also streamline hospital efficiencies. This is seen with Envision (Emcare/Sheridan) and the Hospital Corporation of America (HCA) hospitals, who rely on multiple service lines for this purpose. Community Health Systems (CHS), the next largest hospital corporation, has a group of preferred vendors that participate in their competitive bidding process when contract changes are needed, again, often times to bundle service lines. There are pros and cons to these arrangements, but typically at the level of the individual provider, they can be more beneficial for a number of reasons:

1) Pay rate can be higher because not many people want to work for hospitals that have corporate barriers to provider care. For example, HCA has started to affix tracking devices to physicians to keep track of where they spend their time. No joke - If you take a 20 minute bathroom break, they will know, and ask about your productivity on that shift. If patients are not seen in 15 minutes, or there is a delay, pages are sent to the medical director, regional hospital director, and hospital CEO and a "meeting of the minds" (read: beating of the staff) takes place to identify and solve the problem. These places often need locums (for obvious reasons) and their rate of pay is higher than other locations.

2) When a single group dominates a majority of major service lines (Emergency Medicine and Hospitalist Medicine), they are harder to remove from the hospital because of the startup time needed to become operational, and turnover of medical staff. Once staffed, these are usually very stable contracts.

3) Clinical practice on the EM side can be much easier because hospitalists don't argue over or refuse admissions, and radiologists (if also part of a contract bundle) are very fast with reads. The support from clinical providers allows for high patient throughput and increased RVU potential.

The only major downsides for working for a large hospital corporation are the following:

1) Metrics and pressure from administration is magnified by the contract group management.
2) Large corporations are not likely to provide effective staffing volumes, leading to high levels of nursing turnover.
3) Capital expenses are limited because, unlike not for profit hospitals, there is no donor base. This results in run down departments, poor upkeep and maintenance, and limited availability of new equipment.

Interestingly, competition for market share between large corporate hospital groups and locally dominated hospital systems actually determines rate to some extent, and larger cities have more hospitals in competition, often with themselves. Most major cities have 3 or 4 locally run hospitals that are part of the larger state-wide hospital system, and may even compete with each other for revenue. Here's a neat link to the largest not-for-profit and for-profit systems in the country:

http://www.compassphs.com/blog/heal...s-top-30-largest-hospital-systems-in-america/

While it is "generally" true that saturated and popular markets may have a lower rate due to supply and demand (for the companies who write the checks) that does not mean that all hospitals in the same area are subject to the same rate. As larger hospitals gain market share but dilute themselves because they cannot staff emergency physicians who are board certified, you will begin to see rates go up (like they have exploded in the past 5 years). This is because they are competing with themselves for staff to sustain contractual agreements at the hospital system level.

Do the math - how is this sustainable? Reading through the prior posts in this thread, the answer should become clear that there is a ceiling that can be paid before corporations take a hit to their margins. While some places are willing to pay $300 to $600 per hour to staff locations, they cannot do so indefinitely. Further, they don't want to jeopardize the business relationships they have made with hospital corporations. This is why locums rates are temporary and migratory. Once they can stabilize a contract for a rate structure that supports their margin, the locums well dries up and appears somewhere else. The problem is, more and more physicians are refusing jobs paying $250/hr based on current income trends. This is great for us in the short term, but once market share shifts to the CMG's, new graduates enter the workforce (some being trained by the same hospital/CMG residency programs) they will again be able to dictate market rates, and their rates will be dramatically lower than what is being paid now.

Also remember - the goal of Government-focused reimbursement is to keep patients out of hospitals. The fee for service model is going away, and insurance companies are already beginning to penalize patients and hospitals for unnecessary emergency department visits (read Anthem and Georgia). This will result in a decrease in ED volumes, and with decreasing volumes will come the perceived need for decreased staff. The large CMGs are banking on this, and rates will drop across the board as departments become overstaffed and the shortage of EP's narrows. The only logical way that hospitals will truly be able to keep patients out of the inpatient wards will be to increase their outpatient facilities (SNF's, LTACs, CHF Clinics, etc). These will come at a cost to the hospital systems and - by way of their joint venture - to the CMG's contracted with them. Emcare, as an example, is going to lose revenue because they are tied to the overall operating success of HCA. This is likely part of the reason they have reorganized and rebranded as "Envision."

In the middle of all of this is the occasional local solo community hospital that relies on private donations to keep it's doors open and provide services. These are just as lucrative to CMG's, but also have more likelihood of being staffed by private democratic groups who also need to compete with local market forces. The death of the local democratic group comes when partners retire, realize they can't compete with local market rates being driven up by CMG's, can't recruit new providers, and eventually sell or lose their contracts to the CMG's who come in and offer a lower rate because the hospital is nice and shiny. Again, another contract to the side of the CMG, who will increase their economy of scale and have more market influence to dictate rate. Thats pretty much how this works.

Note, I did not include academic hospitals in this discussion, because pure academic hospitals are always going to have a lower rate due to their CMS funding structure. The only exceptions to this are academic programs that are hybrid university owned/CMG run. Also consider that larger cities may have a larger number of academic centers, which may mean a larger number of VA medical centers, which will always negatively impact physician salary surveys.

Again - back to my solicitation for feedback to the new grads: How is your first job going? How is your pay? Where do you think your salary is going to go after your 90 day income guarantee? What is your plan when you take a pay cut?

1. So basically if you're planning to go work for a CMG you have to commit yourself to the idea you're going to sell out and basically wear a shock collar around your neck for the rest of your days telling you if you've been pooping too long... Wonderful.

2. Based on the content of this thread I can assume, but figured I'd ask outright: Going forward I assume you see the role of SDGs decreasing significantly based on large hospital chains/CMGs. As a result, what is the role of the individual physician in slowing the change in EM? Like you said when new physicians come into the work force and are getting paid $200/hr by the CMG/hospital, that seems like great money. Then the new batch comes in and its $175/hr, and the last group has to take less to compete. Seems like very little can be done by the individual in this situation.

Of course the government would love to keep people out of the hospital, but with the individual mandate + lack of FPs, do you a penalization system as being tenable? I can't imagine people who now have insurance aren't likely interested in waiting 6 weeks to see a FP when they can roll into the ED and get seen today.
 
Of course the government would love to keep people out of the hospital, but with the individual mandate + lack of FPs, do you a penalization system as being tenable? I can't imagine people who now have insurance aren't likely interested in waiting 6 weeks to see a FP when they can roll into the ED and get seen today.

Anything that the government can do to reduce the amount they pay to anyone is completely tenable. It has already started, and bigger penalties are coming over the next few years. This loss is being passed down to contracted emergency physicians in the form of a "quality" portion of their contracts, where a percentage of income can be withheld for unnecessary readmissions or over-utilization of expensive imaging - metrics that are completely up to the hospital (who owns the CMG contract and is losing revenue) to pass on to the contract group. The hospitals know that the CMG has deep pockets (another reason SDG's are being phased out) and as a company can absorb the loss, so they put pressure on the group to reduce readmissions and give subtle hints that "another" group may do the job better. The hospital's frustration gets passed to the CMG administrators, who pass the loss on to you.

None of this is fantasy land - this is how the business works and the pay cuts are already taking place (read Team Health physician contracts)...
 
  • Like
Reactions: 1 users
Wait, what happened with team health pay cuts?


Sent from my iPhone using Tapatalk
 
I work for TeamHealth at my primary job site.
We all just got a raise, not a cut.

Some sites will get pay increases- especially those that have physician shortages, threats from physicians to leave, or need to expand coverage in hard to recruit areas. The point isn't that they are making cuts (which they are in the form of unobtainable contracted metrics), but that they have had the ability to pay you more for years, but eventually got to a point behind the scenes where they HAD to raise rates to protect their contract.

Think of it this way- you've been giving them an interest free loan in the form of labor for the entire time you worked there and they simply decided to make a payment. Not pay the whole thing- a small payment.
 
Some sites will get pay increases- especially those that have physician shortages, threats from physicians to leave, or need to expand coverage in hard to recruit areas. The point isn't that they are making cuts (which they are in the form of unobtainable contracted metrics), but that they have had the ability to pay you more for years, but eventually got to a point behind the scenes where they HAD to raise rates to protect their contract.

Think of it this way- you've been giving them an interest free loan in the form of labor for the entire time you worked there and they simply decided to make a payment. Not pay the whole thing- a small payment.

Oh, your argument/lesson is not lost on me.
I still think I am underpaid.
I just wondered if anything new was coming down the pike that I hadn't year heard about.
 
EmCare is using a helicopter to fly people into Houston.
Think about that for a minute.
 
EmCare is using a helicopter to fly people into Houston.
Think about that for a minute.
As is common to you (at least, more than others), to me, this is cryptic. Spell it out clearly, if only for me. Honest, I thought about it "for a minute", and I still don't get it.

Sure, you get brevity. That is in exchange for clarity. Thanks.
 
  • Like
Reactions: 1 user
They're using helicopters to fly people into Houston because it's cheaper than paying the people who live there to work at some of the sites.
None of the sites needs an helicopter. They're just using it.
 
Top