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?