Approximate overhead

[thorg12]

I'm interested in how much "overhead" there is for a group.
For example if my group collected 100 dollars under my name.
What % goes to our malpractice, billing, other costs.
What % goes to me? Ie salary, 401k match, health insurance.
Just wondering bc my group is now sending us how much they actually bill and actually collect under our name.
I'm sure this varies greatly region to region and group to group; just interested in some numbers.
Thanks

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[Hercules]

I'm interested in how much "overhead" there is for a group.
For example if my group collected 100 dollars under my name.
What % goes to our malpractice, billing, other costs.
What % goes to me? Ie salary, 401k match, health insurance.
Just wondering bc my group is now sending us how much they actually bill and actually collect under our name.
I'm sure this varies greatly region to region and group to group; just interested in some numbers.
Thanks

It's kind of hard to get apples to apples comparisons between groups on this. How much your group bills is almost completely meaningless. But you should be able to get a an idea of your overhead pretty easily by looking at how much you collect pet patient and how much you get paid per patient. The absolute $/pt and % for overhead will vary greatly depending on a number of factors. Your major group overhead will be:
Billing--this is usually a straightforward % of collections unless your group handles it internally instead of outsourcing it. There is no regional variation in this number but it does vary pretty widely between companies. Usually somewhere around 5-10%. This will be one of your largest expenses.
Malpractice insurance--varies from state to state.
Extenders-- if your group employs midlevels and scribes, this is going to be a significant expense.
Miscellaneous--accounting, banking expenses, workmans comp insurance etc.
Administration-- if some of your group handles the administrative duties of the group then their stipends should be considered part of the overhead.

 

[Birdstrike]

I'm interested in how much "overhead" there is for a group.
For example if my group collected 100 dollars under my name.
What % goes to our malpractice, billing, other costs.
What % goes to me? Ie salary, 401k match, health insurance.
Just wondering bc my group is now sending us how much they actually bill and actually collect under our name.
I'm sure this varies greatly region to region and group to group; just interested in some numbers.
Thanks

All very, very, good questions. I would say 19 out of 20 Emergency physicians would have no idea what the answer to this question is. On this board, you may get 3 or 4 who may have a clue as to how to answer this. That will probably be WhiteCoatInvestor and maybe a couple others would have an idea. 19 out of 20 should know, but only 1 in 20 you find will. That knowledge gap, makes it very, very easy for whomever is distributing that money to make however much they want to disappear.

I could tell you what the number is for me, but I'm no longer in a traditional hospital-based EM practice setting, so it would be comparing apples to oranges.

This same lack of knowledge regarding their own collections, expenses, and how it relates to their take home pay would similarly apply to most physicians of any specialty that are in hospital employed settings, also. More and more, doctors are just laying down and giving up knowledge, autonomy and control over their careers and practice lives. As much knowledge as you can gain in this area, the better, in my opinion.

 

[EM_Rebuilder]

I'm interested in how much "overhead" there is for a group.
For example if my group collected 100 dollars under my name.
What % goes to our malpractice, billing, other costs.
What % goes to me? Ie salary, 401k match, health insurance.
Just wondering bc my group is now sending us how much they actually bill and actually collect under our name.
I'm sure this varies greatly region to region and group to group; just interested in some numbers.
Thanks

Malpractice is largely state dependent, cheap in Texas, a few bucks per patients.
Billing and Coding, depends on what you negotiated, but typically the coders get a set fee ($3/chart) and the billers usually get a percentage (6%). Unless you do this stuff in house yourself, but that still costs money.
401K/health Insurance.. Incredibly variable, or just an IC that does not have any of that.

The biggest question is how much goes to the 'guy(s) on top'. Also, is there a subsidy and where is that money. There may or may not be one.

And remember, your just looking at the professional fee. There is also a technical component fee (usually called the facility fee) that is EASILY three times the pro fee, and more likely four or five times it. That is going to your 'facility' where the hospitals claim its being used to provide 'all that unfunded care'. Is yours building a new tower also?

 

[The White Coat Investor]

Coding/Billing around 5%, other overhead ~ 5%, malpractice probably adds up to another 4%.

That doesn't include what we pay extenders, but we're making more from them than we're paying them.

 

[Janders]

All very, very, good questions. I would say 19 out of 20 Emergency physicians would have no idea what the answer to this question is. On this board, you may get 3 or 4 who may have a clue as to how to answer this. That will probably be WhiteCoatInvestor and maybe a couple others would have an idea. 19 out of 20 should know, but only 1 in 20 you find will. That knowledge gap, makes it very, very easy for whomever is distributing that money to make however much they want to disappear.

Agreed, this information is important to understand. Even when I was employed by a big system (making basically hourly dollars), they shared my billings/collections and rough ideas of overhead costs.

Now that I work in a P&L system, ever dollar I collect that DOESN'T go to overhead, I get to keep. Thus, I am keenly interested in keeping overhead as low as practical, and also as FAIR as practical.

To me, overhead is dollars that I don't get in any way/shape/form.
TOTAL COLLECTIONS - OVERHEAD = JANDERS MONEY

What is overhead?
(A) Coding/Billing
(B) Other corporate needs (HR? Workers Comp? retirement account management? Accountant?)
(C) Other group administrative needs (admin stipend, scheduling stipend)
**(D) PA PAY

**PA pay is a bit special. Though you spend money on it, the PA is then going to bill and collect income, likely not only offsetting their salary but potentially turning a profit, depending on setting, pay scale, etc.

JANDERS' MONEY is then used to fund a few things:
(1) Malpractice Insurance
(2) Employer retirement contributions / Employee retirement contributions
(3) Medical insurance premiums for me/family
(4) CME allowance
(5) Hospital credentialing
(6) Other "benefits" I elect to take (dental, umbrella insurance).
(7) SALARY and BONUSES

Some people would call #1-6 "overhead" but I just think of those as money I was given for specific things, pre-tax. All of JANDERS' money that doesn't get used for #1-6 comes to me as cash via salary and bonuses. I can see why you may include malpractice, a big ticket item, as overhead...

To further delineate exactly what overhead costs--
coding/billing costs? 5-8% roughly, depending on location, quality of service, etc.
How much for misc. corporate overhead? Last I saw we were in the neighborhood of 3%
How much for group admin overhead? Highly variable, last I saw we were around 3%, but we set our own admin stipends, and tend to err on the low side.
If you want to count malpractice, mine is a set flat amount per year... but works out in the range of 4% or so.

From my understanding, a LEAN group interested in keeping a very low overhead can push it down to around 12-15%. More typical is perhaps 20%?

This of course varies by TYPE of practice. In an academic setting, you would have the benefit of residents extending the number of patients you can see in one shift, but the obvious need for higher taxes to support academics.

Now I'm not saying you should only take jobs with a low overhead. But you SHOULD understand where your hard earned money is going, and precisely what you are getting for your overhead. Perhaps the overhead is 30% but it is a great practice setting in a great location with lucrative volume and rates.

 

[NinerNiner999]

If we as physicians - especially those who work for large CMG's - had any idea how much money we are actually talking about, we would all work for ourselves. A basic rule of thumb for CMG's is to take your current salary (average), quadruple it, multiply by 90%, and the remaining number is profit. For example, if you are paid 300k per year, you actually may have made your company 1.2mil per year, minus their 10% overhead (or less based on economy of scale, or more based on size of company), or $1,080,000. They take $708,000 each year for their "management fee" or whatever they deem appropriate.

Within this management fee includes staff (several thousand if Emcare or TeamHealth, 5-10 if small local group), benefits, partner bonuses, reserve funds/investments/special projects, etc. Also consider that, since insurance payments are in arrears, there is often a lengthy period of accounts receivable, anywhere from 3-6 months, where billed services are pending income that the company cannot use, but expect to be received.

A single level 5 chart bills around $1200-1300 for the physician. An average level of service for a group with decent coding practices is around 3-3.5, or $550 per chart. Procedures are extra. For simplicity sake, collections vary by payer mix, but are around 50% of total billed amount. If you are an average physician working 1500 hours annually, and seeing 2 patients per hour, and supervising a midlevel who sees 2 patients per hour, for a total of 4 pph, you are generating charges for 6000 patients annually. 6000 patients at $550 per chart is 3.3m billed, or roughly 1.6m before expenses (overhead).

Within this management fee includes staff (several thousand if Emcare or TeamHealth, 5-10 if small local group), benefits, partner bonuses, reserve funds/investments/special projects, etc. Also consider that, since insurance payments are in arrears, there is often a lengthy period of accounts receivable, anywhere from 3-6 months, where billed services are pending income that the company cannot use, but expect to be received.

Smaller groups (local, local regional etc.) can't compete with the larger companies because of their economy of scale. They are not big enough to negotiate the best reimbursement rates with insurers, so their total collections may only be 1.5-2.5 times your annual pay. Often times, these groups receive a stipend from their hospital to maintain overhead and rates, in anticipation of the same account receivable issue above. This is not as easily buffered by smaller groups. Stipends, however, almost a thing of the past, and this is already impacting small group overhead tremendously.

These are all generalized numbers, and as mentioned before, it is very difficult to compare apples to oranges based on many factors, but this is a "basic" rule of thumb...

 

[two guys]

Let's keep this discussion going. I wish more of us were trying to get an answer to these questions.

I've always thought the best way to look at this is to know how much $/rvu you're gorup collects and what you get paid in terms of $/rvu. The difference is the overhead.

We had a pretty long thread about this and there were some helpful PMs sent.

It is hard to generalize because uncompensated care affects the bottom line so greatly. A change from 40% insured (any, including public assistance) to 45% is often quoted as the difference between a profitable contract and one that needs a stipend.

The 2013 RVU conversion factor for medicaire was $34. Private insurance is higher. Uninsured collections is probably less than 1%.

The best I can tell from all of these PMs, if you're getting about $25/rvu you'll make about $100/patient and you're paying out at least $25 and up to $75/patient in "overhead."

I know of one cmg that actually shows you their charges. They charge 500,000 per year to manage 15 docs. This is above and beyond malpractice and other overhead. So, each doc is paying 33,000 per year for "administrative support". Depending on the "support" the might be worth it. I would rather have direct control and relationship with the admin but some would think thats a bargain to just get to show up and do no scheduling or admin.

 

[Arcan57]

Niner, your figure for the RVUs for a level 5 chart seem off by an order of magnitude. Figuring a level 5 chart is slightly less than 5 RVUs and Medicare is paying $34/RVU than the doc would be pocketing $170 per level 5 chart with no overhead.

 

[Hercules]

Niner, your general concepts are good in that CMGs are turning a profit off your labor but it's nothing like what you're assuming. Your numbers assume collecting $275/pt on average. I am a business minded EP and have neither seen nor heard anything close to that. Collecting $120+ is pretty awesome and puts you in a nice position. Collecting $275 might not be impossible, but it's more of a unicorn most of the EM concepts (strong sustainable SDGs, jobs with no nights, admins that bring down milk and cookies and tell you how much they love you) that have been labeled as unicorns on SDN in the past.

 

[Janders]

Agree collections from $100-150 / patient closer to what I've heard of, not 200-500...

 

[The White Coat Investor]

If we as physicians - especially those who work for large CMG's - had any idea how much money we are actually talking about, we would all work for ourselves. A basic rule of thumb for CMG's is to take your current salary (average), quadruple it, multiply by 90%, and the remaining number is profit. For example, if you are paid 300k per year, you actually may have made your company 1.2mil per year, minus their 10% overhead (or less based on economy of scale, or more based on size of company), or $1,080,000. They take $708,000 each year for their "management fee" or whatever they deem appropriate.

What? That's bizarre to think a physician is earning a $300K salary and generating $1.2M in profit. That's way off unless you're working 30 12s a month or something. Don't get me wrong, I don't love CMGs, but their overhead isn't 75%. I'd expect a number more like 15% for overhead and 15% for profit and you get 70% of what you earn. So you're getting 70% instead of the 85% you might be getting in a SDG.

 

[The White Coat Investor]

Agree collections from $100-150 / patient closer to what I've heard of, not 200-500...

I'd buy $200 per patient (that's a great payor mix), but not $500.

 

[coachB]

He seems to be confusing billed vs collected.

 

[two guys]

A level 5 chart generates 4.9 RVU's. If a patient has medicare that will be $166 before overhead (4.9 rvus x 34). Private insurance is more but not a ton more (couldn't imagine more than $40/rvu). Uninsured is usually billed high (think $40/rvu) and collected way low (5% would be pretty nice - 4.9 rvus x $40 x 5% of people actually paying = $45 per uninsured patient).

Niners $1200 for the physician for a level 5 just is simply way off. That would mean a conversion factor of $244 per rvu. That's seven fold higher than the medicaire rate. I don't know how much higher private insurance is, but you can bet it is within 50-100% of medicaire ($41-68/rvu). No way is it 7 times.

His number isn't billed vs collected. It might be that he's talking about the entire bundle of charges for the patient from the provider and hospital. That would be in the ballpark of his numbers (the general number is the physician bill is about 8% of the hospital bill - that's not how it's calculated but it does hold close to true). So if the OP was asking total overhead for the whole visit than it's about 92%. Of course, then you're talking about some serious overhead (building, nurses, techs, CT machines, etc). It's easier just to look at the physician portion of the charge (ie look a dollar per rvu).

 

[NinerNiner999]

"6000 patients at $550 per chart is 3.3m billed, or roughly 1.6m before expenses (overhead)."

To clarify - $550 average per chart BILLED, total 3.3m BILLED, and 50% (1.6m) Collected. This is an average COLLECTION of around $275 per patient, which includes negotiated reimbursement rates for ALL PAYERS (including Medicare/caid AND private insurance) and procedures, which are billed separate from the LOS Code. Think about how much we bill for each critical care patient who gets a central line, intubation, and cardioversion, and it adds up pretty quickly.

These are real numbers.

 

[Vandalia]

"6000 patients at $550 per chart is 3.3m billed, or roughly 1.6m before expenses (overhead)."

To clarify - $550 average per chart BILLED, total 3.3m BILLED, and 50% (1.6m) Collected. This is an average COLLECTION of around $275 per patient, which includes negotiated reimbursement rates for ALL PAYERS (including Medicare/caid AND private insurance) and procedures, which are billed separate from the LOS Code. Think about how much we bill for each critical care patient who gets a central line, intubation, and cardioversion, and it adds up pretty quickly.

These are real numbers.

That is still awfully, awfully, high.

That assumes every patient is a level 5. For us, the actual amount received for a level 5, from a "gold-plated" employer insurance plan, is $140. And 50% collection off of "list price" for emergency medicine is incredibly high. That rate might be appropriate for other specialties, but not when you have EMTALA. If you are collecting 50% of the CONTRACT rates you are doing awfully good.

Now are you including the facility fee? That is really not relevant unless you are also paying all the facility expenses. About 5 years ago, one of the hospital radiology techs attempted to stage a revolt saying to his peers that they were grossly underpaid. His reasoning was that they generated $6,000 an hour for the hospital, so they deserved to be paid at least $120 an hour.

 

[link2swim06]

"6000 patients at $550 per chart is 3.3m billed, or roughly 1.6m before expenses (overhead)."

To clarify - $550 average per chart BILLED, total 3.3m BILLED, and 50% (1.6m) Collected. This is an average COLLECTION of around $275 per patient, which includes negotiated reimbursement rates for ALL PAYERS (including Medicare/caid AND private insurance) and procedures, which are billed separate from the LOS Code. Think about how much we bill for each critical care patient who gets a central line, intubation, and cardioversion, and it adds up pretty quickly.

These are real numbers.

I remember sitting through some hospital admin lecture in med school and they said that our hospital collected 8 cents for each dollar billed. And there are hospitals in California that were apparently only collecting 3 cents per dollar billed. You are citing getting paid 50% of what you bill which is certainly higher than hospitals I have been at.

Healthcare bills are similar to craiglist ads....the price is simply a starting point for negotiations.

And $275 seems high...what codes are generating this figure?

 

[Hercules]

"6000 patients at $550 per chart is 3.3m billed, or roughly 1.6m before expenses (overhead)."

To clarify - $550 average per chart BILLED, total 3.3m BILLED, and 50% (1.6m) Collected. This is an average COLLECTION of around $275 per patient, which includes negotiated reimbursement rates for ALL PAYERS (including Medicare/caid AND private insurance) and procedures, which are billed separate from the LOS Code. Think about how much we bill for each critical care patient who gets a central line, intubation, and cardioversion, and it adds up pretty quickly.

These are real numbers.

Niner, I hate to harp on you but these really aren't real numbers. If you believe that your group actually bills $1300 for each level 5 chart and collects 50%, then you believe that you are collecting $650 for every level 5 patient. I know the billing matrices for groups in multiple states and I can tell you that no one is collecting close to that. Again, no one here will argue that CMGs aren't making a profit off your labor (they couldn't exist if they weren't), but your numbers are just way off. No one has an overhead of 75%. Have you looked at the actual financial reports for the group you're in? If so that's great that you are looking into it, but you may be misreading a portion of it if you think this way.

 

[Apollyon]

Now are you including the facility fee? That is really not relevant unless you are also paying all the facility expenses. About 5 years ago, one of the hospital radiology techs attempted to stage a revolt saying to his peers that they were grossly underpaid. His reasoning was that they generated $6,000 an hour for the hospital, so they deserved to be paid at least $120 an hour.

But you leave out the best part of the story - what happened? There are several outcomes, but they are finite: he got canned, he shut up and kept his job, the pay went up to $120, the pay went up, but MUCH less, or combinations. With "he shut up", that is no pay increase.

 

[Vandalia]

But you leave out the best part of the story - what happened? There are several outcomes, but they are finite: he got canned, he shut up and kept his job, the pay went up to $120, the pay went up, but MUCH less, or combinations. With "he shut up", that is no pay increase.

Resigned in protest after he got laughed out of the CEO's office. I heard someone say that he is working as a manager at Target. But he stood by his principles.

 

[NinerNiner999]

Niner, I hate to harp on you but these really aren't real numbers. If you believe that your group actually bills $1300 for each level 5 chart and collects 50%, then you believe that you are collecting $650 for every level 5 patient. I know the billing matrices for groups in multiple states and I can tell you that no one is collecting close to that. Again, no one here will argue that CMGs aren't making a profit off your labor (they couldn't exist if they weren't), but your numbers are just way off. No one has an overhead of 75%. Have you looked at the actual financial reports for the group you're in? If so that's great that you are looking into it, but you may be misreading a portion of it if you think this way.

Again, these are average numbers, and the average billing is $550. This includes the E/M code plus the total of all procedure codes. It's not unusual for a code to bill over 12 RVU's, or for a joint reduction with sedation to approach 20. These average out with the level 2 med refills, and the level 3's. Seriously. $550 as an average BILLED amount is not unreasonable - add it up. A level 4 patient may total 3.46 RVU's, but the laceration repair, joint reduction, and wound care easily bring that patient's total bill to 10+ RVU's. Please don't underestimate the impact that procedures and additional well-documented services have to the total billing amount.

To imply that 50% of level 5 bills get paid is not a fair analogy. I'm suggesting that total RVU's per month, and total collections per month is close to 50%. As alluded to in a previous post, 45% is the minimum payment percentage for a "profitable" group.

 

[Janders]

Just haven't personally seen collections of $275 / pt.

Let me know where I can get some of that

 

[The White Coat Investor]

Again, these are average numbers, and the average billing is $550. This includes the E/M code plus the total of all procedure codes. It's not unusual for a code to bill over 12 RVU's, or for a joint reduction with sedation to approach 20. These average out with the level 2 med refills, and the level 3's. Seriously. $550 as an average BILLED amount is not unreasonable - add it up. A level 4 patient may total 3.46 RVU's, but the laceration repair, joint reduction, and wound care easily bring that patient's total bill to 10+ RVU's. Please don't underestimate the impact that procedures and additional well-documented services have to the total billing amount.

To imply that 50% of level 5 bills get paid is not a fair analogy. I'm suggesting that total RVU's per month, and total collections per month is close to 50%. As alluded to in a previous post, 45% is the minimum payment percentage for a "profitable" group.

I know my numbers (bill in the 750-800 range, collect in the 150-200 range) per patient. I am also aware of my hourly rate and how it compares to national averages (very well) despite having a relatively low pph rate. I agree that $550 as an average bill is not unreasonable, in fact it's quite a bit lower than I bill.

However, the % of billed to collected is a moving target. If you can bill $550 and collect 50%, that's about the same as me billing $800 and getting 25%. I don't think you can say you have to get 45% to be profitable. As you can see, we're quite profitable at 25%.

 

[NinerNiner999]

Agreed - billing versus collecting is highly variable. The example I give assumes the best of all circumstances (high payer mix, high self-pay rate, and well-negotiated insurance rates).

 

[JMC2010]

Our group bills on average $380/patient and collects about $118/patient (not including any facility fees). These numbers you guys are throwing out are really impressive and i'm having a hard time figuring out why our charges are not all in the same range.

 

[RuralEDDoc]

My group is paid entirely based on performance. All collections are tallied up for the month, then you get paid a portion of this based on your percentage of charges (charges, not collections, so people don't attempt to avoid treating the uninsured).
~9% overhead to billers, coders, malpractice
~5% overhead to site admin. Our medical director, assistant medical director, etc. get a stipend but probably would get paid more hourly by simply doing shifts.
~4% overhead to national group admin. It's a democratic group, so no profit-skimming.
~83% Paid back to individual docs.
17% in admin costs may sound like a lot, but it really isn't. Handling billing, risk management, core measures, EMR implementation, etc, is not easy, and you need to pay to play.

 

[EM_Rebuilder]

You guys are still missing the boat of the facility fee. Add zeros to all these numbers and that's what the hospital is getting paid. The chicken peck is going to the doctors.

You are getting 150-200 per patient, the hospital got 1500-2000 per patient. Naturally they have overhead; nurses, techs, CT scanner, etc are costly....

 

[The White Coat Investor]

You guys are still missing the boat of the facility fee. Add zeros to all these numbers and that's what the hospital is getting paid. The chicken peck is going to the doctors.

You are getting 150-200 per patient, the hospital got 1500-2000 per patient. Naturally they have overhead; nurses, techs, CT scanner, etc are costly....

What makes you think you're entitled to any of the facility fee? Want facility fees? Go open a free standing ED.

 

[Hercules]

What makes you think you're entitled to any of the facility fee? Want facility fees? Go open a free standing ED.

I believe that in an earlier post he said he was opening 2 FSEDs

 

[The White Coat Investor]

I believe that in an earlier post he said he was opening 2 FSEDs

Great! That's how you get facility fees...but you have to pay for the facility too. Last I checked, nurses don't work for free. I'm not saying that's not a good deal too (it sure seems to be) but for a typical EP working in a typical hospital ED, don't expect to get a facility fee.

 

[EM_Rebuilder]

I was just pointing out the numbers we as EP generate versus what we as the EP actually gets paid...

There is often a disconnect. Even when you put unfunded care, etc etc and all into the mix...

For clarification, I did point out above that nurses, CT scanners, etc have a cost as well.

Physician owned FSED should be an important part of the future model of care for Emergency Medicine for our country. It will probably never fully happen though; hospitals will continue to block it and even some of our own peers suggest it is a bad idea....

Texas alone has created over 1000+ new "ER Beds" and over 650 new "Emergency Physician" jobs with a successful model of the FSED. This is a win for our specialty and a win for the publics access to Emergency Medical Care....

 

[Hercules]

I was just pointing out the numbers we as EP generate versus what we as the EP actually gets paid...

There is often a disconnect. Even when you put unfunded care, etc etc and all into the mix...

For clarification, I did point out above that nurses, CT scanners, etc have a cost as well.

Physician owned FSED should be an important part of the future model of care for Emergency Medicine for our country. It will probably never fully happen though; hospitals will continue to block it and even some of our own peers suggest it is a bad idea....

Texas alone has created over 1000+ new "ER Beds" and over 650 new "Emergency Physician" jobs with a successful model of the FSED. This is a win for our specialty and a win for the publics access to Emergency Medical Care....

I agree that it will never fully happen because several states have already legislated against physician owned FSEDs. I love the model and looked into it last year. Unfortunately the state of Alabama doesn't allow physician ownership of the FSED. It can only be owned by a parent hospital and we are also a CON state. I love my EM group and my urgent care but would also love to further diversify and have a FSED.

 

[The White Coat Investor]

I was just pointing out the numbers we as EP generate versus what we as the EP actually gets paid...

There is often a disconnect. Even when you put unfunded care, etc etc and all into the mix...

For clarification, I did point out above that nurses, CT scanners, etc have a cost as well.

Physician owned FSED should be an important part of the future model of care for Emergency Medicine for our country. It will probably never fully happen though; hospitals will continue to block it and even some of our own peers suggest it is a bad idea....

Texas alone has created over 1000+ new "ER Beds" and over 650 new "Emergency Physician" jobs with a successful model of the FSED. This is a win for our specialty and a win for the publics access to Emergency Medical Care....

I have mixed feelings on the concept. What happens when all EDs are free-standing? Is that really better for patients? Why shouldn't hospitals fight against you when you are a direct competitor? How long will you stay in business when the hospitals make it hard for you to transfer patients to them? All of a sudden your 10 or 15 beds are full of boarders and you're having to hire additional staff and resources to care for them.

The other issues I dislike is across many specialties- plastics guys do all their procedures in their office, ortho operates in their own surgical center, GI has their own endoscopy suite and all of a sudden no specialists have a reason to remain on the medical staff. Now the call panel is empty. Is that really better for patients? Is there really no good reason to have us all at a hospital where we can work together for the good of patients?

That said, I'd love to have a piece of the facility fee, but more importantly, have more say over my work environment/EMR/nurses etc.

 

[Birdstrike]

I was just pointing out the numbers we as EP generate versus what we as the EP actually gets paid...

There is often a disconnect. Even when you put unfunded care, etc etc and all into the mix...

For clarification, I did point out above that nurses, CT scanners, etc have a cost as well.

Physician owned FSED should be an important part of the future model of care for Emergency Medicine for our country. It will probably never fully happen though; hospitals will continue to block it and even some of our own peers suggest it is a bad idea....

Texas alone has created over 1000+ new "ER Beds" and over 650 new "Emergency Physician" jobs with a successful model of the FSED. This is a win for our specialty and a win for the publics access to Emergency Medical Care....

Great post. I agree 100%.

 

[Birdstrike]

I have mixed feelings on the concept. What happens when all EDs are free-standing? Is that really better for patients? Why shouldn't hospitals fight against you when you are a direct competitor? How long will you stay in business when the hospitals make it hard for you to transfer patients to them? All of a sudden your 10 or 15 beds are full of boarders and you're having to hire additional staff and resources to care for them.

The other issues I dislike is across many specialties- plastics guys do all their procedures in their office, ortho operates in their own surgical center, GI has their own endoscopy suite and all of a sudden no specialists have a reason to remain on the medical staff. Now the call panel is empty. Is that really better for patients? Is there really no good reason to have us all at a hospital where we can work together for the good of patients?

That said, I'd love to have a piece of the facility fee, but more importantly, have more say over my work environment/EMR/nurses etc.

Don't be deluded into thinking hospitals altruistically are doing everything they do "in the best interest of patients." Hands down, they want money. Period. And if they can make more by crushing doctors, their practices and business ventures, they will. They will translate those conquests into bigger bonuses, higher shareholder dividends, bigger salary pools for administration, perks for themselves, not into altruistic charity programs or other things that benefit patients, nor for things that make nurses or doctors jobs easier. Don't buy into the bait and switch of "when doctors make money it's bad, but when hospitals do it's good and for the "best interest of patients." Don't drink the Kool Aid.

 

[Vandalia]

Don't be deluded into thinking hospitals altruistically are doing everything they do "in the best interest of patients." Hands down, they want money. Period. And if they can make more by crushing doctors, their practices and business ventures, they will. They will translate those conquests into bigger bonuses, higher shareholder dividends, bigger salary pools for administration, perks for themselves, not into altruistic charity programs or other things that benefit patients, nor for things that make nurses or doctors jobs easier. Don't buy into the bait and switch of "when doctors make money it's bad, but when hospitals do it's good and for the "best interest of patients." Don't drink the Kool Aid.

That was not the question.

The question was, "Is that really better for patients?"

The fact that the primary motivation of most hospitals is to make money has no bearing on the question of whether the move away from delivering care at a hospital facility benefits patients. It certainly does mean that we should not take the hospital's assertion that it is "bad for patients" at face value. However, the fact that hospitals benefit from something does not necessarily mean it is bad for patients. Nor does it hold that everything that is good for physicians is good for patients.

The question of whether something is good for patients stands - and must be answered - on its own.

 

[The White Coat Investor]

That was not the question.

The question of whether something is good for patients stands - and must be answered - on its own.

Couldn't have said it better myself.

I guess I'm just not ready to give up on the idea of a "full-service" ED that has ortho, gen surg, hospitalist, intensivist, neuro, ENT, neurosurg, OB/GYN, plastics, GI, cards, nephro, etc on call with a cath team ready to go, CT/MRI/US available 24/7, L&D in house, and maybe even an OR "on standby" a la a level 1 trauma center. I think a lot of good is done that way. Emergency care in my community is fragmenting into smaller and smaller EDs, and now free-standing EDs (hospital owned in my state) and I think it is resulting in worse care for the patients. 15 small/free-standing EDs is not necessarily better than 4 larger "full-service" EDs.

 

[Birdstrike]

That was not the question.

Yes it was the question. It was my question.

Nor does it hold that everything that is good for physicians is good for patients.

Correct. But I assure you, if physicians aren't looking out what is good for you as a physician, no one on Earth will be.

The question of whether something is good for patients stands - and must be answered - on its own.

Of course it must. Hospitals have tons of their own free standing EDs. They see fit to build plenty as feeder sites for their hospitals and accept transfers from them. They consider that plenty "good for patients." When they take a transfer from one they make money (the primary goal of every hospital, not most, as you say) and I never hear them quip that that's "bad for patients." They absolutely should do so from a physician-owned free standing, that is unless they decided to block them as a ploy to crush competition, which they certainly would not hesitate to do, and which certainly would harm patients and would likely be enforceably illegal as an anti-trust violation and an attempt at a monopoly. All the same profit motives that fuel unnecessary care apply to hospitals as much as they do to physicians or anyone else. Don't drink the Kool Aid that for hospitals to make hundred of millions of dollars is good and altruistic, yet for physicians to make a few bucks is bad.

I'm glad certain states like Texas have allowed these opportunities. Such states will continue to be increasingly good places for physicians to practice. We've seen what happens in states that don't support physicians, and instead support hospitals, and attorneys. They become cesspool practice environments with horrendous malpractice climates, bottom of the curve salaries and little chance for independent practice. These are the environments where the plaintiffs attorneys and the hospital-administration profiteers thrive, and physicians become powerless, discouraged and replaceable cogs in a large, impersonal employment system. I see no evidence that patient health is magically any better in these states as a result of making practice quality and opportunities hostile to physicians.

It has been said (paraphrasing Benajmin Franklin) that,

"Those who would give up freedom in exchange for security, will lose both and deserve neither."

This is exactly what is happening and will continue to happen to doctors who give up their independence and freedom for the supposed secure jobs employed by mega systems because they're duped into thinking these mega corporations are altruistic, not seeking profits and are morally superior to physicians. These doctors end up as replaceable and frustrated box checkers with little control over anything. Thank God at least a small minority of doctors are standing up for themselves. God bless them.

 

[DocRGR]

Different question, but are any of you guys doing IC/1099 work billing your own professional fees through a billing company vs a flat hourly or something productivity based? Feel free to PM as well if you don't want to comment on open forum, thanks.