Compensation: The real story

[10YrsOutBurnedOut]

I've been out for 10 years. Did Academics for the first 6, community after that.
I remember when I was a med student and resident, I had trouble finding out what the compensation was for my chosen specialty. And part of the problem why I am burning out now is because it still is so opaque. So here is what I know about compensation in a few states based on myself and two close friends. Each of has has contributed 1 or two places, so no, we aren't jumping around from job to job, but we do have some realistic info from our groups and others.

California:
Join one of the big boy groups, and you will get anywhere between $140-250 an hour. Did you know that they are still ripping you off? At the facilities that have groups that pay everyone fairly based on productivity, $300 is routinely the hourly wage. This is for seeing ~ 3 patients/hour, a mix of sick and not sick. You're humping at $300/hr to be sure, but it's not unsafe. I know some hospitals where EM docs make almost $400/hr, but this is assuming it is a lean billing outfit with no fat for senior partners.

Now let's think about some of the private groups: These old fat cats in their 50s that are partners are bringing in new kids out of residency for ~$150/hr. 2, 3, even 4 years to full compensation (but not necessarily partnership). These fat cats at the top are making over 600k in annual compensation while working a cherry pick schedule of no overnights or weekends. The "kids" typically escalate their compensation $25/hr for each year until they are earnings partners when they top out about $250/hr. Still not equity partners (those who get the real bonus to earn the 600k as above) necessarily.

Montana:
Most of these places are subsidized because of patient volume/low acuity. Most jobs are in the $150-175 range. Some smaller places with private groups will break $200 and bonuses can take it higher, but not great.

Nevada (Las Vegas):
Mostly the big box groups here. You will make $200/hr easy at most places, but you're probably generating wayyyyy more than that 'for the man'. Not many private groups that I've heard of in Nevada.

North Carolina:
Pay is really poor here. Work at one of the academic facilities, and expect to earn less than $150/hr. Join some of the private groups like Apollo and you are a partner (or more accurately, no less a partner that anyone else) and probably make 200-220/hour. Some of the private groups will pay you $130/hr for two years before you might make $225/hr with a sizable bonus that can take your compensation to ~250-260/hr.


TeamHealth, CEP, all the big box national programs - raping EM docs. You are giving away significant chunks of what you earn to them, and believe me, they're getting FAT now that everyone has insurance. You will struggle to earn over $200/hr here. Again, can you make a good living at $200/hr? Sure can! $345k a year for 12 shifts x 12 hours sounds pretty good. But know that you are making money for someone else sitting on their yacht - probably up to $100 for each hour you work.

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[Arcan57]

Have you considered opening a freestanding? If the idea that someone else is making money off of your labor bothers you to the point of increasing burnout then opening a FSED may make sense for you.

 

[Janders]

One of the benefits of open books, regardless of how you end up being paid, is that you get to see precisely how much money you brought in and where it goes.

I would say that if you are busy, and have moderate acutely and at least a moderate payor mix, you shouldn't be surprised to be creating $400/hr of PAID professional income. Especially if some PA coverage is assigned you you, or you are in a high paying state, or a really nice payor mix hospital.

Also recall you need to pay for HR, billing, coding, malpractice, the employer side of benefits (health, dental, eye, umbrella, short/long disability), your PA's if you use them, Employer side of taxes AND whatever part you set aside for administrative / scheduling / night-doc stipending.

The rest of the money is yours, but might not be straight 1099 salary, it might be salary + retirement matching + excellent benefits + year end bonusing.

This is without removing money for some senior partners or whatever crap some groups deal with.

Anyway, just because you create $375/hr of professional income doesn't mean you should get that as your "salary". It is reasonable that $250/hr of salary, $50/hr of retirement, benefits, and bonusing, and $75/hr of "overhead"

Same thing, if you create $450/hr of of professional income and are get $150/hr salary with crap benefits... well something don't add up

 

[canigetawhatwhat]

"Pay is really poor here"

"250-260 an hour"

 

[gutonc]

"Pay is really poor here"

"250-260 an hour"

ROFLCOPTER.

 

[emergentmd]

Of course they are ripping you off. That is what you call a Business. If they are not making $$$ off you, then they would be out of business.

There are ways to make more, Locums, FSED...etc

 

[gro2001]

I don't want this to seem like a criticism of the OP, I appreciate him/her posting and starting a discussion, and maybe this is my young naivette speaking, but I don't really get this line of argument.

A: "We are bringing in way more money than we are being paid. This is unfair."
B: "OK, why don't you branch out on your own? Start your own group and compete for contracts? Open up a FSED?"
A: "Are you crazy? Do you have any idea how much capital investment, financial risk, and just plain work this will take?"
B: "Well, yeah... that's why the business owners are getting their cut. This is the return on their investment"

Basically if the difference between what employees are being paid and what would be 'fair' wages is really huge, this should lead to people opening up their own businesses, if for no other reason than to exploit the difference at the cost of gullible recent EM grads (as most of these theories seem to imply its their youthful ignorance that seems to be driving this problem). If that's not happening, its probably because the wages are relatively close to what's fair.

This is the same reason I don't fully buy the 'first movers' advantage that seems to be invoked by people arguing why its impossible to start new groups and compete for contracts. If the incumbents are making huge profits of our backs, it should be easy for plenty of challengers willing to take in slightly smaller margins to out compete these groups and offer hospitals more competitive contracts. If its not happening, and the common understanding seems to be that its not happening BECAUSE a new group can't slim down margins further than the incumbents, this has to mean the margins are probably as narrow as they are going to get.

 

[Janders]

I think you have a point, but with EM I do fear some areas where the mega-corporate-groups have a complete monopoly on contracts, also contract for hospitalist/anesthesia, and are potentially in very tight with some hospital system administrators. This is the type of situation where it would be very difficult to create a democratic small group and come in and get a contract. You can't under cut the big guys... they aren't getting hospital money to staff the ED.

Now if you DID get a contract, you could easily pay your Docs MORE... but you have to get said contract first. You could easily compete for new HIRES...

 

[gro2001]

I think you have a point, but with EM I do fear some areas where the mega-corporate-groups have a complete monopoly on contracts, also contract for hospitalist/anesthesia, and are potentially in very tight with some hospital system administrators. This is the type of situation where it would be very difficult to create a democratic small group and come in and get a contract. You can't under cut the big guys... they aren't getting hospital money to staff the ED.

Now if you DID get a contract, you could easily pay your Docs MORE... but you have to get said contract first. You could easily compete for new HIRES...

I understand that reality is far from a truly free market and that there are high barriers to entry. But what you said demonstrates some of the contradiction I was pointing out. If the assertion that the mega groups are skimming huge amounts of money off the labor of ER docs and stuffing their own pockets is true, then it should be possible for a challenger to outcompete the mega groups by skimming less and giving the docs more (thus being able to retain better talent) or even pay some of it back to the hospital (and thus get in even tighter with the hospital admins). I don't think the tightness of the relationship between the mega groups and hospital admins would survive being challenged by a deal that is financially better for the hospitals. No one is sentimental about the nature of the arrangements in this industry except the docs. Certainly the hospital admins don't care as long as they look good and the hospital is doing ok financially. The reason the above isn't happening is because the CMGs are the more efficient competitor most of the time.

 

[carbonizedeyesockets]

I am pretty sure that most EM physicians, even the hardcore anti-CMG AAEM folks, do not have a problem with the EM physician not taking 100% of what is billed. We understand that money needs to be siphoned off to cover malpractice insurance, administrative costs, etc, etc. And I don't think many of us have a problem with more senior physicians getting higher pay or fewer hours, or for some of what is taken being taken as profit or put aside for investment. What docs want is transparency, fairness, and some integrity in those who steer the ship. We don't want spineless old-heads who will sell out younger generations like the partner at EMA (NJ) did when they sold out to EmCare (new docs had their hours increased, pay cut, and staffing was cut at many sites. They didn't see a penny of the buy-out. They were screwed by the partners. Those sell-outs are the bane of EM.) I have no respect for anyone in this profession (and world) who is out for themselves and themselves alone.

 

[witzelsucht]

question from a new intern - i worked in a small ER run by an SDG before med school and would very much like to go back there as a doc when i'm finished. i got the sense that they were in the "abuse new guys for $150 + extra nights while fat cats earned $600k" category, although there was no way to be sure with the info I had. that being said, the location is mega +++ for me due to family + in-laws situation and being the only gig in town. what's my strategy to end up there without getting blasted in the ass? am i just going to have to eat the **** sandwich and choose between getting blasted by the SDG, selling my soul to the CMG the next county over, or moving to montana and having my wife kill me?

 

[carbonizedeyesockets]

question from a new intern - i worked in a small ER run by an SDG before med school and would very much like to go back there as a doc when i'm finished. i got the sense that they were in the "abuse new guys for $150 + extra nights while fat cats earned $600k" category, although there was no way to be sure with the info I had. that being said, the location is mega +++ for me due to family + in-laws situation and being the only gig in town. what's my strategy to end up there without getting blasted in the ass? am i just going to have to eat the **** sandwich and choose between getting blasted by the SDG, selling my soul to the CMG the next county over, or moving to montana and having my wife kill me?

Find out how many physicians have made partner in the past few years. SDGs can be just as shady as CMGs. It's not unheard of for some SDGs to hire someone to a partner track and then find a reason to let them go before they make partner. The other thing to consider is that the big CMGs do like to buy up SDGs and as happened w/ EMA, the older docs who are ready to retire may have no qualms with taking on new hires for a partner track and then selling the practice for a huge chunk of cash and leaving those who didn't make partner waving in the wind to either eat **** or look for a better job.

 

[deleted480308]

These are the kind of conversations I wish more staff had with us in school

 

[bravotwozero]

These are the kind of conversations I wish more staff had with us in school

I think you've got enough to learn and worry about in medschool. Once in residency you should have a physician mentor, and they should be a great resource for you, as well as your PD.


Sent from my iPhone using Tapatalk

 

[10YrsOutBurnedOut]

"Pay is really poor here"

"250-260 an hour"

Was referring to the academic places.

 

[gman33]

I don't think docs burnout from lack of money.
The only way I see that is if you choose to work way too many hours to get a higher income.

If you work for someone else they have to profit from the relationship or else there is no reason for them to employ you.

If you don't like it, try to find a better deal or else start your own business.

 

[goodoldalky]

One of the ways I see my partners burn out is by increasing their expenses too quickly. IMO. Their retirements are not set yet, they buy very expensive houses without putting 20% down, they don't pay their loans off right away, they join a country club, then they buy 2 luxury cars and put their kids in private school, their spouse stops working. Next thing they know they have $15K a month in expenses, a lot of that interest, and they have no choice but to pull 16-20 shifts a month, no end in sight.

There are others that don't do that and they work their 10-14, don't get stressed about pay related things, go on vacation when they want, cut back when they want, etc. granted they probably drive a Honda and live in a 3 bedroom house, but pick your poison...

 

[Arcan57]

I am pretty sure that most EM physicians, even the hardcore anti-CMG AAEM folks, do not have a problem with the EM physician not taking 100% of what is billed. We understand that money needs to be siphoned off to cover malpractice insurance, administrative costs, etc, etc. And I don't think many of us have a problem with more senior physicians getting higher pay or fewer hours, or for some of what is taken being taken as profit or put aside for investment. What docs want is transparency, fairness, and some integrity in those who steer the ship. We don't want spineless old-heads who will sell out younger generations like the partner at EMA (NJ) did when they sold out to EmCare (new docs had their hours increased, pay cut, and staffing was cut at many sites. They didn't see a penny of the buy-out. They were screwed by the partners. Those sell-outs are the bane of EM.) I have no respect for anyone in this profession (and world) who is out for themselves and themselves alone.

So a lot of docs do have a problem with older docs making more money or having better schedules. There's a reason that the CMGs almost universally have a flat pay structure with sweetheart schedules either non existent or used as a recruiting tool for the new docs. If CMGs thought they could recruit and retain with graduated pay tiers and fewer night shifts for aging docs then they would. There just isn't (enough) of a demand and as noted by above posters many mid-career docs are trapped by expenses and unable to effectively chase a better work/life balance.

In terms of sell-outs, I agree that they suck for the partnership track docs. I would submit that these sell-outs tend to happen for a reason and unchecked greed from a retiring founder is rarely the cause. If a contract is worth buying out, it's usually because the group is doing a good job but can't maintain the growth demanded by the hospital system. Many of the buy-outs are the result of the partners realizing that they aren't going to be able to keep the contract going forward and trying to salvage something of value out of the 1000s of hours they've put into building and maintaining the group. I would be surprised if the payment for the practice would be enough to make the prepartners "whole" although distributing some portion of the buy-out based on seniority would probably be the most moral thing to do.

 

[deleted109597]

I don't think many of us have a problem with more senior physicians getting higher pay or fewer hours

No, every doc I've met says that people should get the same pay for the same work. That's why most of us hard workers like RVUs, and the slugs like flat rates. I've seen enough of the fire team/ambassadors that come in to "help", get a set schedule of multiple days in a row while the full timers get every other day switches from days to nights, all while getting paid more to piss off the nurses and administration, to say that you're absolutely wrong about this.

Leaders lead. If you're a leader, you work every shift, not just the "good ones". Sure, if someone wants a stipend/buydown to be director/chair/whatever, that's different. They're getting paid to do different work, not less. And it's important work. And after a certain age, the argument used against working nights can just as easily be worded "shouldn't work at all".

I'm sure in residency there are residents you enjoy working with and ones you don't. Just wait until the people you don't like working with are making more than you because of the reasons you've stated.

 

[10YrsOutBurnedOut]

You nailed it.

No, every doc I've met says that people should get the same pay for the same work. That's why most of us hard workers like RVUs, and the slugs like flat rates. I've seen enough of the fire team/ambassadors that come in to "help", get a set schedule of multiple days in a row while the full timers get every other day switches from days to nights, all while getting paid more to piss off the nurses and administration, to say that you're absolutely wrong about this.

Leaders lead. If you're a leader, you work every shift, not just the "good ones". Sure, if someone wants a stipend/buydown to be director/chair/whatever, that's different. They're getting paid to do different work, not less. And it's important work. And after a certain age, the argument used against working nights can just as easily be worded "shouldn't work at all".

I'm sure in residency there are residents you enjoy working with and ones you don't. Just wait until the people you don't like working with are making more than you because of the reasons you've stated.

 

[deleted206819]

One of the ways I see my partners burn out is by increasing their expenses too quickly. IMO. Their retirements are not set yet, they buy very expensive houses without putting 20% down, they don't pay their loans off right away, they join a country club, then they buy 2 luxury cars and put their kids in private school, their spouse stops working. Next thing they know they have $15K a month in expenses, a lot of that interest, and they have no choice but to pull 16-20 shifts a month, no end in sight.

There are others that don't do that and they work their 10-14, don't get stressed about pay related things, go on vacation when they want, cut back when they want, etc. granted they probably drive a Honda and live in a 3 bedroom house, but pick your poison...

I'm two years out of residency and I've bought a home with 0% down, paying my loans off in 10 years, and have 2 luxury cars. My monthly expenses top maybe $10-12k. I'm maxing out my 401k account to the tune of $53k per year, I'm already invested in two FSEDs, and getting a good hourly rate (all RVU) from my SDG. While I am working 180 hours a month, I'm invested in working 48 hours a month in the FSEDs.

I can cut back on my hours and will most likely do so in the next 1-2 years but I can easily afford my lifestyle and still have a whole lot saved.

I understand the need to save money, pay off loans, and perpetually "live like a resident" for several years until the finances are in good condition but there's a price to pay for this scrounging in terms of quality of life, starting a family, and enjoying life while still young. Who knows what will and can happen in the future? If you have the funds, carpe diem and still look after your retirement.

 

[Tungsten5]

Any insight on New England + NY?

 

[RustedFox]

Any insight on New England + NY?

Sucks.

 

[GeneralVeers]

I don't have a problem with CMGs making money off of us. We are expensive and there is overhead, in credentialing, malpractice, and other administrative costs. Like everything this is market driven. Want to work in SFO or AUS? Great, but there is a lot of competition for jobs, and the CMGs know that. They are going to make a huge profit off of the docs that work there because the market dictates that they can pay bargain basement rates. In other states or other cities the job market is tougher for them to fill, and they have to jack up rates to get people to work there. I happen to work in a market where we absolutely rape the CMGS for a regularly hourly rate and for bonuses. They are on net losing money in those areas, but they do so knowing that these sites are part of a larger hospital system and lets them keep their lucrative contracts in AUS or DFW.

When more of us choose to pursue the higher dollar contracts and shun the low-paying ones, it will tend to drive up rates all over.

 

[The White Coat Investor]

I'm two years out of residency and I've bought a home with 0% down, paying my loans off in 10 years, and have 2 luxury cars. My monthly expenses top maybe $10-12k. I'm maxing out my 401k account to the tune of $53k per year, I'm already invested in two FSEDs, and getting a good hourly rate (all RVU) from my SDG. While I am working 180 hours a month, I'm invested in working 48 hours a month in the FSEDs.

I can cut back on my hours and will most likely do so in the next 1-2 years but I can easily afford my lifestyle and still have a whole lot saved.

I understand the need to save money, pay off loans, and perpetually "live like a resident" for several years until the finances are in good condition but there's a price to pay for this scrounging in terms of quality of life, starting a family, and enjoying life while still young. Who knows what will and can happen in the future? If you have the funds, carpe diem and still look after your retirement.

Sounds like you've found a reasonable balance. But 180 hours a month is a lot to do long-term and 10 years is a long time to carry loans. It would seem you could either pay off the loans faster or work fewer hours. I mean, if I was working 180 hours a month any reasonable amount of loans would be gone in 2 years, not 10 despite putting $53K into a 401(k) and driving a nice car. 180 x 12 x $250 = $540K. Let's say $200K to taxes, $120K to other expenses, $53K to the 401(k), $30K a year toward luxury cars, and that still leaves $120K a year for loans. How much do you have in loans that it will take 10 years at that income?

 

[deleted206819]

Sounds like you've found a reasonable balance. But 180 hours a month is a lot to do long-term and 10 years is a long time to carry loans. It would seem you could either pay off the loans faster or work fewer hours. I mean, if I was working 180 hours a month any reasonable amount of loans would be gone in 2 years, not 10 despite putting $53K into a 401(k) and driving a nice car. 180 x 12 x $250 = $540K. Let's say $200K to taxes, $120K to other expenses, $53K to the 401(k), $30K a year toward luxury cars, and that still leaves $120K a year for loans. How much do you have in loans that it will take 10 years at that income?

I just made partner last month so collections are ramping up and therefore not making much at this time. 140 out of the 180 hours are in the main EDs while the next 48 hours are in our FSEDs where we still aren't paying ourselves to bring down debt (working for free essentially). Eventually the 180-190 hours a month will be whittled down to a more manageable number. The plan is to ramp up paying off the school loans ASAP once the collections ramp up.