Future of freestanding EDs

[TrumpetDoc]

I have been doing a lot of reading lately about UCs and Freestanding EDs and there is a LOT of negative press out there on the freestanding model. I mean a lot! All make actually some pretty valid points from a public policy standpoint on costs, when talking about the significant amount of very low acuity people who seek care in FSEDs.

Question for those out there, particularly for those who have been involved in a FSED startup: what's your outlook on FSEDs?

Seems like just a matter of time, and with the amount of press and publicity of costs, before Uncle Sam throws the hammer down, or at least commercial insurers cut back payments.

We are as a group motivated to start one (likely in another state as ours req certificate of public advantage), but my gut is uneasy as to the sustainability of the model
There is a disproportionate amount of press against the model and just a spattering of "pro" press usually in response to negative pressure from media.

Otherwise UC is always an option, but market saturation/competition is an issue there too as everyone an there 6 year old seem to be putting them up.




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[southeastwizards]

Full disclosure: if you look through my brief post history, I am admittedly somewhat disgruntled with the world of EM right now.

I work in both hospital and freestanding emergency departments. Why are the popping up? Because they're making their owners, often ER docs, a **** load of money. And how are they making this money? By charging ER prices (aka facility fees) for minor complaints that could be handled at an UC or PCP.

I know all the selling points. We're helping decrease the burden from overwhelmed hospital ERs. We're providing patients a more pleasant experience, with immediate greeting and brief lengths of stay. We're providing a boutique service that the market is demanding.

Every now and then, I see a sick person come through the FSED. I relish those occasions, because I feel like I'm actually helping. But that's few and far between; the vast majority of the time I'm giving out unnecessary antibiotics to well-insured, upper middle class patients for their bronchitis, who simply want the convenience of not having to schedule a PCP appointment.

In my neck of the woods, here's where it becomes truly bizarre.

Because the FSEDs have become goldmines, and because they're chill places to work at (10-20 patients in 24 hours), many of the ABEM ER docs have switched solely to FS practice. This has actually created a shortage in ABEM docs to staff hospital ERs. (I live in urban/suburban, not rural.) In turn, there has been an influx of FM/IM docs with "EM experience" at the hospital ERs. Do you see what this means? We have created a system in which:

• Specialty trained emergency physicians are now taking care of primary care patients
• Family and internal medicine physicians are now taking care of emergent patients

So to answer your question, no, I do not think this is sustainable. I know this comes off as blasphemy to the docs who are raking in the dough, but the system has to change.

 

[Birdstrike]

I'm pro-FSED. It's the ER doctors version of an independent ambulatory surgery center. In fact, I think it was an epic error that more doctors didn't do this sooner. You may be right that the government could bring the hammer down on reimbursements for these.

Or they may not.

You just don't know. They're content to pay 5-6 times for for identical procedures to be done in hospitals than a doctors office. They're content to pay 2-3 times more to have the same things done in an ASC versus doctors office. (See Pain, Ortho and other subspecialist procedures, ie, Kyphoplasty, etc). Maybe they'll kill these off, or maybe they'll pay buck bucks to buy them out. Maybe they'll increase their reimbursement, decrease it; or decrease or increase yours? Nobody knows.

You'd hope that if they decided to make a major change they'd grandfather in older FSEDs but again, there's no guarantee when you have people with a history of making non-sensical rules writing the rules. There's definitely risk, and you have to manage it (involve lawyers, CPAs, MBAs that know this cold), and feel comfortable with that risk. But there's potential gains, some of which are monetary. Others are intangible (such as being free of EMTALA, hospital politics, what staff to keep or fire, what hours to keep and deciding yourself what "patient satisfaction" is as opposed to administrators).

If you protect yourself asset-wise, plan it well, do your homework and set it up so you have a fair amount of control, it might be right for you. Be aware, that it would involve taking on a second job of "businessman" and the inherent headaches and new set of skills to learn. It might be well worth it. It might not.

In my opinion, ER doctors need to grow a set of stones and take advantage of more opportunities like this while they're still possible, or forever be subject to the whims of administrators, Press-Ganey, and EMTALA in practice settings with zero control, hanging from the puppet strings of others.

(Disclaimer: I do not have specific experience with any FSED or Urgent Care per se, but do have experience with setting up my own outpatient practice in conjunction with a doctor-owned multi-specialty group, of which I am a share holder and on the board of directors, so not entirely dissimilar).

 

[EctopicFetus]

I may have read it wrong but birdstrike, FSEDs are still subject to EMTALA. I think the win is if you own them you control who you are contracted with and dont have to deal with overpaid ignorant administrators telling you what to do.

 

[GeneralVeers]

FSEDs must be EMTALA compliant, and get ambulance traffic too.

I worked a couple of shifts at one and hated it for the following reasons:
1. Pay is low compared to other EM practices (usually about $130-$140/hour)
2. Entitled patients who are demanding and complain if every ridiculous whim of theirs isn't met
3. "Customer Service" approach, and encouraging patients with minor/PCP complaints to come in
4. Very few high-acuity interesting patients.

 

[Birdstrike]

I may have read it wrong but birdstrike, FSEDs are still subject to EMTALA.

Not necessarily. FSEDs are not always subject to EMTALA. It depends on certain factors, but it's not always the case as it is with a hospital ED. I never, ever, would consider being associated with a FSED that was under EMTALA. Never. Open a business that is ruled under a law that entitles all of America to my services for free, with my investment dollars? Excuse me while I break to laugh uncontrollably.

FSEDS are not necessarily, depending on the state and other factors, subject to EMTALA. If you can post something that proves they always are, I will edit and delete everything I wrote in the post above.

 

[@JackShephard]

Full disclosure: if you look through my brief post history, I am admittedly somewhat disgruntled with the world of EM right now.

I work in both hospital and freestanding emergency departments. Why are the popping up? Because they're making their owners, often ER docs, a **** load of money. And how are they making this money? By charging ER prices (aka facility fees) for minor complaints that could be handled at an UC or PCP.

I know all the selling points. We're helping decrease the burden from overwhelmed hospital ERs. We're providing patients a more pleasant experience, with immediate greeting and brief lengths of stay. We're providing a boutique service that the market is demanding.

Every now and then, I see a sick person come through the FSED. I relish those occasions, because I feel like I'm actually helping. But that's few and far between; the vast majority of the time I'm giving out unnecessary antibiotics to well-insured, upper middle class patients for their bronchitis, who simply want the convenience of not having to schedule a PCP appointment.

In my neck of the woods, here's where it becomes truly bizarre.

Because the FSEDs have become goldmines, and because they're chill places to work at (10-20 patients in 24 hours), many of the ABEM ER docs have switched solely to FS practice. This has actually created a shortage in ABEM docs to staff hospital ERs. (I live in urban/suburban, not rural.) In turn, there has been an influx of FM/IM docs with "EM experience" at the hospital ERs. Do you see what this means? We have created a system in which:

• Specialty trained emergency physicians are now taking care of primary care patients
• Family and internal medicine physicians are now taking care of emergent patients

So to answer your question, no, I do not think this is sustainable. I know this comes off as blasphemy to the docs who are raking in the dough, but the system has to change.

Great post.

 

[TrumpetDoc]

I hear you both. I understand the problems with the payment structure that was said before however personally I'm with Bird on this as I'm also very pro FSED.
I'm so incredibly disenfranchise by the way hospitals micromanage our practicing and how this appears to be getting worse and almost weekly basis, as well as the almost full-fledged takeover of our specialty by large corporate groups.
This is an area where we can regain some control. I am with the pros on the usage and benefit of the freestanding emergency departments. I do not, under any circumstances, believe that increasing urgent cares will solve this as we all know we get umpteen a number of urgent care transfers for things they simply "can't handle".
Should they be paid out at emergency department fees? If it's staff by board-certified doctors performing services capable of their specialty, Hell yes! We all know that every ER we all working gets an uncountable number of "urgent care" patients. Freestanding emergency departments are not going to suddenly increase the number of patients who seek the ER for urgent care services; it will simply divert them to another location. Of course, this will cannibalize other ERs as well, but can decrease the overcrowding burden of others at the same time.

Is there a way to make FSEDs a more valuable part of the medical community? Sure. Why couldn't the local insurance providers give the freestanding emergency department staff the power to access their appointment program and/or service and arrange prompt next day follow up, even prompt elective surgery scheduling with the consult of the surgeon through the office of the freestanding ED? We have tried to get this to work through our ER hospital system but of been unsuccessful, but for silly reasons such as staff not wanting the extra work and hospitals wanting the surgery cases and admits for themselves. However, it seems like something that insurance companies at least should be interested in as this can lead to cost savings and decrease admissions for them. I feel that as a physician owned entity, with our goals and objectives in mind, we would have the ability to negotiate this sort of deal with insurance companies and really do have a positive impact on the care of patients in the community. Would it be easy, prob not, but can be done I am sure. In fact I would be surprise if not done already in FSEDs

I'm on the younger side of the age spectrum, so I of course missed out on the "early" boom of this field. However my motivation is very strong and I am already educating myself and plan on formal business training as well. I would have no problem initiating this however as mentioned above, there is considerable risk, and the type of risk that we really have no control over. Besides the inherent risks of any entrepreneurial venture, there's also this elephant in the room of how this will be affected in the future. I suppose, the reason why this seems to worry me more than say another medical venture, as really any medical practice has risks of reimbursement problems, is that there seems to be an overwhelming amount of negative articles and a negative vibe about these entities in the lay press. My fear is that with all this negative push by the lay press, and likely equal lobbying by urging care associations, that this will push the balance more towards a possible significant negative impact on FSEDs, and worse yet, abolishing them.

However there's also this lingering feeling I have inside that if I wait too long to make a move I will be making a big mistake, knowing that even if I decided to partner up and get this process started there is rather significant time frames to get these things operational.

I will say, on the upside, that even the past several months just educating myself, really contemplating going through with such a venture, talking with people, this is really invigorated me and led me to be much more motivated. You start to get the sense that even if your first ideas don't go through, that you know you're going to be able to make something work…Starting to see the light at the end of the tunnel.

 

[TrumpetDoc]

I hear you Veers Working as employee of one I could not do FT either
But owning and operating is a different story.

Agree, with the EMTALA concerns. There is SO much state variation, and a lot of the legislation is really vague.
I suppose I would hope what a colleuge who works in one said is true that if EMTALA bound, it still comes off as, and looks, posh so the uninsured seem to self triage away from it. They uninsured volume is low and they RMA and charge up front.

 

[Birdstrike]

FSEDs must be EMTALA compliant, and get ambulance traffic too.

I worked a couple of shifts at one and hated it for the following reasons:
1. Pay is low compared to other EM practices (usually about $130-$140/hour)
2. Entitled patients who are demanding and complain if every ridiculous whim of theirs isn't met
3. "Customer Service" approach, and encouraging patients with minor/PCP complaints to come in
4. Very few high-acuity interesting patients.

I'm not going to claim to be an expert on FSEDs, but in regards to the EMTALA issue, I would direct you to the links below. My general understanding is, that whether or not you are bound by EMTALA depends entirely on how the FSED is set up, dependent on the State and other factors, but it's not an absolute that one must be bound by EMTALA. It's a complicated enough issue, that you would obviously need to have a healthcare attorney involved if you absolutely need to know every detail, or are considering opening one up.


From the director of a FSED:

"George Pettit, MD November 14, 2012 at 4:56 AM
I have been working at a free-standing ER in Houston for the past 2 years; for the last 6 months I have been the Medical Director. Our ER is owned and operated by an Orthopedist who has offices and a surgery center which is upstairs in our building. Our relationship with this owner has been excellent; although he obviously has to be concerned with profitability, he is an excellent doctor and has made no effort to interfere at all with our practice of medicine. Since we are not affiliated with a hospital, we are not bound by federal EMTALA laws; however, we are licensed by the state of Texas and according to their guidelines, they state that we should obtain contact with an accepting doctor at any hospital that we transfer a patient to. Nevertheless, when we transfer patients, we generally make an effort to deal with the hospital’s transfer center, but if we are able to contact an accepting doctor, we can always just send the patient to the hospital (usually via the hospital ER after we notify the ER doctor). I have discussed this issue with the federal EMTALA experts, and they tell me that as a free-standing ER, not affiliated with a hospital, we are “not capable of committing” an EMTALA violation."

http://freestandingerblog.com/


EMTALA is a federal law. From ACEP:

"IFSEDs generally do not accept Medicare assigment. Thus, they are not regulated at the Federal level"

http://www.acep.org/uploadedFiles/A...n/Freestanding Emergency Departments 0713.pdf


This resource implies that whether or not your facility meets EMTALA guidlines affects how you bill, but isn't mandatory:

http://www.health.ny.gov/facilities.../meetings/2013-09-13/docs/feds_background.pdf

 

[Apollyon]

With a nod to @Birdstrike, I'll quote the Boomtown Rats: "African jungle/Big city streets/The only real difference/Is the people...you meet".

What's the difference between an urgent care and a free standing ED? It certainly isn't so clear to me. One big difference, at least in NY and SC, was whether one could receive ambulances, and, concurrently, were liable for EMTALA. They aren't linked, but occupy the same space. In NY, it is covered under Article 28 of the Public Health Law (EMS is under Article 30). Article 28 dictates what you need if you are receiving ambulances, including staffing.

In South Carolina, I am not so robust on the regulation, but I do know that, if a facility receives ambulances, there has to be at least 2 RNs 24 hours a day (this is not so in PA, as there is a critical access hospital at which I work that has just one RN overnight, with an LPN, but the LPN leaves at 6am, leaving only the doc and the RN in the ED).

What I do not understand is what is an independent, free-standing ED (i.e., not affiliated with a health system)? Is it the Medicare assignment accepting? Can someone with Medicare go to an urgent care? Or does MCare pay the UC (as in "urgent care", not "usual and customary") rate, instead of the cut off at the knees ED rate?

Or are these just names that we call them?

 

[Birdstrike]

With a nod to @Birdstrike, I'll quote the Boomtown Rats: "African jungle/Big city streets/The only real difference/Is the people...you meet".

Nice!

"Tell me why? I don't like Mondays. Tell me why? I don't like Mondays. I want to shoot, the whole day down!" - Boomtown Rats

 

[Hercules]

With a nod to @Birdstrike, I'll quote the Boomtown Rats: "African jungle/Big city streets/The only real difference/Is the people...you meet".

What's the difference between an urgent care and a free standing ED? It certainly isn't so clear to me. One big difference, at least in NY and SC, was whether one could receive ambulances, and, concurrently, were liable for EMTALA. They aren't linked, but occupy the same space. In NY, it is covered under Article 28 of the Public Health Law (EMS is under Article 30). Article 28 dictates what you need if you are receiving ambulances, including staffing.

In South Carolina, I am not so robust on the regulation, but I do know that, if a facility receives ambulances, there has to be at least 2 RNs 24 hours a day (this is not so in PA, as there is a critical access hospital at which I work that has just one RN overnight, with an LPN, but the LPN leaves at 6am, leaving only the doc and the RN in the ED).

What I do not understand is what is an independent, free-standing ED (i.e., not affiliated with a health system)? Is it the Medicare assignment accepting? Can someone with Medicare go to an urgent care? Or does MCare pay the UC (as in "urgent care", not "usual and customary") rate, instead of the cut off at the knees ED rate?

Or are these just names that we call them?

It is defined on a state by state basis. Alabama has a different definition than the SC one you referenced and does not require 2 RNs but does require a rad tech and an EM Boarded Medical Director. Our state regulations also specifically state that "urgent care" cannot be in the name.

 

[EctopicFetus]

Not necessarily. FSEDs are not always subject to EMTALA. It depends on certain factors, but it's not always the case as it is with a hospital ED. I never, ever, would consider being associated with a FSED that was under EMTALA. Never. Open a business that is ruled under a law that entitles all of America to my services for free, with my investment dollars? Excuse me while I break to laugh uncontrollably.

FSEDS are not necessarily, depending on the state and other factors, subject to EMTALA. If you can post something that proves they always are, I will edit and delete everything I wrote in the post above.

I guess in my mind anyone who is an ED takes medicare/medicaid etc. Emtala and many other laws only pertain to those who accept medicare/medicaid though many states like Texas have an EMtala-like law for licensure.

 

[EctopicFetus]

It is defined on a state by state basis. Alabama has a different definition than the SC one you referenced and does not require 2 RNs but does require a rad tech and an EM Boarded Medical Director. Our state regulations also specifically state that "urgent care" cannot be in the name.

Here is another resource.

http://www.ucaoa.org/docs/Article_Freestanding.pdf

search within it for "EMTALA". This is clearly a little bit of the wild west right now but I agree there is money to be made.

 

[EM Junkie]

I work at 2 FSEDs in Houston in addition to my full time gig as a hospital ED Medical Director. I have no ownership interest, however. Pay is $140-160/hr on average, with very low acuity.

Texas law has applied an EMTALA-like obligation on these facilities, but most do not accept Medicare or Medicaid so as to be free from federal interference.

The hospital-affiliated FSEDs are different: they are subject to EMTALA, take Medicare and Medicaid, and can accept ambulances (although I'm not aware of any that actually do).

Personally I see the allure ($$$$), but I view the non-hospital affiliated FSEDs as a scam, especially since so many aren't even staffed by ABEM docs.

 

[Got Em]

Does anyone know if non-physicians can be an owner (partial at least) of FSERs in Texas? I already looked on the DSHS website's PDF and it doesn't mention this anywhere.

 

[link2swim06]

Speaking of EMTALA can anyone explain why attendings cannot deduct all the non-paying patients off their taxes like any other business?

 

[Birdstrike]

Speaking of EMTALA can anyone explain why we cannot attendings cannot deduct all the non-paying patients off their taxes like any other business?

Because the tax laws are written to say that we can't. It's that simple.

Now, if you're asking why the law is written that way, then the answer is a political one, more along the lines of, "There is no support to cut taxes or provide special tax deductions for doctors (regardless of specialty) who fall into the category of 'wealthy.'" There will not be any support for such a tax reduction, no matter how just you feel it is, with this current administration. Obama has in fact raised, and I'm sure would like to raise more, the taxes of those in your/our tax bracket.

Sorry, no tax cut for you. You're "rich." You need to pay your fair share, which translates into "more taxes" not less.

 

[Millennial ER Doc]

BUMP

Please correct me if I'm wrong, but a FSED can be staffed by family med docs.... right?

Do any laws (besides institution specific bylaws) exist that state that a FSED needs an ABEM boarded ER doc?

 

[southerndoc]

BUMP

Please correct me if I'm wrong, but a FSED can be staffed by family med docs.... right?

Do any laws (besides institution specific bylaws) exist that state that a FSED needs an ABEM boarded ER doc?

There are no laws that state that an ER has to be staffed by board-certified emergency medicine physicians. Staffing is dictated by hospital bylaws, not by state laws or regulations.

Most states do not regulate any practice (i.e., as an ER doc you can practice plastic surgery -- but you may have difficulty getting malpractice insurance). One ER doc in Georgia became a plastic surgeon and had her license revoked after several bad outcomes. Criminal charges were filed, but later dropped.

 

[deleted109597]

BUMP

Please correct me if I'm wrong, but a FSED can be staffed by family med docs.... right?

Do any laws (besides institution specific bylaws) exist that state that a FSED needs an ABEM boarded ER doc?

Correct. The ER is pretty much the only place in any hospital that the people working there don't need to be board certified in the job they do. My FSED does require BC/BE. The hospitals in my city of 300,000 do not require it at all of them. One level II trauma staffs with FM docs. There's a level I trauma that has FM docs in another part of the state.
Don't cloud your judgement of FSEDs by using a metric that isn't used by hospitals.

ACEP has looked to "credentialing" FSEDs similar to the ACS does trauma centers. It has so far met resistance and isn't being developed because they're worried they would have higher criteria than most hospitals.

 

[BoardingDoc]

One ER doc in Georgia became a plastic surgeon and had her license revoked after several bad outcomes. Criminal charges were filed, but later dropped.

Damn, this is messed up. 2 people died.

 

[deuist]

Damn, this is messed up. 2 people died.

Was this the dancing doctor? I thought that she was a plastic surgeon according to one of the articles.

Also, no one should working in an emergency department except for a residency-trained emergency physician. That goes for free-standings as well. I briefly moonlighted at a rural freestanding and was horrified to see the family medicine docs stopping CPR to get chest X-rays during a code.

 

[Apollyon]

Was this the dancing doctor? I thought that she was a plastic surgeon according to one of the articles.

Also, no one should working in an emergency department except for a residency-trained emergency physician. That goes for free-standings as well. I briefly moonlighted at a rural freestanding and was horrified to see the family medicine docs stopping CPR to get chest X-rays during a code.

How rural could that freestanding be, if there were two attendings (such as you were, if you were moonlighting as a resident - residency trained, but not BC/BE)? I work rurally, and, for 70-90% of the day, I'm the only doc in the entire hospital.

 

[deleted859535]

Was this the dancing doctor? I thought that she was a plastic surgeon according to one of the articles.

Also, no one should working in an emergency department except for a residency-trained emergency physician. That goes for free-standings as well. I briefly moonlighted at a rural freestanding and was horrified to see the family medicine docs stopping CPR to get chest X-rays during a code.

Wow.

 

[LibBum]

Was this the dancing doctor? I thought that she was a plastic surgeon according to one of the articles.

Also, no one should working in an emergency department except for a residency-trained emergency physician. That goes for free-standings as well. I briefly moonlighted at a rural freestanding and was horrified to see the family medicine docs stopping CPR to get chest X-rays during a code.

The dancing doctor was trained as a dermatologist, then took up plastic surgery.

 

[southerndoc]

Was this the dancing doctor? I thought that she was a plastic surgeon according to one of the articles.

No, totally different patient.

 

[southerndoc]

Damn, this is messed up. 2 people died.

All I can say is that there were many mess ups. It was absolutely unbelievable how botched some of her patients were.

But hey, because Vitals.com has reliable ratings like Press-Ganey, her score is 3.2!

 

[BoardingDoc]

All I can say is that there were many mess ups. It was absolutely unbelievable how botched some of her patients were.

But hey, because Vitals.com has reliable ratings like Press-Ganey, her score is 3.2!

Dead men leave no reviews.

 

[deuist]

How rural could that freestanding be, if there were two attendings (such as you were, if you were moonlighting as a resident - residency trained, but not BC/BE)? I work rurally, and, for 70-90% of the day, I'm the only doc in the entire hospital.

I did not moonlight there as a resident. I picked up a few shifts as a BC EM attending when they got desperate enough to start paying. It was rural, but busy enough to justify 34 hours of coverage a day.

 

[deuist]

The dancing doctor was trained as a dermatologist, then took up plastic surgery.

There were 2 docs in Georgia pretending to be plastic surgeons?

 

[LibBum]

There were 2 docs in Georgia pretending to be plastic surgeons?

Doctor seen singing and dancing during surgery called "threat to public safety" - CBS News

 

[NurWollen]

There was an internist in Arizona pretending to be a plastic surgeon. He was later convicted of murder. Doctor of Death Peter Normann Gets 25 Years in Prison For Deaths of Three Patients

 

[namethatsmell]

There was an internist in Arizona pretending to be a plastic surgeon. He was later convicted of murder. Doctor of Death Peter Normann Gets 25 Years in Prison For Deaths of Three Patients

So I realize it's way more of a leap than this and the other examples in the thread, but are IM and FM docs working in an ED at a meaningfully increased medmal risk since they didn't do formal EM training?

 

[Vandalia]

So I realize it's way more of a leap than this and the other examples in the thread, but are IM and FM docs working in an ED at a meaningfully increased medmal risk since they didn't do formal EM training?

Yes, but that is what they have malpractice insurance for. It is incredibly rare for liability to exceed the insurance limits when all is said and done.

 

[namethatsmell]

Yes, but that is what they have malpractice insurance for. It is incredibly rare for liability to exceed the insurance limits when all is said and done.

Perhaps my question wasn't clear. I meant something more along the lines of "are they sued more to the point they have to pay more for medmal insurance?" I wonder if things will eventually get to the point for non-EM folks working in the ED where they'll have an easy target on their back like that internist doing lipo and then tubing the goose when things go south.

Not trying to start a measuring contest with our FM/IM colleagues, just rambling with the help of scotch.

 

[miacomet]

Perhaps my question wasn't clear. I meant something more along the lines of "are they sued more to the point they have to pay more for medmal insurance?" I wonder if things will eventually get to the point for non-EM folks working in the ED where they'll have an easy target on their back like that internist doing lipo and then tubing the goose when things go south.

Not trying to start a measuring contest with our FM/IM colleagues, just rambling with the help of scotch.

Mmm scotch.

 

[deleted109597]

I doubt there's good data on it. But what we know is the Dunning Kruger effect is real. They don't know and aren't afraid of what they don't know, but thye're overconfident about things they shouldn't be. So you'll see them not give procedural sedation correctly (using fentanyl and versed), or starting cardizem gtt on WPW. But they'll also discharge high risk chest pain and overly workup viral URIs and HTN. There's a spectrum, and a lot of EM docs do that too sadly.
I bet the CMGs do pay more for medmal, but they aren't going to tell us about it. That's the only reason my policy was costing me $20 an hour when I could buy it on the secondary market for $6 an hour. Subsidizing the terrible and the ones that choose to work in terrible states, especially considering envision was self insured.