Is the grass greener, or just a different shade of brown?

[deleted77919]

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[RustedFox]

I left my OldJob (HCA) for NewJob back in December.

The grass is waaaay greener. There's reasonable thought and approach applied to metrics, adequate staffing, and realistic throughput goals. Those were the dealbreakers back at OldJob, where you were penalized and scrutinized for not seeing every patient in 10 minutes or less, not discharging them in 2 hours or less, and not meeting insane Press-Ganey goals. Seriously... talk about "diametricaly opposing goals".

I went back and worked a shift at OldJob for a buddy last month (he had family in-town, wanted the day off). I saw three patients an hour for the first two hours, and in the next hour - there were admins in the department asking "why the wait times were so high". Mind you; the guy that worked the hours before me was slammed, so he couldn't get to everyone - leaving me to pick up patients who were already waiting 35-45 minutes to be seen.

I was stunned. KThxBye.

 

[deleted77919]

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[em1234]

I made the switch from SDG to CMG (heresy, I know) 2 years ago,
My SDG was a really fine place to work. Supportive admin, great department chair (me), good team of docs, nice patients. Problems were the pay sucked (mid atlantic pay) and I was always working more than I wanted because we were always 1 doc away from being fully staffed with lots of day/night flip flops. Add to that the hospital was really small, limited specialists consultants (neuro 2d/wk, cards 3d/wk, no MRI after 5p even for emergencies and at all from Friday to Monday), there were just enough things wrong that after 3 years the little frustrations outweighed the things I enjoyed.

So we packed up our family of 5 moved to where the stars at night, are big and bright....deep in the heart of Texas. After 2 years, the grass is definitely greener with the occasional spot of brown. The pay is crazy. I now make more than double my old salary. I have much better control over my schedule, as an IC with the CMG, I tell them exactly how many shifts I am willing to work each mo, no more, no less. The hospital I joined has a M-Th nocturnist, so I only end up covering a weekend worth of night shifts ever 2-3mos. The hospital has much better specialist coverage. Of course there is monthly grumbling from some C-Suite dbag about some metric that we effectively has no control over, but it never really goes anywhere. I have seen 1 case of corporate assassination of a doc who "didn't fit in" and was subsequently run out, which never would have happened at my old group. That was an eye opener as to the absolute lack of commitment the Sith Lords in charge of the CMG have for their docs.

In the end, I'm happy with the switch. I do grow nostalgic for my old group at times, but the docs I work with now are just as dedicated and steadfast to providing excellent care to a ghetto-ass underserved knife and gun club population. The CMG lets me provide the care that I think is appropriate. The money has been ridiculous. I have paid off all my and my wife's loans that were at >2% all the while maxing out my solo 401k, retirement accounts, saving in 529s, etc. I've been able to get invested into FSED's with people I've met at the CMG. I believe the WCI is right in that these are the golden years of EM. I am glad to be making hay while the sun is shining before bundled payment and punitive pay reduction for utilization become real issues. I'm glad we took the plunge.

Pretty green over here,
-1234

 

[GeneralVeers]

How can you work for a SDG and have low pay? Location shouldn't matter, as a SDG shouldn't be having the administrative overhead of a CMG. Additionally, all the money should stay at the local site, and if you're seeing 2-2.5 pts per hour, there's no reason your hourly shouldn't be at least $300.

 

[RustedFox]

How can you work for a SDG and have low pay? Location shouldn't matter, as a SDG shouldn't be having the administrative overhead of a CMG. Additionally, all the money should stay at the local site, and if you're seeing 2-2.5 pts per hour, there's no reason your hourly shouldn't be at least $300.

It sounds to me that his volume was turbo-low, such that 2-2.5 pts/hour wasn't what they were getting.

 

[GeneralVeers]

It sounds to me that his volume was turbo-low, such that 2-2.5 pts/hour wasn't what they were getting.

Either that or the top tier "partners" were taking a larger share of the collections.

 

[The White Coat Investor]

I left the military 6 years ago where I was making $130K for a SDG with a 2 year partnership track. Now I have no deployments, get to live in a part of the country I like, don't have to deal with insane administrative requirements from the nuttiest "hospital administration" you can possibly imagine, get more vacation, and make 3 times the money for seeing half the patients. Yeah, I guess the grass is greener. Downsides? More drug-seekers and much higher taxes. I can live with that.

 

[RustedFox]

Either that or the top tier "partners" were taking a larger share of the collections.

Maybe; but he says he was dept. chair. Seems to me that would come with partnership, or be a partnership-only position.

- and why is it called the C-suite when its full of D-bags? Discuss.

 

[em1234]

nothing as sinister as greedy mustache twisting upper level partners, or low volume. We saw ~90 people per day. averaging ~1.8-2pph. You both overshot the most import element of the financial viability of a SDG...payor mix. We were a rural hospital that was an unattractive payor combination where our medicare pts were our "big money" patients, uninsured migrant workers and uninsured hill people were very disproportionate, some days as high as 35%, lots of Medicaid, limited private insurance. Obviously, this hospital had continual financial viability issues and was ultimately absorbed by a chain.
I was a full partner, but even our partnership distributions weren't extravagant, ~5-10k twice a year.

I plan on referring to is as the D-Suite from now on.

 

[emergentmd]

I right there with you brother. Been with SDG, CMG and making a alot of money. More now doing some Locums and IC. Going into FSED this year and if we even see 10 pts/dy, I can retire.

 

[RustedFox]

nothing as sinister as greedy mustache twisting upper level partners, or low volume. We saw ~90 people per day. averaging ~1.8-2pph. You both overshot the most import element of the financial viability of a SDG...payor mix. We were a rural hospital that was an unattractive payor combination where our medicare pts were our "big money" patients, uninsured migrant workers and uninsured hill people were very disproportionate, some days as high as 35%, lots of Medicaid, limited private insurance. Obviously, this hospital had continual financial viability issues and was ultimately absorbed by a chain.
I was a full partner, but even our partnership distributions weren't extravagant, ~5-10k twice a year.

I plan on referring to is as the D-Suite from now on.

I hereby propose changing the term "C-suite" to "D-suite" in all parlance associated with SDN.

Second?

 

[BoardingDoc]

While not an attending, I have dealt extensively with this in my old career.

Second.

 

[Tenk]

I have worked a few hospitals and still do. I like my current full time job the most because sometimes patients say thank you to me, I like my staff, and I make good money.

As one of my attendings once told me: it is good to have privileges at many places because sometimes they will call you last minute and offer serious bank to fill a shift. Then when you go there, you realize why you stopped going there in the first place and miss your full time job all the more.

 

[deleted77919]

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[BoardingDoc]

Thanks for everyone's thoughts.

For a partnership track job at a SDG, how long do you guys think is too long as a prepartner. Obviously there is a risk you spend a year (or more) working at a below market rate only to have the group lose the contract, or unfairly not make partner. But assuming a good track rate of prepartners making partner and the contract has been stable (I realize this is no guarantee for the future) how long would you guys be willing to go? None? One year? Three years? Five years? Thoughts?

Not an attending yet, but am looking at jobs. 1-2 years is something I would feel comfortable accepting if the job seemed really great. 3 years would be a very hard sell. Anything over 3 and I wouldn't bother looking at all.

I would also want to know the group's attrition rate on the pre-partner --> partner track and gain some insight into the group's reasons for not promoting those who did not become a partner.

 

[dav86]

Agree with the above. 2 years max. I wouldn't bother with more than 2. You must know the group attrition rate before signing the contract. Our group have only had 3 people not make partner over the past 20 years and only 2 leave for other EM jobs. Most SDG jobs I looked at were two years. A resident friend of mine who went out west only has a year pre partner so it can vary.

 

[coachB]

Thanks for everyone's thoughts.

For a partnership track job at a SDG, how long do you guys think is too long as a prepartner. Obviously there is a risk you spend a year (or more) working at a below market rate only to have the group lose the contract, or unfairly not make partner. But assuming a good track rate of prepartners making partner and the contract has been stable (I realize this is no guarantee for the future) how long would you guys be willing to go? None? One year? Three years? Five years? Thoughts?

I would be very cautious wth extended partnership tracks in today's environment. The SDG is an endangered species and the large CMGs are hell bent on growth. Many long standing, well run groups with amazing compensation have recently sold out. When the existing partners are getting 7 figure payouts they don't really care that you just put in 2-3 years of sweat equity for nothing.

 

[gman33]

I would be very cautious wth extended partnership tracks in today's environment. The SDG is an endangered species and the large CMGs are hell bent on growth. Many long standing, well run groups with amazing compensation have recently sold out. When the existing partners are getting 7 figure payouts they don't really care that you just put in 2-3 years of sweat equity for nothing.

I'd love to believe that sdgs are going to be around for my career, but that does not seem to be the case.

If I was a partner looking to retire, I'd love to get a fat buyout.

I wouldn't consider a prepartner period of more than 1-2 years.

Each situation is unique, but just look closely at the market.

 

[emergentmd]

Thanks for everyone's thoughts.

For a partnership track job at a SDG, how long do you guys think is too long as a prepartner. Obviously there is a risk you spend a year (or more) working at a below market rate only to have the group lose the contract, or unfairly not make partner. But assuming a good track rate of prepartners making partner and the contract has been stable (I realize this is no guarantee for the future) how long would you guys be willing to go? None? One year? Three years? Five years? Thoughts?

Here is what I would do if I came out of residency knowing what I know. I have been partner in a SDG with a 2 yr partner track. I have been with a CMG. I have done Locums at 4+ different sites. I am working on building a FSED. I have a director at my big referral hospital for 6 yrs. I have been member of hospital committees/Med Exec Committee. I have been a member of the credentials Committee.

#1 - NO one Cares about you. As an EM doc or any doc in general, no one really cares about you. You are replaceable. Just because you have an MD attached to your name, you are just as dispensable as any other worker.
#2 - You have to look out for yourself. Its business. Do not inject emotions in your decision. Make a decision with Facts.
#3- SDGs are dying. They will continue to die bc Hospitals understand that EM docs make good money and can take some of that. They will die b/c SDGs just can't negotiate rates and bill as good as a CMG. Its economics. Even if your SDGs are well protected by administration without any threats of a takeover, your billing income has and will continue to go down. Your income is directed related to billings. When billings go down, you either have to hire Midlevels instead of docs or work more hours to keep income stable. But Economics will always win out. Eventually you can be super efficient but your income will eventually go down as payer mix/RVU rates go down. Eventually you will want to be bought out by a CMG. You better be smart to sell out when your contract is still attractive and can make the CMG money.
#4 - Hospital Payer mix will continue to trend towards medicare/medicaid/uninsured and away from private insurers. Why? Insurance companies are paying less, more people are on medicaid, and there are FSEDs who will siphon off the insured. As FSEDs are more accepted, insured pts will be going there. You get better service, faster service for the same if not cheaper price. I have worked in FSEDS. There is Zero wait. I can get labs/CT/full work up in 60 min and out the door in a big room/nice TV/attentive staff/pleasant doctors instead of the local hospital where it would take me 3 hrs where everyone is rushed.
#5 - SDGs income has been going down for the past 5-7 yrs for the same pt/hr. I saw all of the numbers and worked in a decent payermix. We kept our pay up by seeing more pt/hr and hiring Midlevels. But about 2 yrs ago, I could see that as payermix continued to go down, there was no more streamlining to be done. We all were facing decreased pay while working harder/more hours.

Knowing all of this, there is very little benefits in joining most SDGs. Sure there will be a rare unicorn SDG with great payer mix, great environment to work in that has little threat from a CMG. I am sure someone will tell me they work at one, but for 99% of EM docs this will not be the care.

New hires are lucky to be in a Great pay environment with a great shortage of EM docs. Why lock yourself in to 2 yrs of below market pay for the chance to essentially get paid as a partner at market rate? What does being a partner get you?

In my mind being a partner gets you very little as pay is not better than market while taking on a whole lot of risk and headaches. Owning your group means a great deal of stress jumping through all of the hospital's hoops to keep the contract.

Even if I could go directly back to the SDG with the partner distribution today, I would not even consider it.

I make much more doing CMG + Locums where I can make some of my schedule without the headache of ownership.

I would only take a CMG partner track if it is less than 2 yrs, No or very low Buy in, and in a City that I really want to live in.

 

[da8s0859q]

@emergentmd: always enjoy your posts. I signed with a SDG with a long history with the hospital and which has been stable for decades. Lot of ties, both organizational and political, between group and hospital. Bonuses have actually been increasing more recently. You work for it, but it's there. Two year track, slightly hefty buy-in. MGMA median my first year out, roughly.

Might I have found a decent SDG, or would you still have gone CMG if given that option?

 

[emergentmd]

@emergentmd: always enjoy your posts. I signed with a SDG with a long history with the hospital and which has been stable for decades. Lot of ties, both organizational and political, between group and hospital. Bonuses have actually been increasing more recently. You work for it, but it's there. Two year track, slightly hefty buy-in. MGMA median my first year out, roughly.

Might I have found a decent SDG, or would you still have gone CMG if given that option?

There are way too many moving parts for your decision but I would put Partnership tract/increase pay at the bottom of my needs list. There is really nothing magical or special about being a partner anymore unless you are one of the big owners who have a high percentage of the group. Joining a big SDG where you get 1-3% is not worth it.

If you can find a CMG in the same city or a more favored city, then I would not do a partnership track. This is assuming work environment and pay are similar.

It would take alot for my to join a SDG at this time. I would need to be in the city I want to live in, I would need similar pay pre partnership than what is offered locally, I would need a small buy in and partnership track, I would need the same schedule as everyone else. I would never want to be the scheduling whipping boy or have to work at the worse hospital to be prepartner.

The great organization/political ties, relationship, etc.... mean very little. Trust me. If a CMG offers a buy out tomorrow to one of the big owners or the Hospital CEO gets a "bonus" from a CMG to pick them, all the ties are thrown out. I have been through this. The partners, I included, did very well and were happy.

The Pre Partners go the shaft.

 

[The White Coat Investor]

Here is what I would do if I came out of residency knowing what I know. I have been partner in a SDG with a 2 yr partner track. I have been with a CMG. I have done Locums at 4+ different sites. I am working on building a FSED. I have a director at my big referral hospital for 6 yrs. I have been member of hospital committees/Med Exec Committee. I have been a member of the credentials Committee.

#1 - NO one Cares about you. As an EM doc or any doc in general, no one really cares about you. You are replaceable. Just because you have an MD attached to your name, you are just as dispensable as any other worker.
#2 - You have to look out for yourself. Its business. Do not inject emotions in your decision. Make a decision with Facts.
#3- SDGs are dying. They will continue to die bc Hospitals understand that EM docs make good money and can take some of that. They will die b/c SDGs just can't negotiate rates and bill as good as a CMG. Its economics. Even if your SDGs are well protected by administration without any threats of a takeover, your billing income has and will continue to go down. Your income is directed related to billings. When billings go down, you either have to hire Midlevels instead of docs or work more hours to keep income stable. But Economics will always win out. Eventually you can be super efficient but your income will eventually go down as payer mix/RVU rates go down. Eventually you will want to be bought out by a CMG. You better be smart to sell out when your contract is still attractive and can make the CMG money.
#4 - Hospital Payer mix will continue to trend towards medicare/medicaid/uninsured and away from private insurers. Why? Insurance companies are paying less, more people are on medicaid, and there are FSEDs who will siphon off the insured. As FSEDs are more accepted, insured pts will be going there. You get better service, faster service for the same if not cheaper price. I have worked in FSEDS. There is Zero wait. I can get labs/CT/full work up in 60 min and out the door in a big room/nice TV/attentive staff/pleasant doctors instead of the local hospital where it would take me 3 hrs where everyone is rushed.
#5 - SDGs income has been going down for the past 5-7 yrs for the same pt/hr. I saw all of the numbers and worked in a decent payermix. We kept our pay up by seeing more pt/hr and hiring Midlevels. But about 2 yrs ago, I could see that as payermix continued to go down, there was no more streamlining to be done. We all were facing decreased pay while working harder/more hours.

Knowing all of this, there is very little benefits in joining most SDGs. Sure there will be a rare unicorn SDG with great payer mix, great environment to work in that has little threat from a CMG. I am sure someone will tell me they work at one, but for 99% of EM docs this will not be the care.

New hires are lucky to be in a Great pay environment with a great shortage of EM docs. Why lock yourself in to 2 yrs of below market pay for the chance to essentially get paid as a partner at market rate? What does being a partner get you?

In my mind being a partner gets you very little as pay is not better than market while taking on a whole lot of risk and headaches. Owning your group means a great deal of stress jumping through all of the hospital's hoops to keep the contract.

Even if I could go directly back to the SDG with the partner distribution today, I would not even consider it.

I make much more doing CMG + Locums where I can make some of my schedule without the headache of ownership.

I would only take a CMG partner track if it is less than 2 yrs, No or very low Buy in, and in a City that I really want to live in.

I guess I've got to be that guy. While I agree with your overall point, that the number of docs working for SDGs because of the advance of the parasites known as corporate emergency medicine (Primarily EmCare and TeamHealth) is decreasing each year, I think you're playing down the benefits of owning your job way too much. Maybe I am the unicorn and a 1%er and I'm surrounded by unicorns and 1%ers, I have no idea. I guess I need to first list my credentials:

I am the chair of my department. I have served on MECs at two different hospitals in two different states. I have been a medical director and an EMS director. I have worked in a small, low acuity military ED, been staff at a large academic military ED, been an independent contractor in a small town ED staffed by an SDG, been an independent contractor at an inner city knife and gun club staffed by a hospital owned group, and been a pre-partner and partner in an SDG that has seen corporate EM try to steal their contract.

Now let's go point by point.

# 1 It's not true that nobody cares about you. We very much care about our pre-partners. Firing a prepartner is an agonizing and painful decision every time. We bend over backwards to try to make things work out. Not only do we hate firing someone we've come to know and like, we feel terrible about what it does to their career. Plus, we have to work all their shifts for the next 6-12 months until we can hire a replacement. Administration might not care about you as an individual. Your CMG's shareholders definitely don't care about you as an individual. But your partners in your small democratic group? These are the folks I ski with, climb with, canyoneer with, cover their illnesses and maternity leave, treat their kids, sit in a room for 4 hours a month with to hammer out our policies etc. They're hardly random faces on the wall. Plus, although we do occasionally fire a pre-partner, we also make sure there are no bad docs or toxic personalities in a group. Imagine being in a group without "that guy." At an SDG with a nice payor mix in a nice location, you can create a group without "that guy" because there are plenty of people who want what you have (unfortunately that list includes EmCare and TeamHealth.)

# 2 I agree that is true, but the most important thing when evaluating a new job, whether it is residency or what, is the people you will work with. I quickly learned in the military that good people can make the worst job fun and bad people can ruin anything.

# 3 SDGs can negotiate rates just as good as CMGs. They just have to band together with other SDGs to do so. If you're the lone SDG in the wilderness, that can be tough. If your group saw this coming, banded together a decade or two ago with all the other SDGs in the area to keep CMGs out, then no worries. Our rates are just fine and despite seeing quite a low number of pph, our hourly income is at the 75-90% for the specialty. You don't "have to" be bought out by a CMG. That does not have to be the destiny of our specialty. CMGs have serious downsides for doctors, patients, and administrators. As people come to realize that, there may be a backlash against the current trend.

# 4 FSEDs are extremely sensitive to legislation and FSED owners have less money and power than hospital owners. I'll leave it at that.

# 5 Maybe your SDG income is going down for the last 5-7 years. Mine is going up. Don't generalize your situation.

There is incredible benefit to working for an SDG. Let me just list some of the benefits in comparison to working at a CMG:
1) Nobody is skimming profits off me. I pay my legitimate overhead, and take home the rest.
2) I get to decide how busy we want to be at work, how long our shifts are going to be, what our sign out culture will be, how we will pay ourselves, shift differentials, who we hire, who we fire, whether or not and how we use APCs, what we do for a Christmas party, what benefits we will offer, who we will use for coding/billing and how much we will pay them, who will be the leaders of the group. I'm the owner. Sure, there is responsibility with that (I can't just say "I'm only working 12 shifts and that's it" for instance) but there is also great power, power which can be used to reduce burnout, increase income, and increase life satisfaction.
3) You don't feel so isolated that you end up with an attitude that "nobody cares about me."

There are way too many moving parts for your decision but I would put Partnership tract/increase pay at the bottom of my needs list. There is really nothing magical or special about being a partner anymore unless you are one of the big owners who have a high percentage of the group. Joining a big SDG where you get 1-3% is not worth it.

If you can find a CMG in the same city or a more favored city, then I would not do a partnership track. This is assuming work environment and pay are similar.

It would take alot for my to join a SDG at this time. I would need to be in the city I want to live in, I would need similar pay pre partnership than what is offered locally, I would need a small buy in and partnership track, I would need the same schedule as everyone else. I would never want to be the scheduling whipping boy or have to work at the worse hospital to be prepartner.

The great organization/political ties, relationship, etc.... mean very little. Trust me. If a CMG offers a buy out tomorrow to one of the big owners or the Hospital CEO gets a "bonus" from a CMG to pick them, all the ties are thrown out. I have been through this. The partners, I included, did very well and were happy.

The Pre Partners go the shaft.

There are lots of moving parts. I do not regret, however, putting SDG as my number one requirement when I went looking for a post-military job 6 years ago. I had been out into the EM world and seen what was out there and wanted to own my job. It was the right decision for me without a doubt. Will I be constantly worried about EmCare or TeamHealth coming back again and making an offer to hospital administration? Of course. That's why I know the CEOs by their first name and make sure they're happy and occasionally even sacrifice some income to make/keep them happy. There is something magical about owning your job in a true small democratic group. It's called control. And when you ask docs that are 10 years out what would make them happier at work it's having more control over their work environment. That's why these FSED owners are so happy- they get to control EVERYTHING (even more than a SDG that contracts with a hospital, they also own the nurses and equipment.) Yes, there is risk there (primarily legislative) but it's worth taking some risk in your life to make more money and get more control. I wouldn't call an SDG "with big owners" an SDG either. Real democracy isn't nearly as hard to figure out as the CMG officials debating it in ACEP Monthly seem to think. Do you get your share of the money? Do you get your share of the control? Is anyone a bigger partner than anyone else? Those are the questions to ask.

 

[emergentmd]

There are two sides of every coin and everyone should make a decision on what is in their best interests. What risk tolerance they have. What environment they prefer.

If the the benefits of being partner in a SDG outweighs the risks/pay cut, then choose that. If not, then pick a CMG.

You would think that I am a jaded doc. As a matter of fact, I am very happy with my career choice. Happy with my current job/situation. Happy that I got alittle golden parachute by being bought out rather than taken over.

I am one of the lucky ones. My SDG was also a top performer. Had great scores/sats. Had great relationship with the CEOs. Non of this matters when the hospital realizes that they can make a few extra bucks having a CMG come in. This is just the realistic state of medicine.

I too enjoy owning and being part of a SDG. Unless you are at the top of the food chain, most partners have VERY little say in decision making esp in a large SDG. I was director at a hospital and was considered a bigger fish, but at the end of the day, my input mattered very little.

That is why I am forming a FSED with a large equity. I want to make decisions without the overlord watching over me. Sure there are risks of legislation, insurance payment, etc but this has been discussed for 5+ yrs. Maybe they will legislate FSEDs out of existence, but I doubt they will shut down 500+ sites. They may stop giving permits but hopefully will grandfather the existing ones in. Who knows, but I think a risk worth taking.

I have known SDGs who were in the same situation as you. Well connected, made lots of money, thought their contract was airtight. I know of 2 large ones in the past 5 yrs that have been taken over without any compensation.

Your SDG contract is about as solid as the next CEO that comes in.

As to income, if your reimbursement for pp/hr is going up, then you are definitely an exception to the rule. Our Billing company (which covered hundreds of contracts) , put up yearly slides on how income across the board per pt has gone down. Don't make it seem that income is rising per pt unless you are the unicorn.

 

[em1234]

This thread took an interesting turn from is a "new job better than an old job" to "SDG vs CMG vs locums vs FSED"...

For medical students "positive" they are going into EM, and interns and residents who peeked in on this thread in the hopes of learning about horticulture, save a copy of emergentmd and WCI's breakdown of the pros and cons of SDG vs CMG/locums/FSED, etc for future reevaluation. This basically flushes out most of the high and low points of our available current practice settings.

Emergentmd paints a harsh but very realistic view of the challenges facing many SDG as well as EP's in general, all the while pointing out some of the "highlights" of working for a CMG/locums/FSED (did I really just use the words highlights and CMG in the same sentence fragment and in a semi-positive tone?)

WCI wrapped head to toe in a blanket of rainbows, sitting in a Scrooge McDuck pot of gold riding his unicorn expounded on the virtues of what we should all hope to attain in a SDG. He's absolutely right--egalitarian as ballz. If we could go back in time with the help of our terminator ally to blow up cyberdyne syst...uh, I mean Team Health and Emcare and Schumacher and EMP, etc, etc then this would be a better place for all EP's, but until we have that technology we have to come to the realization that the "SDG stamp" doesn't automatically mean equal, doesn't mean safe, doesn't mean fair, doesn't mean secure, and doesn't mean profitable.

My residency did a horrible job, like all residencies, of providing any useful information about the business or finance of medicine. The only consistent message given to us was that all SDG's were good and that all CMG's were the devil, to the point that if you signed with a CMG you got the "I'm not mad, just disappointed" dad look from our program director. Having walked 3 of the 4 paths (SDG, CMG, FSED) my only recommendation is Caveat Emptor, which ever path you select, job seekers. There are numerous ways to skin this cat, many of which can leave you personally, professionally, and financially fulfilled.

Back to watching The People vs OJ Simpson,
-1234

 

[The White Coat Investor]

As to income, if your reimbursement for pp/hr is going up, then you are definitely an exception to the rule. Our Billing company (which covered hundreds of contracts) , put up yearly slides on how income across the board per pt has gone down. Don't make it seem that income is rising per pt unless you are the unicorn.

Look at the surveys man. Medscape's just came out for 2016. We're up 4%+. Again. The Daniel Sterns survey is showing the same thing year after year after year. This is the golden age of Emergency Medicine.

Is a good SDG more rare than it used to be? You bet. But it isn't quite what I would call a unicorn...yet.

But worst case scenario, EmCare comes in tomorrow and gets the contract....I'm in no worse shape than you are! I can still sell myself to the highest bidder, locums/CMG/FSED etc and keep right on going. Yes, there was a little risk when I was a prepartner, but they were still paying me something like 200% of what the military was paying me!

 

[Arcan57]

Look at the surveys man. Medscape's just came out for 2016. We're up 4%+. Again. The Daniel Sterns survey is showing the same thing year after year after year. This is the golden age of Emergency Medicine.

Is a good SDG more rare than it used to be? You bet. But it isn't quite what I would call a unicorn...yet.

But worst case scenario, EmCare comes in tomorrow and gets the contract....I'm in no worse shape than you are! I can still sell myself to the highest bidder, locums/CMG/FSED etc and keep right on going. Yes, there was a little risk when I was a prepartner, but they were still paying me something like 200% of what the military was paying me!

Winter is coming. It's arrived in some areas already. We have the ability to ramp up workload to maintain income in a way that other specialties don't which is attenuating the effect. The payor mix for the country as a whole has gotten worse which was buffered by increasing ED utilization. For approximately the last 6 months (especially 2015 Q4) the part of the country that lies east of the Mississippi have seen dropping patient volumes that haven't been witnessed in the last 5 years. This is either going to lead to a drop in physician hours (less hires, fewer shifts for the docs currently there, more midlevel replacement of prior doc coverage) or in physician pay. While family ties play a huge role in physician location, there's not a lot of room for the pay to fall (especially in N Atlantic) before it becomes economically untenable to practice EM in those locations. Parts of the country have been spared this due to population growth and thriving local economies but those bubbles could easily pop.

Once you start having SDGs congregating together, they start looking a whole lot like CMGs. The basic requirements to keep a contract don't change depending on SDG vs. CMG. Once you have decisions about the contract occurring outside of the group of docs that is directly working at that shop, I don't know that you'll feel much difference in "ownership" between the two models. There are certainly CMGs that allow more or less autonomy than others but honestly a lot of that is going to be a result of the hospital who signed the contract. I've worked at hospitals that I couldn't have even told you who the director was and I've worked at hospitals where the metrics are mailed out daily. I'm sure there is significant variation between (for example) HCA and non-HCA EmCare contracts that are driven by the hospital more so than the CMG.

In terms of the original question, WCI is completely correct that it doesn't worry him personally because he's already made the decision and so every year his SDG makes it prior to folding is a year he comes out ahead. What you really need to look at is what the break even point for pre- + post partnership pay is compared to non-partnership options over time x. That's the length of time that your SDG has to hold the contract for you to see a financial benefit. If it's 2-3 yrs you're (probably) ok, if it's more than 3 yrs you're gambling. If that gambling includes being shafted on the schedule during your pre-partnership track it is unlikely to be worth it.

 

[emergentmd]

Look at the surveys man. Medscape's just came out for 2016. We're up 4%+. Again. The Daniel Sterns survey is showing the same thing year after year after year. This is the golden age of Emergency Medicine.

Is a good SDG more rare than it used to be? You bet. But it isn't quite what I would call a unicorn...yet.

But worst case scenario, EmCare comes in tomorrow and gets the contract....I'm in no worse shape than you are! I can still sell myself to the highest bidder, locums/CMG/FSED etc and keep right on going. Yes, there was a little risk when I was a prepartner, but they were still paying me something like 200% of what the military was paying me!

WCI, I have read many of your posts and have a great deal of respect for you knowledge/experience even if I disagreed.

But you are WAY off base quoting the 4% increase as a rebuttal to my stated decreased reimbursement and you know it. Throwing a 4% increase, while numerically true, only masks decreased reimbursement. ALL of medicine is feeling pressure from decreased reimbursement and EM is not immune. MOST see our revenue per pt RVU is down due to payer mix/contracted rates. This has been the case for 5+ years and I have seen the numbers for not just my previous SDG but from our billing company that handles 100+ contracts.

So what accounts for the 4% increase(you can substitute many specialites here)?
1. EM docs working more hours or seeing more pts/hr - My SDG did this until we hit our limit
2. EM docs hiring PA/NPs - We started to do this when we hit our limit. We eventually started to hit our limit.
3. EM docs starting to do more locums b/c of the extreme shortage at increased rates. Many of my SDG partners started to do this
4. EM docs opening a FSED and doing a killing seeing 1/2 pt per hr. Many EM docs are doing this and I hope to join soon.

My pay as partner with the SDG usually ran around 400+k working working 30hrs/wk for the last 10 yrs of existence. The last 5 yrs was a constant reimbursement struggle and we all kept our pay at about the same level working similar hours but we began to see more pts/hr and then started to hire Midlevels with increased coverage every year. Thus even though my pay didn't materially change, the work became much harder with more supervision.

Only until this past 2 yrs did my pay increase. Last year I made 500K+ working the same 3o hrs a month. Did reimbursement magically increase???? NO.... I just switched out 2 shifts a month working as locums for a CMG and 2 less shifts a month at my primary job.

I AGREE that this is the golden age of EM from Income, flexibility, scarcity, expanded employment options But this has nothing to do with increased reimbursement.

 

[The White Coat Investor]

Once you start having SDGs congregating together, they start looking a whole lot like CMGs. The basic requirements to keep a contract don't change depending on SDG vs. CMG. Once you have decisions about the contract occurring outside of the group of docs that is directly working at that shop, I don't know that you'll feel much difference in "ownership" between the two models. There are certainly CMGs that allow more or less autonomy than others but honestly a lot of that is going to be a result of the hospital who signed the contract. I've worked at hospitals that I couldn't have even told you who the director was and I've worked at hospitals where the metrics are mailed out daily. I'm sure there is significant variation between (for example) HCA and non-HCA EmCare contracts that are driven by the hospital more so than the CMG.

No. There is a fundamental difference. There are two extra people in the room with a CMG. With a CMG, there is the administrator, who must be paid. There is also the shareholder, who must be paid. With an SDG,t he administrator is not the physicians's boss. He is the physician's employee. And there is no shareholder. Anything extra that gets made goes to the doctor, not the shareholder. To avoid that is to only look at your daily work in a shortsighted manner. Ownership, real ownership, matters. It matters in control and it matters in pay.

One shouldn't be a pollyanna, but being a chicken little pessimist is just the other extreme.

 

[The White Coat Investor]

WCI, I have read many of your posts and have a great deal of respect for you knowledge/experience even if I disagreed.

But you are WAY off base quoting the 4% increase as a rebuttal to my stated decreased reimbursement and you know it. Throwing a 4% increase, while numerically true, only masks decreased reimbursement. ALL of medicine is feeling pressure from decreased reimbursement and EM is not immune. MOST see our revenue per pt RVU is down due to payer mix/contracted rates. This has been the case for 5+ years and I have seen the numbers for not just my previous SDG but from our billing company that handles 100+ contracts.

So what accounts for the 4% increase(you can substitute many specialites here)?
1. EM docs working more hours or seeing more pts/hr - My SDG did this until we hit our limit
2. EM docs hiring PA/NPs - We started to do this when we hit our limit. We eventually started to hit our limit.
3. EM docs starting to do more locums b/c of the extreme shortage at increased rates. Many of my SDG partners started to do this
4. EM docs opening a FSED and doing a killing seeing 1/2 pt per hr. Many EM docs are doing this and I hope to join soon.

My pay as partner with the SDG usually ran around 400+k working working 30hrs/wk for the last 10 yrs of existence. The last 5 yrs was a constant reimbursement struggle and we all kept our pay at about the same level working similar hours but we began to see more pts/hr and then started to hire Midlevels with increased coverage every year. Thus even though my pay didn't materially change, the work became much harder with more supervision.

Only until this past 2 yrs did my pay increase. Last year I made 500K+ working the same 3o hrs a month. Did reimbursement magically increase???? NO.... I just switched out 2 shifts a month working as locums for a CMG and 2 less shifts a month at my primary job.

I AGREE that this is the golden age of EM from Income, flexibility, scarcity, expanded employment options But this has nothing to do with increased reimbursement.

I'm not seeing more patients per hour.
Our PA staffing hasn't changed in years.
Nobody in my group is doing locums.
Nobody in my group is doing FSED work.

Yet our reimbursement per patient goes up year after year after year. I have no idea what the issue was with your old group. Perhaps the person doing the negotiating wasn't doing a good job. Perhaps your acuity was falling. Perhaps your group was too small to have any real negotiating power. I have no idea. And maybe I'm riding a rainbow colored unicorn. I have no idea. But I am privy to my group's numbers and the numbers for at least half the groups within 100 miles. The reimbursement per patient is rising. Part of that is higher reimbursement for the same codes, and part of it is a rising acuity.

But again, my point stands. Take a look at the worst case scenario. Someone goes and signs up with an SDG as a pre-partner. They make partner after a year or two. Then they start making good money and have excellent control over their business and work environment. Not quite as high as owning a FSED, but much higher than being a hospital employee, a CMG employee, or a FSED employee. Then it all goes to heck when EmCare manages to wine and dine some administrators into firing good docs running a good business. Now the doc has to make some decisions: He can work for the CMG, he can go do locums, he can go be someone's employee, he can go open a FSED. He hasn't lost anything. Even if he works for peanuts (you know $200K+) while a pre-partner and never actually makes partner, he's only out what, $100-200K after-tax?

The sky might be falling, but it is doing so very slowly. I think a SDG group model is the best way to practice EM, even with its risks, and would feel terrible for a new grad to pass up on a chance to do it, even if only for 5-10 years, because of this chicken little paranoia stuff. (Wo is me, everything sucks so I might as well sign away my soul and go work for a CMG.) So what if you lose your contract? You can always go make a bazillion dollars doing what emergentmd is doing. Many times the reason CMGs get contracts is because few EPs want to live and practice there. The administrator thinks the CMG can do a better job getting reasonably good docs to cover shifts. Well, the CMG can either put in crummy docs until the administrator gets sick of it, or he can throw mucho dinero at the problem and get good docs. But the problem still exists. EPs don't want to live in that town and practice in that hospital. The successful SDGs are in towns that docs want to live in, at hospitals that docs want to work at, and so they get good docs who intelligently want to own the business. It isn't inevitable that CMGs own the entire world.

 

[Arcan57]

No. There is a fundamental difference. There are two extra people in the room with a CMG. With a CMG, there is the administrator, who must be paid. There is also the shareholder, who must be paid. With an SDG,t he administrator is not the physicians's boss. He is the physician's employee. And there is no shareholder. Anything extra that gets made goes to the doctor, not the shareholder. To avoid that is to only look at your daily work in a shortsighted manner. Ownership, real ownership, matters. It matters in control and it matters in pay.

One shouldn't be a pollyanna, but being a chicken little pessimist is just the other extreme.

Shareholders are a way of funding group operations that are difficult/impossible to do just through the normal collections of a group. For stable SDGs in places that recruit for themselves (which I believe your group sounds like it falls under), there's little to no need for an infusion of outside cash since your overhead is a constant, predictable thing. I think there's something you're leaving out of the dynamics of hospital-group contracts (which is awesome if you don't have to deal with it), which is that desire to expand/merge isn't an exclusive feature of CMGs. Hospital systems are getting larger in places that support growth and contracting/merging in places that don't. It's uncommon for a hospital system to want to deal with more than 1 vendor for emergency department staffing which means that you're ability to keep the contract is going to be dependent on being able to grow the size of your groups to keep up with the whims of the hospital. Greatly increasing your staffing involves significant overhead for recruitment as well as to buffer pay until your new shops start hitting productivity goals. That cash is either coming from the bank (which adds overhead in the form of servicing that debt), venture capital (typically requiring ceding significant influence to the VC group in terms of operational decisions), or from shareholders. If you're in a geographically isolated area with a stable population that's not something you're going to need to lose a ton of sleep over but otherwise it's going to be a major factor in keeping the contract. We've had to start staffing 5 FSEDs, 2 hospitals, and add an average of 3 additional docs to each of our existing hospitals in the last 3 years. If we didn't do that we'd lose the contract (which is very damn lucrative for everybody including the docs).

My day to day medical decision making is broken up about as follows: 95+% what I think is best for the patients, 4% complying with hospital guidelines, <1% complying with CMG regulations. I hire the docs that staff my emergency department and do a pretty good job of running interference for them against a relatively punitive hospital peer review environment. Maybe I'm fooling myself but it doesn't feel like I've sold my soul.

 

[emergentmd]

I'm not seeing more patients per hour.
Our PA staffing hasn't changed in years.
Nobody in my group is doing locums.
Nobody in my group is doing FSED work.

Yet our reimbursement per patient goes up year after year after year. I have no idea what the issue was with your old group. Perhaps the person doing the negotiating wasn't doing a good job. Perhaps your acuity was falling. Perhaps your group was too small to have any real negotiating power. I have no idea. And maybe I'm riding a rainbow colored unicorn. I have no idea. But I am privy to my group's numbers and the numbers for at least half the groups within 100 miles. The reimbursement per patient is rising. Part of that is higher reimbursement for the same codes, and part of it is a rising acuity.

But again, my point stands. Take a look at the worst case scenario. Someone goes and signs up with an SDG as a pre-partner. They make partner after a year or two. Then they start making good money and have excellent control over their business and work environment. Not quite as high as owning a FSED, but much higher than being a hospital employee, a CMG employee, or a FSED employee. Then it all goes to heck when EmCare manages to wine and dine some administrators into firing good docs running a good business. Now the doc has to make some decisions: He can work for the CMG, he can go do locums, he can go be someone's employee, he can go open a FSED. He hasn't lost anything. Even if he works for peanuts (you know $200K+) while a pre-partner and never actually makes partner, he's only out what, $100-200K after-tax?

The sky might be falling, but it is doing so very slowly. I think a SDG group model is the best way to practice EM, even with its risks, and would feel terrible for a new grad to pass up on a chance to do it, even if only for 5-10 years, because of this chicken little paranoia stuff. (Wo is me, everything sucks so I might as well sign away my soul and go work for a CMG.) So what if you lose your contract? You can always go make a bazillion dollars doing what emergentmd is doing. Many times the reason CMGs get contracts is because few EPs want to live and practice there. The administrator thinks the CMG can do a better job getting reasonably good docs to cover shifts. Well, the CMG can either put in crummy docs until the administrator gets sick of it, or he can throw mucho dinero at the problem and get good docs. But the problem still exists. EPs don't want to live in that town and practice in that hospital. The successful SDGs are in towns that docs want to live in, at hospitals that docs want to work at, and so they get good docs who intelligently want to own the business. It isn't inevitable that CMGs own the entire world.

I would just say that your situation is a Unicorn. Our SDG was not small (100 docs + 50 Midlevels). There is really not much as an EM group to negotiate. We did negotiate, maybe got alittle better reimbursement but as an ED group, do you really have leverage to tell United Health that we are not going to use you as a provider? Are you really not going to take medicare or medicaid. Negotiating is just a pipe dream.

If your pre partner SDG really is avg market pay, has a low buy in after 1 or 2 yr, same schedule as partner, same hospital selection as partners, then sure I will sign up. BUT I doubt you treat your nonpartners that well. I am sure they are going to the least desirable hospital, or working more nights/weekends than partners, or has a large buy in.. There has to be a decent penalty to buy in.

Anyhow, we are going to have to disagree. You can continue with how great of a deal being a prepartner SDG is while I will disagree that I could get a better deal with a CMG/Locums and not have to pay the penalty of prepartnership.

Obviously you have it good. Of course it won't matter much to you if a CMG takes over. You have gotten your share already, but this conversation to do with SDG partner vs CMG/Locums. It had to do with being a preparter vs CMG/locums. IMO 95% of prepartner SDG takes on way too much risk and uncertainty esp when you can make more doing CMG/locums than being a partner.

I was making 450K+ working 30 hrs/wks a partner which only comes out a shade less than 290/hr. I could make 350+/hr tomorrow doing locums without any prepartner penalty period. I have just seen too many prepartners (including my SDG group) get the shaft waiting their 2+yrs to become a partner. Either they were overpromised, group got taken over, reimbursement dropped, SDG had to take over poor hospital contracts, etc. 2 yrs is a long time in medicine, if someone is willing to take this, then fine. I just want them to realize the risks that no one ever tells them.

 

[The White Coat Investor]

Shareholders are a way of funding group operations that are difficult/impossible to do just through the normal collections of a group. For stable SDGs in places that recruit for themselves (which I believe your group sounds like it falls under), there's little to no need for an infusion of outside cash since your overhead is a constant, predictable thing. I think there's something you're leaving out of the dynamics of hospital-group contracts (which is awesome if you don't have to deal with it), which is that desire to expand/merge isn't an exclusive feature of CMGs. Hospital systems are getting larger in places that support growth and contracting/merging in places that don't. It's uncommon for a hospital system to want to deal with more than 1 vendor for emergency department staffing which means that you're ability to keep the contract is going to be dependent on being able to grow the size of your groups to keep up with the whims of the hospital. Greatly increasing your staffing involves significant overhead for recruitment as well as to buffer pay until your new shops start hitting productivity goals. That cash is either coming from the bank (which adds overhead in the form of servicing that debt), venture capital (typically requiring ceding significant influence to the VC group in terms of operational decisions), or from shareholders. If you're in a geographically isolated area with a stable population that's not something you're going to need to lose a ton of sleep over but otherwise it's going to be a major factor in keeping the contract. We've had to start staffing 5 FSEDs, 2 hospitals, and add an average of 3 additional docs to each of our existing hospitals in the last 3 years. If we didn't do that we'd lose the contract (which is very damn lucrative for everybody including the docs).

My day to day medical decision making is broken up about as follows: 95+% what I think is best for the patients, 4% complying with hospital guidelines, <1% complying with CMG regulations. I hire the docs that staff my emergency department and do a pretty good job of running interference for them against a relatively punitive hospital peer review environment. Maybe I'm fooling myself but it doesn't feel like I've sold my soul.

Where does that cash come from? My pocket. Just like the reward for doing so. With a CMG, you're eliminating the need to bring cash to the table (usually work for less for a while) but you're also giving up the cream when you do well. Actually, often you can negotiate a subsidy from the hospital for opening a new ED. Plus, since you need to hire, you get a little from the difference between pre-partner pay and partner pay too for a year or two.

 

[emergentmd]

We've had to start staffing 5 FSEDs, 2 hospitals, and add an average of 3 additional docs to each of our existing hospitals in the last 3 years. If we didn't do that we'd lose the contract (which is very damn lucrative for everybody including the docs).

Here is one of the killer for income. When we were a SDG early on, we had 4 big hospital. Pay was good, staffing stable, very little worries or overhead. Guess what? Hospital systems get greedy. They want to increase revenue and a referral base by expanding. Who do they expand?

1. Take over poorly managed hospitals with poor patient population.
2. Take over or build FSEDs as a referral base. Much faster and cheaper to throw one of these in an under served area than opening a full hospital
3. Open Urgent care

Guess who makes money from these moves? you got it.... the hospitals. They admit more, do more surgeries, gets the main hospitals filled up, charge their outrageous facility fees. They may lose alittle at each place buy make it up easily through admissions/elective procedures.

Guess who loses money from these moves? you got it.... the ED group. Do you think the hospital will give us a stipend to take over these money losers? NOPE. We just suck it up, hire more docs, take the pay cut.

Taking on a few of these places may be economically feasible, but once they start to pile up, its not worth it. Try telling a board certified doc that you are getting paid less than 150/hr working one of these slow FSEDs.....

And I will tell you rarely would you be given a hospital ER contract that is lucrative.

To anyone wanting to join a SDG and bear the pre partner years, good luck to you and be informed. Everyone has to make their own decisions in life and there is never a right decision for all. Just educate yourself because residency never educated me on this.

I am one of the lucky ones that was promised a great partner track to just be put in a hell hole of a hospital, work crappy shifts to have the rug pulled from under him. I have seen it and have heard many stories.

 

[emergentmd]

Where does that cash come from? My pocket. Just like the reward for doing so. With a CMG, you're eliminating the need to bring cash to the table (usually work for less for a while) but you're also giving up the cream when you do well. Actually, often you can negotiate a subsidy from the hospital for opening a new ED. Plus, since you need to hire, you get a little from the difference between pre-partner pay and partner pay too for a year or two.

Negotiate a subsidy? This is laughable. Keep pushing subsidies and your contract will be on thin ice. Hospital CEOs talk and most do not subsidize an ED group. They just get someone else to come in that will do it without a subsidy.

We tried to negotiate a subsidy to cover FSEDs, that didn't go well.

 

[The White Coat Investor]

If your pre partner SDG really is avg market pay, has a low buy in after 1 or 2 yr, same schedule as partner, same hospital selection as partners, then sure I will sign up. BUT I doubt you treat your nonpartners that well. I am sure they are going to the least desirable hospital, or working more nights/weekends than partners, or has a large buy in.. There has to be a decent penalty to buy in.

You would be (mostly) wrong.

Avg pay for pre-partners in this market- yes. Average pay for emergency physicians, no.
No buy in (just the sweat equity of working for less for 2 years.)
You work an even number of all shifts at all locations. Partners are allowed to pick which of the shifts (days, evenings, nights) they want (with a differential for the less desirable.)
Same hospital selection-even.
Same number of weekends.
Same number of holidays.

So when can I expect your application? 🙂

Seriously, it isn't that hard to set a group up that treats people fairly. I'm disappointed that many SDGs don't.

The goal isn't to milk prepartners. The goal is to hire stable partners that will stay for 30 years who are willing to deal with the hassles of ownership in return for the rewards. I think the rewards dramatically outweigh the hassles.

However, just as I think it is important for new grads to hear my perspective, I also think it is important for them to hear yours. Unfortunately, there are plenty of SDGs that don't treat people all that fairly and there will certainly be some that succumb to the CMG onslaught in the next few years. Maybe even mine. But I think we're good for at least another decade, probably longer but the crystal ball gets so cloudy.

 

[The White Coat Investor]

Negotiate a subsidy? This is laughable. Keep pushing subsidies and your contract will be on thin ice. Hospital CEOs talk and most do not subsidize an ED group. They just get someone else to come in that will do it without a subsidy.

We tried to negotiate a subsidy to cover FSEDs, that didn't go well.

I think we discussed negotiation higher in the thread. Clearly your SDG had issues with that, whether personal or systematic. We got a subsidy for the place we opened last summer. It's fairly standard in this state, although not huge. I agree that issue may get harder in the future.

 

[The White Coat Investor]

Here is one of the killer for income. When we were a SDG early on, we had 4 big hospital. Pay was good, staffing stable, very little worries or overhead. Guess what? Hospital systems get greedy. They want to increase revenue and a referral base by expanding. Who do they expand?

1. Take over poorly managed hospitals with poor patient population.
2. Take over or build FSEDs as a referral base. Much faster and cheaper to throw one of these in an under served area than opening a full hospital
3. Open Urgent care

Guess who makes money from these moves? you got it.... the hospitals. They admit more, do more surgeries, gets the main hospitals filled up, charge their outrageous facility fees. They may lose alittle at each place buy make it up easily through admissions/elective procedures.

Guess who loses money from these moves? you got it.... the ED group. Do you think the hospital will give us a stipend to take over these money losers? NOPE. We just suck it up, hire more docs, take the pay cut.

Taking on a few of these places may be economically feasible, but once they start to pile up, its not worth it. Try telling a board certified doc that you are getting paid less than 150/hr working one of these slow FSEDs.....

And I will tell you rarely would you be given a hospital ER contract that is lucrative.

To anyone wanting to join a SDG and bear the pre partner years, good luck to you and be informed. Everyone has to make their own decisions in life and there is never a right decision for all. Just educate yourself because residency never educated me on this.

I am one of the lucky ones that was promised a great partner track to just be put in a hell hole of a hospital, work crappy shifts to have the rug pulled from under him. I have seen it and have heard many stories.

It's a real issue and important for people to know about. But again, if your group is full of great docs, hospitals WANT you instead of the unknown docs a CMG is going to bring in (assuming they can't get the docs there to stay, which they do about 70% of the time). Again, I can only point to my experience. We were offered a lucrative hospital contract last year for a new hospital because of our reputation. There's a bit of a ramp-up, but the small hospital subsidy and the pre-partner/partner pay differential covered it.

But still, I go back to my original point. If the hospital system starts to ask too much, you can say no, get fired after a year or two, and then work for the CMG they sold the contract to. You've lost nothing. Your only risk is that your SDG implodes as a pre-partner or shortly afterward.

 

[dav86]

I would just say that your situation is a Unicorn. Our SDG was not small (100 docs + 50 Midlevels). There is really not much as an EM group to negotiate. We did negotiate, maybe got alittle better reimbursement but as an ED group, do you really have leverage to tell United Health that we are not going to use you as a provider? Are you really not going to take medicare or medicaid. Negotiating is just a pipe dream.

If your pre partner SDG really is avg market pay, has a low buy in after 1 or 2 yr, same schedule as partner, same hospital selection as partners, then sure I will sign up. BUT I doubt you treat your nonpartners that well. I am sure they are going to the least desirable hospital, or working more nights/weekends than partners, or has a large buy in.. There has to be a decent penalty to buy in.

Anyhow, we are going to have to disagree. You can continue with how great of a deal being a prepartner SDG is while I will disagree that I could get a better deal with a CMG/Locums and not have to pay the penalty of prepartnership.

Obviously you have it good. Of course it won't matter much to you if a CMG takes over. You have gotten your share already, but this conversation to do with SDG partner vs CMG/Locums. It had to do with being a preparter vs CMG/locums. IMO 95% of prepartner SDG takes on way too much risk and uncertainty esp when you can make more doing CMG/locums than being a partner.

I was making 450K+ working 30 hrs/wks a partner which only comes out a shade less than 290/hr. I could make 350+/hr tomorrow doing locums without any prepartner penalty period. I have just seen too many prepartners (including my SDG group) get the shaft waiting their 2+yrs to become a partner. Either they were overpromised, group got taken over, reimbursement dropped, SDG had to take over poor hospital contracts, etc. 2 yrs is a long time in medicine, if someone is willing to take this, then fine. I just want them to realize the risks that no one ever tells them.

I work for a SDG as well. And our MD just said that our collections have gone up due to an increase of pts on a state provided insurance place (about 10 bucks per patient). I have much much less experience that either WCI or emergentmd but I think the SDG is worth the risk. I agree with WCI. Having ownership is important and having a say on how things are run is important. We have a 2 yr pre-partnership track with a sweat equity model. I don't work any more nights than a partner. I do work 3 extra shifts (unpaid) a month, but they are always double covered and not all weekends or holidays. We are expanding and doing well. Took a contract from a CMG and are looking at expanding more. We have good relationships in all three of the hospitals we work at and relationships with the network. I get paid less the first two years but I'm hardly poor (I'll make 250+ this year). We work more than CMGs to start and see lots of patients, but we utilize PAs well and have scribes. We are a very efficient group of physicians. Our partners clear well north of 500k and get 53k in retirement. All of this to work 1500 hrs a year and we have many partners that cut back to 3/4 or 1/2 time and make "only" 300-350k a year (and only work 8-10 shifts a month). Sure our contracts are always in jeopardy, but I think the picture emergentmd paints is also constantly in jeopardy. If legislation passes on FSEDs that cash cow goes away. Sure locums pays 500+/hr now in TX, but EM residency spots are increasing. 1900 this year a lone (it was 1600 three yrs ago). Resident debt loads are pushing 400k. I think the market is going to be flooded over the next ten years. Sure, you have worked 15 years and have made millions, so if things dry up in five yrs who cares, but for all recently matched residents don't get caught up in these figures. I don't think you will be able to make 450-700k in EM for long, or you will have to see 6 pph and work 2100 hrs a year to do it. Once the job market becomes more saturated all of these locums jobs will pay much much less. More near market rate. Then CMG jobs in TX or wherever won't be as appealing. I would pay down your debt as fast as possible, build up a huge FU fund, and adjust your lifestyle to live on 250-300k. You will always be able to make that and probably won't have to work more than 10 shifts to do it. Those are my two cents (though probably worth much much less than that since I just got out).

 

[emergentmd]

You would be (mostly) wrong.

Avg pay for pre-partners in this market- yes. Average pay for emergency physicians, no.
No buy in (just the sweat equity of working for less for 2 years.)
You work an even number of all shifts at all locations. Partners are allowed to pick which of the shifts (days, evenings, nights) they want (with a differential for the less desirable.)
Same hospital selection-even.
Same number of weekends.
Same number of holidays.

So when can I expect your application? 🙂

Seriously, it isn't that hard to set a group up that treats people fairly. I'm disappointed that many SDGs don't.

The goal isn't to milk prepartners. The goal is to hire stable partners that will stay for 30 years who are willing to deal with the hassles of ownership in return for the rewards. I think the rewards dramatically outweigh the hassles.

However, just as I think it is important for new grads to hear my perspective, I also think it is important for them to hear yours. Unfortunately, there are plenty of SDGs that don't treat people all that fairly and there will certainly be some that succumb to the CMG onslaught in the next few years. Maybe even mine. But I think we're good for at least another decade, probably longer but the crystal ball gets so cloudy.

If all SDGs had the same buy in as yours, then it would be a no brainer. But most are not. There will be atleast one painful aspect be it pay, schedule, hospital selection. Yours may just be the most benevolent. Most are not that way. We are all humans, partners are all humans. We all feel after paying our dues as prepartners, there has to be some benefit if it ends being Much higher pay, better schedule, better hospital. Something has to be given to a partner.

I would send you my application but I don't think you could afford me 🙂

I would need atleast 350/hr to leave.

 

[emergentmd]

It's a real issue and important for people to know about. But again, if your group is full of great docs, hospitals WANT you instead of the unknown docs a CMG is going to bring in (assuming they can't get the docs there to stay, which they do about 70% of the time). Again, I can only point to my experience. We were offered a lucrative hospital contract last year for a new hospital because of our reputation. There's a bit of a ramp-up, but the small hospital subsidy and the pre-partner/partner pay differential covered it.

But still, I go back to my original point. If the hospital system starts to ask too much, you can say no, get fired after a year or two, and then work for the CMG they sold the contract to. You've lost nothing. Your only risk is that your SDG implodes as a pre-partner or shortly afterward.

I agree with this. Being a partner you are sitting pretty. Your setup for prepartner sounds reasonable with only alittle risk. You have made your money. I have made my money. Its the new grads that needs to be aware of the risks of being prepartner.

Everyone needs to ask questions, educate themselves.

 

[emergentmd]

I work for a SDG as well. And our MD just said that our collections have gone up due to an increase of pts on a state provided insurance place (about 10 bucks per patient). I have much much less experience that either WCI or emergentmd but I think the SDG is worth the risk. I agree with WCI. Having ownership is important and having a say on how things are run is important. We have a 2 yr pre-partnership track with a sweat equity model. I don't work any more nights than a partner. I do work 3 extra shifts (unpaid) a month, but they are always double covered and not all weekends or holidays. We are expanding and doing well. Took a contract from a CMG and are looking at expanding more. We have good relationships in all three of the hospitals we work at and relationships with the network. I get paid less the first two years but I'm hardly poor (I'll make 250+ this year). We work more than CMGs to start and see lots of patients, but we utilize PAs well and have scribes. We are a very efficient group of physicians. Our partners clear well north of 500k and get 53k in retirement. All of this to work 1500 hrs a year and we have many partners that cut back to 3/4 or 1/2 time and make "only" 300-350k a year (and only work 8-10 shifts a month). Sure our contracts are always in jeopardy, but I think the picture emergentmd paints is also constantly in jeopardy. If legislation passes on FSEDs that cash cow goes away. Sure locums pays 500+/hr now in TX, but EM residency spots are increasing. 1900 this year a lone (it was 1600 three yrs ago). Resident debt loads are pushing 400k. I think the market is going to be flooded over the next ten years. Sure, you have worked 15 years and have made millions, so if things dry up in five yrs who cares, but for all recently matched residents don't get caught up in these figures. I don't think you will be able to make 450-700k in EM for long, or you will have to see 6 pph and work 2100 hrs a year to do it. Once the job market becomes more saturated all of these locums jobs will pay much much less. More near market rate. Then CMG jobs in TX or wherever won't be as appealing. I would pay down your debt as fast as possible, build up a huge FU fund, and adjust your lifestyle to live on 250-300k. You will always be able to make that and probably won't have to work more than 10 shifts to do it. Those are my two cents (though probably worth much much less than that since I just got out).

I am sure you have a good job, and if you are happy, then that is all that matters.

But you are making 250k+ this year but doing 3 days a month for free. I don't see how this is even reasonable. For me, this would be a deal breaker and WCI would probably agree with me.

That is 36 shifts a year or 72 shifts as a prepartner. I make $450/hr at my locums job for each 10 hr shift. So for 72 shifts, that is $324K or $162k/yr that is going to the partners pockets. If I were making 250K, I would be potentially taking a 40% pay cut. Where do I sign out????


BTW, my SDGs only difference bt partner and prepartners was worse hospital to work at and about a 60K pay difference. Schedules all the same, requests all the same. No other penalties other than working at a crappier hospital (same pay RVU rate/pay) and 60k/yr. Buy in about 100K. I believe my SDG had a decent prepartner track. If we were asking prepartners to work 3 extra days probono, I would not be able to sleep at night.

 

[The White Coat Investor]

This thread should be stickied. Maybe I ought to even cut out this exchange between emergentmd and I and make a Pro/Con blog post out of it. Every EM PGY2 needs to read this thread. It's a particularly good debate because nobody in it is wrong. It's just two points of view, both of which are important to understand.

While we're at it, one other reason I think hospitals should prefer a SDG to a CMG. Having the owners working in the pit, and having all of those working in the pit be owners (or soon to be owners) promotes a sense of ownership rather than a time clock punching mentality. For example, emergentmd is selling himself to the highest bidder. FSED, CMG, IC whatever. If this ED implodes, he doesn't care. He has 4 other sites that pay him $350 an hour to come staff them. But I have serious ownership in my hospital (literally and figuratively) and am in it for the long haul. So I treat staff, patients, consultants, administration, and my colleagues differently and I would argue, better. Now, emergentmd is a great guy (gal?) so I'm sure he treats people great. But he is not incentivized to do so like I am and we all know, at least subconsciously, that we do more of what we are incentivized to do.

 

[GeneralVeers]

Unfortunately SDG is not an option for many democratic areas. My home city (Vegas) has only TeamHealth, and EmCare. Even EMP got pushed out of the market because they couldn't compete with the big boys. There was one private group owned by 3 guys, but wasn't an SDG as employees had no rights/ownership. This group just got bought by TeamHealth.

I would love an SDG with reasonable buy-in, $400/hr for partners, flexible schedule, and in an area I'd be willing to live in. Unfortunately I'm not aware of any.

 

[bravotwozero]

No SDGs in Houston either as far as I know. It's mostly emcare and team health plus some small non sdg private groups. If someone knows otherwise, do let me know


Sent from my iPhone using Tapatalk

 

[Janders]

I've jumped in these threads before. We use a SDG model. We actually don't have pre-partners... you get your 80+% of earnings starting on day one, sans buy in. The rest goes to group overhead, (billing, coding, admin, HR, PA salaries, staff party, donations, 401k admin fees, malpractice) which is the same for everyone. It takes 3-4mo for your billing to ramp up, and we cover a base salary for that period... so it feels like you become a "partner" around month 9 when you're out of that hole and start getting quarterly bonuses.

Now this is a rather sweet deal, so we don't have people leave unless they move far away for family reasons. As such we can be picky about who we take, and often take people willing to put in a year of half or more overnight shifts (with a bonus overnight stipend). But they are equal members with full access to their billings from day #1.

While I love the financials and intangibles behind SDGs, I have seen them with 3+ year pyramid scheme buy-ins and mysterious "senior partners" who never work a shift and take a big cut of money. I'd be wary of those. And certainly even with a 2 year buy in there is risk for loss, especially if you are in an area where you can reasonably get $300 or more regularly for per diem work...

 

[The White Coat Investor]

Unfortunately SDG is not an option for many democratic areas. My home city (Vegas) has only TeamHealth, and EmCare. Even EMP got pushed out of the market because they couldn't compete with the big boys. There was one private group owned by 3 guys, but wasn't an SDG as employees had no rights/ownership. This group just got bought by TeamHealth.

I would love an SDG with reasonable buy-in, $400/hr for partners, flexible schedule, and in an area I'd be willing to live in. Unfortunately I'm not aware of any.

I'm not sure there is anywhere that docs make $400 an hour in an area anyone wants to live in at a practice they want to be at.

 

[The White Coat Investor]

I've jumped in these threads before. We use a SDG model. We actually don't have pre-partners... you get your 80+% of earnings starting on day one, sans buy in. The rest goes to group overhead, (billing, coding, admin, HR, PA salaries, staff party, donations, 401k admin fees, malpractice) which is the same for everyone. It takes 3-4mo for your billing to ramp up, and we cover a base salary for that period... so it feels like you become a "partner" around month 9 when you're out of that hole and start getting quarterly bonuses.

Now this is a rather sweet deal, so we don't have people leave unless they move far away for family reasons. As such we can be picky about who we take, and often take people willing to put in a year of half or more overnight shifts (with a bonus overnight stipend). But they are equal members with full access to their billings from day #1.

While I love the financials and intangibles behind SDGs, I have seen them with 3+ year pyramid scheme buy-ins and mysterious "senior partners" who never work a shift and take a big cut of money. I'd be wary of those. And certainly even with a 2 year buy in there is risk for loss, especially if you are in an area where you can reasonably get $300 or more regularly for per diem work...

Just because a group is small and it isn't a CMG doesn't mean it's democratic! And some groups are definitely more democratic than others.

 

[Janders]

benevolent despotism is the finest form of government

 

[emergentmd]

I work for a SDG as well. And our MD just said that our collections have gone up due to an increase of pts on a state provided insurance place (about 10 bucks per patient). I have much much less experience that either WCI or emergentmd but I think the SDG is worth the risk. I agree with WCI. Having ownership is important and having a say on how things are run is important. We have a 2 yr pre-partnership track with a sweat equity model. I don't work any more nights than a partner. I do work 3 extra shifts (unpaid) a month, but they are always double covered and not all weekends or holidays. We are expanding and doing well. Took a contract from a CMG and are looking at expanding more. We have good relationships in all three of the hospitals we work at and relationships with the network. I get paid less the first two years but I'm hardly poor (I'll make 250+ this year). We work more than CMGs to start and see lots of patients, but we utilize PAs well and have scribes. We are a very efficient group of physicians. Our partners clear well north of 500k and get 53k in retirement. All of this to work 1500 hrs a year and we have many partners that cut back to 3/4 or 1/2 time and make "only" 300-350k a year (and only work 8-10 shifts a month). Sure our contracts are always in jeopardy, but I think the picture emergentmd paints is also constantly in jeopardy. If legislation passes on FSEDs that cash cow goes away. Sure locums pays 500+/hr now in TX, but EM residency spots are increasing. 1900 this year a lone (it was 1600 three yrs ago). Resident debt loads are pushing 400k. I think the market is going to be flooded over the next ten years. Sure, you have worked 15 years and have made millions, so if things dry up in five yrs who cares, but for all recently matched residents don't get caught up in these figures. I don't think you will be able to make 450-700k in EM for long, or you will have to see 6 pph and work 2100 hrs a year to do it. Once the job market becomes more saturated all of these locums jobs will pay much much less. More near market rate. Then CMG jobs in TX or wherever won't be as appealing. I would pay down your debt as fast as possible, build up a huge FU fund, and adjust your lifestyle to live on 250-300k. You will always be able to make that and probably won't have to work more than 10 shifts to do it. Those are my two cents (though probably worth much much less than that since I just got out).

Sorry, I reread your post and alittle astounded by your pre partner deal.

Prepartner make 250k/yr. Assuming your shifts are 10 hrs and you work 3dys free/mo or 36 free days a year or 360 hrs extra. Assuming everyone works the avg partner hrs of 1500 a yr, then you work 1860 hrs a yr. So you are getting paid about 134/hr. I assume you are getting some great benefits so bump it up alittle if you like.

Partner make 500K+53K SEP working 1500 hrs/yr. That is a rate of 368/hr.

So you are saying that for 2 yrs, you are ok with a partner making 234/hr or 2.75 times more for the same Hour you work??????

Unless I am missing something, this must be the MOST punitive buy in I have ever heard.

BTW I made north of 500k last year working about 1500hr working CMG+Locums. Yes, I have less say but I also have less headaches that comes with a SDG