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

[emergentmd]

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


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There are prob 20+ SDGs in Houston. They are called FSEDs making more than most SDGs could dream of with full control, no admin oversite, no CMS oversite. They hire whoever they want, fire whoever they want, etc...

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[sonofva]

Our chaplain just told us today that "if the neighbor's grass looks greener, you're not taking good care of your grass."


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[The White Coat Investor]

There are prob 20+ SDGs in Houston. They are called FSEDs making more than most SDGs could dream of with full control, no admin oversite, no CMS oversite. They hire whoever they want, fire whoever they want, etc...

I agree that owning a FSED is one step up on an SDG as far as owning your job goes. I'm still ambivalent about whether they are good for patients and the specialty long term though.

Imagine a scenario where all EDs are FSEDs. What does that look like in terms of emergent, in-person consultations with other specialties? Or a patient who needs to go to the OR with ENT? In some ways, isn't a FSED a parasite on the system just like an outpatient surgical center? I love that both of them puts docs in control, but I'm not sure it's the best thing for patients.

 

[GeneralVeers]

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.

Exactly. I make close to that, in a less-desirable area as a locums (but can still live where I want). For me to move or settle down and join a SDG, it would have to pay extremely well, without the two years of indentured servitude.

 

[The White Coat Investor]

Exactly. I make close to that, in a less-desirable area as a locums (but can still live where I want). For me to move or settle down and join a SDG, it would have to pay extremely well, without the two years of indentured servitude.

Yes, they're far more attractive to those who want to settle down. If you don't want to settle into a single job, you don't want a SDG!

 

[em1234]

I agree that owning a FSED is one step up on an SDG as far as owning your job goes. I'm still ambivalent about whether they are good for patients and the specialty long term though.

Imagine a scenario where all EDs are FSEDs. What does that look like in terms of emergent, in-person consultations with other specialties? Or a patient who needs to go to the OR with ENT? In some ways, isn't a FSED a parasite on the system just like an outpatient surgical center? I love that both of them puts docs in control, but I'm not sure it's the best thing for patients.

My emergent consultations are no different from my independent (nonhospital affiliated) FSED than they are from my regular hospital ED gig. I don't have ENT at either place so if I have an ENT emergency, I pick up the phone and transfer them. No difference for me. Only difference is that the patient spent about 5 seconds in my FSED waiting room, and had my (and the nurse's) undivided attention until they were stabilized with transfer completed and them wheeling out the door. Contrasted with my regular job where they likely would have languished in the waiting room for at least 30 minutes, I would be juggling 8-12 other active patients and at best periodically peaking in on them to make sure they were alive waiting for my local tertiary care center to call me back, so in this sense, I feel I provide FAR superior care to my patient at my FSED than my hospital job.

Also at my FSED, I have consult numbers for hand surgery, ophtho, electrophysiology, general cards, GI, pulm, nephrology, neurology, urology. I can call any of these docs and in most cases get same day follow up and at worst next day for my FSED pts. Thus, I feel confident that the care I provide these patients is better than the care I end up providing my patients at my regular hospital, where the outpt follow up times for the above specialists are measured in fortnights. Is it because most of these patients are insured???? Hell yes, it is. Do I somehow feel that I have sullied my oath or betrayed the righteous indignation that I wield over my private practice colleagues as the REAL doc who sees all and actually provides care to the masses insured or not? No. It's quite pleasurable to call a historically difficult to deal with specialist to refer a patient and have the specialist be excited about seeing the patient, thank me for the consult/referral, and agree to see them in 2 hours in their office. Pt is happy, specialist is happy, I'm happy. Make for a pretty enjoyable work day, and will inevitably extend my career.

In Houston, FSED's have been great for all EPs. FSED's have given EPs the possibility of meaningful ownership and control of their craft. It has extended careers by offering very reasonable pay for a slower paced practice. The Houston FSEDs have pulled an estimated 800 FTE EP's out of the hospital market. This has in turn forced TeamHealth, EM care and Methodist to increase their hourly minimums, up again in the last year. Memorial Hermann and Methodist (Houston's two biggest hospital chains) have been running a cold war style arms race to see who can put up more FSED's in the last 2 years. TeamHealth has even had to increased the pay for their FSED's well above the going rate of the First Choice (largest nonhospital based FSED chain) pay rate just to get bodies to cover the shifts. This rising tide has lifted all ships.

Are FSEDs a parasite on the system? The same way outpatient surgery centers, hospital owned FSEDs, private outpt imaging centers, and lab corps are, I guess that's accurate, but hospitals are pretty unimaginative when it comes to outside financial pressures. They just copy the competition and then try to competitively inhibit. In the late 90's when nonhospital owned surgery centers were popping up, there was lots of discussion about this "new parasite" being the end of hospitals as it would syphon the insured ambulatory surgery patients away from hospitals and they were going to be legislated out citing anti-kickback statutes (any of this sound familiar to anyone else?) and here we are 20 years later and the independently owned surgery center still exists (though most have been bought out by hospitals), as do an ocean of hospital based surgery centers. Is there risk in a FSED? Sure. Probably not that dissimilar to the risk of joining a SDG with an "iron clad" contract getting usurped by a CMG.

Are FSED's good for the albatross that is the American Healthcare System? No, but they are hardly the death knell. More like throwing a few more ice cubes at the Titanic as it sails by. All that being said, I sleep soundly knowing the care I provided my FSED patients is complete, attentive, well explained, tailored, smarter, and something of which, I am proud. It allows me to practice the way I always imagined medicine would be, and that is the system of which I am happy to be part.

Why am I still awake?
-1234

 

[Old_Mil]

For those of you who have switched jobs, do you actually like your new job better, or do you feel like you have just traded one set of hassles and unhappiness for a different set of issues?

I have been at my job for nearly two years, and while there are many aspects I like (supportive admin, reasonable consultants, teaching, ridiculous acuity/procedures, no press-ganey, gorgeous area with friendly people/low cost of living/great public schools), there are a few issues that are really starting to get to me (too many hours, schedule that seems to have been made by throwing darts at a board, worsening boarding issues, relatively low $/hr). The group I am with has been incredibly stable, and there are no attractive alternatives nearby, so a change would mean a big move and it would be difficult to impossible to return here.

What were the issues that you guys just couldn't deal with anymore? How did you make sure your job search went better the second go 'round? Any regrets? Anyone just up and move part way across the country because the job was that good? Any too good to be true but actually exist jobs in FL (if I can't go hiking I at least want to be near scuba diving gosh darn it), or TX (if the job is REALLY that good I can just travel to partake in my hobbies)?

PMs welcome if you don't want to post publicly.

Each time I've changed my job, the next one has been better than the previous.

Part of that is because the first job I had out of residency might have been at the crappiest hospital in the country.

Job #2 wasn't bad when I started but as it changed (volume up 29%, efficiency down thanks to Cerner, new ER medical director his prime directive was "bill better or coverage hrs/pay will be cut", fetal monitoring moved to the ED from LD triage) I realized it was time to bail.

That having been said, only with the most recent change have I come close to approaching this: "supportive admin, reasonable consultants, teaching, ridiculous acuity/procedures, no press-ganey, gorgeous area with friendly people/low cost of living/great public schools"

If you already have that, think long and hard before leaving. I'm not sure how low "low $/hr" is, but as people vote with their feet the stability of the group is something to consider.

 

[RustedFox]

Each time I've changed my job, the next one has been better than the previous.

Part of that is because the first job I had out of residency might have been at the crappiest hospital in the country.

Job #2 wasn't bad when I started but as it changed (volume up 29%, efficiency down thanks to Cerner, new ER medical director his prime directive was "bill better or coverage hrs/pay will be cut", fetal monitoring moved to the ED from LD triage) I realized it was time to bail.

That having been said, only with the most recent change have I come close to approaching this: "supportive admin, reasonable consultants, teaching, ridiculous acuity/procedures, no press-ganey, gorgeous area with friendly people/low cost of living/great public schools"

If you already have that, think long and hard before leaving. I'm not sure how low "low $/hr" is, but as people vote with their feet the stability of the group is something to consider.

I remember the days of you detailing just how poor your "first job" was.

I used to hate Cerner as well; but in all honesty - Cerner + Dragon is the fastest and easiest EMR that I have seen yet in terms of *charting and documentation*. Entering orders.... not so much.

 

[emergentmd]

My emergent consultations are no different from my independent (nonhospital affiliated) FSED than they are from my regular hospital ED gig. I don't have ENT at either place so if I have an ENT emergency, I pick up the phone and transfer them. No difference for me. Only difference is that the patient spent about 5 seconds in my FSED waiting room, and had my (and the nurse's) undivided attention until they were stabilized with transfer completed and them wheeling out the door. Contrasted with my regular job where they likely would have languished in the waiting room for at least 30 minutes, I would be juggling 8-12 other active patients and at best periodically peaking in on them to make sure they were alive waiting for my local tertiary care center to call me back, so in this sense, I feel I provide FAR superior care to my patient at my FSED than my hospital job.

Also at my FSED, I have consult numbers for hand surgery, ophtho, electrophysiology, general cards, GI, pulm, nephrology, neurology, urology. I can call any of these docs and in most cases get same day follow up and at worst next day for my FSED pts. Thus, I feel confident that the care I provide these patients is better than the care I end up providing my patients at my regular hospital, where the outpt follow up times for the above specialists are measured in fortnights. Is it because most of these patients are insured???? Hell yes, it is. Do I somehow feel that I have sullied my oath or betrayed the righteous indignation that I wield over my private practice colleagues as the REAL doc who sees all and actually provides care to the masses insured or not? No. It's quite pleasurable to call a historically difficult to deal with specialist to refer a patient and have the specialist be excited about seeing the patient, thank me for the consult/referral, and agree to see them in 2 hours in their office. Pt is happy, specialist is happy, I'm happy. Make for a pretty enjoyable work day, and will inevitably extend my career.

In Houston, FSED's have been great for all EPs. FSED's have given EPs the possibility of meaningful ownership and control of their craft. It has extended careers by offering very reasonable pay for a slower paced practice. The Houston FSEDs have pulled an estimated 800 FTE EP's out of the hospital market. This has in turn forced TeamHealth, EM care and Methodist to increase their hourly minimums, up again in the last year. Memorial Hermann and Methodist (Houston's two biggest hospital chains) have been running a cold war style arms race to see who can put up more FSED's in the last 2 years. TeamHealth has even had to increased the pay for their FSED's well above the going rate of the First Choice (largest nonhospital based FSED chain) pay rate just to get bodies to cover the shifts. This rising tide has lifted all ships.

Are FSEDs a parasite on the system? The same way outpatient surgery centers, hospital owned FSEDs, private outpt imaging centers, and lab corps are, I guess that's accurate, but hospitals are pretty unimaginative when it comes to outside financial pressures. They just copy the competition and then try to competitively inhibit. In the late 90's when nonhospital owned surgery centers were popping up, there was lots of discussion about this "new parasite" being the end of hospitals as it would syphon the insured ambulatory surgery patients away from hospitals and they were going to be legislated out citing anti-kickback statutes (any of this sound familiar to anyone else?) and here we are 20 years later and the independently owned surgery center still exists (though most have been bought out by hospitals), as do an ocean of hospital based surgery centers. Is there risk in a FSED? Sure. Probably not that dissimilar to the risk of joining a SDG with an "iron clad" contract getting usurped by a CMG.

Are FSED's good for the albatross that is the American Healthcare System? No, but they are hardly the death knell. More like throwing a few more ice cubes at the Titanic as it sails by. All that being said, I sleep soundly knowing the care I provided my FSED patients is complete, attentive, well explained, tailored, smarter, and something of which, I am proud. It allows me to practice the way I always imagined medicine would be, and that is the system of which I am happy to be part.

Why am I still awake?
-1234

Everything above is correct. ANY EM doc who is negatively biased against FSEDs should have their heads checked.

FSEDs is what is driving your pay either directly or indirectly. When a FSED opens up in your city, your city will be short 6-8 full time docs. That drives supply down. Everything in life and medicine is driven by supply and demand curve.

If you asked any hospital based ED group what they would like to change to improve their work, you will find in a FSED.
1. complete control. You want a nurse gone? Check. You want a new EMR system? Check. You want a new break room? Check. You want bonuses for the nurses? Check. You want a different Specialty call group b/c the ortho group is being a pain in the A$$? Check. You want to get rid of metrics? Check. You want a complete call list? Check. You want to control your own schedule? Check. New equipment? Check. A new faster computer? Check
2. increased pay
3. Seeing less than 1 pt/hr
4. a complete referral call list
5. Guaranteed follow up for your patient the next day or two
6. Business/property owndership

The only people it hurts is the hospital and CMG who has lost control of said physician and monopoly on EM doctors. Specialists loves FSED, and beg to be on the call list. I have been to FSEDs and get specialist go to the ED to drop off their cards and food. When is the last time you got that from hospital ED?

 

[emergentmd]

I remember the days of you detailing just how poor your "first job" was.

I used to hate Cerner as well; but in all honesty - Cerner + Dragon is the fastest and easiest EMR that I have seen yet in terms of *charting and documentation*. Entering orders.... not so much.

Your 1st job is usually a terrible job. Why? Ignorance. No one teaches you the business side of medicine. They should put Business medicine course as mandatory the first day.

You walk out of residency and have no clue about the EM environment or pay structure. The only thing you can put your hat on is the Medscape avg pay. i think EM was like 322k this yr. But that 322k avg tell you nothing about pay. Its a number without any basis. I

How many hours are you working?
Is that avg full time community based pay? I doubt it. I am sure its all EM across the board including academics, part time, urgent care docs who will pull the avg down.

f they want to make it more exact, they should tell you what an ED doc in community vs academics gets paid per hr.

So if you got out of residency, you would think market is 322k working 40 hrs a week. That seems about right. But guess what, that puts you at 155/hr. That is a pittance compared to what is really made an hr.

I met a guy who came out of residency near my city (terrible city he had to drive 1 hr to get to from my main city which he lived) making 160/hr in a hospital based ED seeing 2pt/hr. I was floored that someone would take that when you could make 190/hr at FSED in the city we lived in seeing 1/2 pt per hr.

Why? Pure market ignorace.

I would not work at his job for less than 400/hr

 

[deleted109597]

Everything above is correct. ANY EM doc who is negatively biased against FSEDs should have their heads checked.

FSEDs is what is driving your pay either directly or indirectly. When a FSED opens up in your city, your city will be short 6-8 full time docs. That drives supply down. Everything in life and medicine is driven by supply and demand curve.

If you asked any hospital based ED group what they would like to change to improve their work, you will find in a FSED.
1. complete control. You want a nurse gone? Check. You want a new EMR system? Check. You want a new break room? Check. You want bonuses for the nurses? Check. You want a different Specialty call group b/c the ortho group is being a pain in the A$$? Check. You want to get rid of metrics? Check. You want a complete call list? Check. You want to control your own schedule? Check. New equipment? Check. A new faster computer? Check
2. increased pay
3. Seeing less than 1 pt/hr
4. a complete referral call list
5. Guaranteed follow up for your patient the next day or two
6. Business/property owndership

The only people it hurts is the hospital and CMG who has lost control of said physician and monopoly on EM doctors. Specialists loves FSED, and beg to be on the call list. I have been to FSEDs and get specialist go to the ED to drop off their cards and food. When is the last time you got that from hospital ED?

So much this. People like to complain about FSEDs because they argue is skims the cream off the top of the hospitals, or that it's a glorified urgent care, or some other inside the box thinking. FSEDs don't take Medicare/Medicaid because they're not recognized by CMS as emergency facilities. But they can provide better care than some hospital attached EDs. Like anything, there's a gradient, and if they're put up by people who know their medicine and care about more than just profits, they do a good job. Just like those demon "physician owned hospitals" that our current president has made terrible, even though data shows they have better outcomes. It's shocking when the people who know the most about medicine are making the decisions instead of clipboard nurses and MBA suits that equate medicine to Toyota plants.

 

[The White Coat Investor]

So much this. People like to complain about FSEDs because they argue is skims the cream off the top of the hospitals, or that it's a glorified urgent care, or some other inside the box thinking. FSEDs don't take Medicare/Medicaid because they're not recognized by CMS as emergency facilities. But they can provide better care than some hospital attached EDs. Like anything, there's a gradient, and if they're put up by people who know their medicine and care about more than just profits, they do a good job. Just like those demon "physician owned hospitals" that our current president has made terrible, even though data shows they have better outcomes. It's shocking when the people who know the most about medicine are making the decisions instead of clipboard nurses and MBA suits that equate medicine to Toyota plants.

What do you mean you don't take medicare/medicaid? At what point do you tell the patient that and how do you avoid EMTALA issues related to that? Do you just see those patients and send them the bill personally?

 

[deleted77919]

…

 

[Arcan57]

This has been a fantastic discussion. Thanks everyone for your thoughts.

To answer the $/hr question, well, it doesn't sound like it is enough to get emergentmd out of bed. The other shop in town is an HCA Emcare nightmare, pays $15/hr better but it is IC no benefits. I am employed doc and our effective rate is bolstered somewhat by the benefits. Being an employed 501c3 and seeing PSLF also helps. I currently have half the payments necessary to qualify for loan forgiveness. We also have a retirement plan that is defined benefit, no employee contibutions necessary. It comes out to about 1% of your pay per year worked (could retire at 55 with 1/4 of my salary, 65 with 35% etc). The downside to this is it means my 401k contributions cap at 18k/yr.

In general I think I have a pretty good gig, but it doesn't sound like my gig begins to touch how great people have it at FSEDs. If the pay were a little higher and the hospital could conjure up about 25 more ED beds and 100 more inpatients beds things would be ideal. Those plans (at least for beds, not pay) are in the works but won't help for the next 5 years.

I imagine I will stick things out, but man, 1 patient per hour at 300/hr sounds great. I currently see >2/hr, admit rate is >30% and place a central line or perform an intubation nearly every shift.

Be very clear. If you are the owner of a FSED that was set up in the right way you will make bank. You will also have put a substantial part of your assets at risk to fund start-up costs. If you are the doc working at a FSED you don't have ownership in then you will be making something between UC and low ED rates (currently FSED pay is about $80-90/hr less than market rate in my city) to see somewhere in the neighborhood of 0.8 pts/hr. Also be very clear. If all or most of your shifts are at FSED, you will lose your ability to function in a busy hospital ED pretty quickly. Some of this will be because you will lose the ability to tolerate the BS that comes with major EDs (holds, bitchy consultants, incompetent/insufficient nurses, etc) and some of it will be that 95% of your volume is going to be things that would have been easily handled in a UC or with a trip to the cough/cold section of your local pharmacy.

 

[emergentmd]

Be very clear. If you are the owner of a FSED that was set up in the right way you will make bank. You will also have put a substantial part of your assets at risk to fund start-up costs. If you are the doc working at a FSED you don't have ownership in then you will be making something between UC and low ED rates (currently FSED pay is about $80-90/hr less than market rate in my city) to see somewhere in the neighborhood of 0.8 pts/hr. Also be very clear. If all or most of your shifts are at FSED, you will lose your ability to function in a busy hospital ED pretty quickly. Some of this will be because you will lose the ability to tolerate the BS that comes with major EDs (holds, bitchy consultants, incompetent/insufficient nurses, etc) and some of it will be that 95% of your volume is going to be things that would have been easily handled in a UC or with a trip to the cough/cold section of your local pharmacy.

Of course you are going to take a pay cut working at a FSED vs a hospital based ED. You are seeing 1pt/hr. By workload, you are definitely getting a better deal out of the FSED.

I don't know what your FSED rates are, but in Texas its atleast 180/hr. Working 3, 12 hrs shifts a wk(36 hr per wk work load), you are still making 336k/yr above the national avg. And this is an IC rate. Once you are a partner and open up your own (I am not talking about neighbors either), the income becomes obscene.

I think anyone who works/partners at a FSED should do locums in a busy hospital. Get paid a decent rate (350+/hr) and get all the pathology/volume they want.

Once my FSED opens up, I will still be working 3-6 shifts of locums a month to keep up my skills. Is there risks to opening one up? Yes. Will it break me if it goes down the toilet? Hardly. Even if my FSED only hits 10pts/dy, I will be able to retire in 3 yrs. I am not sure if FSEDs will be viable in 10 yrs, but I quite sure nothing much will change in 3 yrs.

 

[emergentmd]

What do you mean you don't take medicare/medicaid? At what point do you tell the patient that and how do you avoid EMTALA issues related to that? Do you just see those patients and send them the bill personally?

Most FSED take nothing but commercial insurance. taking medicare/medicaid would destroy the basis of a FSED. Once the medicaid population hears that a FSED will take them, it becomes a medicaid clinic. I might as well work in a hospital based ED.

Once a pt walks in the door, they are told that medicaid/medicare is not taken. All pts gets a medical screening exam. If they are true emergencies, they will be seen and billed later. If they are not, they will be given a choice to pay to be seen or go somewhere else. No different than what some hospital based EDs are doing.

EMTALA only requires a MSE. We all can do an MSE in 2 seconds. If you come with medicaid for a cough, vitals are stable, you essentially are cleared and can go to your clinic.

Any EM doc who hopes that FSEDs should closed down do not realize the grave consequences. I would think there are 400+ fseds in Texas. That would put 2400 ED docs in the market. Watch your pay Plummet and job flexibility plummet once the SDG and CMG have 2400 boarded docs knocking on their door. I would guess that this is more than what graduates yearly.

 

[filhodeinferno]

Most FSED take nothing but commercial insurance. taking medicare/medicaid would destroy the basis of a FSED. Once the medicaid population hears that a FSED will take them, it becomes a medicaid clinic. I might as well work in a hospital based ED.

Once a pt walks in the door, they are told that medicaid/medicare is not taken. All pts gets a medical screening exam. If they are true emergencies, they will be seen and billed later. If they are not, they will be given a choice to pay to be seen or go somewhere else. No different than what some hospital based EDs are doing.

EMTALA only requires a MSE. We all can do an MSE in 2 seconds. If you come with medicaid for a cough, vitals are stable, you essentially are cleared and can go to your clinic.

Any EM doc who hopes that FSEDs should closed down do not realize the grave consequences. I would think there are 400+ fseds in Texas. That would put 2400 ED docs in the market. Watch your pay Plummet and job flexibility plummet once the SDG and CMG have 2400 boarded docs knocking on their door. I would guess that this is more than what graduates yearly.

I wish more hospitals would do a quick 2 minute MSE and turn people away at the door like that. Of course, that'd never happen because it cuts into the bottom line. I'm guessing it is still profitable for them to bill Medicare for a viral URI visit, even when it technically might be more 'honest' to turn them away at the door and send them to the grocery store to buy some DayQuil.

 

[emergentmd]

I wish more hospitals would do a quick 2 minute MSE and turn people away at the door like that. Of course, that'd never happen because it cuts into the bottom line. I'm guessing it is still profitable for them to bill Medicare for a viral URI visit, even when it technically might be more 'honest' to turn them away at the door and send them to the grocery store to buy some DayQuil.

They would never do this b/c they like the Volume number and high pt satisfaction. Sats would plummet if you told 3/4 of the pts that they should go home. Good luck telling that medicaid pt that.

 

[RustedFox]

They would never do this b/c they like the Volume number and high pt satisfaction. Sats would plummet if you told 3/4 of the pts that they should go home. Good luck telling that medicaid pt that.

Thissss.... city.

 

[deleted77919]

…

 

[emergentmd]

There was a private hospital where I did my residency training that would do just that.

The problem they had was they were trying to be a private hospital catering to the upper middle class and only seeing insured patients while being situated in a less than great area. They hired an NP to sit in a little room and anyone who didn't have insurance (or were medicaid) and came with a non-life threatening sounding complaint (cough, genital discharge, etc) would get quickly seen and told a scripted "You have been seen in our emergency department and after a medical screening exam we have determined you do not have a life threatening condition. If you would like to be seen as a clinic patient we will need payment upfront." Of course no one ever paid, and simply left.

SO they turned themselves into a FSED?

 

[deleted109597]

What do you mean you don't take medicare/medicaid? At what point do you tell the patient that and how do you avoid EMTALA issues related to that? Do you just see those patients and send them the bill personally?

Caveat: I don't have an FSED or work at one, but I know a lot about them.

FSEDs aren't bound by EMTALA because they don't take CMS money (aren't even allowed). HOPDs (hospital based ones) can, because they have CMS contracts for the big hospitals. That's why those often have higher volumes. First Choice is somehow going to, probably because they used their size to convince the gubmint that they're "worthwhile". You can bill the pro fee for Medicaid/Medicare patients, but not the facility fee.
That being said, in Texas, the state does require them to perform an EMTALA type screening exam. Some take ambulance traffic, some don't. That's usually more political than anything (the hospitals really don't want it to happen, unless they own the freestanding).

Think of them as patient centered medical emergency homes for patients and you'll feel better I guess. I like to think of it as EPs finally getting to control their destinies.

 

[GeneralVeers]

I love the FSEDs and what they've done for our specialty. I hope they continue to spread, and are around for a long time. Because of FSEDs I've seen my salary almost double in the last 5 years, combined with greater schedule flexibility and better quality of life......all without actually working in an FSED.

The biggest barrier I see to myself working in a FSED is the huge drop in salary the first year or two to become an owner. Most require 6 24 hour shifts/month at about $100/hour in order to "buy in". After that there's no gaurantee of a profit, and of course the legislative situation could change. I'm much happier raping the CMGs for all I can for as long as I can. They deserve it.

 

[The White Coat Investor]

Caveat: I don't have an FSED or work at one, but I know a lot about them.

FSEDs aren't bound by EMTALA because they don't take CMS money (aren't even allowed). HOPDs (hospital based ones) can, because they have CMS contracts for the big hospitals. That's why those often have higher volumes. First Choice is somehow going to, probably because they used their size to convince the gubmint that they're "worthwhile". You can bill the pro fee for Medicaid/Medicare patients, but not the facility fee.
That being said, in Texas, the state does require them to perform an EMTALA type screening exam. Some take ambulance traffic, some don't. That's usually more political than anything (the hospitals really don't want it to happen, unless they own the freestanding).

Think of them as patient centered medical emergency homes for patients and you'll feel better I guess. I like to think of it as EPs finally getting to control their destinies.

Interesting. I hadn't realized most of these were opting out of CMS. Thanks for taking the time to answer.

 

[GeneralVeers]

Interesting. I hadn't realized most of these were opting out of CMS. Thanks for taking the time to answer.

It makes sense. Why be bound by EMTALA, have to adhere to CMS guidlines, and accept poorly-paying Medicare patients?

 

[deleted109597]

Interesting. I hadn't realized most of these were opting out of CMS. Thanks for taking the time to answer.

They're not opting out. They can't opt in unless they're hospital affiliated.

 

[The White Coat Investor]

They're not opting out. They can't opt in unless they're hospital affiliated.

So do you post a sign on the front door "we don't take Medicare/Medicaid." And then if someone checks in, you do a screening exam, tell them they don't have an emergency but if they would like to stay they'll need to pay cash now? What if they have an emergency? Do you then tell them you'll be sending them a bill?

 

[deleted109597]

So do you post a sign on the front door "we don't take Medicare/Medicaid." And then if someone checks in, you do a screening exam, tell them they don't have an emergency but if they would like to stay they'll need to pay cash now? What if they have an emergency? Do you then tell them you'll be sending them a bill?

Presumably. Most of them are pretty upfront about billing.
http://www.fcer.com/care
http://www.gtec24.com/why-free-standing-emergency-centers-cannot-accept-medicare-medicaid/
https://www.acep.org/Clinical---Practice-Management/Freestanding-Emergency-Departments/

 

[Brahnold Bloodaxe]

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).

This. Is the part that scares the crap out of me. As someone mentioned earlier, it is ultimately supply and demand that drives everything else. So long as there isn't a glut of EM docs, the worst depredations of corporate medicine will be not be visited on the field. There is only so much the CMGs and hospitals can do to screw you if they're desperately short for your services. Change the balance of power in the supply-demand equation and all bets are off...

Is there anyone controlling the EM residency expansions, or is this a runaway process that will end badly? I don't understand why some fields just don't get it. Ortho, derm, heck, even general surgery have kept tabs on their spots. Pathology, rads, and anesthesiology haven't, and look at the difference. I'd have thought the beating those other fields suffered would have made some impact on TPTB in EM.

 

[RustedFox]

This. Is the part that scares the crap out of me. As someone mentioned earlier, it is ultimately supply and demand that drives everything else. So long as there isn't a glut of EM docs, the worst depredations of corporate medicine will be not be visited on the field. There is only so much the CMGs and hospitals can do to screw you if they're desperately short for your services. Change the balance of power in the supply-demand equation and all bets are off...

Is there anyone controlling the EM residency expansions, or is this a runaway process that will end badly? I don't understand why some fields just don't get it. Ortho, derm, heck, even general surgery have kept tabs on their spots. Pathology, rads, and anesthesiology haven't, and look at the difference. I'd have thought the beating those other fields suffered would have made some impact on TPTB in EM.

Conventional wisdom round here says not to worry; visits are up like crazy. All of my job sites are in need of "more beds and more docs".

 

[deleted109597]

Conventional wisdom round here says not to worry; visits are up like crazy. All of my job sites are in need of "more beds and more docs".

And there's thousands of jobs out there that are currently held by non emergency docs. Eventually hospitals will have to use EM docs. Right?

 

[Brahnold Bloodaxe]

Conventional wisdom round here says not to worry; visits are up like crazy. All of my job sites are in need of "more beds and more docs".

I hope so, but damn, the pace of expansion is stretching credulity. We went from 1613 slots in 2008 to 1763 slots in 2013. Then all of a sudden it shot up to 1900 by this year. Not only is the rate of growth worryingly fast, but it's also accelerating! Family med is suffering a shortage but their spots actually declined from 2008 to 2013, and then again from 2013 to 2016. Lo and behold, their salaries have finally started to rise of late. I'm not saying EM is going to suffer an immediate salary trend in the opposite direction of Family Med as a result of the opposite direction in supply, but I'm just sayin'. Things are rosy till they aren't anymore, and residency spots seem to be the only thing left that physicians actually have some control over, so I'm surprised to see them squander that control.

 

[RustedFox]

And there's thousands of jobs out there that are currently held by non emergency docs. Eventually hospitals will have to use EM docs. Right?

I sure hope so, for the sake of our patients. It's the MLP game that bothers me. EVERY shift, I have to chase down or call back one of their patients, and we've actually made it policy now at my one shop that all ESI level 3 patients MUST be staffed with a physician upfront as a result.

 

[RustedFox]

And there's thousands of jobs out there that are currently held by non emergency docs. Eventually hospitals will have to use EM docs. Right?

I would loooove to get into some of those rural jobs, even if the pay is meh. However... I need to be out of debt, first. The crippling debt is the real problem, here; and before any Kangaroo crews pop up and clamor that the "government" is the answer... No.

 

[emergentmd]

Once EM demands goes up there will be market forces to drive demand down or supply up. No different than any other field or business.

As you will never drive demand down b/c people Love the ER vs going to the clinic, you have to ramp up supply. That is what you are seeing.

Increase EM slots, increase use of Midlevels are ramping up supply. FSED is counterbalancing and driving supply down. This is why it is currently the golden age of EM. How long will it lasts? Who knows.

But if FSED are continued to spread throughout the country, The extra 2-300 EM spots is a drop in the bucket.

All EM docs need to worry about is if FSEDs are deemed illegal. That is when pay will plummet.

But I am happy to ride the shortage and joining the the FSED crowd.

I find great satisfaction getting regular calls to cover locums shift and telling them that they can't afford me. They do ask what my price is, and the conversation quickly ends when I tell them.

 

[Brigade4Radiant]

There are too many EM spots being generated. We can't just depend on the idea of FSEDs to save us.

 

[Amazingmuzmo]

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

Which part of the country are you able to make that 500k for 1500hr CMG+Locums? Couldn't be in the NE or Midatlantic...?

 

[Brahnold Bloodaxe]

Just curious: do people working in regions with lower hourly rates like the Northeast or West Coast typically work more shifts than those in Texas/Southeast in order to still have a reasonable income, or does hourly income have no effect on average hours worked?

 

[shoal]

at abem oral boards i was talking to a college who is in much more desirable area then me and was speaking of the local salaries as 320-340k/yr which is similar to mine but thenbstarted talking hours and those jobs are putting in 25%+ more hours then i am.

i work 120-130 hrs a month vs 150-160.



Sent from my VS986 using Tapatalk

 

[RustedFox]

I got a buddy that wants a war-chest to do *something* with. He put in 208 hours last month.

I sis-out if I get near 150.

 

[Brahnold Bloodaxe]

Hmm, that's bad lol. This means that if the average hourly rate in EM drops, whether due to oversupply or reimbursement cuts, people will work more hours in order to compensate, which in turn will increase supply and cut hourly rates even further.

 

[emergentmd]

Hmm, that's bad lol. This means that if the average hourly rate in EM drops, whether due to oversupply or reimbursement cuts, people will work more hours in order to compensate, which in turn will increase supply and cut hourly rates even further.

Thats right. EM is one of the few fields where you can make as much/work as you want or as little as you want without any start up cost, wait time.

I can see some docs working more to compensate if pay goes down, but most would just be happy making 300K/yr.

I am lucky to be in the middle of my career and nothing that happens will bother me but i don't think pay will change much for atleast 10 years.

 

[EDParallax]

I sure hope so, for the sake of our patients. It's the MLP game that bothers me. EVERY shift, I have to chase down or call back one of their patients, and we've actually made it policy now at my one shop that all ESI level 3 patients MUST be staffed with a physician upfront as a result.

Hmm, care to share some of these cases? Hypothetically speaking of course.

My new gig requires signing off on MLP charts without seeing the patients (I know, standard ) but it still will be new for me.

Sent from my SM-G920T using SDN mobile

 

[RustedFox]

Hmm, care to share some of these cases? Hypothetically speaking of course.

My new gig requires signing off on MLP charts without seeing the patients (I know, standard ) but it still will be new for me.

Sent from my SM-G920T using SDN mobile

I don't wanna turn this into yet another "MLP=LOL thread". I love the MLPs I work with; but some of them need some serious oversight.

29 year old male, hand bashed by some kind of machinery at work. Seen 2 days ago; given Rx for doxy/bactrim that he didn't fill. Now the finger is hot with some ascending lymphangitis. Fever to 101.9. Tachy in the 110s. Guy meets sepsis criteria (SIRS+source).

No workup. Nothing. Shot of Rocephin... sent home.

I didn't find out until 2-3 days later when the chart pops up in my queue to sign.

I can't sign off on that. No way. Been trying to call this patient. No answer.

 

[TooMuchResearch]

Send police to the house for a welfare check *sort of sarcastic face*

 

[BoardingDoc]

Now the finger is hot with some ascending lymphangitis. Fever to 101.9. Tachy in the 110s. Guy meets sepsis criteria (SIRS+source).

Not anymore. Sepsis 3 guidelines have been out for a couple of months now.
New definition is 2 or more of the following 3 items
-hypotension (SBP < 100)
-AMS (GCS <15)
-Tachypnea (R >= 22)

Severe sepsis no longer exists

Septic shock is now Sepsis +
-persistent hypotension despite fluids requiring pressors
AND
-lactate >= 2

 

[RustedFox]

Not anymore. Sepsis 3 guidelines have been out for a couple of months now.
New definition is 2 or more of the following 3 items
-hypotension (SBP < 100)
-AMS (GCS <15)
-Tachypnea (R >= 22)

Severe sepsis no longer exists

Septic shock is now Sepsis +
-persistent hypotension despite fluids requiring pressors
AND
-lactate >= 2

Thanks for updating me. For realsies. I had been meaning to podcast this, but life is just a tsunami of stuff these days.

I'll tell that to the "compliance police" next time they come to agitate me with their clipboards.

 

[TooMuchResearch]

Not anymore. Sepsis 3 guidelines have been out for a couple of months now.
New definition is 2 or more of the following 3 items
-hypotension (SBP < 100)
-AMS (GCS <15)
-Tachypnea (R >= 22)

Severe sepsis no longer exists

Septic shock is now Sepsis +
-persistent hypotension despite fluids requiring pressors
AND
-lactate >= 2

I think this is a composite of that recent paper discussing a new (non-prospectively validated if I recall) definition and the new CMS non-sense.

Severe sepsis is still a thing.
You don't have to follow that new paper, I.E. not ready for prime time.
I don't think payers have caught on to the new CMS non-sense yet, but your hospital may have so you may as well follow it.

 

[da8s0859q]

It's not that I don't "get it". Sepsis and its spectrum of disease is a big deal. Obviously.

But I think things have gone just a little too far.

 

[wololololololo]

While spots are increasing, I don't think it will go the way of rads or path given nature of the work and the average shelf life of EM compared to those specialties.