$200/hr salary

[Birdstrike]

The Myth Of An "Hourly Pay Rate" For Emergency Physicians


Here's something recruits don't understand about these hourly rate quotes. Often times they are lost leaders. Sometimes they're quoting you are higher number than they can promise. But more importantly, many newbies make a critical error when thinking economically about this. They conclude, "If they will pay me $200/hr to work full time at this job, they'll pay me $200/hour to work part time at this job."

Wrong!

They probably do have some people at that job making $200 or more per hour at that job. That's because they're working their butts off generating it.. That money doesn't come off a money tree.

Know this: Any job has overhead. I've posted it here a million times. It costs money to put you in the pit for a shift. Read again. The minute you set foot at your new job, you generate a certain amount of costs to that group, or "overhead" (admin fees, billing, malpractice insurance, professional fees, DEA license, main office rent, group employees, group attorney fees, account fees, and other costs of running a group, ie, "business". The list goes on and is a half page long). There's a certain amount of hours you have to put it, just to break even and generate ZERO dollars per hour for your group. Only after that point does the curve shoot up and it's not linear. In other words, the first 1/3 of your shift, you're working for free, at a cost to the group, just to break even. Beyond that point, since some of the overhead is fixed, the guy that works 30% more than you, and generates 30% more RVUs, collects for the group 50, 60 or 70% more dollars per hour than you (not just 30% more).

For that (and other) reasons, they'd much, much, much rather have one doc that works 200hr per month, than 2 docs that work 100 hr per month, or even worse, 3 doctors that each work 66 hours per month.

Here's the mythical pre-EM though process:

"I can live on $50,000 per year now, therefore, as an EM attending I can always just work only 1, 8-hour shift per week, or 416 hours per year, and make $83,200 per year (at $200/hour), and be the happiest person on Earth, making much more than I did as a resident, practically not working at all! That's amazing!"

Wrong!

No group would ever, ever, pay you to do that, because not only would you not make $200/hour, you wouldn't generate $200/hr or even one penny per hour. How so? Your overhead costs would be more than your collections would even generate.

Why? It comes back to the economic inertia or the amount of patient charges you need to bring in, to pay for

FIXED OVERHEAD.

There's no mythical healthcare dollar tree in fee-for-service medicine. These quotes often seem "too good to be true" for the pre-EM people. Not because you can't earn that much. You can. You've just got to work very hard and earn every penny of it, and under no circumstances can you expect that you can cut your hours without limit and still get paid like the big boys.

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[da8s0859q]

Here's the mythical pre-EM though process:

"I can live on $50,000 per year now, therefore, as an EM attending I can always just work only 1, 8-hour shift per week, or 416 hours per year, and make $83,200 per year (at $200/hour), and be the happiest person on Earth, making much more than I did as a resident, practically not working at all! That's amazing!"

Wrong!

So obviously it'll vary from place to place, but how "little" do you suppose a group would allow someone to work without any extenuating circumstances?

 

[HunterGatherer]

So obviously it'll vary from place to place, but how "little" do you suppose a group would allow someone to work without any extenuating circumstances?

I think he is stating that a part timer is not going to find that $200/hr rate due to overhead and will make less per hour than their full time counterparts in the same shop.

 

[Apollyon]

I think he is stating that a part timer is not going to find that $200/hr rate due to overhead and will make less per hour than their full time counterparts in the same shop.

The opposite was true in Hawai'i - part timers made more. People on the "partnership track" made significantly less per hour. (Neither paid $200/hr, though - that was only on Maui.)

 

[la gringa]

I think he is stating that a part timer is not going to find that $200/hr rate due to overhead and will make less per hour than their full time counterparts in the same shop.

that is exactly what locums goes for in my state.

 

[Birdstrike]

.

 

[wlubin]

The pay is relative to how many hours in a shift and how many shifts you will work. Like a previous poster wrote it also about the benefits. There are numberous other factors that affect the offered pay. Not to mention facilities have different units of measurement that they use to calculate the value of a doctor.

 

[EctopicFetus]

I kind of have to disagree. Being a part timer can be extra financially worthwhile in the short term. Long term I think it wouldnt be hard to work a few shifts per month.

Going rate in town is about $180/hr as a 1099.

 

[GeneralVeers]

I can work whatever I want with my current gig. Usually I work about 12 shifts which supplies me enough income. If I want, I can go down to four shifts a month or zero.

 

[Birdstrike]

I can work whatever I want with my current gig. Usually I work about 12 shifts which supplies me enough income. If I want, I can go down to four shifts a month or zero.

1. Could you do this at your last job and the one before that?

2. Is your new job a very large group?

3. If you decide to take a breather and cut back from 12 to 4 shifts per month for the next six months, who works your 50 extra shifts over that 6 months, and will they be asked if they want to pick them up or is it mandatory?

4. In the future, if 2 or three others do the same, at the same time, are you asked to take up a part of the extra shifts?

5. What if no one wants to?

 

[Birdstrike]

So obviously it'll vary from place to place, but how "little" do you suppose a group would allow someone to work without any extenuating circumstances?

What about this scenario? Common or not?

You request to cut your shifts down by 2 shifts per month. That's 24 shifts per year. Does your group director just say, "That's cool. We'll just short the department and let wait times go up, door-to-doctor times go up, and patient satisfaction go down (Press Ganey) and piss off the hospital, ie, the hand that feeds me"?

No.

He wants to keep his job, and though he likes to think of himself as an independent guy who is "part owner" of a democratic EM group and "has his partners' backs", he's really a de facto employee of the hospital just like every other ER doctor, in fact more so. If he doesn't keep them happy, he and your group, and more importantly you, could be left with no hospital, no ER to cover, no patients and therefore, no job.

Therefore, to avoid such an Armageddon-like scenario which constantly hangs over his head, he decides to keep to his goal of staffing the department to the hospital's absurd goal of all patients being seen by an MD within 15 minutes of hitting the door, no matter how unpredictable the flow, no matter how many cars roll over, or customers, OOPS-I-mean families-of-4 decide to come in for "school notes" and well checks.

Following me?

So now, his day really sucks, ever since you rolled in his door and told him of your need to take some more "me time," because all of a sudden he's got 24 more shifts he's got to unload on a group that's been short enough that they just had to hire a new guy. Since generally, most EM groups are either fully staffed or more likely short due to the nationwide shortage of BC/BE EPs, not a single doc wants to pick up extra shifts. If by chance hiring you has brought them to full staff, he knows within 6 months, volume will have grown 5%, which will put his 17 doc group, 0.85 full-time physician equivalents short and not in the position to have people rolling into his office asking to have their hours cut. Then his imagination runs wild about Obamacare kicking in, and what if volume increases more than 5% and the payer mix tanks with more Medicaid patients in the mix. He then loosens his tie, swallows more than the allotted dose of tums, and starts to wonder if his 401k is near goal, so he can get out of this gig....

Then, he brings it up at the group meeting, and all 17 heads turn towards you and think, "Why the hell doesn't the new guy want more shifts? I don't want more shifts. We just hired him to soak up a bunch of shifts. He's got student loans to pay back, and he's 10 years younger than me. No thanks, bro."

So, even if you didn't have the entire problem of overhead and paying for docs that don't want to work full time, you have the problem of,

Who's going to work your shifts?

In 2013 and moving forward, is Emergency Medicine practiced in a vacuum?

Or do he hospitals want you to see every patient in 15 minutes, keep them happy, and make mad cash for them and corporate?

Is "Medicine" king?

Is the textbook King?


Or is the Customer (Hospital's Money) King?


If you aren't going to commit to the hospitals goals, doesn't someone in your group have to? If not, will EPDMG (Undercut Pit Doc Management Group) going to come in, offer to do it cheaper and the hospital kick you and your group to the curb without cause?

That being said, I'm sure you can find several examples of EPs that work at a very large group, with very little turnover, that is laid back enough to allow a senior physician or someone else with a specific situation (but not everyone) to work the mythical 6 shifts per month, for $115,000 per year with no pressure to work more or step aside for someone who will. I'm sure my post will be followed by several examples of such. Is that the exception?

Or the rule?

In the setting of a nationwide BC/BE EP shortage, will you be asked to work how much they need you to work, or how much you need you to work?


These are the 4 things you need to do:

Business- move as many patients through the department day and night to keep the your real boss, the hospital, happy. Also, chart, code and comply with billing to keep your group happy.

Medical- know enough medicine to maintain a basic level of competence (excelling to the highest level is not required by The Machine, only optional or if you desire to do so out of pride).

Legal- cover yourself, group and hospital legally so as not to make lawsuits easy for the lawyers.

Political- seek out and robotically follow government "red tape" without any regard to reason or logic (not joking) such as "meaningful use," "compliance committee," "ICD 10," "Medicare compliance," and "10 point review of systems," "billing requirements," "E&M coding distributions," and "Joint Commission." Our "god" works in mysterious ways.


Are we in the Golden Age of Medicine? Or are we entering a new era? Are we more similar to Osler and Marcus Welby or are we more like cogs and replaceable de facto employees of a massive and highly regulated, Business-Medico-Legal-Political Machine?

 

[GeneralVeers]

1. Could you do this at your last job and the one before that?

2. Is your new job a very large group?

Hospital employee, 15 docs employed

3. If you decide to take a breather and cut back from 12 to 4 shifts per month for the next six months, who works your 50 extra shifts over that 6 months, and will they be asked if they want to pick them up or is it mandatory?

Not sure. I have no minimum or maximum shifts in the contract. I just request the number of shifts I want (usually 8-10) and they give me those.

4. In the future, if 2 or three others do the same, at the same time, are you asked to take up a part of the extra shifts?

No. I am IC. The other docs in the group are all FT W2 employees and have to work a minimum number of hours (110 I think), so the chance of this happening is small.

5. What if no one wants to?

See #4. They are contractually obligated to work 110 hours. I am not.

 

[Birdstrike]

Hospital employee, 15 docs employed

Not sure. I have no minimum or maximum shifts in the contract. I just request the number of shifts I want (usually 8-10) and they give me those.


No. I am IC. The other docs in the group are all FT W2 employees and have to work a minimum number of hours (110 I think), so the chance of this happening is small.


See #4. They are contractually obligated to work 110 hours. I am not.

As an IC, who pays your malpractice insurance, and how much does it cost, approximately?

 

[GeneralVeers]

As an IC, who pays your malpractice insurance, and how much does it cost, approximately?

Hospital pays it. Many IC jobs do have the hospital pay it, if you're not part of a locums company. By not going with a locums company, you save the hospital a lot of money (they can pay the locums company as much as $100/hour for your services) so they are happy to pay malpractice which is much less.

I do have to pay other benefits, like 401K, disability, health insurance, etc. As I've stated earlier, the calculated cost of that is about $30/hour.

I was able to get rid of the things I hated about last job with EMP:
1. Toxic work environment which puts patients directly in danger.
2. Local site directors who are completely detached or outwardly hostile and intimidating towards the docs.
3. Greedy corporate managers of the CMG who attempt to fire anyone who disagrees with them, or points out problems with their management.
4. Watching my salary fall every year due to "decreasing collections" at my site, even though the corporate managers are buying Masseratis, and spending $3 million to build a "learning center" at their corporate headquarters.
5. Seeing 3 pts/hour safely and efficiently (while covering up the hospital's lack of regard for patient safety), then getting hate-mail from the hospital for that one patient who is pissed why I didn't give antibiotics.

 

[Birdstrike]

Hospital pays it. Many IC jobs do have the hospital pay it, if you're not part of a locums company. By not going with a locums company, you save the hospital a lot of money (they can pay the locums company as much as $100/hour for your services) so they are happy to pay malpractice which is much less.

I do have to pay other benefits, like 401K, disability, health insurance, etc. As I've stated earlier, the calculated cost of that is about $30/hour.

I was able to get rid of the things I hated about last job with EMP:
1. Toxic work environment which puts patients directly in danger.
2. Local site directors who are completely detached or outwardly hostile and intimidating towards the docs.
3. Greedy corporate managers of the CMG who attempt to fire anyone who disagrees with them, or points out problems with their management.
4. Watching my salary fall every year due to "decreasing collections" at my site, even though the corporate managers are buying Masseratis, and spending $3 million to build a "learning center" at their corporate headquarters.
5. Seeing 3 pts/hour safely and efficiently (while covering up the hospital's lack of regard for patient safety), then getting hate-mail from the hospital for that one patient who is pissed why I didn't give antibiotics.

Great post. I quoted it as a great list of things EM residents should be aware of so they can be on the lookout to avoid them.

Not to beat a dead horse, but in reference to this part:

"I do have to pay other benefits, like 401K, disability, health insurance, etc. As I've stated earlier, the calculated cost of that is about $30/hour."

The "$30/hr" calculation comes from the hours you are working. If you decrease the hours or shifts, like you suggested in an earlier post, your "cost" of those benefits, per hour, doubles. (Same costs divided by a lower number, gives a bigger number, or greater cost per hour). If you cut you hours, you don't get a proportional discount on the cost of your "benefits, like 401K, disability, health insurance, etc.", do you?

No.

The same goes for your malpractice insurance and the cost of it to the hospital. If you cut your hours, they don't get a discount on your insurance, do they?

No, not anymore than they would be charged more if you increase you shifts.

Why belabor what some would ignore as a boring or irrelevant point?

To show that there are forces behind the amount of hours an EP is expected to work, so that ER residents have realistic expectations and aren't shocked if the get pushback about wanting to cut their hours, or not wanting to continuously suck up unstaffed shifts. You have to understand the economics of how you are paid. I hope everyone gets full control of their work hours and lifestyle and never has to work an hour more than their burnout thread hold can withstand, or an hour less than their budget can withstand. But if they can't, or sense they won't be able at a job they're looking at, maybe I can help them be a little more street smart about the issues so as not to trip on the same wires some of the rest of us have.

Also, if you are not aware of how every single patient case or procedure you do, gets coded, billed, collected and filtered through the system to generate your salary, I guarantee you, just like happened to G.Veers, someone will take advantage of that ignorance and bleed dollars out of that equation and make a habit out of diverting it towards "other projects" (that's Italian for someone else's Maserati) and not into your own pocket.

Most ER residencies (and all medical training in general) are atrociously negligent in teaching these economic, political, administrative and business-related forces that work behind the scenes to affect your career, life and job satisfaction. They're much more focused on marketing an ideal that is more attractive to recruits.

I learned the hard way.

GeneralVeers obviously learned the hard way.

Pay attention.

 

[GeneralVeers]

The "$30/hr" calculation comes from the hours you are working. If you decrease the hours or shifts, like you suggested in an earlier post, your "cost" of those benefits, per hour, doubles. (Same costs divided by a lower number, gives a bigger number, or greater cost per hour). If you cut you hours, you don't get a proportional discount on the cost of your "benefits, like 401K, disability, health insurance, etc.", do you?

At my prior site there was a 108/hr per month minimum to maintain benefits, which came to about 12-13 shifts per month. Also, when I worked more at my previous job, my salary didn't go up, rather stayed the same. Guess who kept that extra $30/hour?

Currently I work around 12 shifts at two sites. The nice thing is that I have the flexibility to work as much or as little as I want.

I wish we could all stand up against these large CMGs and change how they do business. I slaved away for five years to make someone else a lot of money, and in exchange got grief, threats, and insults for my time and trouble.

 

[Arcan57]

What about this scenario? Common or not?

You request to cut your shifts down by 2 shifts per month. That's 24 shifts per year. Does your group director just say, "That's cool. We'll just short the department and let wait times go up, door-to-doctor times go up, and patient satisfaction go down (Press Ganey) and piss off the hospital, ie, the hand that feeds me"?

No.

He wants to keep his job, and though he likes to think of himself as an independent guy who is "part owner" of a democratic EM group and "has his partners' backs", he's really a de facto employee of the hospital just like every other ER doctor, in fact more so. If he doesn't keep them happy, he and your group, and more importantly you, could be left with no hospital, no ER to cover, no patients and therefore, no job.

Therefore, to avoid such an Armageddon-like scenario which constantly hangs over his head, he decides to keep to his goal of staffing the department to the hospital's absurd goal of all patients being seen by an MD within 15 minutes of hitting the door, no matter how unpredictable the flow, no matter how many cars roll over, or customers, OOPS-I-mean families-of-4 decide to come in for "school notes" and well checks.

Following me?

So now, his day really sucks, ever since you rolled in his door and told him of your need to take some more "me time," because all of a sudden he's got 24 more shifts he's got to unload on a group that's been short enough that they just had to hire a new guy. Since generally, most EM groups are either fully staffed or more likely short due to the nationwide shortage of BC/BE EPs, not a single doc wants to pick up extra shifts. If by chance hiring you has brought them to full staff, he knows within 6 months, volume will have grown 5%, which will put his 17 doc group, 0.85 full-time physician equivalents short and not in the position to have people rolling into his office asking to have their hours cut. Then his imagination runs wild about Obamacare kicking in, and what if volume increases more than 5% and the payer mix tanks with more Medicaid patients in the mix. He then loosens his tie, swallows more than the allotted dose of tums, and starts to wonder if his 401k is near goal, so he can get out of this gig....

Then, he brings it up at the group meeting, and all 17 heads turn towards you and think, "Why the hell doesn't the new guy want more shifts? I don't want more shifts. We just hired him to soak up a bunch of shifts. He's got student loans to pay back, and he's 10 years younger than me. No thanks, bro."

So, even if you didn't have the entire problem of overhead and paying for docs that don't want to work full time, you have the problem of,

Who's going to work your shifts?

+1. I'm not sure if you were ever director but the feeling you just described is spot f%^-ing on. I've steadily watched the numbers of shifts I work a month (we do 10h) creep up from 12 to 16 while almost every month one of my FT docs requests to cut down to half time for one or more months. And the administrative side is only getting harder as we get pulled into every meeting they can think to slot us into because C-suite thinks we should be full-time admin just like the directors of all the other departments they control. And they don't seem to fully grasp that a director that doesn't work clinically has exactly zero pull with the "rank and file" docs.

We're still able to keep it a pretty sweet gig for our docs but it's like herding cats while dodging boulders being tossed off a cliff.

 

[Birdstrike]

+1. I'm not sure if you were ever director but

No, but I could tell you probably were by your response to a couple previous posts of mine. It's all good. Glad to have you back. Sorry my post got you banned. LOL.

 

[la gringa]

Veers -

were you at one of the hospitals that later lost their contract?