Are locums rates really declining?

[EctopicFetus]

You’re assuming that current trends will continue. EM kinda sucks to do. It’s attractive due to perceived high salary and low workload. In reality most midlevels are getting paid pretty poorly for a relatively high stress environment with crap schedules. A significant number of new grads are biding their time to get out of the ED and into something with a stable schedule. Do you anticipate current level of interest persisting among med students as the perception that a bubble is bursting propagates? The days of walking into a job in a top 10 market while making fat $$$ on day 1 as a new grad may be ending.

In general a bet against EM is a bet for increased rationality, decreased utilization, and a healthier population in the US.

I would short EM physician salary if I could. The reasons are numerous.

1) Major push to pay less for ED visits (See amazon, google, consolidation amongst payers, telemedicine)
2) Over supply of ED docs
3) Wall Street —> with all the CMGs in bed with “investors”/ publicly traded / Private equity
4) Crushing student debt. That 1st year ed doc is too ******ed and his residency taught him/her nothing about the business of medicine. 180K/yr for 2000 hours! Hell yeah!
5) MLPs / FP “ED fellowships”
6) Hospital administration is too stupid (In lieu of making the EDs efficient they try to hit meaningless metrics)
7) consolidation by hospitals —> leads to increased likelihood of CMG involvement and the issues above.

My friends in AZ said the locums pinch is on. No more bonuses etc.

Thank god I work for an SDG and outside of losing our contract those factors above dont really apply. #1 & #7 do.. the rest are irrelevant to my practice.

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[Alvarez13]

I would short EM physician salary if I could. The reasons are numerous.

...

Thank god I work for an SDG and outside of losing our contract those factors above dont really apply. #1 & #7 do.. the rest are irrelevant to my practice.

When you lose your contract...

 

[Money Moniker]

You’re assuming that current trends will continue. EM kinda sucks to do. It’s attractive due to perceived high salary and low workload. In reality most midlevels are getting paid pretty poorly for a relatively high stress environment with crap schedules. A significant number of new grads are biding their time to get out of the ED and into something with a stable schedule. Do you anticipate current level of interest persisting among med students as the perception that a bubble is bursting propagates? The days of walking into a job in a top 10 market while making fat $$$ on day 1 as a new grad may be ending.

In general a bet against EM is a bet for increased rationality, decreased utilization, and a healthier population in the US.

The thing is midlevel numbers are exploding. They've doubled the number of training slots in less than 5 years (there were 11,000 NPs graduating in 2011 and in 2016 there were 25,000) and are on track to double them again! That field is headed for an enormous implosion in job opportunities and income, but that will make them MORE attractive to hire for corporate bean counters, not less. Additionally, when they're desperate to find a job due to oversupply, they'll be perfectly happy with the the crappy ED environment and the only people biding their time will be newly minted NPs back doing bedside nursing waiting for a spot to open up doing anything else, anywhere else.

As for med students getting spooked about EM, you're forgetting that there is a bottomless ocean of third world doctors who'll gladly come and take their place. Fields like pathology have been dead to AMGs for decades and yet pathology residencies continue to expand and churn out ever more "providers" with training from the 4 corners of the world. Something like half of IM and FM residencies are almost exclusively FMG. These dudes in India and Pakistan make $300 per month, they'll gladly come over to the USA and practice even if the hourly rates drop to $15/hr. There will never be a shortage of warm bodies is what I'm saying.

I would short EM physician salary if I could. The reasons are numerous.
......
Thank god I work for an SDG and outside of losing our contract those factors above dont really apply. #1 & #7 do.. the rest are irrelevant to my practice.

But if the EM job market is destroyed and you get a glut of desperate docs willing to work for peanuts, what's going to stop the CMGs from utilizing their army of minimum wage slaves to underbid your contract with the hospital? If your payer mix allows your group to make $400/hr (for example), the CMG will roll in and offer the hospital CEO a " reverse stipend" of $100/hr for every doc, which will still leave $150/hr for the CMG if they pay their docs $150/hr. I just can't see a situation where the average EM hourly rate is really low but there are a handful of SDG oases that somehow maintain magically high rates. With that said I'm glad to hear you've got FU money at this point haha.

 

[EctopicFetus]

When you lose your contract...

cute.. been there done that my friend. Im financially free. Im willing to wager that wont happen. Happy admin, no stipend, happy nurses.. yawn.. always a possibility for sure but mean its a lot easier when you are FI. That being aid the pendulum is swinging the other way since the CMGs cant deliver, LOL..

 

[Status Sciaticus]

You’re assuming that current trends will continue. EM kinda sucks to do. It’s attractive due to perceived high salary and low workload. In reality most midlevels are getting paid pretty poorly for a relatively high stress environment with crap schedules. A significant number of new grads are biding their time to get out of the ED and into something with a stable schedule. Do you anticipate current level of interest persisting among med students as the perception that a bubble is bursting propagates? The days of walking into a job in a top 10 market while making fat $$$ on day 1 as a new grad may be ending.

In general a bet against EM is a bet for increased rationality, decreased utilization, and a healthier population in the US.

;

LOL, a healthier US population is never going to happen. EM may be hot right now given the number of ED docs that are board certified, but it will stabilize slightly lower, although not by much given the nature of the work and the patient population/shiftwork nature of the job.

 

[GeneralVeers]

;

LOL, a healthier US population is never going to happen. EM may be hot right now given the number of ED docs that are board certified, but it will stabilize slightly lower, although not by much given the nature of the work and the patient population/shiftwork nature of the job.

I think you are correct. There is definitely a floor for physician salary, as at some point the nature of our work, schedule, and BS we have to deal with necessitates a certain premium in pay. At this point I wouldn't work for < $200/hour anywhere. That is the number for which I would leave the EM job force and seek other opportunities.

I am also not threatened by foreign medical grads. Our specialty, more than most in medicine requires a very good understanding of English, not to mention understanding U.S. culture. Foreign grads are going are going to fail miserably on both of those counts.

 

[InternistDO]

For anyone curious, out of the 2,278 PGY-1 EM spots this year, only 29 were filled by non-US IMGs. Even in pathology, more than half the spots are still filled by US MD and DO students.

http://www.nrmp.org/wp-content/uploads/2018/04/Main-Match-Result-and-Data-2018.pdf

 

[Got Em]

There is so much doom and gloom everywhere in this forum. Midlevels are not just prevalent primary care fields, they're also taking over surgical fields and subspecialties as well. There are derm NPs, pain NPs, and lastly surgical NPs who can do parts of the procedure deemed "non-critical" and have the surgeon only be present during the "critical" times. Oh, and the link below shows in the UK some NPs can now perform minor surgeries without supervision.

Meet the nurse who will soon perform surgery on patients alone

 

[EctopicFetus]

Let me be clear I am bullish on sdgs. Our volumes are gonna go up / stabilize and we control our staffing. Outside of losing my contract I’m golden and thats with a pretty bad payer mix.

The economics of cmgs and sdgs are completely different.

Much like the burger flipper May be replaced by a burger flipping machine.

The owner of the burger store only has to worry about a better burger.

I’ll take my chances.

Ef

There is so much doom and gloom everywhere in this forum. Midlevels are not just prevalent primary care fields, they're also taking over surgical fields and subspecialties as well. There are derm NPs, pain NPs, and lastly surgical NPs who can do parts of the procedure deemed "non-critical" and have the surgeon only be present during the "critical" times. Oh, and the link below shows in the UK some NPs can now perform minor surgeries without supervision.

Meet the nurse who will soon perform surgery on patients alone

 

[GeneralVeers]

Let me be clear I am bullish on sdgs. Our volumes are gonna go up / stabilize and we control our staffing. Outside of losing my contract I’m golden and thats with a pretty bad payer mix.

The economics of cmgs and sdgs are completely different.

Much like the burger flipper May be replaced by a burger flipping machine.

The owner of the burger store only has to worry about a better burger.

I’ll take my chances.

Ef

The CMG can always off the hospital a better (and cheaper) burger. Do they cheat and mis-label the ingredients? Of course.

 

[emergentmd]

Let me be clear I am bullish on sdgs. Our volumes are gonna go up / stabilize and we control our staffing. Outside of losing my contract I’m golden and thats with a pretty bad payer mix.

The economics of cmgs and sdgs are completely different.

Much like the burger flipper May be replaced by a burger flipping machine.

The owner of the burger store only has to worry about a better burger.

I’ll take my chances.

Im willing to wager that wont happen. Happy admin, no stipend, happy nurses.. yawn.

Ef

My SDG was the top trusted/most respected group in our hospital as rated by the medical staff. Our nurses/manager loved our group. CEO loved our group. We had people in MEC, past Chief of staff, had a member in almost every hospital committee. No stipend.

Well, we are a CMG now.

All SDGs are vulnerable and may have nothing to do with your group. You could be the best group, take no stipend, follow all the CEO's orders like a whipped puppy and still lose our contract when the CMG comes in and offers the hospital a kickback, take on a terrible hospital no one wants, or offers to run the hospitalist group without a stipend. If the hospital's bottom line is better with a CMG, your days are numbered.

 

[EMPertinent]

Well, this thread has been thoroughly disheartening. I'm an intern and am suddenly feeling genuinely freaked out that I'm not going to be able to pay down my mortgage-sized student loans through this specialty I thought would be financially stable. Anyone have a glass-is-half-full take on EM compensation (you know, for the kids?)

 

[GonnaBeADoc2222]

Well, this thread has been thoroughly disheartening. I'm an intern and am suddenly feeling genuinely freaked out that I'm not going to be able to pay down my mortgage-sized student loans through this specialty I thought would be financially stable. Anyone have a glass-is-half-full take on EM compensation (you know, for the kids?)

The EM forum of SDN is "doom and gloom omgzzz the sky is falling no one should ever go into EM never ever ever" literally all the time. Sprinkle in the almost constant "you're so stupid for not living in a zero tax state and working for less than $300/hr, but I'm not going to tell you how to get these rates" and I'm not surprised you're feeling this way. There is a certain facebook group of EM docs where the negativity, witch hunt-ery and general toxicity got so bad that I just had to leave.

CMG penetration and residency expansion have been active for 20 years. The same stuff has been happening in anesthesia - they're not starving either. No one here is a health system economist. Would it be reasonable to expect that EM rates will stagnate or decline slightly and not continue on the rocketship ride that they've been on? - probably. EM is likely the highest paid (by hour) specialty today. I wouldn't leave your residency just yet.

 

[EctopicFetus]

The CMG can always off the hospital a better (and cheaper) burger. Do they cheat and mis-label the ingredients? Of course.

I’m no noob, this is my 2nd SDG. 10 years in. I know how they like to play the game. Ive been there. All I’m saying is I believe my group is in good shape. I’m in leadership of it and while there is always risk our C suite has experience with 2 CMGs and lets say it wasn’t positive. Again there is always risk...

 

[namethatsmell]

Here’s another way this could all play out over the next couple decades...


CMGs will continue to upcode charts and downstaff overall coverage and trim physician hours while pushing mid-levels to see sicker patients. Interim profits rise.

Eventually, a noticeable amount of patients get hurt and lawsuits pile up and the popular press jumps all over it. There are also more bouncebacks and more unnecessary “care” which increases the CMG’s billing but costs CMS and private payers more and more. Oh, and all that upcoding that’s been going on? An even bigger bullseye is cast on the CMGs.

CMGs, faced with both legal and public backlash will lose contracts and may well be unloaded from VC portfolios. Large hospital groups and insurers buy parts of them up. There won’t be enough pie left to support a large CMG middleman. Along the way, there will be a small renaissance of SDGs that rise from the ashes.

As more and more of healthcare continues to consolidate, increasing proportions of specialties (EM, hospitalists, anesthesia, etc) will become direct employees.

Along the way, the amount of EM Physicians will rise somewhat, though not as much as expected due to the many factors already listed in this thread. Patient volumes unlikely to go down thanks to societal expectations. Salaries will go down somewhat, but not crash. The employement landscape will change, but the sky will not fall.

Sure, none of this may happen, but it wouldn’t be completely terrible if it did. Do you know many miserable EM docs working at Kaiser or the VA (the two largest integrated corps I know of)? I know zero.

 

[EctopicFetus]

My SDG was the top trusted/most respected group in our hospital as rated by the medical staff. Our nurses/manager loved our group. CEO loved our group. We had people in MEC, past Chief of staff, had a member in almost every hospital committee. No stipend.

Well, we are a CMG now.

All SDGs are vulnerable and may have nothing to do with your group. You could be the best group, take no stipend, follow all the CEO's orders like a whipped puppy and still lose our contract when the CMG comes in and offers the hospital a kickback, take on a terrible hospital no one wants, or offers to run the hospitalist group without a stipend. If the hospital's bottom line is better with a CMG, your days are numbered.

I get it man. We are at risk. That being said when someone who doesn’t know anything comes here and says “when” its stupid. Yes at some point my group will lose our contract. Is it in a year? 10 years? 50 years? It will happen. That being said each deal is unique and from speaking with CMG leaders and hospital leaders I think the momentum is swinging the other way nationally and more importantly to me it is staying the course locally.

My old group sold out to a CMG (though I opposed it). Hence I left. I learned a lot through that experience not the least of which was the diversify my income. Now not including real estate I have 4 sources of income (not including from my wife’s work).

Any smart SDG now you are at risk constantly. I feel good about my groups situation. I was in Arizona during the great takeover there. I had friends in all the groups EmCare bought. AZ went from having a decent number of good to great SDG jobs to now having almost none. Lessons were learned (those were voluntary sales except 1).

 

[EctopicFetus]

Here’s another way this could all play out over the next couple decades...


CMGs will continue to upcode charts and downstaff overall coverage and trim physician hours while pushing mid-levels to see sicker patients. Interim profits rise.

Eventually, a noticeable amount of patients get hurt and lawsuits pile up and the popular press jumps all over it. There are also more bouncebacks and more unnecessary “care” which increases the CMG’s billing but costs CMS and private payers more and more. Oh, and all that upcoding that’s been going on? An even bigger bullseye is cast on the CMGs.

CMGs, faced with both legal and public backlash will lose contracts and may well be unloaded from VC portfolios. Large hospital groups and insurers buy parts of them up. There won’t be enough pie left to support a large CMG middleman. Along the way, there will be a small renaissance of SDGs that rise from the ashes.

As more and more of healthcare continues to consolidate, increasing proportions of specialties (EM, hospitalists, anesthesia, etc) will become direct employees.

Along the way, the amount of EM Physicians will rise somewhat, though not as much as expected due to the many factors already listed in this thread. Patient volumes unlikely to go down thanks to societal expectations. Salaries will go down somewhat, but not crash. The employement landscape will change, but the sky will not fall.

Sure, none of this may happen, but it wouldn’t be completely terrible if it did. Do you know many miserable EM docs working at Kaiser or the VA (the two largest integrated corps I know of)? I know zero.

Really? While I agree with the beginning 2/3rds I would expect CMG EM pay to drop by 10%. It is starting now. That being said I know a large number of people in AZ working for 300+ / hr for CMGs. I have been offered 300+ 3 times locally here in TN. I haven’t even been looking for work. I spoke with someone before about the actual jobs and process because I took none of those jobs.

The reason no one wants to share is simple. If you get the info on the job my rates would go down. There is a floor in EM I think for a new grad its 150. I wont leave my house for under 300 unless it is an easy job. Those over 300 required a 60-90 min commute. My “main” job is better without the hassle.

 

[emergentmd]

Well, this thread has been thoroughly disheartening. I'm an intern and am suddenly feeling genuinely freaked out that I'm not going to be able to pay down my mortgage-sized student loans through this specialty I thought would be financially stable. Anyone have a glass-is-half-full take on EM compensation (you know, for the kids?)

You will be fine. Your debt will be easily serviced. Rate may drop alittle, you may not be able to go anywhere you want but you will still make as much per hr as any speciality/work almost anywhere you want.

Every field has their bumps in the road. EM is no different.

I may not get constant calls/txt to cover shifts but I still do. I may not get $500/hr like a year ago but I will get $400.

Even if you make $200/hr that still is 350K a yr. Most people would kill to make 350k/yr and would do much worse than being an EM doc.

I would not trade this for any specialty even if I made 350k vs 500k a yr.

 

[namethatsmell]

Really? While I agree with the beginning 2/3rds I would expect CMG EM pay to drop by 10%. It is starting now.

I'm not quite sure what you're referring to you don't agree with? Can you clarify?

Glad to hear you're also seeing SDGs starting to gain traction again. I know of a few new SDGs as well and it's awesome to see them push out the CMGs.

 

[EctopicFetus]

I'm not quite sure what you're referring to you don't agree with? Can you clarify?

Glad to hear you're also seeing SDGs starting to gain traction again. I know of a few new SDGs as well and it's awesome to see them push out the CMGs.

Sorry I’m post nights and my mind isnt quite clear yet. I was referring to the VA / Kaiser. The VAs i know have a revolving door of LSU (ED) docs. Kaiser is a different animal due to people willing to accept anything to live in California. Even there people I know are always looking for something better. That makes average type jobs extremely competitive in the big cities.

 

[namethatsmell]

Sorry I’m post nights and my mind isnt quite clear yet. I was referring to the VA / Kaiser. The VAs i know have a revolving door of LSU (ED) docs. Kaiser is a different animal due to people willing to accept anything to live in California. Even there people I know are always looking for something better. That makes average type jobs extremely competitive in the big cities.

Ah I see.

I know people who work at Kaiser in Cali, Colorado, and mid-Atlantic and they're all pretty darn happy. FWIW, my buddies in Denver say Kaiser is the hardest EM gig to land there right now.

I know fewer docs working at the VA and all are pretty happy as well -- biggest complaint there is the lower acuity. I have been told there is a big difference in work environments there as only some of their EDs are run and staffed by EM boarded docs. All of them love the patients and med mal climate.

But hey, it's all anecdotal and I appreciate your insight. Personally, after working for a CMG I'd give my left nut to work at Kaiser or a decently-run VA. Being in a SDG where everybody is truly equal is probably the best for most folks. Or locums if you are up for the travel.

 

[sum dude]

This is terrifying, particularly since I've agonized over these very same trends you mention and seeing a current attending reinforce them point by point makes it harder to dismiss them as neuroticism.

How bad could things really get? There are a finite number of EDs in the United States and so presumably there are also a finite number of physician shifts required to keep them running. Unlike other specialties, you can't just strike out on your own and set up an outpatient shop as an EM doc so if we ever get to the point where the supply of EM docs exceeds the number of available ED shifts, it'd be game over.

There are 2300 PGY1 spots, soon to be 2500, so that implies a workforce size of 60-70,000 EM docs depending on average career length. There are >30,000 midlevels graduating each year, which works out to about 900,000 midlevels at steady state. If 10% of them want to go into EM that's 90,000, if 20% that's 180,000.

Are there even enough EDs in this country to accommodate anywhere from 150,000 to 220,000 "providers" looking for ED jobs without completely destroying the hourly rates? This sounds like an utter catastrophe happening in slow motion.

When I started little less than a decade ago, 130-140/hr was solid. Now 200-225 is median most places. I'd expect salaries closer to when I started in 10 years. You won't starve, but the big-boom days of "I won't go here for <400/hr" will be gone

 

[alpinism]

The EM forum of SDN is "doom and gloom omgzzz the sky is falling no one should ever go into EM never ever ever" literally all the time. Sprinkle in the almost constant "you're so stupid for not living in a zero tax state and working for less than $300/hr, but I'm not going to tell you how to get these rates" and I'm not surprised you're feeling this way. There is a certain facebook group of EM docs where the negativity, witch hunt-ery and general toxicity got so bad that I just had to leave.

CMG penetration and residency expansion have been active for 20 years. The same stuff has been happening in anesthesia - they're not starving either. No one here is a health system economist. Would it be reasonable to expect that EM rates will stagnate or decline slightly and not continue on the rocketship ride that they've been on? - probably. EM is likely the highest paid (by hour) specialty today. I wouldn't leave your residency just yet.

Good ole EM Docs huh?

Don't worry they've got a Wellness Ranch now lolz

 

[namethatsmell]

When I started little less than a decade ago, 130-140/hr was solid. Now 200-225 is median most places. I'd expect salaries closer to when I started in 10 years. You won't starve, but the big-boom days of "I won't go here for <400/hr" will be gone

I agree with the premise, but only a couple scenarios where I could imagine where the average being in the mid 100s:

1) nursing and midlevel rates go way down as well since many currently earn 80-$120/hr (unlikely to happen anytime soon as many RNs would quit)

2) doctors are mostly replaced by AI (unlikely to happen during our careers, if ever)

3) a prolonged economic depression (maybe the most possible in our careers)

 

[miacomet]

Ah I see.

I know people who work at Kaiser in Cali, Colorado, and mid-Atlantic and they're all pretty darn happy. FWIW, my buddies in Denver say Kaiser is the hardest EM gig to land there right now.

I know fewer docs working at the VA and all are pretty happy as well -- biggest complaint there is the lower acuity. I have been told there is a big difference in work environments there as only some of their EDs are run and staffed by EM boarded docs. All of them love the patients and med mal climate.

But hey, it's all anecdotal and I appreciate your insight. Personally, after working for a CMG I'd give my left nut to work at Kaiser or a decently-run VA. Being in a SDG where everybody is truly equal is probably the best for most folks. Or locums if you are up for the travel.

Kaiser and the VA both have a 40 hour work week- less than appealing to me, and at some VAs you have to call an off-site nurse for permission to admit. Agreed it's better than the implosion in SDGs, and certainly better than a CMG, although expect a big cut in Kaiser's underfunded pension and they just cut the VA pension.

I think Kaiser is actually a very different job than the VA- many years on a partnership track etc without job security.

 

[tkim]

Good ole EM Docs huh?

Don't worry they've got a Wellness Ranch now lolz

Membership Ranch

 

[sum dude]

I agree with the premise, but only a couple scenarios where I could imagine where the average being in the mid 100s:

1) nursing and midlevel rates go way down as well since many currently earn 80-$120/hr (unlikely to happen anytime soon as many RNs would quit)

2) doctors are mostly replaced by AI (unlikely to happen during our careers, if ever)

3) a prolonged economic depression (maybe the most possible in our careers)

Here's the current environment:

Insurances and businesses are discouraging ED usage (see this article about 20% decrease in Mass.)

Private hospitals such as HCA flood the physician market with residency slots (happening in FL, where they opened up 4 new residencies in smallish hospitals)

midlevels start staffing rural ED's (already happening)

Publically traded groups like Envision facing heavy scrutiny for their aggressive OON billing, leading to decreased revenue

Multiple balance billing bans which limit ED group bargaining power.

All these add up to decreasing physician reimbursement in ED. The future is not nearly as bright as it was 6-7 years ago.

 

[namethatsmell]

Here's the current environment:

Insurances and businesses are discouraging ED usage (see this article about 20% decrease in Mass.)

Private hospitals such as HCA flood the physician market with residency slots (happening in FL, where they opened up 4 new residencies in smallish hospitals)

midlevels start staffing rural ED's (already happening)

Publically traded groups like Envision facing heavy scrutiny for their aggressive OON billing, leading to decreased revenue

Multiple balance billing bans which limit ED group bargaining power.

All these add up to decreasing physician reimbursement in ED. The future is not nearly as bright as it was 6-7 years ago.

I'm aware of these things.

It doesn't change my view that while EM salaries will likely dip they probably won't fall through the floor. I was pointing out some factors that make it less likely EM salaries will plummet. How low do you think salaries will drop?
The increase of EM residency spots is probably the biggest issue right now. Much in medicine is cyclical and things always change.

30 years ago nobody wanted to do derm. Look who's laughing now.

12 years ago I heard from many attendings that CT surgery was a dying field...wrong.

8 years ago everybody was saying anesthesiologists wouldn't be able to find a job in the future. They're still needed and their salaries are still amongst the highest in medicine.

Psychiatry is now an increasingly popular field for graduating med students.

Radiology's competitiveness has been on the level of OB/GYN in recent matches.

Who'd have predicted all these things? Nobody. All of these fields' salaries have gone up or remained respectable.

Who knows what the future holds for EM? Nobody. What history does tell us is that people won't stop getting sick and our species will continue to invent new ways to hurt ourselves.

While we need to stand up to things that hurt our field, I think every EM doc should have a side career/exit strategy. This not only helps with burnout and gives you more control of your life, but allows you to be diversified in case everything does go to complete crap (and I'm eating crow).

 

[southerndoc]

Anesthesiology has lobbied hard for CRNA's not being able to practice autonomously. If they lose that, their salaries will plummet.

EM averaged a lot lower pay 10 years ago. It will likely return to that. That's not saying that people will be making minimum wage.

 

[deleted859535]

EM averaged a lot lower pay 10 years ago. It will likely return to that. That's not saying that people will be making minimum wage.

I wonder about this part. While I think many of us chose EM for many reasons, both financial/logical and otherwise, I've gotta figure that as hard as people work in many places, they're not going to continue to do so if their salaries get cut dramatically and may just pack up for a slower pace somewhere else. My shops are like that.

 

[Status Sciaticus]

Anesthesiology has lobbied hard for CRNA's not being able to practice autonomously. If they lose that, their salaries will plummet.

EM averaged a lot lower pay 10 years ago. It will likely return to that. That's not saying that people will be making minimum wage.

There are 27 states, if I remember correctly, that have independent/autonomous CRNA practice. MGMA & Medscape surveys show no real difference in these states when compared to their regional averages.

 

[Brigade4Radiant]

lol either MD training is needed or isn't EM doesn't have "mommy" track or hours conductive to family life they may flood into but the thing with all these midlevels is that there are other fields they can go into. Emergency medicine is tough.

 

[Makati2008]

Membership Ranch

No way I could be a part of that “ranch”. Donations with no ownership possibility makes it seem like I’m paying for someone else to make money in the future.....

 

[miacomet]

I dunno. EM is a pretty tiring field, and it's certainly not getting easier. If salaries drop significantly, docs will head to admin, urgent care, telehealth etc. I agree the market may flood, but I also think the younger crowd is interested in working fewer hours and not averse to leaving clinical medicine. Why slave in the ER on nights and weekends when you can do telehealth or utilization review?

 

[emergentmd]

I did a month of all nights one summer to see how it would work out with my family/kids. Pay had a $500 stipend so maybe another $7500 a month.

I will tell you that I have great respect for Nocturnist. You sleep gets really messed up, you don't sleep well during the day. My body just could not sleep 8 hrs at a time. I would sleep maybe 4-5 if lucky. Wake up, feel tired, and affects everyone around me.

I could do a night now and then but still difficult the next day. I am glad I don't have to do nights anymore.

 

[miacomet]

Any thoughts on the following locums companies? Delta, StaffCare, CompHealth, Sumo, and Weatherby? I used to like Weatherby and Comphealth, but they seem to have gone down, and Delta has a truly bizarre contract that asks flagrantly illegal questions such as "have you ever seen a therapist." WTF???

 

[gamerEMdoc]

In general a bet against EM is a bet for increased rationality, decreased utilization, and a healthier population in the US.

Yeah. My money is on the continued irrational use of increased resources by an unhealthy US population.

 

[miacomet]

Yeah. My money is on the continued irrational use of increased resources by an unhealthy US population.

Yes, but midlevels and CMGs. And...ED visits are down by 10% over the last year or so.

 

[wamcp]

I'm aware of these things.

It doesn't change my view that while EM salaries will likely dip they probably won't fall through the floor. I was pointing out some factors that make it less likely EM salaries will plummet. How low do you think salaries will drop?
The increase of EM residency spots is probably the biggest issue right now. Much in medicine is cyclical and things always change.

30 years ago nobody wanted to do derm. Look who's laughing now.

12 years ago I heard from many attendings that CT surgery was a dying field...wrong.

8 years ago everybody was saying anesthesiologists wouldn't be able to find a job in the future. They're still needed and their salaries are still amongst the highest in medicine.

Psychiatry is now an increasingly popular field for graduating med students.

Radiology's competitiveness has been on the level of OB/GYN in recent matches.

Who'd have predicted all these things? Nobody. All of these fields' salaries have gone up or remained respectable.

Who knows what the future holds for EM? Nobody. What history does tell us is that people won't stop getting sick and our species will continue to invent new ways to hurt ourselves.

While we need to stand up to things that hurt our field, I think every EM doc should have a side career/exit strategy. This not only helps with burnout and gives you more control of your life, but allows you to be diversified in case everything does go to complete crap (and I'm eating crow).

What about the risk of medicare for all? Or NHS style system? Or healthcare becomes VA run? The VA pays 180/hr for ED work. Politics and the rabbled mass of voters who want free everything is a huge risk to all of us

 

[wamcp]

Yeah. My money is on the continued irrational use of increased resources by an unhealthy US population.

Would you bet against socialist and populist voters intent on pushing for universal healthcare?

Look how little the NHS pays A doctor's pay within the NHS

Wanna do ER work for 60/hr?

 

[miacomet]

Would you bet against socialist and populist voters intent on pushing for universal healthcare?

Look how little the NHS pays A doctor's pay within the NHS

Wanna do ER work for 60/hr?

This is why the NHS can't staff their ERs. They use locums, at rates double that. They can't fill their ER residencies, either.

Canadian and Aussie EM docs are paid comparably to the US, and no nights in Oz!

 

[GeneralVeers]

This is why the NHS can't staff their ERs. They use locums, at rates double that. They can't fill their ER residencies, either.

Canadian and Aussie EM docs are paid comparably to the US, and no nights in Oz!

Correct, but my concern would be that we wouldn't have rationality in the U.S. and pay ED physicians accordingly. Our bankrupt country will seek to reduce healthcare costs in any way it can, and our physician salaries are one big fat easy target for them.

We'd have to have a special carve-out or become salaried employees, as "Medicare for All" would certainly mean universal pay cuts for doctors if we were paid Medicare rates for all patients. It's amazing to me that the people pushing this scheme aren't aware that thousands of hospitals would immediately shut their doors if they had to subsist on only Medicare rates.

 

[southerndoc]

Correct, but my concern would be that we wouldn't have rationality in the U.S. and pay ED physicians accordingly. Our bankrupt country will seek to reduce healthcare costs in any way it can, and our physician salaries are one big fat easy target for them.

We'd have to have a special carve-out or become salaried employees, as "Medicare for All" would certainly mean universal pay cuts for doctors if we were paid Medicare rates for all patients. It's amazing to me that the people pushing this scheme aren't aware that thousands of hospitals would immediately shut their doors if they had to subsist on only Medicare rates.

I have a feeling those hospitals that close their doors would become government-operated hospitals. Part of me thinks that the ACA and CMS-mandated measures that cost hospitals money are the first steps toward this.

 

[miacomet]

Correct, but my concern would be that we wouldn't have rationality in the U.S. and pay ED physicians accordingly. Our bankrupt country will seek to reduce healthcare costs in any way it can, and our physician salaries are one big fat easy target for them.

We'd have to have a special carve-out or become salaried employees, as "Medicare for All" would certainly mean universal pay cuts for doctors if we were paid Medicare rates for all patients. It's amazing to me that the people pushing this scheme aren't aware that thousands of hospitals would immediately shut their doors if they had to subsist on only Medicare rates.

Whatever. Canada and Aus can afford it. Let's hope we go that way, not to the NHS.

 

[GeneralVeers]

Whatever. Canada and Aus can afford it. Let's hope we go that way, not to the NHS.

They can afford it because they are able to ration care. We are culturally unable to ration care in this country (old people vote!), so there will never be effective cost containment.

 

[bronx43]

They can afford it because they are able to ration care. We are culturally unable to ration care in this country (old people vote!), so there will never be effective cost containment.

Health care utilization isn’t the biggest driver for cost in this country. It’s that there are cartels (pharma, hospital systems, med devices, insurers) that are able to fix cost due to their dominance of the market and the laws allow it.

 

[GeneralVeers]

Health care utilization isn’t the biggest driver for cost in this country. It’s that there are cartels (pharma, hospital systems, med devices, insurers) that are able to fix cost due to their dominance of the market and the laws allow it.

No. The biggest problem is futile end-of-life care. 80% of Medicare spending is done in the last year of life, most of it on futile care of no benefit.

 

[miacomet]

No. The biggest problem is futile end-of-life care. 80% of Medicare spending is done in the last year of life, most of it on futile care of no benefit.

Actually, there's increasing evidence that we don't know when people are going to die and that it's fairly hard to predict. Retrospectoscope is always 20/20. Ashley Shreves has done some great work on this.

 

[bronx43]

No. The biggest problem is futile end-of-life care. 80% of Medicare spending is done in the last year of life, most of it on futile care of no benefit.

Compare the cost of anything between the US and the rest of the world in dollars. Same drugs, same surgeries, same devices, same imaging. This large discrepancy is explained by cost fixing and is a large, if not the largest, driver of healthcare cost in the US.

Do you have actual data that most of Medicare dollars are spent on “futile care of no benefit?” I don’t think you do, because I’ve seen multiple studies quoting different numbers and the 80% statistic is not substantiated. I can pull up study after study that more or less debunks this notion.

Furthermore, end of life spending was estimated to be 11% of overall health care spending when factoring in private payers and Medicaid. Even if you allowed everyone on Medicare to die “at the end of life” you still wouldn’t save the system.

Don’t get me wrong... do I think there should be prolonged end of life care for someone with a terminal diagnosis? Not necessarily. But to pin the overarching cost problem on this is just foolishly misguided.

 

[southerndoc]

Compare the cost of anything between the US and the rest of the world in dollars. Same drugs, same surgeries, same devices, same imaging. This large discrepancy is explained by cost fixing and is a large, if not the largest, driver of healthcare cost in the US.

Do you have actual data that most of Medicare dollars are spent on “futile care of no benefit?” I don’t think you do, because I’ve seen multiple studies quoting different numbers and the 80% statistic is not substantiated. I can pull up study after study that more or less debunks this notion.

Furthermore, end of life spending was estimated to be 11% of overall health care spending when factoring in private payers and Medicaid. Even if you allowed everyone on Medicare to die “at the end of life” you still wouldn’t save the system.

Don’t get me wrong... do I think there should be prolonged end of life care for someone with a terminal diagnosis? Not necessarily. But to pin the overarching cost problem on this is just foolishly misguided.

I'm not sure if it's 80%, but I think the point is being missed: a large portion of CMS expenditures are made during the last year of a person's life, and a lot of it is made on care that is futile. Like you, I've seen various statistics, and whether it's 20% or 60%, it doesn't matter. Futile care is futile care, and it's costly.